CHAPTER 1
Introduction
The Government of India, with the objective of meeting the basic requirement of Health for all, has launched the National Rural Health Mission (NRHM) 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 Centres, Primary Health Centres and Sub Centres 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 —Ayurvedic, 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 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 (PRI) 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 mission, 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
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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 will 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 that 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 context of 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 part of monitoring, Ministry of Health and Family Welfare (MOHFW), Government of India, therefore, proposed a rapid assessment of the implementation of NRHM by Population Research Centres (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 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 Surakha Yojana (JSY) 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
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Utilization of untied funds NRHM has drawn a plan of action at all levels of 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 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 Committees (VHSCs) have 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 case of referral and transport in emergency situations. Each Sub Centre will have an untied fund @ Rs.10, 000 per annum. Likewise, each PHC and CHC is provided with untied funds of Rs. 25, 000 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 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 was 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.
Janani Suraksha Yojana
Janani Suraksha Yojana, 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, 3 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 & Kashmir. In the remaining states and UT’s categorized as High Performing States
(HPS) similar provisions have been made wherein Anganwadi worker (AWW) or Traditional Birth
Attendant (TBA) 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 the RHM
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 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 is 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 Indian Public Health Standards (IPHS).
Assessment of health and family welfare situation at the 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
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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, Integrated Child Development Services (ICDS) etc., NHRM attempts to move towards one common VHSC 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 aims 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 i. To examine the utilization of untied funds under different activities at sub centre, PHC and CHC level ii. To highlight the problems faced by CHC and PHC Incharge and ANMs in receiving and utilization of funds iii. To seek the opinions of CHC and PHC Incharge and ANMs regarding the sufficiency of funds iv. To study the role of village health committee particularly Sarpanch/Panch at Sub Centre level and Rogi Kalyan Samiti in the utilization of funds at CHC and PHC level. Janani Surakha Yojana i. To assess the role of ANM/ASHA in providing services to the beneficiaries of the JSY ii. To seek the opinions of ANMs/ASHAs regarding the sufficiency of funds and timely disbursement of funds iii. To study the role of other health officials in the implementation of the scheme at district level iv. Review engagement of private sector including accreditation and compensation v. To highlight the problems faced by the beneficiaries in receiving the services/funds Facility up gradation under RHM i. To assess the level of up gradation of health facilities ii. To assess the availability and adequacy of infrastructure, furniture, equipment, Medicines/drugs and vehicle in the Sub Centres, PHCs and CHCs iii. To examine the availability of manpower medical & paramedical
5 iv. To assess the availability of type of services and facilities v. To assess the clients perception regarding quality of services through exit interviews and seek views of the community vi. To seek opinion of doctors and para medical staff regarding the type and quality of services provided to the community. Assessment of health and family welfare situation at the village level i. 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 data was collected through instruments structured at different levels. The secondary data regarding the physical and financial progress of various components of NRHM was collected from various health officials associated with the implementation of NRHM. Information regarding the implementation of the NRHM, its planning, monitoring and problems were 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 for rapid appraisal in consultation with this PRC. The present report is the first in the series and pertains to Rajouri district.
A set of 11 questionnaires was 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 Centres held in Srinagar, Kashmir 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 Rajouri were bilingual, consisting of questions in both Urdu and English. Before printing the questionnaires, pretest of the Urdu questionnaires was carried out by the PRC.
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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 Rajouri district it was planned to collect information from the District Hospital Rajouri, 2 CHCs, 4 PHCs and 12 Sub Centres. Rajouri district has a total of 7 CHCs/Sub District Hospitals. These are Sunderbani, Darhal, Nowsehra, Kandi, Thanamandi, Kalakote and Teryath. Of these 7 CHCs, Sunderbani and Darhal are functioning as First Referral Units (FRU’s). 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 at least 1 is a FRU. From each CHC, two PHCs were to be selected based on distance from headquarter and 24x7 functioning. In Darhal we selected PHC Manjakote (24X7) and PHC Lah and in CHC Kandi, PHC Budhal (24X7) and PHC Tralla 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 1 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 selected CHCs, PHCs, Sub Centres and Villages are as under:
CHC PHC Sub Centre Village Kakora Kakora Katarmal Hayatpora Hayatpora Manjakote Lower Hayat Pora Rajdhani Rajdhani Dharya Moda Darhal Khablan Khablan Jhumrathi Mehar Behrote Behrote Lah Kote 7
Badha Kanna Badha Kanna Nallah Badha Kanna Kandi Kewal Kewal Lower Kewal Targian Targian Budhal Kandra Moda Dandote Dandote Khanya Gali Sankari Sankari Payeen Tralla Rehan Rehan Dandote Sodagala Sodagala Bandrian It was planned to cover 50 households in each village. Despite best efforts the team could successfully complete interviews in 1196 households in the district. 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/Mukhia. 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 door and Out door patients 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, we could not conduct Exit Interviews for In Patients at CHCs and PHCs. The Exit Interviews were successfully completed with 73 out patients and 10 in patients. Apart from this information was collected from the office of Chief Medical Officer
(CMO) and District Programme Management Unit (DPMU) 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.
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Field work The field work for the study was conducted during January February, 2009. Data was collected by a team, consisting of 6 field investigators, a supervisor cum editor and a field coordinator. 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/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 Centres covering 24 villages. A total of about 1300 households were visited and interviews could be successfully completed for 1196 households. Besides, we collected information from 10 ASHAs, 11 members of Gram Panchayats/Dehi Committee/Auqaf Committee Members/Mukhiyas/Sarpanchs. Information was successfully completed from all the 12 Sub Centres, 4 PHCs, 2 CHCs and District Hospital Rajouri. So far as the Exit Interviews are concerned, the findings are based on the responses collected from 73 Out Patients and 10 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.
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Presentation of Findings This report is divided into ten chapters. Chapter I is the introduction. Chapter II deals with the health care facilities available at the State Level. Similarly, Chapter III presents the situation of NRHM at the District level, with special reference to District Hospital. Chapter IV, V, VI and VII are similar presentations respectively for CHCs, PHCs, and SCs. The findings pertaining to ASHAs are presented in Chapter VIII. Opinion of the members of the Village Health and Sanitation committees are depicted in Chapter VIII. The perception of households and clients who utilized the services from government health institutions regarding the quality of services is discussed in Chapter IX and X respectively.
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CHAPTER 2
RHM in Jammu & Kashmir
Introduction Situated between 320 17' N and 37° 6' N latitude, and 73° 26' E and 80° 30' E longitude on the northern extremity of India, Jammu and Kashmir occupies a position of strategic importance with its borders touching the neighboring countries of Afghanistan in the north west, Pakistan in the west and China and Tibet in the north east. To its south lie Punjab and Himachal Pradesh, the two other States of India. The total geographical area of the State is 2,22,236 square kilometers and presently comprises 22 districts in three divisions namely Jammu, Kashmir and Ladakh. The Kashmir division comprises the districts of Anantnag, Kulgam, Pulwama, Shopian, Srinagar, Ganderbal, Budgam, Baramulla, Bandi Pora and Kupwara. The Jammu division comprises the districts of Doda, Ramban, Kishtwar, Udhampur, Reasi, Jammu, Samba, Kathua, Rajouri and Poonch. The Ladakh division consists of Kargil and Leh districts. Every region has distinct social, economic, linguistic and cultural characteristics.
Population and health According to 2001 Census, Jammu and Kashmir had a population of 10 million, accounting roughly for 1 percent of the total population of the country. The decadal growth rate during 1991 2001 was about 29.4 percent which was higher than the decadal growth rate of 21.5 percent at the national level. 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 for the country as a whole (933). Twenty five percent of the total population lives in urban areas which is almost the same as the national level. Scheduled Castes account for about 8 percent of the total population of the State as against 16 percent at the national level. Scheduled Tribe population account for 11 per cent of the total population of the State as compared to 8 percent in the country. Jammu and Kashmir is one of the most educationally backward States in India. As per 2001 Census, the literacy rate among population age 7 and above was 55 percent as compared to 65 percent at the national level. Female literacy (43 percent) continues to be lower than the male literacy (67 percent).
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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 All India Level. With the introduction of Reproductive and Child Health 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 Reproductive and Child Health Programme (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.
The State has made tremendous progress during the planned era in terms of development of health infrastructure 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
12 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 Ayurvedic 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 Centres, 346 Medical Aid Centres, and 417 ISM dispensaries. Besides, 302 institutions are delivering area specific health care services which include STD/VD Clinics, TB Centres, Leprosy Centres and Trachoma/Amchi Centres.
ational Rural Health Mission In order to strengthen the public health care delivery system by community ownership of health facilities, NRHM was launched in the State in 2005 2006 like other parts of the country. J&K has been identified as one of the high focus States under NRHM. NRHM is not only focussing the health care but is also focussing its attention towards important determinants of good health like nutrition, sanitation, hygiene, safe drinking water etc. The perspective plan for the NRHM aims to revamp the public health system to be more responsive, efficient and effective through a multi pronged approach. The state seeks to provide accessible, affordable, and quality health care to the rural population, especially the vulnerable section. NRHM in the State expects to reduce Maternal Mortality Rate to 100 per 1,00,000 live births, Infant Mortality Rate to 30 per 1000 births and the Total Fertility Rate to 2.1 by the year 2011 2012. It also aims considerable reduction in Communicable & Non Communicable Diseases, especially TB, water born diseases, etc. Another focus of NRHM in J&K is to improve Adolescence Sexual Reproductive Health through integrated Adolescent’s Friendly Health Services.
Towards this direction, the State government is taking concrete steps to strengthen 1907 SCs and provide required staff 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 upgradation to make them functional on 24X7 bases. Besides, 56 CHCs have been identified for upgradation to serve as FRUs as per IPHS standards. 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
13 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 state plans to thoroughly orient the members of these committees about NRHM and village level actions to be taken up for improving health. 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 incentivize the 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. 1. Increasing access to improved healthcare at household level through the female health activist (ASHA), especially to the vulnerable 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.
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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. Decentralisation 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 Manager, Finance Manager, Accounts Manager, and a Data 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. 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. In addition to this District Health Societies and DPMU have also been registered in District Kulgam, Reasi and Ganderbal recently. 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 Programme and Block Accounts Manager.
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Upgradation 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. The State has selected 70 CHCs to be upgraded as per IPHS norms. The physical upgradation has been completed in 15 CHCs as on 31 March 2008 and in remaining CHCs, upgradation is in progress. Besides, 24 CHCs are functioning as FRU on 24X7 bases and 15 more CHCs are being upgraded to function as FRUs on 24X7 basis. Similarly, 96 PHCs had been taken up for up gradation to function on 24X 7 basis in the first phase and 85 of these PHCs had made operational during 2007 2008 as required infrastructure and staff had been provided to them to function on 24X7 bases. Of these PHCs, 25 were conducting a minimum of 10 deliveries per month.
Rogi Kalyan Samitis 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 funds 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 the 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 funds @ Rs. 10,000 each has been released to 1907 SCs, however annual maintenance grant of Rs. 10,000 was released to only 644 SCs.
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 funds are transferred to all the districts electronically.
ASHA The State has also initiated the process of selection and training of ASHAs and has by now completed it. Around ten thousand Female Accredited Social Health Activists (ASHA) have been
16 selected and put in place in all the villages. Of the 9764 ASHAs selected, 9500 have been trained in Module I and 8900 in Module II. Training in module II is under progress. ASHA kits having generic drugs (both Allopathic and AYUSH) have been supplied to 9500 ASHAs. However, State needs additional 500 ASHAs to cover all the hamlets.
Village Health and Sanitation Committee Under NRHM every Sub Centre is supposed to have a Village Health and Sanitation Committee. Since Panchayats are not functional in the State, therefore, authorities had difficulties in constituting VHSC. However members of old panchatas/dehi committees/Auqaf committees, Numberdars, Chowkidars and Anganwadi Worker have nominated as members of VHSC. Bu April, 2008 a total number of 6788 Village Health and Sanitations Committees had been constituted.
Village Health and utrition Days As malnutrition among women and children is a common problem in the country, therefore, NRHM has a strong component of improving the nutritional landscape of the country by organizing fixed Village Health and Nutrition Days in every village in collaboration with Anganwadi Centres. Government of Jammu and Kashmir has taken a lead in organizing VHND and during 2007 2008 and 48464 number of VHND have been organized at various Angan Wadi Centers in the State. However, the number of VHND has declined to 22602 during 2008 2009.
Family planning Family planning services in the State are provided by a network of hospitals, CHCs, PHCs and SCs. As per NFHS 3 about one half of couples of reproductive age in the State were using a method of family planning. Majority of the acceptors are using female sterilization. Though efforts have been made to involve men in family planning by popularizing NSV and male spacing methods but the results are not yet encouraging. The information provided by SPMU shows that laprolization is still very popular as 1969 coulees accepted laprolization to plan their families during 2007 08 while as the number of NSY acceptors during the same period was 1499.
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Public Private Partnership The involvement of non government and private sector is critical for the success of NRHM. Therefore NRHM seeks partnership with non government health care organizations and private service providers through better regulation and transparent system of accreditation for quality health care services at agreed costs and norms. Some progress has also been made in involving private health institutions for achieving public health goals. Seven private health facilities have been identified for PPP mainly for the implementation of JSY. However none of these facilities is yet to be accredited for implementing JSY. Though some NGO have also been involved in the implementation of NRHM but their work is yet to be evaluated.
Janani Suraksha Yojana JSY scheme was launched in the State in 2006 2007. With the implementation of JSY, the number of women coming for institutional deliveries increased considerably; but because of certain irregularities in its implementation, the scheme was discontinued in 2007 2008 and the momentum generated by JSY soon faded away due to the nonpayment of incentives to women opting for institutional deliveries. This eroded the credibility of ASHAs and they stopped motivating women to deliver in health institutions. Besides, State hospitals located in Jammu and Srinagar where majority of the women prefer to deliver were not covered under JSY. This also added to the problems of ASHAs in motivating women to opt for institutional deliveries. Consequently, the number of JSY beneficiaries declined from 13127 in 2006 07 to 10568 in 2007 2008.
Institutional deliveries One of the main objectives of NRHMA is to promote institutional deliveries. Though Jammu and Kashmir has one of the best institutional delivery rates but with the introduction of JSY, the number of women coming for institutional deliveries increased considerably. However, momentum generated by JSY soon faded away due to the non payment of incentives to women opting for institutional delivery. As per the information collected from SPMU and the State Health Action Plan, the total number of institutional deliveries was 83016 in 2005 2006. The number of institutional deliveries recorded increased to 224888 in 2006 2007 but declined to 151244 in 2007 2008. Information regarding the number of registered JSY women and number
18 of women opting for institutional deliveries by caste was not available from the State Programme Management Unit.
However if one critically analyses the number of institutional deliveries and calculates the crude birth rate by only taking into account the institutional deliveries, the CBR for Jammu and Kashmir works out to be 19 per thousand population in 2006 2007 and 12.6 in 2007 2008. FHS 3 and other latest surveys conducted in J&K show that about 45 percent of births take place at home and if we adjust the births delivered at home the CBR for 2006 2007 works out to be 27 and for 2007 2008 CBR works out to be 18.27. While as the SRS has reported a CBR of 19 for the same period. This raises a lot of questions regarding the authenticity of number of institutional deliveries and JSY beneficiaries reported during 2007 2008 by the SPMU.
Health action plans State Health Action Plan and District Health Action Plans for 2007 2008 have been prepared for all the 22 districts. The government used the services of a Delhi based private agency for the preparation of State and District Action Plans. Our discussion with the health officials at various levels revealed that the DAPs prepared by this agency are stereotypes and 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 and neither did they conduct any household surveys. The copies of State and the District Action Plans for 2007 2008 are available on the website of the State Rural Health Mission www.jknrhm.com. So far as the State and District Action Plans for the current year is concerned, State officials reported that the action plan for the State as well as for all the Districts have been prepared but Officials at the District Level reported that the action plan of Rajouri District for the current year has been prepared by SPMU at Jammu without any consultative process involving the DPMU, BMUs, RKSs, VHSCs or community members. Since copies of latest action plans are neither available on the website of the State Health Society nor were they made available to us so it could not be established whether the State and District Health Action Plans have been prepared as per NRHM guidelines or not.
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CHAPTER-3 District Schedule
Introduction Carved out of the district of Poonch in 1968 to facilitate process of development and better supervision, Rajouri district has an area of 2630 Sq. km. The district is located between 700 and 740 4″ East longitude and 320 58″ and 330 35″ North latitude. The district is flanked by Poonch and Shopian district in the north, Jammu district in the south, Udhampur district in the east and Mirpur area of the Pakistan Occupied Kashmir in the west. Rajouri district has peculiar physical features. The Dhaula Dhar range runs across the north eastern part of the district and topography of Rajouri, Budhal and part of Kalakote tehsils consists of numerous hills and small valleys. The tehsils of Sunderbani, Nowshera and part of Kalakote is mostly plain. The climate of the district varies from sub tropical in the southern part comprising Nowshera, Sunderbani and Kalakote to temperate in the northern part encompassing the areas of Rajouri, Budhal and Darhal blocks of the district. The district receives an average rainfall of 500 mm and the average temperature varies from a minimum of 7.4 to a maximum of 37.4 degree Celsius. Historically, Rajouri gained popularity during the day of Mughal Empire as the Mughal rulers used to stay at Rajouri for couple of days while on movement from Delhi to Srinagar and Srinagar to Delhi.
The District Rajouri has been administratively divided into six Tehsils namely Rajouri, Kalakote, Budhal, Thannamandi, Nowshera and Sunderbani. The entire District having 382 villages and six important Towns is sub divided into seven Rural Development Department Blocks namely Rajouri, Manjakote, Darhal, Budhal, Kalakote Nowshera and Sunderbani. The Head Quarter of the District is a Rajouri.
The District has been divided into 4 medical blocks to provide health care services. The medical blocks are Sunderbani, Nowshera, Kandi and Darhal. Each block is divided into 3 6 sectors (Figure 1). Nowshera is the largest block with 6 sectors and Sunderbani is the smallest block and has 3 sectors. Kandi block has 5 sectors and Darhal block has 4 sectors.
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MEDICAL BLOCKS AND SECTORS DISTRICT HEADQUARTER RAJOURI
MEDICAL BLOCK MEDICAL BLOCK MEDICAL BLOCK MEDICAL BLOCK SU DERBA I OWSHERA KA DI DARHAL
SECTOR SECTOR OWSHERA SECTOR KA DI SECTOR DARHAL SU DERBA I
SECTOR SECTOR SEERI SECTOR BUDHAL SECTOR KALAKOTE THA AMA DI
SECTOR LAMBERI SECTOR KHAWAS SECTOR TARYATH SECTOR MA JAKOTE SECTOR LA GAR SECTOR DALHORI
SECTOR RAJOURI
SECTOR LAM SECTOR TRALLA
SECTOR KALLAR CHATTYAR
Population The population of the district in 1981 was 3.02 lakhs which went up 4.8 lakhs as per 2001 Census. Thus the district has registered a growth rate of 58.2 percent during 1981 2001 as against 68.2 percent in the state as a whole. As per the latest estimates, the population of the district has increased to around 5.8 lakhs. According to 2001 Census, density of the population in the district was 184 persons per sq. kilometers as against 46 persons in Jammu and Kashmir. The district is predominantly rural in character as only 7 percent of the total population lives in urban areas as compared to 25 percent in the State. The literacy percentage as per 2001 census was 58 percent, which is slightly higher than the State average of 55 percent. Female literacy in the district (44 Percent) is at par with the State average (43 percent). The literacy rate in urban areas (87 percent) is one and half times more than the literacy rate in rural areas (55 percent). According to 2001 census, the district recorded a sex ratio of 878, which is lower than the state sex ratio of 892 females per thousand males. Urban sex ratio of 726 females per thousand males in the district is the lowest in the state. Scheduled Castes account for 8 percent of the total population of the district which is same as in the State. Scheduled Tribe population account for 33 per cent of the total population of the district as against 11 percent in the State. District Rajouri offers a representative character of the State in clime, culture and secular outlook. The district presents a 21 composite culture Pahari, Gojri, Dogri and Kashmiri. Irrespective of ethnic groups all speak the Pahari language with ease.
Health infrastructure
There is a District Hospital, 7 Sub District Hospitals/CHCs, 22 Primary Health Centres, 15 Allopathic Dispensaries, 25 Ayurvedic & Unani Dispensaries (ISM), 143 Sub Centres, 1 Urban Health Centres (Evening Clinic) and 2 Mobile Medical Aid Centre which are catering to health and family welfare needs of the population. Besides, there is a Private Nursing Home (KRS Nursing Home) at Sunderbani which has not yet been accredited for JSY. Of the 7 Sub District Hospitals/CHCs, 2 (Sunderbani and Darhal) are functioning as First Referral Units and the process is on to upgrade the remaining 5 CHCs (Thanamandi, Kandi, Nowshera, Teryath and Kalakote) to function as FRUs in the second phase. Of the 22 PHCs, 2 (Manjakote and Budhal) have been upgraded to function as 24X7 PHCs in the First phase. PHCs Shahdara Sharief, Lamberi, Siot, Moughla will be made functional on 24X7 basis in the second phase. The district hospital is accommodated in the old building and a new building for DH is under construction at Kheora. All 7 CHCs have government buildings. To mitigate the problems of accommodation of CHCs, 2 new buildings are under construction for 2 CHCs. Of the 22 PHCs, though 5 are housed in rented buildings but buildings are under construction for 3 PHCs. Of the 143 SCs, 65 have government building and the remaining have rented accommodation, however buildings for 12 SCs are under different stages of completion. IPHS facility Surveys have not yet been initiated in the district and therefore in none of the facilities IPHS up gradation has been completed. Facilities for institutional delivery The facilities for institutional delivery both normal and caesarean are available in the District Hospital Rajouri. Normal delivery facilities are also available in CHC Sunderbani, Darhal, Kandi and Nowshera. Operation theatre for caesarean deliveries are available in some of the CHCs but due to non availability of Gynaecologists, anaesthetists, blood bank, regular electric supply and support staff, C section deliveries are not conducted in Darhal and Kandi CHCs. Complete BeMoc are available in the District Hospital. BeMoc facilities except for neonatal hypothermia jaundice are also available in 4 CHCs (Sunderbani, Darhal, Kandi and Nowshera). CeMoc facilities are provided by DH and to some extent by CHC Sunderbani. New Born Care Units have been established in DH, CHC Sunderbani and Darhal and PHC Manjakote Moughla.
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Human resource Rajouri district has acute shortage of Specialist Doctors and Medical Officers. Of the sanctioned 130 positions of Medical Officers only 46 (35 percent) are in position. Four MBBS Doctors and 22 AYUSH Doctors have recently been appointed on contractual basis under NRHM. The district has a total sanctioned strength of 7 Gynaecologists, though 5 of them are in position but 2 of the CHCs (Darhal and Kandi) were without any Gynaecologist. No appointments of Gynaecologists have yet been made on contractual basis. Chief Medical Officer reported that they are unable to find qualified doctors who are willing to work in rural areas. Of the 6 regular positions of Anaesthetists, 2 are vacant and similarly 3 posts of Paediatricians (out of 5) are vacant. There are 18 regular positions of other specialists (Orthopaedician, Ophthalmologist, Dental Surgeons, Surgery, Radiologists, ENT, Pathology, Dermatology etc) but only 14 are in position. Almost all these Specialists are working in District Hospital and almost all the CHCs are without any specialists. Thirty one percent of the posts of Staff Nurses (SN) are also vacant. Fourteen SNs have been recruited on contractual basis recently. The position of ANMs is satisfactory. Of the sanctioned 208 positions of ANMs in the district 197 are in position. Besides, 64 ANMs have been appointed on contractual working under NRHM.
District Programme Management Unit District Programme Management Unit (DPMU) has been put into place in the District. The post of District Programme Manager, District Accounts Manager and District Monitoring and Evaluation officer were in place. However, the officials of the DPMU expressed that the staff working with the DPMU are getting lesser salaries than their counterparts in other States. For example while a DPM in Jammu and Kashmir is paid Rs. 15,000, the DPM in Bihar and Jharkhand is paid Rs. 23,000 Rs. 25,000. Same is the case with District Accounts Manager and District Data Officer. Block Programme Management Unit has been made operational in 7 blocks. Rogi Kalyan Samitis (RKS) As per the guidelines CHCs are to be brought under community ownership through the system of Rogi Kalyan Samiti (RKS). RKS would be a committee which would have members from the Civil Society, PRI, Health Professional, and NGOs. Once the RKS is constituted they are to be registered with the concerned authorities. CHCs for which a RKS has been authorized to retain the user fee at the institutional level for its day to day needs were to be given a grant of Rupees 23
One lakh. Information regarding the number of facilities having RKS registered was collected from District Programme Manager (DPM). It was reported by the DPM that RKS have been constituted and registered for the District Hospital, all the 7 Sub District Hospitals/CHCs and 22 PHCs. RKSs are functional in all the health institutions but they do not meet regularly. The minutes of the meetings of some of the RKSs were available with the DPM. VHSCs have been constituted in 199 SCs and by 2007 2008, joint accounts have been made operational in case of 175 SCs
Janani Suraksha Yojana (JSY) Janani Suraksha Yojana (JSY) is one of the innovative components under the overall umbrella of NRHM to universalize utilization of maternal health care services. JSY integrates the cash assistance with ANC during the pregnancy period, institutional care during delivery and immediate post partum period in a health centre by establishing a system of coordinated care by field level health worker. The basic aim of the Yojana is to reduce the IMR from 58 to < 30 by 2010. The MMR which is presently 407 and is proposed to be reduced up to 100 and increase the institutional deliveries from 47 percent to 80 percent during the given period of time. The JSY envisages that the benefit of the Yojana should be given to women of all the BPL families for the first two births. However, the benefit is due to mother even after the third birth, if she of her own accord chooses to undergo sterilization in the health facility where she delivered, immediately after the delivery. The scheme also envisages that the cash incentive is also due to such pregnant woman falling in the above category even though she is not registered under JSY previously but needs institutional care for delivery. Under the scheme the CMOs have to identify private medical institutions/practitioners to which women could be referred for deliveries in the absence of a government medical set up under the JSY. JSY was made operational in Jammu and Kashmir w.e.f April, 2006 and during 2007 08 a total number 18920 women were registered under JSY in Rajouri district but incentive money was paid to only 781 women. The State Government had observed certain problems in the implementation and disbursement of payment to beneficiaries under JSY so it had stopped funding under JSY to the women opting for institutional deliveries since April 2008. From April, 2008 to March 2009, JSY in Rajouri district was partly operational. Incentive money was paid only to ASHA workers and no payments were given to the women opting for institutional deliveries. Thus during 2008 09, JSY money has not been paid to any women opting institutional
24 delivery. However ASHA workers mentioned that they also were not paid any incentive money under JSY since April 2008. This has demoralized the ASHAs and efforts of the ASHAs to motivate women to go for institutional deliveries received a severe setback. However, funds have now been released for the implementation of JSY and cash benefit is now a days paid to the beneficiaries. As far as the amount available under JSY is concerned, an amount of Rs. 26, 29,900 was available with the district under JSY and it had utilized Rs. 15, 86, 600 (60 percent). During 2008 2009, Rs. 48 lakhs were available with the district but only Rs. 5,70,602 (12 percent) were utilized under JSY up to February, 2009. The district authorities have not yet developed any partnership with any private institution/practitioner for the implementation of JSY. KRS Nursing Home at Sunderbani has been identified to have PPP in the implementation of JSY. Performance of institutional deliveries The information collected from the DPMU Rajouri shows that a total number of 18,920 women were registered under JSY during 2007-08 and a total number of 5,797 institutional deliveries were recorded in the district during the same period. However, the number of institutional deliveries declined to 2049 during 2008-2009. All the women who delivered in a health facility during 2007-2008 were registered under JSY but only 781 had received cash incentive under JSY. During 2008-2009, none of the women who had delivered in a health facility had received JSY cash incentive. Of the 18,920 women who were registered under JSY during 2007-08, 7 percent were SC, 23 were ST and 70 percent belonged to general category. While as the percentage of SC and ST population in the district is 8 percent and 22 percent respectively. The percentage of institutional deliveries belonging to SC and ST community in 2007-08 was 8 percent and 23 percent respectively. Since information regarding institutional deliveries by caste was not available from some CHCs, so the reliability of information maintained by the DPMU regarding number of institutional deliveries by caste in the district is questionable.
Other initiatives A total number of 635 VHNDs have been organised in the district during 2007 2008. Besides district has proposed to hold 1 Health Mela but it could not be organised. As far family planning is concerned, 1683 women had opted for sterilization and 9 men had accepted NSV. 25
Financial mechanism All the vertical health societies set up for the implementation of various Health and Family Welfare programmes were to be merged into a District Health Society. It was mentioned by the Finance Manager of the District Programme Management Unit that District Health Society (DHS) has been constituted and registered in the district and on paper all different societies have been merged to District Health Society (DHS) but practically all different societies work independently. There is not a common bank account for all programmes in the district and funds under various programmes are received as per the old system. The first District Action Plan was prepared by a private agency in 2006 07 but since then no new District Action Plan has been prepared for Rajouri district. In fact the officials of the DPM unit mentioned that one of the objectives of the Ist District Action Plan was to train the officials of the health department at various levels to prepare action plans but the private agency which was entrusted with the job of preparation of DAP did not pay much attention to this aspect. Consequently, the officials of the health department do not have enough technical capability to prepare a DAP. Recently they have come to know that the District Health Action Plan has been prepared for Rajouri district by SPMU.
DPMU was not fully aware about the criterion used for the allocation of funds to the district. However, they were sure that funds are not received on the basis of Annual Action Plan, but are probably received on the basis of a set formula like the size of population and topography and RCH Flexi pool funds. The funds are transferred from the State to District Health Society electronically. All the 143 Sub Centres have opened joint bank accounts of ANM with Sarpanch/Headman of the village and all these bank accounts are functional. During 2008 09, each of the 7 CHCs had received an amount of Rs. 1 Lakh and each of the 22 PHCs had received Rs. 50,000. There are 143 SCs in the district and each one of them had received Rs. 20 thousand (Rs. 10,000 as untied fund and Rs. 10,000 as AMG).
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Part B District Hospital Introduction In the hierarchical health care system of the Government of India in a district, the district hospital is the apex body, which provides specialised health care services to people on subsidised costs. Every district is expected to have a District Hospital (DH).
District Hospital Rajouri has been established in the year 1967 and is housed in a building which is nowadays called Old Block. This building was constructed by the Mughal Emperors and was used by them as a Saria (Rest House) while visiting Kashmir from Delhi and back. Another Building which is called the New Block was constructed in 1989 and houses the Gynaecological Section. A new Hospital Complex for District Hospital at Kheoda is currently under construction and is expected to be completed within a year.
District Hospital Rajouri caters to the heath care needs of about 6 lakh population. The Hospital was the only source of treatment for majority of the population till 1974 75. The Hospital is located within the city on the road side and is less than 0.5 Kms from the bus stand. The nearest CHC is Darhal located at a distance of about 25 Kms from Rajouri and the farthest CHC is Kandi (Kottranka) which is at a distance of about 60 kms. However, due to terrain topography it takes about 2 hours by public transport to reach Rajouri from Kandi and 1 hour from Darhal. IPHS facility survey has not been carried out in the district hospital. Medical Superintendent of the hospital mentioned that he was not aware of IPHS facility survey and the methodology to conduct it.
Infrastructure The DH Rajouri is spread over an area of about 20 kanals. The hospital has total bed strength of 100 beds. As mentioned above that the present hospital is located in the residential area, however the new hospital complex is under construction in the outskirts of the city. The Hospital has not yet obtained environmental clearance from the Pollution Control Board (PCB) but the hospital has applied to PCB for environmental clearance and the case of environmental clearance is under process. As the major part of the hospital is housed in an old building which was constructed as a 27 saria and not as a hospital, therefore, it is not disable friendly as per the provisions of Disability Act (Ramp, lift, wheel chair movement etc.).
Space All consultation/treatment and diagnostic rooms in a hospital should have adequate waiting space adjacent to each room for patients. But it was found that waiting space for the patients adjacent to consultation and diagnostic rooms is not available in the hospital. In fact there is no concept of waiting rooms in the district hospital. Consequently, the patients use to wait for their turn on the corridors and staircases of the hospital. Though registration counter, doctors duty rooms, treatment rooms, pharmacy, intensive care Unit (ICU), emergency services, examination and preparation rooms are available in the DH but the present building has inadequate space for all these services. Doctor’s duty rooms are few in number and Pharmacy has inadequate space. In fact DH uses one of the public utilities for the storage of intravenous fluids (see Photograph). Blood Bank/Blood Storage unit facility has recently been added to the DH complex. High dependency wards and isolation room is not available in the hospital.
Hospital services Kitchen is available in the Hospital, but the dietary services have been outsourced to a private agency. The private agency uses the hospital kitchen for the preparation of food. The kitchen of the hospital is in a very poor condition (see photograph). It was also found that the patients admitted in the hospital prefer not to receive the food from the hospital. On the day of our visit, it was found there were 38 patients in the hospital who were supposed to receive dinner from the hospital but only 9 preferred to receive it and out of 9 who received it 3 partly consumed it and remaining 6 preferred not to consume it. Patients mentioned that the quality of food provided is so poor that patients prefer to arrange their own food. Some patients also mentioned that stale and unhygienic food is distributed by the contractor.
Central sterile and supply department, Engineering back up, proper ventilation in the wards and provision for fire fighting is not available in the hospital. Hospital does not have a proper laundry and the bed sheets and other washables are washed in a nearby stream. There is no proper facility of drinking water for patients as there are no water coolers/refrigerators or water filters in the
28 hospital. The hospital does not have round the clock water supply as the overhead water storage tank of the hospital is currently not functional. The Directorate of Health Services and the State Pollution Control Board has issued orders to all hospitals and private Nursing Homes to comply with the norms of disposal of bio medical waste. However, it was observed that the norms of proper disposal of biomedical waste are not followed by the hospital. Bio medical waste of the hospital is sometimes buried in pit but it is also thrown in open. The research team also observed that bins of three different colours were procured by the Hospital for the segregation of bio medical waste but three different coloured bins were not available in each and every unit of the hospital. For example, there was only 1 yellow coloured bin in the emergency ward and 2 yellow coloured bins in the IPD wards. It was also observed that these bins were not even used by the paramedical staff. They also used to throw the used syringes, cotton, drip sets etc on the floor.
Staff quarters There are 8 residential quarters for medical staff and 10 quarters for Para medical staff available in the hospital complex and all these residential quarters are occupied by the medical and paramedical staff. Some of the para paramedical staff staying in the quarters are not working with District Hospital. Parking place is adequately available in the hospital.
Medical Records The hospital has a Medical records section but not only the space is limited but also the staff working in the medical records section has not received any training in maintaining medical records of the hospital. In fact the files of the patients were seen to be stored in a haphazard manner. Even the addresses of the patients was not either written or was partially written on In door Admit cards. Besides, the information maintained by various units of the department was also not properly maintained. Doctors in the same unit maintain records on the same register differently. Some doctors record age, sex, address and parentages of the patients, while as some do not record it. The technicians working in laboratories and other diagnostic units complained that stationery items for maintaining records are not provided to them. It was however mentioned by the Medical Superintendent that the disease classification is being carried out by the hospital as per protocols.
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The hospital has a telephone facility which is installed in the Medical Superintendents room. The IPD wards, examination and diagnostics rooms do not have any telephone or intercom facility. Computer is available in one of the labs but internet and fax facility is not available in the hospital.
Obstetric and gynaecological services Information regarding Obstetric and Gynaecological Section was collected from the Female Multipurpose Worker in the gynaecology section. The hospital has a separate ward for females with a capacity of 10 beds. The maternity ward at the time of survey was however under repairs. Since information regarding inpatient days of care and bed days available was not available in the gyanecology section, therefore it was not possible to calculate bed occupancy rate. Direct estimates however revealed that the bed occupancy rate in the maternity section during 2007 08 was 146. In other words there are 1.46 patients per bed per day in the hospital, which indicates that the bed capacity is too small to meet the demand of institutional deliveries in the hospital. The Gynaecologists reported that due to the non availability of adequate beds, they are left with no choice but to refer the high risk cases to Jammu.
A total number of about 3300 women had attended the OPD of Gynaecological section of the hospital. The gyane section has reported about 500 deliveries during the last three months (October December). The hospital has a separate Operation Theatre available for Gynaecological and Obstetrics Section. During 2007 08, 2241 women delivered in the hospital. Of these deliveries, 198 (9 percent) were C section deliveries and 67 were assisted deliveries. Services for MTP, mid trimester abortion, ectopic pregnancy and retained placenta and hysterectomy are available in the hospital and during 2007 08 a total number of 676 MTPs, 36 Hysterectomies and 2 Ectopic Pregnancies were performed in the hospital. Facilities for the management of eclampsia, suturing and infertility treatment are not available in the hospital. Information regarding the number of Retained placenta and PPH was not maintained by the gynaecological section.
Surgical services Information regarding the surgical section was collected from the Theatre Supervisor. During the last 3 months a total number of 2025 patients had visited the hospital for surgical consultation. 30
During the last 3 months a total number of 425 surgeries were performed in the surgical and gyane section of the hospital. The number of patients visiting the surgical OPD or the number of surgeries performed in the surgical section in the hospital by gender was not available from the hospital records. Emergency (accident and other emergency) services are available in the hospital to a limited extent. Facilities for spleen and portal hypertension surgery, abdomen surgery, breast surgery, hysterectomy and piles are available in the hospital. Records available in the surgical section indicate that the hospital has performed 67 emergency surgeries, 93 abdomen surgeries, 3 breast surgeries, 14 hysterectomies and 4 surgical procedures for piles. Facilities for pancreas and leprosy reconstructive surgery are not available at the District Hospital.
Medical services Information pertaining to Medical Section of DH Rajouri was collected from the Medical Officer and FMPW of the Medical Section. The total number of patients who attended the OPD of the medical section during 2007 2008 was 3852 and the number of patients attending the OPD during the last 3 months (Oct Dec., 2009) was 700. Facilities for the treatment of Dermatology and Venerology (skin and VD) RTI/STI are not available in the DH. Similarly, hospital does not have specialists to provide services for Pleural Aspiration, Pleural Biopsy, Bronochoscopy, Lumbar Puncture, Pericardial tapping, Skin scrapping for fungus/AFB, Bone Marrow Biopsy, Endoscopic Specialised Procedures and Psychiatric Disorders.
Paediatric services Information pertaining to Paediatric Section was collected from the Medical Officer in charge of paediatric section. The OPD section has provided services to 7215 children during the last three months. Breakup of patients who visited paediatric section by sex was not available. There is no separate ward for children but hospital has reserved 8 beds in different wards for children and separate information regarding number of children provided IPD services during 2007 08 was not available. Medical Officer reported that facilities for Asphyxia management, management of severe malnourished children, management of Neo Natal Sepsis, Management of Dehydration and Diarrhoeal cases and Management of Respiratory Tract Infection/Pneumonia cases are available in the paediatric section.
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Equipments and drugs in paediatric section A Cradle is not available in the paediatric section. Incubator and Phototherapy unit was available but both were not in working condition. Radiant Heat Warmer, Laryngoscope, Suction Machine and Thermometer and Bag with Mask in working condition were available in the section. ORS, Vitamin A Solution and Paediatric Antibiotics were not available. Iron Folic Acid Tablets were available but they were at the verge of expiry.
Diagnostic section As the post of Radiologist in the hospital was vacant, therefore, information pertaining to the availability of various diagnostic facilities was collected from the technicians working in different sections of the hospital. X ray, ECG and Ultrasound facilities are available in the Hospital. Ultrasound guided Biopsy is not available in the DH. A total number of 2494 X Rays, 573 Ultrasounds and 273 ECGs have been carried out in the hospital during the last 3 months.
Laboratory services Information regarding laboratory was collected from the Pathologists of the Hospital. A total number of 6870 Haematology tests (HB, TLC, DLC, CT, ESR etc) were conducted in the District Hospital laboratory during the last 3 months. Besides, 980 urine tests were carried out in the hospital. The number of tests performed on stool and semen was 6 each. Besides, tests were carried out for CSF Analysis and Aspirated fluids.
Facilities for PAP smear, Split Skin Smear examination for leprosy, Histopathology, Microbiology and Physiology (Pulmonary Function Test) are not available in the DH. Facilities for Sputum testing are available and during the last 3 months 199 Sputum tests were conducted in the laboratory including those which were conducted under RNTCP. Around 100 Serology tests and 680 Biochemistry tests were also carried out in the hospital.
Our informal discussions with the patients who had come for OPD services and also with IPD services revealed that patients mostly utilize services of the private lab facilities even for routine urine, blood tests and X ray, ECG and Ultrasound. They narrated that the doctors probably have either lost faith on the technical capability and efficiency of hospital lab facility and
32 recommended the patients to these private labs even for routine tests or there is some nexus between these private labs and the doctors posted in District Hospital.
Human resource Information regarding the No. of Sanctioned posts and No. of posts in position was collected from the office of Medical Superintendent. The overall situation is fairly satisfactory in the case of Specialists. The hospital has two sanctioned positions of Specialists in each of the fields of Medicine, Surgery, Anaesthesiology, Orthopaedics and Dental Surgery. All these positions are in place in the DH.
Obstetrician/gynaecologist For the provision of reproductive health particularly for females a gynaecologist/ obstetrician is essential. Though, DH has 3 positions of Gynaecologists/Obstetricians but all the 3 are vacant. On the other hand one Assistant Surgeon and one Gynaecologist (with short term trained MO) are working in the Hospital against these vacancies. The hospital has 1 post each of Paediatrician, Pathologists, ENT Surgeon, Ophthalmologist and Radiologist. Except Radiologist, and 1 position of Dental surgeon, all other posts are in position. Of the 16 General Doctors, only 50 percent (8) are in position. The Hospital has no positions of Public Health Manager, Psychiatrist, Dermatologist, Microbiologist and AYUSH Physician.
The position of paramedical staff is satisfactory in the DH. There are 13 sanctioned positions of Staff Nurses, 5 positions of Laboratory Technicians, 6 ANMs and 6 Pharmacists. All these positions are in place. Besides the sanctioned positions of ECG Technicians, Ophthalmic Assistant, X ray Technician and Ward Boys are also in place. The administrative positions consist of 1 position of Office Superintendent, 2 Accountants, 16 Peons, 2 Cooks, 1 Gardner and a Chowkidar.
As the District Hospital caters to a population of more than 6 lakhs and specialist services are not available in CHCs, therefore, this hospital has a heavy work load. But, the available staff strength of Specialists does not suffice the increasing work load of patients. This has resulted in the practice of corruption in availing the services. Consequently, a substantial proportion of patients prefer to avail the health care services from the Doctors at their Private clinics.
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Ambulances The Hospital has 5 vehicles which are used as ambulances. A thorough look at these vehicles shows that there is little difference between a load carrier and an ambulance vehicle. In fact, a stretcher and occasionally an oxygen cylinder is the only difference between the two. All these ambulances lack basic life support system installed Oxygen System, Portable Suction Unit, Traction Splints, Padded Board, Splints, Ring Cutter, Blood Pressure Apparatus and Defibrillator cum Monitor. The equipments apart, these ambulances move without any support staffs and no paramedic staff accompanies the ambulance and most of the work is done by the driver alone. Besides, these heavy trucks consume lot of POL than medium or small ambulances and the charges for transporting a patient from Rajouri to Jammu is about Rs. 1800. The private medium vehicles charges only Rs. 1000 1500, therefore, patients prefer a private vehicle than the hospital ambulance in case of emergency. There is therefore a need to provide medium vehicles for ambulances fitted with required equipments to transport the patients. Medical Superintendent mentioned that due to the heavy patient load to be referred to tertiary care hospitals, it is not possible to provide ambulances with basic life support system. It is suggested that the government should take initiatives to establish centralised ambulance services in the State.
Rogi Kalyan Samiti Rogi Kalyan Samiti for the DH has been constituted and is registered. The hospital charges user fee for conducting laboratory tests, X ray, ECG, Ultrasound and ambulance. Patients belonging to BPL, category and ST/SC are exempted from the user fee. User fee exemption is given by the Medical Superintendent. But it was observed that there is no clear cut criterion for exemption from user fee. Till date RKS has not generated any additional resource. During 2008 2009, RKS has met only once. DH has not put up any display board in the hospital showing details of the members of RKS or number of RKS meetings held.
NRHM envisages that each health facility should have a complaint/suggestion box so that the problems faced by the public in assessing the health care facilities can be addressed and action can be taken on the suggestions given by them but there is no feedback mechanism in place for grievances redressal by RKS in the DH. Suggestion and complaint box was also not available in DH. However, there is a display board in the hospital giving the contact numbers of Secretary Health, and Director Health Services Jammu to register their complaints of corruption. 34
Some additional observations The condition of the beds and bedding in the Gyane ward was found to very poor. In fact most of the beds were so rusted that it had resulted in big holes, but were still put to use. The bed sheets in the wards had not been changed for the last one week.
It was mentioned by many patients that any patients who comes here with a complication of abdominal pain is advised to go for appendicitis surgery. It needs to be mentioned that of the surgeries performed in the hospital during last 3 months, the number of abdominal surgeries is the highest.
At the time of survey, painting and white washing of the OPD rooms and IPD wards was going on in the Hospital without shifting IPD patients to some other wards. Most of the patients were complaining of nausea and vomiting but there was no body to heed to their complaints.
Almost all the patients admitted for surgical services mentioned that depending upon the nature of surgery; they have to pay an amount ranging from Rs. 1000 Rs 3000 to the Surgeon and the support staff for undergoing surgery.
Though smoking is banned in the hospital but patients as well as their attendants and were seen smoking in the IPD wards. o body from in the hospital was preventing them from smoking in the wards.
Rag pickers were seen collecting used syringes, IV fluid bottles and other hospital waste from the premises of the hospital.
Instead of a female sweeper posted in District Hospital, it was her husband who was actually performing her duties.
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CHAPTER-4
Community Health Centre Introduction Community Health Centre (CHC) or Sub District Hospital function as the secondary level of health care and is designed to provide first referral curative as well as specialized health care to rural population. It caters to approximately 80,000 population in tribal/hilly areas and 1,20,000 population in plain areas. It also provides facilities for obstetric care and specialist consultation. CHCs are generally 30 bedded hospitals with Operation Theatre, X-ray, Labour room and Laboratory facilities. It is manned by 4 medical specialists i.e. Surgeon, Physician, Gynaecologist and Paediatrician. It provides specialized care in medicine, obstetric and Genecology, Surgery and Paediatrics. Rajouri district has a total of 7 CHCs/Sub District Hospitals. These are Sunderbani, Darhal, Nowsehra, Kandi, Thanamandi, Kalakote and Teryath. Of these 7 CHCs, Sunderbani and Darhal are functioning as First Referral Units (FRU’s) and the remaining 5 are being gradually upgraded to function as FRUs.
An attempt was made to collect and analyse regarding the function of CHCs by collection information about availability of infrastructure, manpower, equipments, drugs, facilities for institutional deliveries and services outcome from Darhal and Kandi CHCs of Rajouri district and the findings are presented below.
Coverage (C1) As mentioned above that a CHC located in a hilly area is expected to serve a population of 80,000. Both the CHCs are located in hilly areas and each covers a population of 50,000. The nearest PHC to the CHCs in both the cases is at a distance of 20-25 Kms and the farthest PHC is 70-80 Kms from the but due to the more terrain topography in Darhal, it takes 2 hours to reach the nearest PHC and 3 hours to reach the farthest PHC. The time taken to reach the nearest PHC from Kandi CHC is half an hour and it is almost two and a half hours journey to reach the farthest PHC. District hospital is at a distance of 23 Kms from Darhal CHC and 60 Kms from Kandi CHC.
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Infrastructure (Table C1) Table C1 also presents the distribution of CHCs with selected infrastructural facilities such as own building, toilet facility, continuous supply of tap water, electricity, labour room, laboratory, Pharmacy, OPD rooms, Telephone, computer, internet, diagnostic facilities, ambulance, etc in each CHC. Both the CHCs are housed in government buildings. Kandi CHC is located in a building which is quite old and has inadequate space to house all requisite facilities which a CHC is supposed to have. Darhal PHC has a bed strength of 10 and Kandi has a bed strength of 12 beds. Separate wards are available for male and female in Darhal but in Kandi there is a single ward to accommodate both male and female patients. Normal electricity is available in both the CHCs which is irregular and erratic. The standby facility in the form of a portable generator is available in CHC Kandi. CHC Darhal has 2 generators but both are non functional. It has recently placed an order for the purchase of a portable generator to run the computer. Solar light system was installed in Darhal in 2002 but it has also become non functional for the last 6 months. Both the CHCs have a land line telephone connection and a computer. While Darhal also has an internet connection, Kandi is yet to acquire it.
Ambulance Darhal CHC has 3 vehicles which are used as ambulances and all the 3 are in working conditions. On the Contrary, Kandi has 2 vehicles but only 1 is in running condition. However, none of the ambulances has standard ambulance specifications.
Laboratory In the context of provision of RCH services, the availability of a laboratory in CHCs to test the blood and urine of the women seeking antenatal care as well as for the diagnosis of RTI/STI among men and women is critical. Both the CHCs have a laboratory. ECG facility is available in Darhal but not in Kandi. X-Ray facility is available in both the CHCs. Ultrasound was found to be available in Darhal only. Both the BMOs mentioned that due to irregular electricity, they are unable to efficiently use the available equipments.
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Operation theatre is available in Darhal but not in Kandi. OT in Kandi is currently under construction. The OT in Darhal is not being used currently for obstetric and gynaecological purposes. In the context of the National population policy 2000, goal of eighty percent institutional deliveries, the availability of a labour room is a critical facility for a CHC. Labour room is available in both the CHCs but separate areas for septic and aseptic deliveries are not available in both the CHCs. Under RCH programme funds are being provided to have a new born care corner in every CHC. New born baby care corner is also not available in any of the CHCs. Information regarding JSY beneficiaries is maintained by both the CHCs.
Pharmacy for drug dispensing and drug storage is an important infrastructural component for efficient service delivery of the CHCs and both the CHCs have a Pharmacy for drug dispensing and drug storage. The CHCs should have a counter near the entrance to obtain contraceptives, ORS packets, Vitamin A and medicines but such a counter near the entrance of the CHC is not available in any of the CHCs. 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. But none of the 2 CHCs has separate toilets for male and female. In fact the available toilets in both the CHCs were so unhygienic that they were not being used by the patients.
Grievance redressal NRHM envisages that each health facility should have a complaint/suggestion box so that the problems faced by the public in availing the health care facilities can be addressed and action can be taken on the suggestions given by them. Suggestion and complaint box was available in CHC Darhal only. However, it was found that this box has not been opened since it was fixed on the wall.
OPD Rooms are available in both CHCs. There are no waiting rooms in the CHCs but space for waiting outside OPD rooms is available in both the CHCs. The space for waiting is adequate in Kandi CHC only. Drinking water is not available in the waiting space in Darhal but the same is
38 available in Kandi CHC. Emergency room/casualty is available in both the CHCs but separate wards for males and females are available in Darhal only. However, it was found that the Doctors were not examining the patients in the examination rooms but were using the front lawn of the CHC to examine the patients. When one of the doctor at CHC Darhal was asked why he is not examining the patients in the OPD Rooms, it was mentioned that since it is very cold inside, he wants to enjoy the sunny days of winter. Sanitation and cleanliness (Table C1) Table C1 also presents information regarding sanitation and cleanliness of the CHCs. Darhal CHC has a soak pit and the sewerage system of Kandi CHC is connected to an open drain. Guidelines for the disposal of waste material are not followed by any of the CHCs. The waste material is thrown in open by both the CHCs. Overall OPD rooms, wards, compound/premises and wards in both the CHCs were clean but the condition of toilets was poor in both health institutions.
Any social service of the kind of the health services should inform its target beneficiary of the services it delivers and its responsibilities, ideally with a sign board outside its premises to raise the awareness of community. It was found that the prominent display boards establishing the service availability in local language were available in local language (Urdu and English) in both the CHCs. CHCs are expected to maintain names of JSY beneficiaries in their record and since the incentive under JSY was not being paid to beneficiaries, the 2 CHCs were maintaining a register of JSY cards of the beneficiaries. Staff position (Table C2) CHCs are generally manned by 4 Specialists/doctors, 7 staff nurses, 1 Dresser, 1 Pharmacist, 1 Lab Technician, 1 Block Extension Educator (BEO), 1 Radiographer, 2 Ward Boys, and 10 support staff like dhobi, sweepers, chowkidar, peon, mali etc. NRHM guidelines, however, suggest that a CHC should have 7 Medical Officers and 10 Staff Nurses. However presently, both the CHCs have been sanctioned with a post each of Surgeon, Physician, Gynaecologist, Paediatrician, and Anaesthetists. All these positions are vacant in CHC Kandi. The posts of Obstetrician, Paediatrician and Anaesthetist are vacant in Darhal CHC also. Of the 7 sanctioned positions of general line doctors, only 1 is in position. In Kandi CHC, the lone sanctioned position of general line doctor is in position. There are no positions of doctors who are trained with short time
39 courses in obstetric or anaesthesia in both CHCs. Though in CHC Darhal one Obstetrician has been recruited on contractual basis but she was on maternal leave. In Kandi two doctors have been hired on contractual position. Thus of the 12 sanctioned regular positions of doctors in Darhal only 3 are in position and in Kandi of the 6 regular positions of doctors only 1 is in positions. Both the CHCs have a sanctioned position of 1 LHV and Block Extension Educator (BEE) but in both the CHCs, these two positions were vacant. All sanctioned positions of ANMs and Pharmacists, Lab Technicians, Ophthalmic Assistants in both the CHCs were in position. There are 4 sanctioned positions of Staff Nurses in Darhal and 2 in Kandi. While all the 4 are in position in Darhal but none is currently posted in Kandi. The posts of Radiographer, Registration clerk, OT attendant, Pharmacist/Compounder are not available in the CHCs. The post of Statistical Assistants is available in Darhal only but it is vacant, however, 1 person has been engaged on contractual basis to work as Statistical Assistant/Data Entry Operator. Of the 3 regular posts of Drivers in Darhal, one has been filled up and 2 more have been appointed on contractual basis. Similarly, there are 2 posts of Drivers in Kandi but only 1 is in position. However, another driver is working on contractual basis. Thus both the CHCs face acute shortage of both specialist doctors as well as physicians.
Availability of specific services (Table C3) CHCs are supposed to provide general health care services but they are also supposed to provide some specific services like emergency care for sick children, full range of family planning services, AYUSH services, VCTC, cataract surgery, treatment of RTI/STI, DOTS etc. Some of the CHCs have been upgraded to function as FRUs on 24X7 bases. Though both the CHCs under study were functioning on 24X7 basis but only Darhal is currently working as an FRU and proposal for Kandi to function as a FRU is under consideration. Emergency care for sick children was reported to be available in Darhal only. Full range of family planning services, AYUSH services, VCTC, and cataract surgery are not available in the 2 CHCs. Treatment of RTI/STI and DOTS were reportedly available in both the CHCs.
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Status of specific interventions (Table C4) Lack of accountability in the CHCs has been the main reason for patients preferring private facilities. To bring in quality accountability in the health services, Indian Public Health Standards (IPHS) have been set up for CHCs. These standards have been fixed by a high powered task group at the national level through a consultative process with the states and other experts. IPHS is a novel concept to fix benchmarks of infrastructure including building, manpower, drugs, quality assurance through introduction of treatment protocols. Most importantly they also define the level of services that a CHC would be expected to provide. Under RCH funds are being provided to CHCs for conducting IPHS facility surveys; however, it was found that none of the CHCs in Rajouri has yet initiated any action to conduct IPHS facility survey. In fact none of the officials at the CHCs was aware about the terminology of IPHS facility survey.
Transfer of funds Funds to the CHCs are not transferred electronically in any of the PHCs.
Rogi Kalyan Samitis Rogi Kalyan Samitis have been constituted and registered in all the CHCs in the district. The objective of RKS is to finalize the CHC Health Plan, supervise household and health facility survey and organise public hearing and health camps in order to make the planning process activity intensive. In this connection, RKS have to meet regularly. But it was found that RKS meetings are not organised regularly. BMOs mentioned that they do not get cooperation from various members of the RKS to attend the meetings. CHCs had to display the names of the of members and the number of RKS meetings held at a prominent place but we could not see any display board showing the number of members and number of meetings organised by RKSs in any of the CHCs. RKSs does not generate any resources through user fees. The only fund available with the RKSs is untied funds which is used by all the CHCs. RKSs are also supposed to have a mechanism for the redressal of grievances but there was no feedback mechanism in place for grievances redressal in any of the CHCs.
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Citizen’s charter A Charter of Citizen’s Health Rights is to be prominently displayed outside all the CHCs. This Charter would include the services to be given to the citizens and their right in that regard, information regarding grants received, medicines and vaccines in stock. It was found that MOs generally at the CHCs 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 both the CHCs but it included only the working hours and the facilities available in the CHCs. When the MOs were asked to report whether all standard treatment guidelines and protocols are available in the CHCs it was reported by the MOs that all standard treatment guidelines and protocols are not available in any of the CHCs.
Residential facilities (Table C5) Residential facilities for doctors and paramedical staff are available in both the CHCs. There are 2 quarters for doctors and 2 quarters for paramedical staff available at CHC Darhal and similarly in CHC Kandi only 1 quarter each for doctors and other staff is available. All these quarters are occupied by the medical and he paramedical staff of these CHCs.
Availability of laboratory facilities (Table C6) 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, malaria, syphilis, HIV among men and women is critical. Though both the CHCs have a functional laboratory but we also tried to know what various tests are actually conducted in these laboratories. Blood grouping, Haemoglobin, bleeding time, clotting time, urine examination, rapid test for pregnancy, blood smear, test for malaria parasite are carried out in both the CHCs, while as blood sugar, blood smear, diagnosis of RTI/STI, RPR test for syphilis are available in Darhal only. Rapid test for HIV is not carried out in any of the CHCs.
Performance of laboratory (Table C7) 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. In Darhal CHC, lab staff 42 appointed on contractual basis under NRHM and the regular Lab Technician used to maintain records of laboratory tests separately. A look at Table C7 shows that the performance of Darhal is better than CHC Kandi. CHC Darhal has conducted slightly more than 2 hundred Haemoglobin and urine tests but Kandi has done less than 50 tests. The number of malaria parasite tests done at Darhal was 536 but only 30 at Kandi. However, Kandi has recorded two times more pregnancy tests than Darhal. The number of blood smear examinations for blood grouping range from a highest of 91 in Darhal to a low of 18 in Kandi. It was also observed that the performance of the lab tests conducted in Darhal drastically declined after the Gynaecologist proceeded on maternity leave. Monthly analysis of lab performance revealed that once contractual laboratory assistants were recruited, the number of tests conducted by the regular lab technician declined drastically.
Surgeries performed (Table C9) Operation Theatre is available in Darhal CHC, but due to the non availability of Gynaecologists, Eye Surgeon and Anaesthetist, caesarean deliveries, general surgeries, laparoscopic or conventional surgeries for family planning or Cataract surgeries were not performed during 2007-08 in Darhal. Other reasons for not conducting surgeries were lack of proper equipments/poor physical state of operation theatre and non availability of assured power supply. However, some minor surgeries and a few MTPs had been performed in Darhal during 2007-08. Operation Theatre was not available in Kandi.
Labour room (Table C10) The availability of a labour room is a critical facility for a CHC. Though labour rooms are available in both the CHCs but due to the non availability of Gynaecologists and support staff C-section deliveries were not conducted during 2007-08. Normal deliveries used to be conducted at CHC Darhal during 2007-08 but at the time of survey even facility for normal deliveries was not available due to non availability of required staff. As far as the number of institutional deliveries during 2007-08 is concerned, information from CHC Darhal was available for 9 months (July- March). The number of institutional deliveries attended by CHC Darhal during July, 2007-March 2008 was 85 and number of institutional deliveries performed by CHC Kandi during 2007-08 was
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105. As the maintenance of records regarding the institutional deliveries in both CHCs was haphazard and they had not maintained any information regarding the timing of delivery so we could not infer how many of the deliveries had been carried out between 8 pm to 8 am. However, Medical Officers maintained that CHCs during 2007-2008 were not functioning on 24X7 bases; therefore, all the deliveries were carried out during day time only. Almost all the women who had delivered at CHC Darhal or Kandi during 2007-08 had been registered under JSY but none of them was paid any financial incentives under JSY because of non availability of funds under JSY.
Facilities for resuscitation of neonates were not available in any of the CHCs and therefore, no child was resuscitated during 2007-08 at the 2 CHCs.
Availability of selected equipments (Table C12) Certain equipments are essential for the delivery of primary and secondary care health services at the CHCs. This section discusses the status of the 2 CHCs with respect to the availability of these inputs on the date of survey. Information was collected not only about the availability of equipments but also whether the equipments are in working condition and the information is presented in Table C12. Boyles apparatus, Defibrillator, Ventilator for OT, Hydraulic operation table, Phototherapy unit Baby incubator and Gloves dusting machines are not available in any of the CHCs. The only two equipments available in both the CHCs in working condition are Oxygen cylinder and Resuscitation trolley. ECG machine Cardiac monitor for OT, Horizontal high pressure steriliser, Vertical High Pressure Sterilizer and OT Care Fumigation apparatus in working conditions are available in Darhal but are not at all available in Kandi. Of the 15 items in Table C12, Darhal has 7 and Kandi has only 3. Thus, while the condition of both the CHCs with respect to the availability of equipments is poor but problem is more serious in Kandi than in Darhal.
Availability of drugs (Table C12) The information on whether CHCs are equipped with necessary drugs, contraceptives, vaccines, kits and other necessary material with data on stock out and regularity of supplies is also
44 presented in Table C12. It was found that IFA Syrup, ORS (Zinc), Injection Oxytocin, Injection Magnesium sulphate, Tablet Misoprostal, Tablet Progestrone, Silver Sulphadiazine ointment, Injection Prociane Penicillin, Syrup Amoxcylin are not provided to the CHCs. Darhal CHC reported irregular supply and stock out of Iron Folic Acid Tablets, Oral Pills and IUD 380 whileas Kandi had adequate and regular supplies of these 3 items during the last 6 months. Both the CHCs reported irregular supply and stock out of ORS and Vitamin A during the last six months. The supply position of Fluconzole, Co-trimoxazole (Kid), Tablet Nefidipine, Injection Gentamycin, Injection Lignocaine, Inj Adrenaline, Cap. Doxycycline, IV Fluids, Injection Atropine and Injection Pentazocine Lactate was reported be satisfactory in Darhal. Kandi CHC reported stock out and irregular supplies of Co-trimoxazole (Kid) and Injection Lignocaine during the last 6 months.
Availability of services (Table C13) CHCs are expected to provide full range of family planning services including Laparoscopic Ligation, safe abortion services, blood storage facilities, counselling for HIV.AIDS, VCTC and AYUSH facilities. They are also supposed to provide some general services like primary management of wounds, factures, and management of cases of poisoning, dog bite and burns. Both minor as well as some selected major surgeries are also to be performed by the CHCs. However, it was found that full range of family planning services are not available at the CHCs. CHCs only provide Oral Pills, and condoms. Even facilities for insertion of IUDs are also not available at the CHCs. Safe abortion services, treatment of RTI/STI, primary management of wounds, fractures, burns, dog bite, poisoning are available at both the CHCs. Blood storage, VCTC and AYUSH facilities are not available at these 2 CHCs. Counselling facility on HIV/AIDS is available at Darhal and not at Kandi.
Service outcome (Table C14) Information was collected regarding the service outcome of various services that were provided at the CHCs during the last three months. Information of the service outcome by caste and tribe was not available in Darhal CHC and was partly available in Kandi.
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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. On an average, 32 women had been registered at CHC Darhal for ANC services per month and all of them had been registered under JSY. The mean number of ANC cases registered in a month during the last three months in CHC Kandi was 70 but no information was available regarding the number of women who were registered under JSY. Out of the 70 ANC cases in Kandi, 30 are from ST category and 5 belong to SC community. Under RCH, efforts are to be made by the ANMs to register pregnant women for ANC as early as possible. It was found that of the 32 ANC cases, only 10 (30 percent) had been registered for ANC in the first trimester. In Kandi 42 percent of ANC had been registered in the first trimester.
The RCH schedule recommends that as part of antenatal care, women should receive two doses of TT vaccine, adequate supply of iron and folic acid tablets or syrup to prevent and treat anaemia, and at least three antenatal check-ups that include blood pressure checks and other procedures to detect pregnancy complications. The information collected from the two CHCs reveals that on average only 11 to 13 women per month have received 3 checkups as RCH schedule. The percentage of women who were registered for ANC and also received 3 checkups was 36 percent in Darhal and 18 percent in Kandi. Information pertaining to the number of ANC cases who were registered under JSY and had received 3 ANC Checkups was not available from the 2 CHCs.
One of the important elements of ANC is to provide women two doses of tetanus toxoid vaccine. Both Darhal and Kandi had given TT injection to 20-30 women per month. Of the 27 women who had received TT, 2 were SC and 13 were from ST category.
JSY beneficiaries CHCs are expected to maintain detailed information about JSY beneficiaries. However it was found that JSY cards had been prepared but CHCs had not maintained detailed information about various antenatal health care facilities extended to JSY beneficiaries. One of the reasons
46 expressed for this state of affairs by the Medical Officers and Community Health Officers is that due to the non availability of incentive money under JSY, workers stopped taking interest in maintaining information regarding JSY beneficiaries. They maintained that almost all the JSY beneficiaries are provided antenatal care services as per RCH guidelines but since they have not paid money to them, therefore, information regarding JSY beneficiaries was not maintained.
The provision of iron and folic acid (IFA) tablets to pregnant women to prevent nutritional anaemia forms an integral part of the safe motherhood services as part of the RCH Programme in India. The programme recommendation is that women consume 100 tablets of IFA during pregnancy. Surprisingly, information regarding the number of women who were given IFA was not available from the 2 CHCs.
Obstetric complication During ANC, doctors are expected to detect women with pregnancy and obstetric complications and refer them to appropriate health facility for the management of these complications. Due to the irregular availability of Gynaecologist at Darhal and non availability of Gynaecologist at Kandi, this activity seems to have suffered a lot. During the last 3 months only 15 women with obstetric/pregnancy complications have been identified at CHC Darhal and 2 of these women were referred from PHC/SCs. Kandi CHCs has not recorded any such case with pregnancy complications.
Institutional deliveries CHCs are expected to handle both normal as well as caesarean deliveries. But CHC Darhal has not recorded any institutional delivery during the last 3 months mainly because of the non availability of staff particularly Gynaecologist. Even though Gynaecologist was not available at Kandi but it has attended at total of 27 normal deliveries during the last three months (9 per month).
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Child immunization Though both the CHCs are actively implementing the Universal Immunization Programme for children but their performance is not so good. On an average in a month only 21 infants have been given BCG, 43 have been given DPT3 and 15 have received Measles at CHC Darhal. The mean monthly number of infants who have received BCG, DPT3 and measles from CHC Kandi is 17, 2 and 19 respectively. This means that dropout rates in immunization in both the CHCs are substantial. As has already been mentioned that Vitamin A and IFA syrup was not in the supply of the CHCs during the last 5-6 months prior to survey, therefore, none of the children was either given Vitamin A or IFA syrup in both the CHCs.
Family planning CHCs 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 CHCs revealed that the PHCs are not involved in providing family planning services to the couples who need them. The only family service provided by 2 CHCs is insertion of IUDs (Copper-T). During the last 3 months prior to survey both the CHCs had recorded a monthly average of 10-11 IUD/CU-T users.
Indoor facility All the CHCs have been provided beds to admit patients and treat them. But it was found that none of the CHCs has a regular IPD facility available and patients are not admitted in these 2 CHCs for night stay. Both these CHCs normally admit patients during day time for 2-3 hours for administration of IV fluids and for the management of minor sickness. Those patients who need extended medical supervision (beyond 4 PM) are referred to District Hospital, Rajouri or SMGS Jammu. The mean monthly average number of day care IPD patients was 176 in Darhal and 92 in Kandi. Information about IPD patients by caste and tribe was not available from any of the CHCs. Medical Officers mentioned that due to the shortage of doctors and paramedical staff, irregular electricity, non-availability of any heating arrangement and blood bank etc they are unable to provide regular IPD services.
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Referrals CHCs also have to act as referral centres for SCs and PHCs. Those of the patients who cannot be managed by the CHCs are to be referred to District Hospital or tertiary care hospitals. Both the CHCs usually refer patients to District Hospital Rajouri. A few cases are also referred to tertiary care hospitals located in Jammu city. During the last 3 months both the CHCs had referred 4-5 cases per month to DH Rajouri. PHCs and CHCs working under the jurisdiction of the two CHCs generally do not refer cases to Darhal and Kandi. PHCs and Sub Centres also refer the patients to DH Rajouri. MOs, reported that the staff working in the SCs and PHCs are aware that the CHCs are not well equipped to manage complicated cases. Therefore, they generally advise the patients to avail the services from DH or city based hospitals in Jammu. Location of CHC vis-a-vis PHCs and SCs is another issue which needs to be addressed. PHC Manjakote is situated at a distance of 23 Kms from District Rajouri and Darhal is at a distance of 50 Kms from Manjakote. If PHC Manjakote refers patients to Darhal, they have to pass through District Hospital Rajouri. Naturally, PHC Manjakote has no option but to refer patients directly to DH. Another issue regarding under utilization of services in general and referral services in particular is that people have no confidence on the services provided by the CHCs. People generally bypass the primary and secondary care health institutions and visit the tertiary care hospitals even for the treatment of minor illnesses.
CHCs are also expected to provide treatment to leprosy patients and enrol TB cases for DOTS. These activities are undertaken by the 2 CHCs on a limited extent.
Bed occupancy rate and OPD attendance As has already been mentioned that the beds for IPD patients were available in the CHCs but both the CHCs were not offering IPD facility for want of doctors, support staff, infrastructure, etc. Therefore, Bed Occupancy Rate could not be worked out for the 2 CHCs. Even the information regarding OPD patients was not maintained properly. The information made available to us seems to be an underestimate given the workload that we observed in the CHCs during our visit. As per the information provided by the 2 CHCs , average daily OPD attendance during the last three months works out to be 28 in Kandi CHC and 20 in Darhal CHC. Number of
49 female patients attending OPD clinics in both the CHCs is comparatively higher than male patients.
Overall, it may be concluded that though some infrastructure has been provided to the CHCs and some of the CHCs have even been upgraded as FRUs but adequate staff particularly doctors and specialists have not yet been put in place in these CHCs. Consequently, most of the infrastructure provided to these CHCs remains to be underutilized. Though IPD wards are available but again due to shortage of doctors, IPD services have not become functional. Labour rooms are available in the CHCs but due to the non availability of Gynaecologists, Anaesthetists and support staff and other required facilities, C-section deliveries are not conducted in the CHCs. Thus, due to the non availability of staff, the CHCs have neither been able to meet the increasing demand of health care services nor have they been in a position to stop the patients from visiting District Hospital, State Hospitals and private clinics.
Table C1. Coverage and Availability of Infrastructure in Darhal and Kandi CHCs CHC Coverage DARHAL KANDI Population Served by the CHC Numbers 50,000 50,000 Nearest PHC Coverage Area Distance 25 20 Nearest PHC Coverage Area: Time 120 30 Farthest PHC Coverage Area: Distance 80 70 Farthest PHC Coverage Area: Time 180 150 District Hospital Area: Distance 23 60 District Hospital Area: Time 60 90
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No of Beds: Male 5 6 No of Beds: Female 5 6 Status of Building Own Government Building 1 1 Rented Premises - - Other Rent: Free Building - - Electricity in all parts: No Regular electricity supply 1 1 Regular electricity supply in all parts - - 30 or more beds Yes - - No 1 1 Generator Yes - 1 No 1 - Continued
Table C1. Coverage and Availability of Infrastructure in Darhal and Kandi CHCs CHC Coverage DARHAL KANDI Telephone Yes 1 1 No - - Computer Yes 1 1 No - - Internet Connection Yes 1 - No - 1 Running Vehicle/Ambulance Yes 1 1 No - - Laboratory Yes 1 1 No - -
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ECG Facilities Yes 1 - No - 1 X Ray Facilities Yes 1 1 No - - Ultrasound Facilities Yes 1 - No - 1 Operation Theatre Yes 1 - No - 1 OT used for Gynaecology Yes - - No 1 - Labour Room Available Yes 1 1 No - - Separate Areas for Septic and Aseptic Deliveries Yes - - No 1 1 New Born Care Corner Yes - - No 1 1 JSY Beneficiaries Maintained in Record Yes 1 1 No - - Pharmacy for Drug Dispensing and Drug Storage Yes 1 1 No - - Continued
Table C1. Coverage and Availability of Infrastructure CHC DARHAL KANDI Counter Near Entrance of CHC to Obtain Contraceptives, ORS, Vitamin A and Medicines Yes - - No 1 1 Separate Public Utilities (Toilets) for Males and Females Yes - - No 1 1 Suggestion / Complaint Box Yes 1 -
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No - 1 OPD Rooms / Cubicles Yes 1 1 No - - Waiting space for Patients Yes 1 1 No - - Waiting Room have Adequate Sitting Place Yes - 1 No 1 - Drinking Water Available in the Waiting Area Yes - 1 No 1 - Emergency Room / Casualty Yes 1 1 No - - Separate Wards for Males and Females Yes 1 - No - 1 Type of Sewerage System Soak Pit 1 - Open Drain - 1 Connected to Municipal Sewerage - - Other - - Waste Material is Being Disposed Buried in a Pit - - Collected by an Agency - - Incernation - - Thrown in Open 1 1 Continued
Table C1. Coverage and Availability of Infrastructure in Darhal and Kandi CHCs CHC DARHAL KANDI Status of Cleanliness of OPD Good 1 1 Fair - - Poor - - Status of Cleanliness of Compound /Premises Good - - Fair 1 1 53
Poor - - Status of Cleanliness of Room / Wards Good 1 - Fair - 1 Poor - - Prominent Display Boards Regarding Service Available in Local Language Yes 1 1 No - - JSY Beneficiaries Maintained in Record Yes 1 1 No - - Pharmacy for Drug Dispensing and Drug Storage Yes 1 1 No - - Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines Yes - - No 1 1
Table C2:Position of Medical Staff & Paramedical Staff in Darhal and Kandi CHC CHC DARHAL KANDI Type of Staff No. in position No. in position General Surgeon: Sanctioned Numbers 1 1 General Surgeon: Regular in Position Numbers 1 - General Surgeon: Contractual Recruited Numbers - - General Surgeon: Total in Position Numbers 1 - Physician: Sanctioned Numbers 1 1 Physician: Regular in Position Numbers 1 - Physician: Contractual Recruited Numbers - - Physician: Total in Position 54
Numbers 1 - Obstetrician / Gynaecologist: Sanctioned Numbers 1 1 Obstetrician / Gynaecologist: Regular in Position Numbers - - Obstetrician / Gynaecologist: Contractual Recruited Numbers 1 - Obstetrician / Gynaecologist: Total in Position Numbers 1 - Medical Officer Trained with Short Term Obstetrics Course: Sanctioned Numbers - 1 Paediatrician: Sanctioned Numbers 1 1 Paediatrician: Regular in Position Numbers - - Anaesthetist: Sanctioned Numbers 1 1 Anaesthetist: Regular in Position Number - - Continued
Table C2:Position of Medical Staff and Paramedical Staff CHC DARHAL KANDI No. in Type of Staff position No. in position General Duty Medical Officer: Regular in Position Numbers 1 1 General Duty Medical Officer: Contractual Recruited Numbers - 2 General Duty Medical Officer: Total in Position Numbers 1 3 Eye Surgeon: Sanctioned Numbers - - Public Health Nurse: Sanctioned Numbers - - Lady Health Visitor (LHV):Sanctioned Numbers 1 1 55
Lady Health Visitor (LHV):Regular in Position Numbers - - Lady Health Visitor (LHV):Contractual Recruited Numbers - - Lady Health Visitor (LHV):Total in Position Numbers - - Block Extension Educator (BEE):Sanctioned Numbers 1 1 Block Extension Educator (BEE):Regular in Position ANM: Sanctioned Numbers 4 2 ANM: Regular in Position Numbers 4 2 ANM: Contractual Recruited Numbers - - ANM: Total in Position Numbers 4 2 Staff Nurse: Sanctioned Numbers 4 2 Staff Nurse: Regular in Position Numbers 4 - Staff Nurse: Contractual Recruited Numbers 1 - Staff Nurse: Total in Position Numbers 5 - Continued
Table C2:Position of Medical Staff and Paramedical Staff CHC DARHAL KANDI Type of staff No. in position NO. in position Dresser: Sanctioned Numbers - - Pharmacist / Compounder: Sanctioned Numbers 4 2 Pharmacist / Compounder: Regular in Position Numbers 4 2 Pharmacist / Compounder: Contractual Recruited Numbers - - 56
Pharmacist / Compounder: Total in Position Numbers 4 2 Lab Technician: Sanctioned Numbers 1 1 Lab Technician: Regular in Position Numbers 1 1 Lab Technician: Contractual Recruited Numbers 2 - Lab Technician: Total in Position Numbers 3 1 Radiographer: Sanctioned Numbers - - Ophthalmic Assistant: Sanctioned Numbers 1 1 Ophthalmic Assistant: Regular in Position Numbers 1 1 Ophthalmic Assistant: Contractual Recruited Numbers - - Ophthalmic Assistant: Total in Position Numbers 1 1 Statistical Assistant / Data Entry Operator: Sanctioned Numbers 1 - Statistical Assistant / Data Entry Operator: Regular in Position Numbers - - Statistical Assistant / Data Entry Operator: Contractual Recruited Numbers 1 - Statistical Assistant / Data Entry Operator: Total in Position Numbers 1 - Continued
Table C2:Position of Medical Staff and Paramedical Staff CHC DARHAL KANDI Type of staff No. In position No. In position OT Attendant: Sanctioned Numbers - - OT Attendant: Regular in Position Numbers - - OT Attendant: Contractual Recruited Numbers - - OT Attendant: Total in Position 57
Numbers - - Ambulance Driver: Sanctioned Numbers 3 2 Ambulance Driver :Regular in Position Numbers 1 1 Ambulance Driver: Contractual Recruited Numbers 2 1 Ambulance Driver: Total in Position Numbers 3 2 Registration Clerk: Sanctioned Numbers - -
Table C3. Availability of Specific Services in Darhal and Kandi CHCs CHC Availability of Specific Services DARHAL KANDI Functioning on 24 x 7 Basis Yes 1 1 No - - Functioning as FRU Yes 1 - No - 1 Emergency Care for Sick Children Yes 1 - No - 1 Full Range of Family Planning Services Yes - - No 1 1 AYUSH Services Yes - - No 1 1 VCTC Yes - - No 1 1 Cataract Surgery Yes - - No 1 1 Treatment of STI/RTI Yes 1 1 No - - Dots Yes 1 1 No - -
Table C4. Status of Specific Interventions in Darhal and Kandi CHCs CHC DARHAL KANDI IPHS Facility Survey been Carried out Yes - - No 1 1
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Funds Being Electronically Transferred from District Yes - - No 1 1 Registered Rogi Kalyan Samiti Yes 1 1 No - - RKS Generate Resources: User Fees - - Yes - - No 1 1 Money generated by RKS being used Yes 1 1 No - - Display board showing no. of meetings & members of RKS Yes - - No 1 1 Feedback mechanism in place for grievances redressed by RKS Yes - - No 1 1 Citizen Charter Been Publically Displayed Yes - 1 No 1 - All Standard Treatment Guidelines and Protocols Available Yes - - No 1 1
Table C5: Status of Residential Facilities for Doctors and Other Staff in CHCs CHC DARHAL KANDI Residential Facility for Doctors Yes 1 1 No - - Non-Occupied Residential Quarters Yes - - No 1 1
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Main Reasons for Non: Occupancy: Dilapidated Condition Yes - - No - - Main Reasons for Non: Occupancy: Insecurity Yes - - No - - Main Reasons for Non: Occupancy: Lack of Electricity and Water Supply Yes - - No - - Residential Facility for other staff Yes 1 1 No - - Non-Occupied Residential Quarters Yes - - No 1 1
Table C6. Availability of Laboratory Facilities in Darhal and Kandi CHCs CHC Laboratory Testing DARHAL KANDI Blood Grouping Yes 1 1 No - - Haemoglobin Yes 1 1 No - - Bleeding Time Clotting Time Yes 1 1 No - - RTI/STIs Yes 1 - No - 1 Blood Sugar 60
Yes 1 - No - 1 Malaria Parasite Yes 1 1 No - - Urine Test Yes 1 1 No - - Rapid Test for Pregnancy Yes 1 1 No - - RPR Test for Syphilis Yes 1 - No - 1 Rapid Test for HIV Yes - - No 1 1 Blood Smear: Yes 1 1 No - -
Table C7: Number of Lab. tests done in CHCs in last 3 calendar months CHC Type of tests done DARHAL KANDI Haemoglobin Numbers 224 45 Blood Sugar Numbers 20 - Blood Grouping Numbers 91 18 Blood Smear Numbers 282 - Bleeding Time Clotting Time Numbers 139 3 RTI/STIs Numbers - - Malaria Parasite Numbers 536 30 Rapid Test for Pregnancy Numbers 60 120 RPR Test for Syphilis Numbers - -
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Rapid Test for HIV Numbers - - Urine Test Numbers 202 25
Table C8: Number of surgeries performed during in CHCs 2007-2008 CHC Type of surgeries DARHAL KANDI Caesarean Sections Numbers - - No of C Section Deliveries for JSY Numbers - - Surgical Cases Numbers - - Cataract Numbers - - Tubectomy Numbers - - Laparoscopic Sterilisation Numbers - - NSV Numbers - - Conventional Vasectomy Numbers - - MTP Numbers 30 - Laprotomy Numbers - -
Table C9: Reasons for not conducting surgeries in Darhal and Kandi CHCs CHC DARHAL KANDI Non availability of doctor/anaesthetist/staff Yes 1 - No - - Lack of equipment/poor physical state of the operation theatre Yes 1 - No - -
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No power supply in the OT Yes 1 - No - - Other Yes - - No 1 -
Table C10. Status of performance of Labour Room in Darhal and Kandi CHCs during 2007-2008 CHC DARHAL KANDI Total Institutional Deliveries Numbers 88 105 Deliveries Carried Out from 8.PM to 8 AM Numbers - - Institutional Deliveries for JSY Card Holders Numbers 85 105 No of Neonates Resuscitated Numbers - -
Table C12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI Boyles Apparatus : Available Yes - - No 1 1 Boyles Apparatus : Working Yes - - No - -
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ECG Machine : Available Yes 1 - No - 1 ECG Machine : Working Yes 1 - No - - Cardiac Monitor for OT : Available Yes 1 - No - 1 Cardiac Monitor for OT : Working Yes 1 - No - - Defibrillator for OT : Available Yes - - No 1 1 Defibrillator for OT : Working Yes - - No - - Ventilator for OT : Available Yes - - No 1 1 Ventilator for OT : Working Yes - - No - - Horizontal High Pressure Sterilizer : Available Yes 1 - No - 1 Horizontal High Pressure Sterilizer : Working Yes 1 - No - - Continued
Table C12: Status of availability of Equipments & drugs in Darhal and Kandi CHC
CHC DARHAL KANDI Vertical High Pressure Sterilize : Available Yes 1 - No - 1 64
Vertical High Pressure Sterilize: Working Yes 1 - No - - OT Care Fumigation Apparatus : Available Yes 1 - No - 1 OT Care Fumigation Apparatus: Working Yes 1 - No - - Gloves Dusting Machines : Available Yes - - No 1 1 Gloves Dusting Machines: Working Yes - - No - - Oxygen Cylinder : Available Yes 1 1 No - - Oxygen Cylinder: Working Yes 1 1 No - - Hydraulic Operation Table : Available Yes - - No 1 1 Hydraulic Operation Table: Working Yes - - No - - Resuscitation Trolley : Available Yes 1 1 No - - Resuscitation Trolley: Working Yes 1 1 No - - Continued
Table C12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI Phototherapy Unit : Available Yes - - No 1 1 65
Phototherapy Unit: Working Yes - - No - - MVA Syringe : Available Yes - 1 No 1 - MVA Syringe: Working Yes - 1 No - - Baby Incubator : Available Yes - - No 1 1 Baby Incubator: Working Yes - - No - - Iron Folic Acid :Stock Out Yes 1 - No - 1 Iron Folic Acid: Irregular Supply Yes - - No 1 1 Oral Pills : Stock Out Yes 1 - No - 1 Oral Pills: Irregular Supply Yes - - No 1 1 IUD 380 : Stock Out Yes 1 - No - 1 IUD 380: Irregular Supply Yes 1 - No - 1 Continued
Table c12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI ORS : Stock Out Yes 1 1 No - - 66
ORS : Irregular Supply Yes 1 1 No - - ORS with Zinc Adjutant as Per Policy : Stock Out Yes 1 1 No - - ORS with Zinc Adjutant as Per Policy : Irregular Supply Yes 1 1 No - - Vitamin A : Stock Out Yes 1 1 No - - Vitamin A : Irregular Supply Yes 1 1 No - - Tab Fluconazole : Stock Out Yes - - No 1 1 Tab Fluconazole : Irregular Supply Yes - - No 1 1 Tab Metronidazole : Stock Out Yes - 1 No 1 - Tab Metronidazole : Irregular Supply Yes - 1 No 1 - Tab Co Trimoxazole : Stock Out Yes - 1 No 1 - Tab Co Trimoxazole : Irregular Supply Yes - 1 No 1 - Continued
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Table c12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI Tab Nefidipine : Stock Out Yes - - No 1 1 Tab Nefidipine : Irregular Supply Yes - - No 1 1 Inj. Oxytocin : Stock Out Yes 1 1 No - - Inj. Oxytocin : Irregular Supply Yes 1 1 No - - Inj. Gentamycin : Stock Out Yes - - No 1 1 Inj. Gentamycin : Irregular Supply Yes - - No 1 1 Inj. Magnesium Sulphate : Stock Out Yes 1 1 No - - Inj. Magnesium Sulphate : Irregular Supply Yes 1 1 No - - Tab Misoprostal : Stock Out Yes 1 1 No - - Tab Misoprostal : Irregular Supply Yes 1 1 No - - Tab Progestrone : Stock Out Yes 1 1 No - - Tab Progestrone : Irregular Supply Yes 1 1 No - - Continued
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Table c12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI Inj. Lignocaine Hydrochloride : Stock Out Yes - 1 No 1 - Inj. Lignocaine Hydrochloride : Irregular Supply Yes - 1 No 1 - Inj. Pentazocine Lactate : Stock Out Yes - - No 1 1 Inj. Pentazocine Lactate : Irregular Supply Yes - - No 1 1 Inj. Adrenaline : Stock Out Yes - - No 1 1 Inj. Adrenaline : Irregular Supply Yes - - No 1 1 Cap Doxycycline : Stock Out Yes - 1 No 1 - Cap Doxycycline : Irregular Supply Yes - - No 1 1 Silver Sulphadiazine Oint :Stock Out Yes 1 1 No - - Silver Sulphadiazine Oint : Irregular Supply Yes 1 1 No - - IV Fluids : Stock Out Yes - - No 1 1 IV Fluids : Irregular Supply Yes - - No 1 1 Continued 69
Table c12: Status of availability of Equipments & drugs in Darhal and Kandi CHCs CHC DARHAL KANDI Inj. Procaine Penicillin : Stock Out Yes 1 1 No - - Inj. Procaine Penicillin : Irregular Supply Yes - - No 1 1 Inj. Atropine : Stock Out Yes - - No 1 1 Inj. Atropine : Irregular Supply Yes - - No 1 1 Syp. Amoxycyclin : Stock Out Yes 1 1 No - - Syp. Amoxycyclin : Irregular Supply Yes 1 1 No - - IFA Syrup : Irregular Supply Yes 1 1 No - - IFA Syrup : Stock Out Yes 1 1 No - -
Table C13. Availability of Specific Services in Darhal and Kandi CHCs CHC DARHAL KANDI Medicine Yes 1 1 No - - Surgery Yes 1 - No - 1 Obstetric Gynae
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Yes 1 - No - 1 Paediatrics Yes - - No 1 1 Dots Yes 1 1 No - - Cataract Surgery Yes - - No 1 1 Leprosy Diagnosis Management and Referral Services Yes 1 - No - 1 Emergency Services (24 Hrs) Yes 1 1 No - - Mobile Medical Unit Yes - - No 1 1 Separate Neo Natal Care Unit Available Yes - - No 1 1 Emergency Care for Sick Children Yes 1 - No - 1 Continued
Table C13. Availability of Specific Services in Darhal and Kandi CHCs CHC DARHAL KANDI Full Range of Family Planning Services Including Laparoscopic Ligation Yes - - No 1 1 Safe Abortion Services 71
Yes 1 - No - 1 Treatment of STI/RTI Yes 1 1 No - - Blood Storage Facility Yes - - No 1 1 Counselling Facility on HIV / AIDS / STD etc Yes - 1 No 1 - Voluntary Counselling and Testing Centre Yes - - No 1 1 AYUSH Facility Yes - - No 1 1 Primary Management of Wounds Yes 1 1 No - - Primary Management Fracture Yes 1 1 No - - Primary Management of Cases of Poisoning Snake Insect or Scorpion Bite Yes 1 1 No - - Primary Management of Dog Bite Yes 1 1 No - - Primary Management of Burns Yes 1 1 No - - Management of RTI/STI Yes 1 1 No - -
Table C14. Service out come in Darhal and Kandi CHCs CHC Service out come DARHAL KANDI ANC Registration: SC INA 5 ST INA 30 72
Others INA 35 Total ANC Registration: Total 32 70 JSY Cases Registration: SC INA INA ST INA INA Others INA INA Total JSY Cases Registration: Total 32 INA 1st Trimester Registration SC INA 2 ST INA 13 Others INA 15 1st Trimester Registration: Total 10 30 ANC Given 3 Checkups as Per RCH Schedule: SC INA 2 ST INA 3 :Others INA 8 ANC Given 3 Checkups as Per RCH Schedule: Total 11 13 Out of Above the No of JSY Beneficiaries: SC - INA ST - INA Others - INA Out of Above the No of JSY Beneficiaries: Total - INA ANC Given TT SC INA 2 ST INA 13 Others INA 12 ANC given TT: Total 20 27 No of JSY Beneficiaries : SC - INA ST - INA Others - INA No of JSY Beneficiaries: Total - INA Continued
Table C14. Service out come in Darhal and Kandi CHCs CHC Service out come DARHAL KANDI ANC Completed IFA Prophylaxis: 73
SC INA INA ST INA INA Others INA INA ANC Completed IFA Prophylaxis: Total INA 14 Out of No of JSY Beneficiaries: SC INA INA ST INA INA Others INA INA Out of No of JSY Beneficiaries: Total INA INA No of Pregnant Women Identified and Attended with Obstetric Complications : SC INA INA ST INA INA Others INA INA No of Pregnant Women Identified and Attended with Obstetric Complications: Total 5 INA Referred from PHC / SHC : INA SC INA INA ST INA INA Others INA INA Referred from PHC / SHC: Total 2 INA No of JSY Cases (Out of Total Institutional Deliveries) SC - INA ST - INA Others - INA Total Institutional Deliveries: Total - 9 No of JSY Cases (Out of Total Institutional Deliveries):Total - INA No of Infants Given BCG SC INA 1 ST INA 7 Others INA 9 No. of Infants Given BCG: Total 21 17 No of Infants Given DPT3 SC INA 2 ST INA 8 Others INA 17 No of Infants Given DPT3:Total 43 27 Continued
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Table C14. Service out come in Darhal and Kandi CHCs CHC Service out come DARHAL KANDI No of Infants Given Measles SC INA 2 ST INA 5 Others INA 12 No of Infants Given Measles: Total 15 19 No of Infants Given Vit. A First Dose - - SC 0 0 ST 0 0 Others 0 0 No of Infants Given Vit. A First Dose: Total 0 0 Children Given IFA Syp: SC Numbers - - Children Given IFA Syp: ST Numbers - - Children Given IFA Syp: Others Numbers - - Children Given IFA Syp: Total Numbers INA 3 IUD Inserted: SC Numbers INA 4 IUD Inserted: ST Numbers INA 3 IUD Inserted: Others Numbers 10 11 IUD Inserted: Total Numbers INA INA Total Indoor Patients: SC Numbers INA INA Total Indoor Patients: ST Numbers INA INA Total Indoor Patients: Others Numbers 176 92 Total Indoor Patients: Total Numbers INA INA No of Cases Referred Beyond CHC:SC Numbers INA INA No. of Cases Referred Beyond CHC:ST Numbers INA INA Continued 75
Table C14. Service out come in Darhal and Kandi CHCs CHC Service out come DARHAL KANDI No. of Cases Referred Beyond CHC: Others Numbers 4 5 No of Cases Referred Beyond CHC: Total Numbers - INA No. of Leprosy Cases Currently Under Treatment CHC:SC Numbers - INA No. of Leprosy Cases Currently Under Treatment: ST Numbers - INA No of Leprosy Cases Currently Under Treatment: Others Numbers - 1 No. of Leprosy Cases Currently Under Treatment: Total Numbers INA INA No of New TB Cases Enrolled For Dots: SC Numbers INA INA No. of New TB Cases Enrolled For Dots: ST Numbers INA INA No. of New TB Cases Enrolled For Dots: Others Numbers 2 5 No. of New TB Cases Enrolled For Dots: Total Numbers No of Cases Given Blood Transfusion in Last 3 Months Numbers INA INA Bed Occupancy Rate in the Last 12 Months Rate 0 0 OPD Attendance Male Average 7 10 OPD Attendance Female Average 10 13 OPD Attendance Children Average 3 5 76
Out of the Total OPD Attendance Specify the Referred Cases from PHC / SHC Average - 1 I A= Information not available
77
CHAPTER-5 Primary Health Centre Introduction The primary health centres have the major responsibility of providing both preventive and curative health care services in the area. This includes delivery of reproductive and child health services, such as, antenatal care and immunization in addition to routine inpatient and outpatient services. Compared to District Hospitals or Community Health Centres, Primary Health Centres are accessible to a larger population, as one PHC is expected to serve 30,000 population. However, just the availability of PHCs is not sufficient for the effective delivery of these services. They should also have essential infrastructure, staff, equipment and supplies. This chapter presents the status of the 4 PHCs surveyed in Rajouri district with respect to the availability of selected infrastructure, staff, equipment and supplies, training of medical and para medical staff besides service outcome. The PHCs studied are Manjakote, Lah, Tralla and Budhal. Manjakote and Budhal PHCs are functioning on 24X7 bases.
Coverage (P1) As mentioned above that a PHC is expected to serve a population of 30,000. Manjakote PHC which is functioning as a 24x7 PHC covers a population of 30,000 and the remaining 3 PHCs have a coverage area of less than 10,000 population. The population being served by Tralla PHC is as low as 3612. The number of SCs working under Manjakote is 12 while the number of SCs working under remaining 3 PHCs is 3 to 4. The distance to the nearest SC from PHCs ranges from 7 Kms for Tralla to 0 Km in Manjakote. In Manjakote PHC, Manjakote SC is operating within the PHC itself. The distance to the farthest SC from PHC was reported to be 12 Kms in Manjakote and 8 10 Kms in remaining 3 PHCs. The time taken to reach the farthest SC from a PHC is about 4 hours in Manjakote, 2 hours in Lah and 70 75 minutes in case of Tralla and Budhal PHCs. Manjakote PHC has a bed capacity of 10 beds (5 male and 5 female). Budhal PHC also has a bed capacity of 10 beds and the number of beds available in Lah and Tralla is 5 and 6 respectively. However, in these 3 PHCs, male and female beds have not been designated separately. Only Manjakote PHC is reportedly equipped to provide basic obstetric services.
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Infrastructure (Table P2) Table P2 presents the distribution of PHCs with selected infrastructural facilities such as own building, toilet facility, continuous supply of tap water, electricity, labour room, laboratory, Pharmacy , OPD rooms, telephone, telephone, computer and internet facilities in each PHC. Three PHCs (Manjakote, Tralla and Budhal) are functioning from their own building. In the context of the National Population Policy, 2000 goal of eighty percent institutional deliveries, the availability of a labour room is a critical facility for a PHC. All the selected PHCs in the district have a labour room.
Any kind of social service of the kind of the health services should inform its target beneficiary of the services it delivers and its responsibilities, ideally with a sign board outside its premises to raise the awareness of community. It was found that the prominent display boards establishing the service availability in local language were available only in 2 PHCs located in Darhal block. Though, some information regarding the services available was displayed in Tralla and Budhal PHCs but it was incomplete and not in local language. PHCs are expected to keep updated records of JSY beneficiaries but such information was not maintained by PHC Lah.
Pharmacy for drug dispensing and drug storage is an important infrastructural component for efficient service delivery of the PHCs and all the 4 PHCs have a Pharmacy for drug dispensing and drug storage.
In PHCs 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. However, only 1 PHC out of 4 PHCs have separate public utilities for males and females.
NRHM envisages that each PHC should have a complaint/suggestion box so that the problems faced by the public in assessing the health care facilities can be addressed and action can be taken on the suggestions given by them. But except Manjakote none of the PHCs have fixed a suggestion/complaint box. OPD rooms/cubicles are available in all the PHCs but doctors mentioned that OPD rooms are inadequate and have inadequate space. Though the PHCs have 79
OPD rooms but on the day of our visit both the Doctors (Medical Officer as well as Assistant Surgeon) were examining the patients in the open compound of the PHC, which raises a lot of questions regarding the privacy maintained by the doctors while examining the patients. In any health facility, continuous supply of water is a critical input. However, less than one fourth of the surveyed PHCs have tap water supply. With the exception of Manjakote none of the PHCs have tap water supply, which is one of the major problems faced by the PHCs.
Provision of immunization to children and pregnant women is one of the important functions of the PHC. PHCs need electricity for purposes of lighting, operating equipment and for storage of vaccines at specified temperatures in a refrigerator/ freezer. But it was found that none of the PHCs have regular power supply. In fact all the PHCs have routine electric supply which is erratic and irregular. As far as communication facilities are concerned none of the PHCs have a telephone, computer or internet facilities.
Sanitation and Cleanliness (Table P2) Table P2 also presents information regarding sanitation and cleanliness of the PHCs. Only 1 PHC had a soak pit and the remaining three to had an open drain. Guidelines for the disposal of waste material are not followed by any of the PHCs. Of the 4 PHCs, 2 throw the waste material in open and 2 burn it in a pit. Standby facilities for electricity (Generator) are not available in any of the PHCs. Separate areas for septic and aseptic deliveries are not available in any of the PHCs. Under RCH programme funds are being provided to have a new born corner in every PHC but it was found such a facility was available in Manjakote PHC only. Overall OPD rooms, wards and compound/premises of the all the PHCs were reasonably clean.
Staff Position (Table P3) The availability of at least one Medical Officer (MO) on the role of PHC is absolutely essential. The government has sanctioned the position of at least one MO and 1 contractual MO. Besides, each PHC has been provided with a position of AYUSH Medical Officer (AMO). Manjakote and Budhal PHCs have been sanctioned with 2 positions of MOs. However the regular positions of MOs in PHC Lah and Tralla were vacant. One post of regular MO in PHC Budhal was also vacant. The contractual positions of MOs and positions of AMOs in all the PHCs were in place. Thus all the PHCs were functioning with at least 1 MO but Manjakote and Budhal had 3 MOs. 80
Each PHC has been provided with 2 posts of Pharmacist (1 regular and 1 Contractual) and both the positions in all the PHCs were in place. The ANM has a key role to play in the implementation of the RCH programme at the PHC as well as in the outreach activities of PHCs. Therefore, each PHC has been provided with a regular post of ANM and in some PHCs additional positions of contractual ANMs have also been provided. The regular positions of ANMs in all the PHCs were in place. Along with the laboratory for pathological tests the availability of a Laboratory Technician on the PHC staff is necessary. There are no sanctioned posts of Lab Technicians (LTs) in PHC Lah and Tralla. The sanctioned post of LT is vacant in Manjakote but is in position in Budhal. Manjakote and Budhal PHCs have been provided with contractual positions of LTs. Thus Budhal PHC is functioning with 2 LTs and Manjakote has 1 LT. The regular post of 1 driver stands sanctioned in all the PHCs except Lah but in position in PHC Budhal only. PHC Manjakote has been provided with a contractual position of driver. Thus of the 4 PHCs only 2 PHCs (Manjakote and Budhal) has a driver in position.
The posts of regular Staff Nurse (SN) is available in all the PHCs and all the PHCs had filled up these positions. Both the PHCs which are functional on 24X7 bases have also been provided with a contractual position of SN. The sanctioned position of Lady Health Visitor (LHV) was reported to be available in PHC Budhal but even in this PHC, this position was reported to be vacant. One post of Laboratory Assistant was sanctioned in PHC Manjakote and PHC Budhal and in PHC Tralla and Lah; no posts of Laboratory Assistants were available. The posts of Laboratory Assistants were in place in PHC Manjakote and Budhal. Very recently post of Junior Lab Technician has been sanctioned in PHC Tralla and Lah. The post of Block Health Education and Information Officer stands sanctioned in each PHC but such a post was found to be vacant in PHC Tralla. Under NRHM a lot of emphasis is being given to HMIS and for this the post of Statistical Assistant (SA) is of utmost importance. Though each PHC has been sanctioned with a position a SA but PHC Tralla declined to have such a sanctioned position. Of the three remaining 3 PHCs this position is in place in PHC Manjakote only. Thus it may be concluded that most of the sanctioned positions are in place in Manjakote and Budhal PHCs but the remaining 2 PHCs face acute shortage of staff.
Status of Training (Table P4)
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The distribution of PHCs with at least one doctor with an in service training during 2007 2008 in selected health care aspects given in Table P4 presents an unsatisfactory situation. None of the PHCs had a doctor trained in pre service IMNCI or new born care or safe abortion methods. Only 1 PHC (Budhal) reported that they have at least one person who has undergone skill birth attendant training. Informal discussions with both medical and paramedical staff revealed that the staff posted in remote areas hardly gets any opportunity to participate in the trainings that are being organised under RCH.
Labour Room (Table P5 and P6) The availability of a labour room is a critical facility for a PHC. Under RCH efforts have been made to have labour rooms in each PHC. Besides, trained staff is being provided to PHCs to conduct institutional deliveries. Though labour rooms are available in all the 4 PHCs but they are currently in use only in 3 PHCs. The labour room in PHC Lah is not currently being used because of non availability of a doctor. Table P6 provides information regarding the number of institutional deliveries handled by the PHCs during 2007 2008. The number of institutional deliveries attended by PHC Manjakote during the reference period was 100 and the corresponding figures for PHC Tralla and Budhal were 31 and 20 respectively. Keeping in view the population served by these PHCs their performance on account of institutional deliveries is not satisfactory. The maintenance of records regarding the institutional deliveries in all the 3 PHCs was very poor and they had not even maintained any information regarding the timing of delivery so we could not infer how many of the deliveries had been carried out between 8 Pm to 8 Am. However, since none of the PHCs during the reference period was functional on 24X 7 bases, therefore all the deliveries might have been carried out during day time. Facilities for resuscitation of neonates were not available in any of the PHCs and therefore neither any child has been resuscitated nor was such information available from any of the PHCs.
Laboratory facilities (Table P7) In the context of provision of RCH services, the availability of laboratory in PHC 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. Though all the PHCs had a functional laboratory but we also tried to know what various testing facilities are being conducted in these laboratories. Haemoglobin, bleeding time, clotting time, rapid test for pregnancy, blood smear test for malaria parasite are 82 carried out in all the PHCs, while as blood sugar, blood smear, diagnosis of RTI/STI with wet mounting, grams stain etc, RPR test for Syphilis and Rapid test for HIV are not carried out in any of the PHCs. Testing facilities for urine is available in 3 PHCs and blood grouping tests are conducted only in 2 PHC located in Kandi block. It was also found that though the facilities for rapid pregnancy test are available at PHC Manjakote but due to the non availability of strips, such tests have not been conducted in this PHC for the last 4 months.
Performance of laboratory (Table P8) Information regarding the number of tests conducted during the last 3 months prior to survey was collected from each PHC and the same is presented in Table P8. Only PHC Manjakote has carried out about 100 Haemoglobin tests during the last 3 months, and PHC Tralla has carried out 57 tests and the remaining 2 PHCs have carried out less than 40 Haemoglobin tests during the same period. The highest number of urine examinations (58) has been carried out by PHC Budhal and the lowest number of 33 by PHC Tralla. Both the PHCs which have conducted blood grouping tests have carried out less than 10 tests during the last 3 months. The number of blood smear examinations for malaria parasite range from a highest of 59 in Budhal to a low of 25 in Manjakote. About 20 40 rapid tests for pregnancy have been conducted by PHC Lah, Tralla and Budhal.
Status of specific interventions (Table P9) In order to provide health care that is quality oriented and sensitive to the needs of the community a set of standards are being recommended for Primary Health Centre to be called Indian Public Health Standards (IPHS) for PHCs. Currently the IPHS for Primary Health Centres have been prepared keeping in view the resources available with respect to functional requirement for Primary Health Centre with minimum standards such as building manpower, instruments, and equipments, drugs and other facilities etc. Under NRHM funds are being provided to PHCs for conducting IPHS facility surveys, however it was found that none of the PHCs in Rajouri has yet initiated any action to conduct IPHS facility survey. In fact none of the officials at the PHCs was aware about the terminology of IPHS facility survey.
As has already been mentioned that of the 4 selected PHCs, 2 (Manjakote and Budhal) were functioning on 24X7 basis. Though AYUSH doctors were providing services at all the 4 PHCs 83 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.
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 organised by RKSs in any of the PHCs. RKS does not generate any resources through user fees. The only fund available with the RKS is untied funds which are used by all the PHCs. RKS are also supposed to have a mechanism to redressal of grievances but there was no feedback mechanism in place for grievances redressal by RKSs in any of the PHCs. 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 PHC Tralla only. When the MOs were asked to report whether all standard treatment guidelines and protocols are available in the PHCs it was reported by all the MOs that all standard treatment guidelines and protocols are not available in any of the PHCs.
Availability of Services (Table P9) PHCs are supposed to provide some general services like primary management of wounds, factures, malnourishment of children, RTI/STI, MTP services and management of minor surgeries. All the PHC provide services for management of wounds, management of malnourished children, primary management of burns and management of RTI/STIs. AYUSH services are also available at all the PHCs. But facilities for MTP are not available at any of the PHCs. Facilities for the primary management of fracture, management of neonatal asphyxia, sepsis, minor surgeries like drainage of abscess, primary management of dog bite are available in 2 PHCs. Three 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, Budhal PHC reported availability of 10 services, and Manjakote and Tralla reported 7 services each while as only 6 facilities were reportedly to be available in Lah PHC.
Availability of selected Equipments (Table P10)
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Certain equipments are essential for the delivery of primary health services at the PHCs. This section discusses the status of PHCs with respect to the availability of these inputs on the date of survey. Information was collected not only about the availability of equipments but also whether the equipments are in working condition and the information is presented in Table P10. Three of the PHCs do not have a patient trolleys and only PHC Budhal reported to have a working patient trolley available. Stretcher, examination table, delivery table, thermometers, and microscopes in working conditions were available in all the PHCs but Wheel chair was not found to be available in any of the PHCs. Oxygen cylinders in working condition were also available in all PHCs except PHC Tralla.
Suction apparatus in working condition was available in PHC Manjakote and Budhal. Infant warmer in working condition was not available in 3 PHCs (Lah, Tralla and Budhal). Radiant warmers, Cradle, Laryngoscope, water purifier, Auto analyser, in working condition were not available in any of the PHCs. Autoclave and sterilization equipment in working condition was not available in some PHCs. Though bag and mask and Suction machine were available in 3 PHCs but they were in working condition only in 1 PHC. Oxygen mask in working condition was also available only in 1 PHC. Haemoglobin meter was available in all the PHCs but it was in working condition in 2 PHCs only. Resuscitation equipment was available in 2 PHCs but it was reported to be in working condition in a single PHC. Of the 23 items discussed above, PHC Manjakote has 14 items in working condition, PHC Budhal has 15 and PHC Lah and Tralla has 7 and 8 equipments in working conditions respectively. So the 2 24X7 PHCs are comparatively better equipped than other PHCs.
Availability of Drugs (Table P11) The information on whether PHCs are equipped with necessary drugs, contraceptives, vaccines, kits and other necessary material with data on stock out and regularity of supplies is presented in Table P11. It was found that Iron syrup, Vitamin A, Tablet maethergin, Magnesium sulphate, Partograpg, Syrup cortramoxazole, Paracetamol, Haemoccele, Ringers Lactate are not provided to the PHCs. Two of the PHCs 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. But the IFA, which was available with the ASHAs had already passed the date of expiry. The position with regard to the availability of oral pills was somewhat
85 satisfactory as only 1 PHC had the experience of their stock out and all were satisfied with the regularity of supplies of OPs. None of the PHCs reported shortage or irregularity in the supplies of measles vaccine. Of the 4 PHCs, 3 reported that they were out of stock of ORS for some time during the last 6 months and also the supplies of ORS are irregular. Methergine tablets and Albendazole tablets were also recorded to be out of stock by 3 PHCs and all these 3 PHCs reported their supply to be irregular. So far as IUDs are concerned, all the PHCs mentioned that their supply is regular but three of the 4 PHCs had no supplies at the time of survey. Injection Oxytocin was out of stock in 2 PHCs but 3 PHCs mentioned that it is regularly supplied to them. Fluconzole was reported to be out of stock at any time during the last 6 months by 3 PHCs and supply was also reported to be irregular by 2 PHCs. Similarly 75 percent of the PHCs experienced stock out of MVA syringes and ciprofloxacin tablets. One of the PHCs also has witnessed stock out of AD Syringes, Bandage and Disposable gloves. However, their supply was reported be regular by most of the PHCs. Though 2 of the PHCs reported that they were short of AYUSH drugs for some time during the last 6 months but their supply was reported to be regular by 75 percent of the PHCs. Both the supply as well as the stock position of DOTS was found to satisfactory in all the PHCs but MDT Blister packs are not provided to the PHCs.
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 and 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 in PHC Manjakote and Lah.
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 Manjakote had registered 23 ANC cases in a month and all of them were registered under JSY. PHC Budhal had registered 73 ANC cases but only 4 of them had been registered for JSY. The mean number of ANC cases registered in a month during the last three months in PHC Tralla and Lah was 5 and all these women had
86 been issued JSY cards. Of the 73 ANC cases in Budhal, 27 are from ST category and all the 5 ANC cases from Tralla are ST category. 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 women registered in Manjakote and Lah PHCs had been registered for ANC in the first trimester. But only 40 percent of such cases in Budhal were registered in the first trimester. Ironically, information maintained by the PHC Manjakote and Budhal regarding number of women who had received 3 ANC checkups was so haphazard that it could not be established what number of women in the last 3 months had received 3 ANC checkups. In PHC Lah and Tralla also the mean number of women who were given 3 ANC checkups was very small (1 and 3 respectively).
One of the important elements of ANC is to provide two doses of tetanus toxoid vaccine. Manjakote, Lah, and Tralla PHC had given TT1 to all registered women but only 40 percent of the registered ANC cases in Budhal PHC had received TT1. Information regarding administration of TT2+ Booster to ANC cases was not available from PHC Manjakote. Only PHC Budhal had given TT2+ booster to 44 women. Of these 44 women 39 percent are ST, 5 are SC and 48 percent are from general category. Lah and Tralla PHCs also had given TT2+ booster doze to an insignificant proportion of women.
The provision of iron and folic acid (IFA) tablets to pregnant women to prevent nutritional anaemia forms an integral part of the safe motherhood services as part of the RCH Programme in India. The programme recommendation is that women consume 100 tablets of IFA during pregnancy. Information collected from the 4 PHCs during the last 3 months reveals that the mean number of women who completed IFA prophylaxis in Manjakote, Lah and Tralla was 23, 2 and 5 respectively. Information regarding IFA was not available from PHC Budhal.
As per as institutional deliveries are concerned, the performance of all the 4 PHCs is very poor. PHC Lah currently does not handle institutional deliveries. Even at other PHCs the number of institutional deliveries recorded per month ranges between 2 4 only. All the institutional deliveries at PHC Manjakote, Budhal and Tralla though had been registered under JSY but none of them was paid any financial incentives under JSY because of non availability of funds under JSY.
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Child Immunization 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 only 36 infants have been given BCG and Measles at PHC Manjakote while as 42 have received DPT3. Very few infants have received immunization from PHC Lah and Tralla. The mean monthly number of infants who have received BCG, DPT3 and measles from PHC Budhal is 17, 37 and 24 respectively. This means that dropout rates in immunization in all the PHCs are substantial. 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.
Family Planning 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 method provided by 3 PHCs is IUD (Copper T). The three PHCs on an average during the last 3 months have provided IUD services to 4 or 5 women in a month.
Indoor Facility 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 Manjakote is 50 and in Budhal it is 56. Information about IPD patients by caste and tribe was not available from any of the PHCs. Medical Officers mentioned that due to the shortage of doctors and paramedical staff, irregular electricity, lake of any heating arrangement they are unable to provide regular IPD services.
As far as outpatients are concerned, on an average Manjakote PHC has provided services to about 1000 patients in a month. The corresponding figures for Lah, Tralla and Budhal are 166, 332 and
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833 respectively. Information regarding the caste/tribe of the patients who had availed the services is not maintained by any of the PHCs.
PHCs are also supposed to treat RTI/STI clients but the two 24X7 PHCs under study have not treated any RTI/STI case during the last 3 months. The mean monthly number of RTI/STI cases treated at PHC Lah and Tralla works out to be 4 and 19 respectively.
So far as the maternal deaths are concerned, it was found that PHCs do not maintain any information regarding the number of deaths that take place in PHCs so information regarding maternal deaths was not available from any of the PHCs. PHCs are also supposed to refer complicated obstetric cases to CHCs or district hospitals. Information regarding complicated cases referred to higher level institutions is not maintained by any of the PHCs. In fact while we were collecting information from one of the PHCs, we observed that one lady was bought to a PHC for delivery. The lady had some complications and the Assistant Surgeon posted at the PHC examined the patient and advised the attendants to take her to District Hospital Rajouri or State Hospital Jammu for delivery. Neither this case was entered on OPD records nor was any referral slip given to the patient. Thus PHCs hardly bother to maintain any information regarding the patients referred to secondary or tertiary care hospitals.
Since none of the PHCs had expertise available to carry out cataract surgeries, therefore no cataract surgeries have been carried out at PHCs during the last 3 months. So far as the new TB cases enrolled for DOTS are concerned, PHC Manjakote has registered a total of 12 cases during the last 3 months, while as PHC Lah and Budhal had enrolled 1 case per month. None of the leprosy cases had completed treatment leprosy. Record maintenance (Table P13) Record keeping and its updating is an important component of NRHMA. All the PHCs are expected to maintain and regularly update information records pertaining to the number of households, couples, births and deaths, use of contraception, immunization and post natal care and JSY beneficiaries. SCs are also required to maintain information regarding the funds utilized under untied funds. In order to have uniformity in maintaining information, State government is expected to provide 9 registers to each PHC. The registers to be provided to the SCs are: antenatal register, eligible couple register, post natal care register, family planning register, birth
89 and death register, immunization register, meeting register, JSY register, and untied funds register. The survey team collected information about the availability of these registers and wherever they were available the team verified whether there was any entry in these registers during the last 1 month. Our finding reveal that all the PHCs generally maintain 3 registers namely ante natal register, immunization register and untied funds register. Eligible couple register and post natal care register was found to be maintained by only 2 PHCs. Family Planning register, Meeting Register was available with 3 PHCs. Birth and death register and JSY register was maintained by just 1 PHC. Of the 9 registers, Manjakote had 6 registers, Lah had 4 registers, Tralla and Budhal had 7 registers. It was found that most of the registers maintained by the PHCs were not up to date. MOs expressed that printed registers as per RCH format have not been provided to them. The workers maintain information on blank registers and each PHC has devised its own format for recording information.
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Table P1. Coverage and facilities of Primary Health Centre CHC DARHAL KANDI PHC Coverage and facilities Manjakote Lah Tralla Budhal Number of SC Under the PHC Numbers 12 3 3 4 Population Covered Numbers 30,000 6,000 3,612 8,000 Nearest SC in the Coverage Area: Distance - 3 7 5 Nearest SC in the Coverage Area: Time - 30 45 15 Farthest SC in the Coverage Area: Distance 12 8 9 10 Farthest SC in the Coverage Area: Time 240 120 70 75 Nearest CHC : Distance 40 37 21 20 Nearest CHC: Time 90 120 90 90 No of Beds : Male 5 5 6 10 No of Beds : Female 5 - - - PHC Functioning on 24 x 7 Basis Yes 1 - - 1 No - 1 1 - PHC Equipped to Provide Basic Obstetric Services Yes 1 - - - No - 1 1 1 PHC with 4-6 Beds Yes - 1 1 - No - - - -
Table P2. Primary Health Centers by Infrastructure CHC DARHAL KANDI PHC Infrastructure Manjakote Lah Tralla Budhal PHC functioning in govt. building 91 Yes 1 - 1 1 No - 1 - - Labour Room Yes 1 1 1 1 No - - - - Continued
Table P2. Primary Health Centers by Infrastructure CHC DARHAL KANDI Infrastructure PHC Type of Sewerage System Manjakote Lah Tralla Budhal Soak Pit Connected to Municipal Sewerage - 1 - - Open Drain - - - - Other 1 - 1 1 How Waste Material is Being Disposed - - - - Buried in a Pit Collected by an Agency - 1 - 1 Incernation - - - - Thrown in Open - - - - Standby Facility Available 1 - 1 - Yes No - - - - Separate Areas for Septic and Aseptic Deliveries Available 1 1 1 1 Yes No - - - - New Born Care Available 1 1 1 1 Yes No 1 - - - Status of Cleanliness of OPD - 1 1 1 Good Fair 1 1 1 1 Poor - - - - Status of Cleanliness of Compound / Premises - - - - Good Fair - 1 1 1 Poor 1 - - - Status of Cleanliness of Room / - - - -
92
Wards Good Fair 1 1 - - Poor - - 1 1
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Table P3: Staff Position of in Primary Health Centre CHC DARHAL KANDI PHC Type of Staff Manjakote Lah Tralla Budhal Medical Officer : Sanctioned 2 1 1 2 Regular in Position 2 0 0 1 Contractual Recruited 1 1 1 2 Total in Position 3 1 1 3 Pharmacist : Sanctioned 1 1 1 1 Regular in Position 1 1 1 1 Contractual Recruited 1 1 1 1 Total in Position 2 2 2 2 ANM : Sanctioned 1 1 1 1 Regular in Position 1 1 1 1 Contractual Recruited 0 0 1 0 Total in Position 1 1 2 1 Lab Technician : Sanctioned 1 0 0 1 Regular in Position 0 0 0 1 Contractual Recruited 1 0 0 1 Total in Position 1 0 0 2 Driver : Sanctioned 1 0 1 1 Regular in Position 0 0 0 1 Contractual Recruited 1 0 0 0 Total in Position 1 0 0 1 Continued
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Table P3: Staff Position of in Primary Health Centre CHC DARHAL KANDI PHC Type of Staff Manjakote Lah Tralla Budhal Medical Officer AYUSH : Sanctioned 1 1 1 1 Regular in Position 0 0 0 0 Contractual Recruited 1 1 1 1 Total in Position 1 1 1 1 Staff Nurse : Sanctioned 2 1 0 0 Regular in Position 1 1 0 0 Contractual Recruited 2 0 0 0 Total in Position 3 1 0 0 Lady Health Visitor : Sanctioned 0 0 0 1 Regular in Position 0 0 0 0 Contractual Recruited 0 0 0 0 Lab Assistant Total in Position 0 0 0 0 Sanctioned 1 1 1 0 Regular in Position 1 1 1 0 Contractual Recruited 0 0 0 0 Total in Position 1 1 0 0 Block Health Education and Information Officer : Sanctioned 1 1 1 1 Regular in Position 1 1 1 1 Contractual Recruited 0 0 0 0 Total in Position 1 1 0 1 Statistical Assistant : Sanctioned 1 0 0 0 Regular in Position 95 1 0 0 0
Contractual Recruited 0 0 0 0 Total in Position 1 0 0 0 Table P4: Status of training of personnel at Primary Health Centre CHC DARHAL KANDI Training PHC Manjakote Lah Tralla Budhal Pre Service IMNCI Yes - - - - No 1 1 1 1 Safe Abortion Methods Yes - - - - No 1 1 1 1 Skill Birth Attendant Training Yes - - 1 - No 1 1 - 1 New Born Care Yes - - - - No 1 1 1 1
Table P5: Availability of Labour Room in Primary Health Centre CHC DARHAL KANDI PHC PHC Trall Labour Room Manjakote Lah a Budhal Availability of Labour Room Yes 1 1 1 1 No - - - - Labour Room Currently in Use Yes 1 - 1 1 No - 1 - - Reasons for Deliveries Not Conducting in Labour Room: Non Availability of Doctors / Staff Yes - 1 - - No - - - - Poor Condition of the Labour Room Yes - - - - No - 1 - - No Power Supply in the Labour Room Yes - - - - No - 1 - - Other Yes - 1 - - No - - - -
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Table P6: Status of performance of Labour Room during 2007-2008 CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal Number of Deliveries Total Institutional Deliveries Numbers 100 - 31 20 Deliveries Carried Out from 8 Pm to 8 Am Numbers - - - - Institutional Deliveries for JSY Card Holders Numbers 100 - 31 6 No. of Neonates Resuscitated Number - - - -
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Table P7: Availability of Laboratory Testing in PHC CHC DARHAL KANDI PHC Availability Laboratory Testing Manjakote Lah Tralla Budhal Hemoglobin Yes 1 1 1 1 No - - - - Urine RE Yes 1 - 1 1 No - 1 - - Blood Sugar Yes - - - - No 1 1 1 1 Blood Grouping Yes - - 1 1 No 1 1 - - Blood Smear Yes - - - - No 1 1 1 1 Bleeding Time, Clotting Time Yes 1 1 1 1 No - - - - Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc Yes - - - - No 1 1 1 1 Blood Smear Examination for Malaria Parasite Yes 1 1 1 1 No - - - - Rapid Test for Pregnancy Yes - 1 1 1 No 1 - - - RPR Test for Syphilis Yes - - - - No 1 1 1 1 Rapid Test for HIV Yes - - - - No 1 1 1 1 98
Table P8: Number of tests done in PHC in last three calendar months CHC DARHAL KANDI PHC Type of Test Manjakote Lah Tralla Budhal
Hemoglobin Number 110 17 57 35 Urine RE Number 48 - 33 58 Blood Sugar Number - - - - Blood Grouping Number - - 2 8 Blood Smear Number - - - - Bleeding Time, Clotting Time Number - 16 - 22 Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc Number - - - - Blood Smear Examination for Malaria Parasite Number 25 49 41 59 Rapid Test for Pregnancy Number - 19 31 38 RPR Test for Syphilis Number - - - - Rapid Test for HIV Number - - - -
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Table P9: Status of specific Interventions CHC DARHAL KANDI PHC Status of Specific Interventions Manjakote Lah Tralla Budhal IPHS Facility Survey done Yes - - - - No 1 1 1 1 PHC Functioning on 24 x 7 Basis Yes 1 - - 1 No - 1 1 - AYUSH Doctor Providing Services Yes 1 1 1 1 No - - - - Registered Rogi Kalyan Samiti Yes 1 1 1 1 No - - - - RKS generating resources through user fees Yes - - - - No 1 1 1 1 Money generated by RKS being used Yes 1 1 1 1 No - - - - Display board showing no. of meetings & members of RKS Yes - - - - No 1 1 1 1 Citizen Charter Publically Displayed Yes - - 1 - No 1 1 - 1 All Standard Treatment Guidelines and Protocols Available Yes 1 - - - No - 1 1 1 Feedback mechanism in place for grievances redressed by RKS Yes - - - - No 1 1 1 1 Continued
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Table P9: Status of specific Intervention CHC DARHAL KANDI PHC Status of Specific Interventions Manjakote Lah Tralla Budhal Primary Management of Wounds Yes 1 1 1 1 No - - - - Primary Management Fracture Yes - 1 - 1 No 1 - 1 - Management of Neonatal Asphyxia, sepsis Yes 1 - - 1 No - 1 1 - Management of Malnourished Children Yes 1 1 1 1 No - - - - Minor Surgeries Like Draining of Abscess etc Yes 1 - - 1 No - 1 1 - Primary Management of Cases of Poisoning / Snake Insect or Scorpion Bite Yes - - - 1 No 1 1 1 - Primary Management of Dog Bite Cases Yes - - 1 1 No 1 1 - - Primary Management of Burns Yes 1 1 1 1 No - - - - Facility for MTP Available Yes - - - - No 1 1 1 1 Management of RTI/STI Yes 1 1 1 1 No - - - - AYUSH Services Yes 1 1 1 1 101
No - - - -
Table P10: Availability of selected equipments in PHC CHC DARHAL KANDI PHC Equipments available/working Manjakote Lah Tralla Budhal Patient Trolley: Available Yes - - - 1 No 1 1 1 - Patient Trolley: Working Yes - - - 1 No - - - - Examination Table: Available Yes 1 1 1 1 No - - - - Examination Table: Working Yes 1 1 1 1 No - - - - Delivery Table: Available Yes 1 1 1 1 No - - - - Delivery Table: Working Yes 1 1 1 1 No - - - - Wheel Chair: Available Yes - - - - No 1 1 1 1 Wheel Chair: Working Yes - - - - No - - - - Stretcher / Trolley: Available Yes 1 1 1 1 No - - - - Stretcher / Trolley: Working Yes 1 1 1 1 No - - - - Oxygen Cylinder: Available Yes 1 1 1 1 102
No - - - - Oxygen Cylinder: Working Yes 1 1 - 1 No - - 1 - Continued
Table P10: Availability of selected equipments in PHC CHC DARHAL KANDI PHC Equipments available/ working Manjakote Lah Tralla Budhal Suction Apparatus: Available Yes 1 1 1 1 No - - - - Suction Apparatus: Working Yes 1 - - 1 No - 1 1 - Infant Warmer: Available Yes 1 - - - No - 1 1 1 Infant Warmer: Working Yes 1 - - - No - - - - Radiant Warmer: Available Yes - - - - No 1 1 1 1 Radiant Warmer: Working Yes - - - - No - - - - Cradle: Available Yes - - - - No 1 1 1 1 Cradle: Working Yes - - - - No - - - - Autoclave: Available Yes 1 1 1 1 103
No - - - - Autoclave: Working Yes 1 - 1 1 No - 1 - - Sterilization Equipment: Available Yes 1 - 1 1 No - 1 - - Continued
Table P10: Availability of selected equipments in PHC CHC DARHAL KANDI PHC Equipments available/ working Manjakote Lah Tralla Budhal Sterilization Equipment: Working Yes 1 - - 1 No - - 1 - Bag and Mask: Available Yes 1 - 1 1 No - 1 - - Bag and Mask: Working Yes - - 1 1 No 1 - - - Laryngoscope: Available Yes - - - - No 1 1 1 1 Laryngoscope: Working Yes - - - - No - - - - Oxygen Mask: Available Yes - - - 1 No 1 1 1 - Oxygen Mask: Working Yes - - - 1 No - - - - Thermometer: Available Yes 1 1 1 1 No - - - - 104
Thermometer: Working Yes 1 1 1 1 No - - - - Suction Machine: Available Yes 1 - 1 1 No - 1 - - Suction Machine: Working Yes 1 - - 1 No - - 1 - Continued
Table P10: Availability of selected equipments in PHC CHC DARHAL KANDI PHC Equipments available/working Manjakote Lah Tralla Budhal Water Purifier: Available Yes - - - - No 1 1 1 1 Water Purifier: Working Yes - - - - No - - - - Microscope: Available Yes 1 1 1 1 No - - - - Microscope: Working Yes 1 1 1 1 No - - - - Haemoglobinometer: Available Yes 1 1 - 1 No - - 1 - Haemoglobinometer: Working Yes 1 1 - 1 No - - - - Auto Analyser: Available Yes - - - - No 1 1 1 1 Auto Analyzer: Working Yes - - - - No - - - - Autoclave: Available Yes 1 1 1 1 No - - - - Autoclave: Working Yes 1 - 1 1 105
No - 1 - - Resuscitation Equipment: Available Yes 1 - 1 - No - 1 - 1 Resuscitation Equipment: Working Yes 1 - - - No - - 1 -
Table P11: Status of Availability of Drugs CHC DARHAL KANDI PHC Type of Drugs Manjakote Lah Tralla Budhal IFA Tablets: Stock Out in Last 6 Months Yes 1 - 1 - No - 1 - 1 IFA Tablets: Irregular in Last 6 Months Yes - 1 1 1 No 1 - - - Iron Syrup: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Iron Syrup: Irregular in Last 6 Months Yes 1 1 1 1 No - - - - Oral Pills: Stock Out in Last 6 Months Yes - - - 1 No 1 1 1 - Oral Pills: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 Vitamin A: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Vitamin A: Irregular in Last 6 Months Yes 1 1 1 1 No - - - - Measles Vaccine: Stock Out in Last 6 Months Yes - - - 1 106
No 1 1 1 - Measles Vaccine: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 ORS: Stock Out in Last 6 Months Yes - 1 1 - No 1 - - 1 Continued
Table P11: Status of Availability of Drugs CHC DARHAL KANDI PHC Type of Drugs Manjakote Lah Tralla Budhal ORS: Irregular in Last 6 Months Yes - 1 1 1 No 1 - - - Tab Maethergin: Stock Out in Last 6 Months Yes - 1 1 1 No 1 - - - Tab Maethergin: Irregular in Last 6 Months Yes - 1 1 1 No 1 - - - Tab Albendazole / Mabendazole: Stock Out in Last 6 Months Yes - 1 1 1 No 1 - - - Tab Albendazole/Mabendazole: Irregular in Last 6 Months Yes - 1 1 - No 1 - - 1 IUDs: Stock Out in Last 6 Months Yes - 1 - - No 1 - 1 1 IUDs: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 Inj. Oxytocin: Stock Out in Last 6 Months Yes - 1 - 1 No 1 - 1 - 107
Inj Oxytocin:Irregular in Last 6 Months Yes - 1 - - No 1 - 1 1 Magnesium Sulphate: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Magnesium Sulphate: Irregular in Last 6 Months Yes 1 1 1 1 No - - - - Continued
Table P11: Status of Availability of Drugs CHC DARHAL KANDI PHC Indicator Manjakote Lah Tralla Budhal Tab Fluconazole: Stock Out in Last 6 Months Yes 1 - 1 1 No - 1 - - Tab Fluconazole: Irregular in Last 6 Months Yes 1 - 1 - No - 1 - 1 Partograph: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Partograph: Irregular in Last 6 Months Yes 1 1 1 1 No - - - - MVA Syringe: Stock Out in Last 6 Months Yes - 1 1 1 No 1 - - - MVA Syringe: Irregular in Last 6 Months Yes - 1 1 - No 1 - - 1 Tab Ciprofloxacin: Stock Out in Last 6 Months Yes 1 - 1 1 No - 1 - - Tab Ciprofloxacin: Irregular in Last 6 Months Yes 1 - 1 - 108
No - 1 - 1 Spy Cotrimoxazole: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Spy Cotrimoxazole: Irregular in Last 6 Months Yes - 1 1 - No 1 - - 1 Continued
Table P11: Status of Availability of Drugs CHC DARHAL KANDI PHC Indicator Manjakote Lah Tralla Budhal Spy Paracetamol: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Spy Paracetamol: Irregular in Last 6 Months Yes 1 1 1 1 No - - - - Ringers Lactate: Stock Out in Last 6 Months Yes - - - - No 1 1 1 1 Ringers Lactate: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 Haemoccele: Stock Out in Last 6 Months Yes - 1 1 1 No 1 - - - Haemoccele: Irregular in Last 6 Months Yes - 1 1 - No 1 - - 1 AD Syringes: Stock Out in Last 6 Months Yes - - 1 - No 1 1 - 1 AD Syringes: Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Disposable Gloves: Stock Out in Last 6 Months 109
Yes - - - 1 No 1 1 1 - Disposable Gloves: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 Bandages: Stock Out in Last 6 Months Yes - - - 1 No 1 1 1 - Continued
Table P11: Status of Availability of Drugs CHC DARHAL KANDI PHC Type of Drugs Manjakote Lah Tralla Budhal Bandages: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 AYUSH Drugs: Stock Out in Last 6 Months Yes - 1 - 1 No 1 - 1 - AYUSH Drugs: Irregular in Last 6 Months Yes - 1 - - No 1 - 1 1 Dots Drugs: Stock Out in Last 6 Months Yes - - - - No 1 1 1 1 Dots Drugs: Irregular in Last 6 Months Yes - - - - No 1 1 1 1 MDT Drugs Blister Packs: Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - MDT Drugs Blister Packs: Irregular in Last 6 Months Yes 1 1 1 - No - - - 1 110
Table P12 : Service Outcome (based on data for last three months) CHC DARHAL KANDI Indicator PHC Total ANC Registration : Manjakote Lah Tralla Budhal SC INA INA INA INA ST INA INA 5 27 Others INA INA 0 36 Total 23 5 5 73 Total JSY Case Registered : SC INA INA 0 1 ST INA INA 5 1 Others INA INA 0 2 Total 23 INA 5 4 1st Trimester Registration : SC INA INA 0 4 ST INA INA 0 10 Others INA INA 0 15 Total 23 5 0 29 ANC Given 3 Checkups : SC INA INA 0 INA ST INA INA 3 INA Others INA INA 0 INA Total INA 1 3 INA ANC Given TT1 : SC INA INA 0 4 ST INA INA 5 10 Others INA INA 0 15 Total 23 5 5 29 ANC Given TT2+ Booster : SC INA INA 0 2 ST INA INA 2 17 Others INA INA 0 21 Total INA 2 2 44 ANC Completed IFA Prophylaxis : SC INA INA 0 INA ST INA INA 5 INA Others INA INA 0 INA Total 23 2 5 INA Continued
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Table P12 : Service Outcome (based on data for last three months) CHC DARHAL KANDI Indicator PHC Manjakote Lah Tralla Budhal Total Institutional Deliveries : SC INA 0 0 0 ST INA 0 2 0 Others INA 0 0 2 Total 4 0 2 2 No of JSY Cases : SC INA INA 0 0 ST INA INA 2 0 Others INA INA 0 0 Total 4 INA 2 2 No of Infants Given BCG : SC INA INA 0 2 ST INA INA 7 7 Others INA INA 0 9 Total 36 5 8 17 No of Infants Given DPT3 : SC INA INA 0 6 ST INA INA 12 13 Others INA INA 0 18 Total 42 15 12 37 No. of infants given measles SC INA INA 0 3 ST INA INA 3 9 Others INA INA 0 12 Total 35 17 3 24 No of Infants Given Vit A First Dose : Total 0 0 0 0 Syp. IFA : Total 0 0 0 0 IUD (Copper-T) Inserted : SC INA - - 1 ST INA - 4 1 Others INA - 1 2 Total 4 - 4 5 Male Sterilization Carried Out : Total 0 0 0 0 Female Sterilization Carried Out : Total 0 0 0 0 112
Continued
Table P12 Service Outcome (based on data for last three months) CHC DARHAL KANDI PHC Indicator Manjakote Lah Tralla Budhal Total Indoor Patients : SC INA INA 0 INA ST INA INA 0 INA Others INA INA 0 INA Total 50 9 0 56 Total Out Patients : SC INA INA INA INA ST INA INA INA INA Others INA INA INA INA Total 1005 166 332 833 RTI / STI Cases Treated : SC 0 INA 0 0 ST 0 INA INA 0 Others 0 INA INA 0 Total 0 4 19 0 No of Maternal Deaths in 2007 2008 : SC INA INA 0 0 ST INA INA 0 0 Others INA INA 0 0 Total INA INA 0 0 No of Cases of Obstetric Complications Referred Beyond PHC : SC INA 0 0 INA ST INA 0 0 INA Others INA 0 0 INA Total INA - - 1 No of Cataract Surgeries Carried Out : Total 0 0 0 0 No of New TB Cases Enrolled For Dots : SC INA INA 0 INA ST INA INA 0 INA Others INA INA 0 INA Total 4 1 0 1 No of New Leprosy Cases Registered for MDT : Total 0 0 0 0 No of Leprosy Cases Completed Treatment for Leprosy :
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Total 0 0 0 0 I A= Information not available
Table P13: Status of record maintenance CHC DARHAL KANDI PHC Type of Records Manjakote Lah Tralla Budhal Ante Natal Register Yes 1 1 1 1 No - - - - Eligible Couple Register Yes 1 - 1 - No - 1 - 1 Post Natal Care Register Yes - - 1 1 No 1 1 - - Family Planning Register Yes 1 - 1 1 No - 1 - - Birth and Death Register Yes - - - 1 No 1 1 1 - Immunization Register Yes 1 1 1 1 No - - - - Meeting Register Yes 1 1 - 1 No - - 1 - JSY Register Yes - - 1 - No 1 1 - 1 Untied Funds Register Yes 1 1 1 - No - - - 1
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CHAPTER 6
Sub Centre
Introduction Sub Centers (SCs) are the most peripheral health institutions catering to the health care needs of the rural population. It is the most peripheral contact point between the Primary Health Care system and the community. It is manned by one Multi Purpose Worker (male) and one Multi Purpose Worker (female) /ANM. Even though the sub centre wise population norm at the national level has been met, there are wide interstate variations.
Under the Rapid Appraisal Survey, a total of 12 SCs were surveyed from 4 PHCs in Rajouri district. The SCs selected were Kakora, Hayat Pora and Rajdhani from PHC Manjakote. Khablan, Behrot and Badakana Scs were selected from PHC Lah. Similarly, we selected Sankari, Reyan and Sodagalla SCs from PHC Tralla and Kewal, Targaien and Dandote SCs from Budhal PHC. This chapter presents the findings of the information collected from these 12 SCs.
Coverage A SC on average in Rajouri district covers 2978 population which is at par with the government of India guidelines of having a SC for every 3000 population in hilly areas. On an average a SC covers 4 villages/habitations in the district. Of the 12 SCs, only 2 are overloaded with the responsibility of providing the health services to 5 or more villages and all of them are located in Darhal block (Table S1).
The mean distance to the farthest village from the sub centre in the district is 3.8 kms. Only 3 SCs have a village at a distance of 5 kms or more. The mean distance from the SCs to PHC is 5.6 kms and mean distance from SCs to CHC is 28 Kms. The SCs located in Manjakote PHC are farthest (30 Kms or more) from the CHC than SCs located in other PHCs. On the contrary, the SCs located in Manjakote PHC nearer to DH Rajouri than CHC Darhal and communication links to Darhal from Manjakote pass through DH Rajouri. It is, therefore, suggested that there is a need to reorganize blocks and Manjakote PHC should be put under the administrative control of CMO directly or it should be made an independent Medical Block.
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As the topography of the selected SCs is highly terrain and there are no roads, therefore the public generally have to approach SCs by foot. The mean time taken to travel from the farthest village to the SCs worked out to be 73 minutes. The mean time taken from the farthest village to SCs is slightly higher in Kandi than in Darhal. The mean time taken from a SC to PHC by public transport is 69 minutes and it is two hours and 15 minutes in case of CHCs. Average time taken to visit a CHC from SC located in Darhal CHC is very high compared to SCs located in Kandi. In fact patients from Manjakote are directly referred to DH Rajouri than to CHC Darhal because DH Rajouri is more close to Manjakote.
Of the 12 selected SCs, three were without a functional ASHA, 7 had 1 ASHA each and 1 SC namely Hayat Pora had 2 ASHAs.
Infrastructure (Table S2) Own building Fifty percent of SCs have their own government building. All the three SC in Manjakote have their own building and none of the SCs in Budhal has a government building. Sub Centres are required to conduct India Public Health Standards (IPHS) Surveys in their operational villages but IPHS surveys have not yet been conducted in any of the surveyed SCs. None of the SCs have a labour room. The SCs lack proper drinking water facilities as none of the SCs was found to have piped water. Similarly all the SCs face acute shortage of electricity. Only 2 out of 12 SCs had electricity supply but even in these 2 SCs also it was erratic, irregular and with very low voltage. Telephone facility has not yet been provided to any of the SCs in the district. So far as the type of sewerage system is concerned, only one of the SCs located in Manjakote had a soak pit and the remaining 11 were connected to open drains.
Disposal of waste material SCs generally do not have any facility to dispose off the waste material. It was reported by 75 percent of the SCs that they throw the waste material in open and only 2 SCs (16 percent) bury it in a pit.
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Staying Place of A M Quarter (Table S3) The presence of the ANM in the Sub Centre area round the clock is essential for the people to avail the health services. That is why the government has focused on providing quarters to the ANM at SCs. Only 1 of the SCs (Reyan) was found to have a residential quarter. But this quarter is now in a depilated shape and ANM does stay in this quarter. It was also found that none of the ANMs stay in the SC village but the proportion of SCs where the ANM is staying in the SC area, but not in the SC village is 25 percent. Thus, 75 percent of the ANMs stay outside the SC area (Table S3). This is not a conducive situation, where a large number of ANMs stay away from the SC or even away from the SC’s area.
Staff (Table S4) The information on health workers of SCs by sex was collected for both sanctioned posts and filled posts. The same information is presented in Table S4. The filled post or the post in position is taken from the total sanctioned posts of SCs in each SC.
Though all the SCs now have a sanctioned post of male worker, but only 75 percent of them are in position. The proportion of SCs with at least one filled in post for male health worker varies from 66 percent in Darhal to 83 percent in Kandi. The situation is the worst in SCs of Manjakot where only 33 percent SCs have a male health worker.
The role of female health worker is very important at SCs. Only 8 percent of the SCs do not have a female health worker in position. The lone SC which was without a female health worker was Targaien in Budhal PHC of Kandi Block. Under NRHM districts have been provided funds to recruit additional ANMs and in fact 50 percent of the SCs had additional ANMs. The percentage of SCs which had both the positions (ANM as well as Male Health worker) filled in was 75 percent and the percentage which had all the three positions filled in was 25 percent.
Labour room (Table S5) In the context of the National population policy, 2000 goal of eighty percent institutional deliveries, the availability of a labour room is a critical facility for a all the health facilities. But till date none of the SCs in the district has been provided with the facility of a labor room (Table S5).
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Equipment (Table S7B) Certain equipment is essential for the delivery of RCH services. This section discusses the status of SCs with respect to the availability of these inputs on the day of survey. None of the SCs have Haemoglobin meter, bag and mask, suction machine, height measuring scale, reagent strips for urine tests, Cuscos Speculum, Mucus extractor, and Fetoscope. The only equipments available in some SCs are Thermometer and weighing machine. Thus SCs are poorly equipped to deliver RCH services in the district. BP apparatus is an essential component of antenatal care. But only 50 percent of the SCs have a functional BP apparatus.
For the identification of low birth weight babies as well as for assessing the nutritional status of the infants and monitoring their growth, infant weighting machines in PHCs is essential. This instrument is also not available in all the SCs in the district.
Stock of vaccines, contraceptives and prophylactic drugs (Table S8) The information on whether SCs were supplied with necessary contraceptives, vaccines, drugs and kits is supplemented with data on the availability of stock of these items on the date of survey. Table S8 presents the distribution of SCs, which had some stock of ach of the contraceptives (Nirodh, oral pills, IUD, emergency contraceptives), vitamin A, IFA tablets, ORS packets, disposable delivery kit, pregnancy test kit, disposable gloves, drugs (Flucanaxole tablets, Misoprostal tablets, Tablets, Cotrimoxazol, Ciprofloxan tables and paracetomol syrup)
(a) Contraceptives In Rajouri district 67 percent of the SCs had stock of oral pills or condoms but percentage of SCs which had stock of both (oral pills and condoms) was only 41 percent. Emergency contraceptive and IUDs were not found to be available in any of the SCs.
(b) Prophylactic drugs About 42 percent of the surveyed SCs in the district reported having some stock of IFA tablets. But ANMs reported that these are at the verge of expiry. Vitamin A solution was not available at any SCs. The ORS packets were available with 67 percent of the SCs in both the blocks. It was available in all the 3 SCs of Manjakote PHC, 1 in Lah PHC, and 2 each in but Budhal and Tralla PHCs. 118
Disposable Delivery Kit (DDK), Pregnancy test kit, Partogarph was reported to be not available by all the selected SCs. Only 2 SCs (both located in Budhal PHC) reported availability of disposable gloves.
(c) Drugs Every SC is supposed to have some essential drugs like Flucanaxole vaginal tablets, Misoprostal tablets, Cotrimoxazol tablets, Ciprofloxan tablets for the management of Reproductive tract infections and sexually transmitted infections. But none of the surveyed SCs in Rajouri district had any supplies of Flucanaxole vaginal tablets, or Misoprostal tablets. Cotrimoxazol syrup, Ciprofloxan tablets and paracetomol was available in less than 50 percent of the SCs. The supply position was comparatively better in SCs located in Budhal PHC of Kandi CHC.
Specific skills and procedures (Table S9) All the SCs are expected to provide various services in the area of maternal and child health care, family planning and others. Information on the activities carried out by SCs during the three months preceding the date of survey was collected. As seen in Table S9, that except for 1 SC all other SCs (92 percent) are registering pregnancies within three months of pregnancy. Two third of the SCs reported that they carry out 3 ANC visits as per RCH guidelines. While as all the SCs located in Kandi CHC mentioned that they carry out ANC visits but only 2 SCs in Darhal mentioned this activity. However, our observations reveal that none of the ANMs carry out ANC visits. If at all any ANM visits for ANC services, she does not follow RCH schedule.
ANMs are also expected to carry out specific examinations like blood pressure, haemoglobin and urine tests of pregnant women but it was found that these activities are just carried out by only 2 SCs both located in Darhal CHC. ANMs mentioned that due to the non availability of any lab and manpower they are unable to carry out these investigations. SCs are also expected to provide IFA tablets and TT injection free of cost to pregnant women and all the SCs mentioned that they do provide IFA tablets and TTI to pregnant women.
Though ANMs are trained to identify high risk pregnancies but it was found that only 75 percent of the ANMs mentioned that they are actually identifying high risk pregnancies. SCs identifying 119 high risk pregnancies are somewhat higher in Kandi than in Darhal. Under RCH programme, all the ANMs are being trained to insert IUDs (Cu T) but unexpectedly none of the ANMs mentioned that they have received any training regarding insertion of IUCD. Consequently, IUCD services are not available in any of the 12 SCs visited by the evaluation team. As per RCH guidelines all the ANMs should have been trained in the syndromic treatment of RTI/STI but it was again mentioned by all the ANMs that they have not received any training in syndromic treatment of RTI/STI. Thus it appears that the ANMs have not been trained to implement various key components of RCH programme in the district as yet.
The only component which is being carried out by all the SCs is immunization of children. This activity was carried out by the SCs even before RCH. Thus, there is not much change in the working of SCs after the implementation of RCH/NRHM.
Service outcome (Table S10) As mentioned above that SCs are expected to provide various services in the area of maternal and child health care, family planning and treatment of RTI/STI. In order to examine the performance of the SCs we collected some information regarding the number of women registered for ANC, number of high risk pregnancies identified, number of deliveries conducted at the SCs and number of neonatal infections identified and managed. Since, delivery facilities are not available in any of the SCs; therefore, deliveries are not conducted at SCs. Similarly, SCs also do not provide any services regarding insertion/removal of IUCDs. Though some ANMs mentioned that they identify high risk pregnancies but practically this activity has been undertaken by only 2 SCs. These 2 SCs have identified a total of 3 high risk pregnancies during the last three months. Similarly, identification and management of neonatal infections and referral of pregnant women to next higher facility by SCs is almost a neglected activity. Only 1 SC has referred 2 women for delivery to next higher facility.
Record maintenance (Table S11) Record keeping and its updating is an important component of NRHM. All the SCs are expected to maintain records and regularly update the information pertaining to the number of, households, couples, births and deaths, use of contraception, immunization and post natal care and JSY beneficiaries. SCs are also required to maintain information regarding the funds utilized under 120 untied funds. In order to have uniformity in maintaining information, all the State governments are expected to provide 10 registers to each SC. The registers to be provided to the SCs are: household survey register, antenatal register, eligible couple register, post natal care register, family planning register, birth and death register, immunization register, meeting register, JSY register, and untied funds register. The survey team collected information about the availability of these registers and wherever they were available the team verified whether there was any entry in these registers during the last 1 month. Our findings reveal that all the SCs generally maintain two registers namely ante natal register and immunization register. Meeting register and eligible couple register was not found maintained by any of the SCs. Household register was maintained by only 2 SCs and postnatal care register was available in 3 SCs. Other registers like family planning register, birth and death register, JSY register and untied funds register and cash book was maintained by 33 percent of the SCs. The survey team found that the system of keeping records is haphazard. These registers have not been provided as per IPHS standards. ANMs mentioned that they buy blank registers and formats of Monthly Progress Reports from their own pocket and devise their own format for maintaining information. ANMs also expressed that although a lot of emphasis is given on maintenance of records but hardly any training has been provided to them in the maintenance of records. Thus there is a lot of scope to improve the MIS under NRHM.
During the course of survey we had a chance to visit one of the Xerox shops located near a PHC. Xerox copies of the formats of Monthly Progress Reports of Sub Centres were for sale at the Xerox shop. When we inquired from the owner of the Xerox shop regarding these formats, he informed us mentioned that these are for sale and cost Rs. 2 per copy. The customers are A Ms from different Sub Centres who come to the PHC to attend monthly meetings. Before the meeting starts, A Ms purchase a copy of the MPR. There are some officials of the PHC who help them to fill up these formats. So if this is the state of HMIS at the SC level, the quality and reliability of the information of HMIS at PHC, CHC, District and State level can well be judged.
A M’s awareness about JSY (Table S12) ANMs are expected to be fully aware about JSY, its eligibility criterion, and the amount payable under the scheme. Of the 12 ANMs interviewed, 11 ANMs (92 percent) reported to have heard
121 about JSY. An amount of Rs. 1400 is being paid to the JSY beneficiaries in Rajouri district but there was a difference of opinion among the ANMs regarding the amount payable to JSY beneficiaries. The mean amount payable under JSY as reported by the ANMs works out to be Rs. 1255. ANMs attributed this confusion to the modifications made in the JSY guidelines by the State government from time to time. This is substantiated by the fact that the amount payable under JSY depicted in the wall paintings and hoardings is not uniform. In some paintings it is shown as Rs. 1000 and in other hoardings it is Rs. 500 and yet in others advertisements it is Rs. 1200. Though the JSY scheme envisages that Rs 500 should be paid to a woman in case she utilizes full ANC but delivers at home but in Rajouri district no amount was paid to such women. This is also substantiated by the fact that all ANMs mentioned that no amount was paid to the women for home deliveries. Besides, the State government does not reimburse transportation charges and consequently all the ANMs mentioned that they are not aware about the amount of transportation charges paid under JSY.
Since the main objective of introducing JSY is to increase the demand for institutional deliveries, therefore, ANMs were asked to report whether they have observed any increase in the demand for institutional deliveries in their respective areas after the implementation of JSY scheme. Surprisingly, only 1 ANM out of 11 (9 percent) reported having observed some increase in the demand for institutional deliveries after the introduction of JSY scheme in the district. Almost all the ANMs mentioned that once the scheme was introduced in the district, there was much enthusiasm among ASHAs, ANMs and also among the expectant mothers about the scheme but once cash incentives under JSY were withdrawn, the demand for institutional deliveries received a severe setback. Some of the ANMs also expressed that incentives under JSY could not improve the institutional deliveries rate because of poor quality of services and prevalence of large scale corruption in the district hospital and non availability of adequate facilities for institutional deliveries at PHCs and CHCs.
Performance of JSY (Table S13) In order to assess the performance of JSY, we collected information from all selected SCs regarding the number of JSY cases registered in the last 3 months. On an average, a SC has registered 8 cases under JSY during the last 3 months. The number of cases registered is higher in
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SCs located in Kandi CHC than in Darhal CHC. In fact, 4 SCs in Darhal CHC and 3 SCs in Kandi CHC have not registered any JSY case during the last 3 months. ANMs mentioned once the cash incentive under JSY was withdrawn in the district they stopped registering women under JSY. Some of the ANMs mentioned that even after withdrawing the cash incentive under the scheme they continued to register women under JSY but after they were abused and rebuked by these women for non payment, they stopped registering women under JSY.
Though 5 of the SCs had registered a total of 84 cases under JSY but the SCs had no information whether any of these women had delivered in any health institution. Almost all the ANMs reported that women generally visit their parental houses for delivery and as such it becomes difficult for them to track these women at the time of delivery.
As mentioned above that the scheme of cash incentives under JSY in Rajouri district was not in operation for the last 1 year, so no money had been disbursed by any of the ANMs under JSY to women in Rajouri district.
Status of untied grants (Table S14) The information collected regarding the receipt of untied funds under NRHM by SCs reveals that only 75 percent of the SCs had received untied funds. All the SCs in Darhal block reported to have received untied funds while as only 33 percent of the SCs in Kandi block reported to have received untied funds. All the SCs who have received untied funds reported to have utilized them. All the ANMs in Darhal block have a joint account with the Sarpanch/Village head while as in Kandi only 33 percent of the SCs have opened a joint account with Sarpanh/GP. When the SCs were asked to show any written record of decisions taken to spend this amount only 1 SC had maintained such information. Similarly SCs were also requested to show any written record of transactions being carried out on untied funds and it was found that all the SCs who had received untied funds had maintained such information. Sarpanchs are expected to review the expenditure records of SCs but not all Panchayats/Sarpanchs do so which is established by the fact that the expenditure records of 22 percent of the SCs were not reviewed by the Sarpanchs in the districts. SCs can utilize the untied funds on a variety of items like purchasing drugs, arranging transport, paying of electricity and telephone bills, arranging water coolers and white washing. However none of the SCs was found to have utilized untied funds on purchasing drugs, arranging transport, 123
paying of electricity or telephone bills. On the contrary, SCs had generally used this fund for furnishing, furniture and obtaining BP apparatus.
So far as our observations regarding untied funds are concerned it was found that SCs located in Kandi block have not received the amount under Untied Funds. On the contrary, these SCs have received some furniture items like chairs, tables, almirah, buckets, and BP apparatus from the office of BMO. The purchases have been made by the BMO for all the SCs in the block without consulting VHSC or ANM and distributed them among SCs. As the ANMs of Kandi block mentioned that they have not received the untied funds, we therefore, thought it prudent to collect some more information about the implementation of untied funds at the SC level.
Our detailed discussion with the ANMs revealed that once the untied funds were received by the BMOs, they were directed to open a joint bank account with Sarpanch/Chowkidar/Mukhia/ of the village. The ANMs took the signatures/thumb impressions of the Sarpanch on the application forms and opened a joint bank account. Once the joint bank account was opened, a cheque was book issued to them. BMO centralized the purchase for Sub Centres and placed order for purchase of furniture and other items on behalf of SCs. At the time of the delivery of supplies, ANMs also received bills and were directed to pay the amount to the supplier under untied funds.
Thus overall it ca concluded that there has not been much improvement in the functioning of the SCs even after NRHM. SCs used to be closed for most of the time before NRHM and not much improvement has been witnessed in that. The supply of drugs, patient load, ANC services, skills, immunization services, outreach services, monitoring and supervision of SCs, HMIS has not improved much. Planning process is still centralized and whether health and RCH/Family Welfare has certainly merged is questionable. NRHM and general health at the SC level are two entities. Health Pharmacists still believes that he has nothing to do with NRHM and it is the ANM who has to take care about NRHM. There has not yet been much change in the perception of community members about the image of ANM and quality of services delivered by SCs in the rural areas of the district..
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Table S1: Sub Centres Coverage
CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
Average
Sub centre Kakora Pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote percentage
Coverage of Sub-Centre Population coverage 3500 870 2000 3000 2400 2900 3600 5000 2800 2168 4500 3000 2978.2 Number of villages covered by Sub Centre 6 6 4 3 4 5 4 4 4 4 4 4 4 Distance between PHC and SC (in kms) Farthest village to Sub Centre 5 4 4 1 2 2 4 4 8 3 2 7 3.8 Sub Centre to PHC 5 6 6 4 3 4 6 10 8 5 7 3 5.6 Sub Centre to CHC 40 60 30 4 45 15 35 23 40 15 18 16 28.4 Time Taken (In minutes) to travel in public transport / available mode from Farthest village to Sub Centre 70 70 70 70 70 70 75 72.5 80 75 72.5 80 72.9 Sub Centre to PHC 72.5 60 90 72.5 60 90 67.5 60 65 67.5 60 65 69.2 Sub Centre to CHC 105 180 180 105 180 180 90 110 150 90 110 150 135.8 No. of ASHAs working in the Sub Centre 1 2 1 1 1 0 0 1 1 0 1 0 1 125
Table S2: Sub Centres Infrastructure CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
% of Sub-
Sub centre centre Sub Kakora -pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote centre Availability of Infrastructure in
Sub Centres (Yes: 1; No: 0) Functioning in designated government building 1 1 1 1 0 1 0 0 0 1 0 0 50 IPHS Facility Survey Done 0 0 0 0 0 0 0 0 0 0 0 0 0 Labour Room 0 0 0 0 0 0 0 0 0 0 0 0 0 Piped water supply 0 0 0 0 0 0 0 0 0 0 0 0 0 Regular electricity supply 0 1 0 0 0 1 0 0 0 0 0 0 16.7 Telephone 0 0 0 0 0 0 0 0 0 0 0 0 0 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 16.7 Collected by Agency ------1 - - - - - 8.3 Incernation ------
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Thrown in Open 1 1 1 1 1 - - 1 1 1 1 - 75
Table S3: Sub Centres with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre quarter CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
% of Sub
Sub centre Kakora Pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Centres
Residential status of ANM (Yes: 1; No: 0) Sub Centre with ANM quarter 0 0 0 0 0 0 0 1 0 0 0 0 8.3 Sub Centre with ANM staying in SC's quarter 0 0 0 0 0 0 0 0 0 0 0 0 0 Sub Centre with ANM staying within SC's village 0 0 0 1 0 1 1 0 0 0 0 0 25 Sub Centre with ANM staying outside SC's village 1 1 1 0 1 0 0 1 1 1 1 1 75 Reason for ANM not staying in SC quarter: Quality of quarter ------1 - - - - 100 Family related reasons ------Security reasons ------1 - - - - 100 Education and other facilities for children not available ------1 - - - - 100 Water/ Power facility not available ------Own residence is nearby ------
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Table S4: Sub Centres with Staff in Position CHC DARHAL KANDI Sub PHC Manjakote Lah Tralla Budhal centres with specific staff
Sub Sub centre Kakora Hayat Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagala Kewal Targaien Dandote available Availability of Staff (Yes: 1; No: 0) Health worker male in position 0 0 1 1 1 1 1 1 1 1 1 0 75 Health worker female in position 1 1 1 1 1 1 1 1 1 1 0 1 91.7 Additional ANM contractual 1 0 0 0 1 1 1 1 0 0 1 0 50
Table S5: Availability of Labour Room in Sub Centre CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal % of Sub centres
Sub centre Kakora Hayat Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote
Labour Room (Yes: 1; No:0) Availability of Labour Room 0 0 0 0 0 0 0 0 0 0 0 0 0 Labour Room currently in use 0 0 0 0 0 0 0 0 0 0 0 0 0 Reasons for not using Labour Room ANM not staying ------Poor condition ------No power supply ------
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No electric supply ------Other ------Table S7 B: Percentage of SCs with functional equipments CHC DARHAL KA DI
PHC Manjakote Lah Tralla Budhal
% of Sub centres with functional Sub centre equipment Kakora Kakora Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Functional equipments (Yes:1; No:0) Steriliser 0 0 0 0 0 0 0 0 0 0 0 1 50 Haemoglobin meter 0 0 0 0 0 0 0 0 0 0 0 0 0 Bag & Mask 0 0 0 0 0 0 0 0 0 0 0 0 0 Suction Machine 0 0 0 0 0 0 0 0 0 0 0 0 0 Thermometer 1 0 0 0 1 1 0 1 1 0 0 0 83.3 BP Apparatus 1 0 0 0 0 0 0 1 0 0 1 1 50 Weighing Machine 1 0 0 0 0 0 0 1 1 0 1 1 83.3 Height Measuring Scale 0 0 0 0 0 0 0 0 0 0 0 0 0 Reagent Strips for Urine Test 0 0 0 0 0 0 0 0 0 0 0 0 0 Cuscus Speculum 0 0 0 0 0 0 0 0 0 0 0 0 0 Mucus Extractor 0 0 0 0 0 0 0 0 0 0 0 0 0 Fetes cope 0 0 0 0 0 0 0 0 0 0 0 0 0
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Table S8: Status of availability of drugs CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal % of Sub centres reporting availability of drug on date of
Sub centre Kakora Pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote survey Type of Drugs Available (Yes:1; No:0) Iron/ Folic Acid 1 0 0 1 0 0 1 0 0 1 1 0 41.7 Disposable Delivery Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 Oral Pills 1 0 1 1 0 1 1 1 0 1 0 1 66.7 Emergency Contraceptive 0 0 0 0 0 0 0 0 0 0 0 0 0 Condoms 1 1 1 1 0 0 0 1 0 1 1 1 66.7 IUD 0 0 0 0 0 0 0 0 0 0 0 0 0 ORS 1 1 1 1 0 0 0 1 1 1 1 0 66.7 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 0 0 0 0 0 0 0 0 0 0 Syp Cotrimoxazole 1 0 0 0 0 1 0 0 0 1 0 0 25 Syp.Paracetamol 0 0 0 0 0 1 0 0 1 1 1 1 41.7 Vi. A 0 0 0 0 0 0 0 0 0 0 0 0 0 Tab Ciprofloxacin 0 0 0 1 0 1 0 0 1 1 1 1 50 Disposable Gloves 0 0 0 0 0 0 0 0 0 0 1 1 16.7
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Table S9: Status of record Maintenance CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal % of Sub centres reporting availability of specific
Sub centre Kakora Pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote skills/procedure Type of Skills/Procedures (Yes:1; No:0) Register pregnancy within three month 1 1 1 1 0 1 1 1 1 1 1 1 91.7 Carry out 3 ANC visits as per the RCH schedule (1st: 6th month 2nd: 7th month 3rd: 9th month) 1 0 0 0 0 1 1 1 1 1 1 1 66.7 Carry out specific examinations like Blood Pressure Haemoglobin and Urine 0 0 0 1 0 1 0 0 0 0 0 0 16.7 Provision of TT IFA etc. 1 1 1 1 1 1 1 1 1 1 1 1 100 Identification of High Risk Pregnancies 1 0 1 1 0 1 1 1 1 1 1 0 75 Is the ANM carrying out IUCD insertion/ removal 0 0 0 0 0 0 0 0 0 0 0 0 0 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 0 0 0 0 0 0 0 Is the ANM trained in syndromic treatment of RTI/ STI 0 0 0 0 1 0 0 0 1 0 0 0 16.7 Immunization services 1 1 1 1 1 1 1 1 1 1 1 1 100
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Table S10: Service Outcome (Based on the data for last 3 months) CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal % of Sub centres reporting availability of specific skills/ Sub centre procedure Kakora Kakora Pora Hayat Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Indicator Total ANC registered 24 6 10 15 0 12 10 30 30 12 16 2 14 Out of total ANC number registered in 1st trimester 10 2 0 0 0 0 1 0 5 0 8 0 2 No. given 3 ANC visits as per the RCH schedule 0 2 9 3 0 8 8 7 11 4 10 0 5 No. of High Risk Cases identified 0 0 0 0 0 1 0 0 2 0 0 0 * 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 0 0 0 0 0 2 0 0 0 * No. of neonate infections identified and referred 0 0 0 0 0 0 0 0 0 0 0 4 * No. of IUCD insertions in 2007-2008 0 0 0 0 0 0 0 0 0 0 0 0 0
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Table S11: Status of Record Maintenance CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
% of SCs reporting Sub centre record Kakora Kakora Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Type of Records maintained (Yes:1; No:0) Household Survey Register 0 1 0 0 0 0 0 0 1 0 0 0 17 Ante Natal Register 1 1 1 1 0 1 1 1 1 1 1 1 92 Eligible Couple Register 0 0 0 0 0 0 0 0 0 0 0 0 0 Post Natal Care Register 0 0 0 0 0 0 1 1 1 0 0 0 25 Family Planning Register 0 0 0 0 0 0 1 1 1 1 0 0 33 Birth and Death Register 0 1 1 0 0 0 1 1 0 0 0 0 33 Immunisation Register 1 1 1 1 1 1 1 1 1 1 1 1 100 Meeting Register 0 0 0 0 0 0 0 0 0 0 0 0 0 JSY Register 1 0 0 0 0 0 1 1 1 0 0 0 33 Untied Funds Register 1 0 1 0 0 0 0 1 1 0 0 0 33 Cash Book 1 0 1 1 0 1 0 1 1 0 1 1 33
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Table S12 A: Status of Awareness of ANM about JSY Scheme ANM's awareness about JSY Value Aware about JSY Number of ANMs interviewed 12 Number of ANMs reporting awareness 11 Percent reporting awareness 91.7 Aware about average amounts to be given to beneficiaries for A. Institutional Delivery 1256 B. Home Delivery - C. Transport Facility - ANM reporting increase in demand for Institutional delivery after implementation of JSY Scheme Number of ANMs interviewed 11 Number of ANMs reporting awareness 1 Percent reporting awareness 9.1
Table S13: Status of performance of ANM under JSY Scheme CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
Average per Sub
Sub centre Kakora Hayat Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Centre
Performance of ANM under JSY Scheme Total cases of JSY registered in last 3 calendar months 10 0 0 0 0 8 0 24 30 12 0 0 8 Total number of JSY cases resulted in Institutional deliveries in last 3 months 0 0 0 0 0 0 0 0 3 0 0 0 * Total cash disbursed in last 3 calendar months for JSY cases (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0 Home Deliveries (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0 Institutional Deliveries (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0 134
Transport Costs (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0 Amount given to ASHA (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0
Table S14: Status of Untied Grants CHC DARHAL KANDI PHC Manjakote Lah Tralla Budhal
% of Sub
Sub centre Kakora Hayat Pora Rajdhani Khablan Behrote Badakana Sankari Reyan Sodagalla Kewal Targaien Dandote Centres
Status of Untied Grants (Yes:1; No:0) Sub Centre received Untied Grant 1 1 1 1 1 1 0 1 1 0 1 0 75 Sub Centre reported expenditure from Untied Grant 1 1 1 1 1 1 0 1 1 0 1 0 100 ANM having a joint account with the Sarpanch/ any other GP functionary 1 1 1 1 1 1 0 1 1 0 0 0 89 Sub Centre reporting maintenance of register to record the decisions taken to spend this amount 0 0 0 0 1 0 0 0 0 0 0 0 11 Sub Centre reporting written record of transactions being carried out on Untied funds 1 1 1 1 1 1 0 1 1 0 1 0 100 Sub Centre reporting that Sarpanch/ others ever reviewed the expenditure records 1 1 1 1 0 1 0 1 1 0 0 0 78
Spent on Purchase of Drugs ------Arranging Transport ------Paying of Power/ Telephone bills ------Arranging facilities like Water Cooler etc. for patients ------Other (like white wash maintenance etc.) 1 1 1 1 1 1 - 1 1 - 1 - 100
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CHAPTER 7
Status and Performance of ASHA
One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female community health activist ASHA’ or Accredited Social Health Activist. These ASHAs are supposed to act as a ‘bridge’ between the rural people and health service outlets and play a central role, in achieving national health and population policy goals. ASHA is to be selected from the village itself and accountable to it. The ASHAs are trained to work as an interface between community and the public health system. They are supposed to work on voluntary basis, although compensation is provided to them for specific activities and services. This chapter evaluates the performance of ASHAs in Rajouri district. The findings are based on the information collected from 10 ASHAs working in the selected villages.
NRHM guidelines envisage that there should be one ASHA for every 1000 population. However, the average population served by an ASHA in the selected villages in Rajouri is 1290 and the average number of villages/habitations served by ASHAs was found to be 2.6. This means that each and every village/habitation in Rajouri does not have an ASHA.
Selection of ASHAs (Table A1) The information collected from the CMO revealed that there are 395 villages in the district and 410 ASHAs have been selected to work in the villages. But it was found during the survey that some of the ASHAs have stopped working due to the non payment under JSY. NRHM guidelines envisage that ASHA must primarily be a woman resident of the village – married/ widowed/ divorced, preferably in the age group of 25 to 45 years. She should be a literate woman with formal education up to class eight. This may be relaxed only if no suitable person with this qualification is available. She will be chosen through a rigorous process of selection involving various community groups, self help groups, Anganwadi Centres, the Block Nodal officer, District Nodal officer, the village Health Committee and the Gram Sabha. However, information collected during the survey revealed that there is no set procedure for the selection of 125
ASHAs and selections are based on personal, political and bureaucratic considerations. This is established by the fact that the selection of only 50 percent of ASHAs was reported to be based on the recommendation of ANM/Village Health committee/Anganwadi worker and the remaining 50 percent were selected on other considerations.
Training of ASHAs (Table A2) Capacity building of ASHA is being seen as a continuous process. ASHA is supposed to undergo series of training episodes to acquire the necessary knowledge, skills and confidence for performing her spelled out roles. The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. However, it is clarified that ASHA training is a continuous one and that she has to develop the necessary skills & expertise through continuous on the job training. After a period of 6 months of her functioning in the village it is proposed that she be sensitized on HIV / AIDS issues including STI, RTI, prevention and referrals and also trained on new born care.
The information collected from the office of CMO shows that all the 410 ASHAs in the district have received nine days of training in Module 1 and 160 have also been trained in Module 2 (15 days). The information collected from the selected ASHAs also show that all of them have received training for Module 1 and 60 percent have also received training in Module II.
ASHA Kits (Table A2) The mission envisages that ASHAs will be empowered with knowledge and a drug kit to deliver first contact healthcare in her village. She will act as a depot holder for essential provisions being made available to all habitations like Oral Rehydration Therapy (ORS), Iron Folic Acid Tablet(IFA), chloroquine, Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. There will be regular and timely replenishment of ASHA kits. However, the information collected from the ASHAs reveals that 1 out of every 5 interviewed ASHAs had not received ASHA kits. All ASHAs who had received the kit reported that once drugs and other supplies exhaust in the kit, they are not again supplied in time.
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Role and Performance of ASHAs (Table A2) NRHM envisages that ASHA will be a health activist in the community who will create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services. She would be a promoter of good health practices and will also provide a minimum package of curative care as appropriate and feasible for that level and make timely referrals. ASHA will provide information to the community on determinants of health such as nutrition, basic sanitation & hygienic practices, healthy living and working conditions, information on existing health services and the need for timely utilisation of health & family welfare services. She will counsel women on birth preparedness, importance of safe delivery, breast feeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child. ASHA will mobilise the community and facilitate them in accessing health and health related services available at the Anganwadi/sub centre/primary health centers, such as immunisation, ante natal check up (ANC), post natal check up (PNC), supplementary nutrition, sanitation and other services being provided by the government.
Information was collected regarding the role played by the ASHAs in the villages and their performance. It was found that only 20 percent of the ASHAs are working as a DOTS provider. The average number of JSY cases facilitated during the last 3 months before survey worked out to be 2.3. All the ASHAs complained that had not the State government stopped giving JSY incentive to women they would have registered many more women under JSY.
ASHA’s have lost the credibility in the society. Women consider them to be agents and not facilitators and therefore find it difficult to continue working as ASHA. This has resulted in loss of interest among ASHAs to motivate women for ANC and institutional deliveries. The following remarks by two ASHA’s illustrates the concerns of majority of ASHAs.
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“We have become ineffective in our area due to non availability of money under JSY. o money is given to women who deliver in health institutions or women who avail A C but deliver at home. Though we give them full care throughout their pregnancy but still women have lost their faith in us because of money and they call us thieves. Consequently we are facing a lot of difficulties to motivate people for institutional deliveries”. “Since no money is presently available under JSY, we are rebuked and abused by women whom we had registered for JSY. This has demoralized ASHAs to perform their duties. ow even our family members criticise us and discourage us to work as ASHAs”.
The average number of children with diarrhoea who were given ORS by ASHA during the last three months prior to survey worked out to be 23. ASHAs reported that the incidence of diarrhoea in the region during the last three months was low because of winter and the incidence of diarrhoea during summer.
ASHAs seem to have stopped motivating women to go for institutional deliveries as the average number of women who were accompanied by the ASHA for institutional delivery works out to be less than 1. ASHAs mentioned that without JSY benefit it has become problematic for them to motivate or accompany pregnant women for institutional delivery. Another reason mentioned by the ASHAs for low level of institutional delivery is the terrain topography and consequent non availability of road transport. Besides, ASHAs mentioned that prevalence of corruption in the district hospital is another important reason for women not to prefer an institutional delivery. ASHAs are also supposed to distribute oral pills among women of reproductive ages and on an average an ASHA has distributed oral pills among 50 women during the last three months. Since the prevalence of malaria in Rajouri during winter months is very low, therefore, ASHAs had no or very little workload on account of malaria in the three months prior to survey. Though ASHAs have played some role in identifying new pregnancies but they have played no role in arranging women’s meetings or in arranging health and nutrition days.
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Incentives received (Table A2) As per NRHM guidelines, ASHAs will receive performance based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programmes, and construction of household toilets. However, it was found that ASHAs have received very little amount as incentive under NRHM. On an average an ASHA has just received Rs. 213 per month during the last one year. The average amount received per month is Rs. 183 under JSY, Rs. 10 for sterilization and Rs. 20 for other activities like pulse polio immunization. Almost all the ASHAs expressed that the main incentive which they were supposed to get was for JSY but when the government stopped the incentive under JSY, their incomes drastically declined. Consequently, they are not in a position to motivate women to come forward for institutional deliveries. ASHAs also expressed that whatever little incentive money they are getting under JSY, it was not paid to them timey and they are made to make frequent visits to BMO office to get it. Problems faced by the ASHAs (Table A3) All the ASHAs were asked to list the problems which they face in implementing programme activities under NRHM. It was mentioned by 90 percent of the ASHAs that non availability of money for JSY cases is the main reason which is responsible for tardy implementation of NRHM activities in the district. Another problem faced by the ASHAs in implementing the programme is inadequate training received by them. It was mentioned by ASHAs that the training received by them was grossly inadequate. Though the Module I training was of 9 days duration but the classes were irregular and time table was not followed strictly. Delayed supply of drugs was yet another problem faced by ASHAs in implementation of NRHM. ASHAs mentioned that the supplies are grossly inadequate, irregular and are not provided in time. Surprisingly, IFA tables which had already been expired had been supplied to a few ASHAs. Thirty percent of the ASHAs complained that the behaviour of the health officials particularly Community Health Officers is not appropriate. Yet another problem faced by the ASHAs in improving the institutional deliveries is lack of adequate facilities for institutional deliveries at CHCs and PHCs. ASHA expressed that facilities for caesarean section deliveries are not available in any of the PHCs or CHCs. Even at the 24X7 PHCs adequate staff is not available for conducting normal deliveries after working hours. This severely affects their working.
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Suggestions made by ASHAs (Table A3) All the selected ASHAs were requested to report the support which they require to enable them to implement the programme more effectively and multiple responses were recorded. It was suggested by almost all the ASHAs that they need more training that will help them to understand their job well. ASHAs also suggested that incentives based on performance of the ASHAs should be stopped and the scheme of fixed remuneration should be introduced. ASHAs mentioned that JSY scheme failed in the district because of the inadequate monitoring on behalf of higher officials and resultant corruption in the scheme and why should ASHAs suffer on account of this. They also mentioned that Rajouri is a backward area, health facilities are inadequate and has terrain topography and it is very difficult to implement the scheme effectively. Therefore, they are not in a position to motivate many women for institutional deliveries and thereby get reasonable amount under JSY. It was suggested that they should be given a fixed honorarium of Rs. 1000 for working as ASHA and some more amount based on performance.
Technical competence of ASHAs (Table A4) We tried to assess the technical competence of ASHAs by asking them a series of questions regarding their knowledge about prevention of diarrhoea, ideal time for initiating breast feeding and exclusive breastfeeding months for a child. When the ASHAs were asked to report important steps which should be taken for prevention of diarrhoea it was found that all the ASHAs know that proper hand washing and use of safe water can prevent child diarrhoea. Only 30 percent each of the ASHAs mentioned that use of covered containers and proper disposal of garbage can also prevent diarrhoea. However, large majority of ASHAs) had correct knowledge regarding ideal timing for initiating breastfeeding. Ninety percent of the ASHAs correctly mentioned that new born children should be breast fed within one hour of delivery. Ninety percent of the ASHAs also correctly knew that child should be exclusively breastfed for six months. These findings show that though majority of the ASHAs have correct knowledge about the timing of initiation of breastfeeding and duration of exclusive breast feeding but all the ASHAs are not fully aware about various steps that should be taken for prevention of diarrhoea.
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Conclusion Proper procedures have not been followed for the selection of ASHAs. Though all the ASHAs have received some training but ASHAs were not satisfied with the quality of training. Management support for ASHAs was found to be lacking and ASHAs are feeling that they are left alone in the village without having any linkage with the health system where they refer the patients. Lack of medical staff more particularly non availability of gynaecologists at PHCs and CHCs has severely hampered the functioning of ASHAs. Non availability of funds for disbursement to women under JSY has defamed the image of ASHAs. Prevalence of corruption in DH Rajouri is also responsible for low performance of ASHAs. The study suggests that following steps need to be taken for the success of ASHAs in the district. ASHAs should strictly be selected as per the ASHA guidelines. In addition to the main training, periodic retraining of ASHAs may be held for two days once in every alternate month where interactive sessions will be held to help them to refresh and upgrade their knowledge and skills, as provided in the original guidelines for ASHA. ASHAs should be linked with nearest functional health facility for referral services and their referrals be honoured on priority basis by various health institutions. Identified transport for referral of cases from village to facility. Besides, monthly meetings of ASHAs at PHCs should not become a formality but should be interactive and ASHAs should be given an opportunity to share their own experience, problems, etc. The supply of drug kits should be adequate and regular. Besides, ASHAs should get their incentive money in time and they should not be compelled to waste time, money and energy in visiting BMO/CMO offices to claim their incentive.
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Table A1. Status of ASHA Status of ASHA Value A. Number of ASHA interviewed in the district 10 B. Average population served by ASHAs interviewed 1290 C. Average number of village/habitations served by ASHAs covered 2.6 D. Percentage of ASHAs by method of selection Selected on recommendation of ANM 20 Selected on recommendation of Gram Pradhan 30 Selected on recommendation of Anganwadi worker - Selected on recommendation of Village Health Committee - Previously worked as Dai 10 Other 50 E. Percentage of ASHA undergone training 100 F. Percentage of ASHAs undergone training by modules Module 1 100 Module 2 60 Module 3 - Module 4 - G. Percentage of ASHAs issued ASHA kit 80
Table A2: Role and Performance of ASHA Role and Performance of ASHA Percent A. Percentage of ASHAs who are DOTS provider 20 B. Average monthly no. of JSY cases facilitated in last 3 months by ASHA 2.4 C. Average number of cases handled in last 3 months Children with diarrhoea given ORS 23.3 Number of cases 10 Accompanied institutional delivery cases 0.7 Number of cases 10 Number of Oral Pills distributed 50.3 Number of cases 10 Number of Malaria Patients given drugs 0.9 Number of cases 10 Number of new pregnancies identified 3.8 Number of cases 10 Number of group meetings like Mahila Mandals arranged 0.4 Number of cases 10 Number of Health and Nutrition day arranged - Number of cases 10 D. Average money incentive received by an ASHA on an average per month JSY 183 Sterilization 10 VHND -
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Other 20 Total 213 Number of ASHA interviewed in the district 10
Table A3: Distribution of ASHAs by reported types of difficulties faced and kind of support required 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 90 Adequate training is not provided 50 Delayed supply of drugs 50 Behaviour of staff in health facilities is not appropriate 30 Inadequate facilities for institutional deliveries 70 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 90 ASHA should be paid a fixed remuneration 70 Payments should be made timely 80 Other 10 Number of ASHA interviewed in the district 10
Table A4: Distribution of ASHAs by reported awareness on different aspects Reported awareness on different aspects Percent A. Percentage of ASHAs reporting important steps for prevention of diarrhoea Hand washing 100 Use of safe water 100 Use of covered container 30 Proper disposal of garbage 30 Other - Don't know - B. Percentage of ASHAs reporting ideal time for initiating breastfeeding Within 1 hour of delivery 90 Within 6 hours of delivery - Within 24 hour of delivery - After child has given water honey ghutti etc - Other - Don't know 10 C. Percentage of ASHAs reporting exclusive breastfeeding months for a child 2 months - 3 months - 6 months 90 Number of ASHA interviewed in the district 10
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CHAPTER 8
Role of Village Panchayats
The institution of Village Panchayat has to play a major role in the implementation of NRHM at the village level. Under NRHM Village Panchayats were to be empowered to control and manage the public health infrastructure in rural areas. A committee known as Village Health and Sanitation Committee (VHSC) was to be constituted in every SC within the overall framework of Village Panchayat in which proportionate representation from all the hamlets was to be ensured. The objective of this committee is to finalize the Village Health Plan. It has also to be responsible for over view and support for the household survey, preparation of Village Health Registers and organize activities like health camps to facilitate the planning process.
So far as the involvement of Gram Panchayats in the implementation of NRHM in Jammu and Kashmir at village level is concerned, it needs to be clarified that the term of the elected members of Panchayats has expired some 5 years back and fresh election have not yet been held. Consequently, Panchayaiti Raj Institutions in rural areas have become non functional. However in some villages, Old Panchayats are still looking after the welfare of the villages and in some villages Dehi Committees have been constituted locally to execute Rural Development Works. Some other villages have Auqaf Committees to run the affairs of mosques/shrines. In the absence of elected representatives of Panchayats, health officials have also involved the members of old Panchayats or members of Dehi Committees/Auqaf Committees or other responsible persons mainly Chowkidars/Numberdars/Teachers in the implementation of NRHM and made them as members of the Village Health and Sanitation Committees (VHSC). Therefore, during the course of survey, information regarding the situation of health, sanitation, nutrition and functioning of SCs was collected from persons who were members of the VHSC. In all a total of 11 persons were interviewed. The average population of a village Panchayat is about 5600 and mean number of households in a Panchayat is 735 (Table G1). The villages covered under the study had substantial concentration of Scheduled Tribe households but Scheduled Caste households were very few. The average number of Scheduled Tribe households in a Panchayat is 173. The average household size in the selected Panchayats works out to be 7.4 persons and mean household size in case of ST households is 7.7.
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Awareness and involvement of Panchayats (Table G2) One of the functions of the village Panchayat is to monitor the functioning of the SCs. Members of the VHSC are also supposed to check the attendance of the ANMs. But it was reported by 45 percent of our respondents that ANM is not regularly available in the SC. Members of the Panchayat/Dehi committees should be aware of the ANM Tour plan and in fact the ANM should plan her tour in consultation with the Panchayat members. But it was expressed by all our respondents that they are not aware of ANM Tour plan as they are never involved by the ANMs in the planning of health care services in the villages. Almost all our respondents expressed that ANMs are not available at the SCs for most of the time, therefore, people in general have lost faith on ANMs and they prefer to visit the local PHC, CHC or DH even for the treatment of minor ailments. Only 18 percent of our respondents opined that SCs provide timely services to the patients. As far as the satisfaction of the respondents with the services provided by the SCs is concerned, none was satisfied with the services.
IEC ANM should involve members of the Panchayat or any other local body in planning and conducting information, education and communication activities. However, all our respondents mentioned that neither ANM has conducted any IEC activities during the last year nor they were involved in planning or conducting any IEC activity in their area.
VHSC As mentioned above that Implementation Framework of the NRHM provides for the constitution of a Village Health and Sanitation Committee for every SC. The objective of this committee is to help the ANM in preparing the SC action plan and help her in planning and implementing various programmes related to health, hygiene, nutrition, sanitation and drinking water. Besides ANM, ASHA and representatives of the village Panchayat, VHSC should have representatives from women, NGOs and Women Self Help Groups. To enable the Village Health & Sanitation Committee to reflect the aspirations of the local community especially Scheduled Castes, Scheduled Tribes, Other Backward Classes are fully reflected in the activities of the committee due representation should be given to these communities. So far as the constitution of VHSC in Rajouri is concerned, it was found that though these committees have been constituted but they have not been constituted as per NRHM guidelines. VHSC has only one representative from the village i.e Chowkidar or Numberdar or any member of the Auqaf/dehi committee. None of these
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VHSC has any women member or representatives from other backward classes. This committee has not been given any publicity and generally people are not aware of such committees in the villages. This is perhaps the reason that about half our respondents who as per SC records are the members of the VHSC were not aware that VHSC has been constituted in their villages. After the constitution of VHSC, the members of the VHSC were to be oriented and trained to carry out the activities expected of them. But no such orientation/training programme has been conducted by the health department for the members of the VHSC. Consequently, these members are not well aware about their roles and responsibilities. The only role that most of the respondents know is that they have to cooperate with the ANM in utilizing untied funds.
VHSC meetings VHSC is supposed to regularly organize meetings to discuss issue which the community members face in availing health care services and find solutions for these problems. However, it was found that meetings of VHSC are not a regular feature even in those SCs where respondents are aware about the existence of VHSC. Only 17 percent of the respondents mentioned that meetings of VHSC are organized but these meetings are irregular and there is no time schedule for these meetings. In fact it was mentioned by all the respondents that ANM generally contacts them at the time of utilization of untied funds when she needs our signatures.
Village health action plan One of the important functions of the VHSC is to help and guide ANM in preparing the Village Heath Plan (VHP). The members are neither aware of any VHP nor they have any knowledge about any consultative process to be followed for the preparation of VHP.
Untied fund Every such committee duly constituted under NRHM is entitled to an annual untied grant of Rs.10, 000/ , which could be used for any of the following activities: (a) as a revolving fund from which households could draw in times of need to be returned in installments thereafter, (b) For any village level public health activity like cleanliness drive, sanitation drive, school health activities, ICDS, Anganwadi level activities, household surveys etc. (c) In extraordinary case of a destitute women or very poor household, untied grants could even be used for health care need of the poor household. (d) The untied grant is a resource for community action at the local level and shall only be used for community activities that involve and benefit more than one household.
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Nutrition, Education & Sanitation, Environmental Protection, and Public Health Measures shall be key areas where these funds could be utilized. Every village is free to contribute additional grant towards the VHSC. Thus the intention of this untied grant is to enable local action and to ensure that public health activities at the village level receive highest priority.
The State Government has released untied funds @ Rs. 10.000 to all the 1907 SCs in the State. The District as well as block records also show that untied funds have been released and utilized by all the SCs in Rajouri district. But when we asked the members of the VHSC about the receipt of untied funds it was found that they were ignorant whether the VHSC has received any money under Untied Funds or not. As some of the ANMs also mentioned that they have not received the untied funds, we therefore, thought it prudent to collect some more information about the implementation of untied funds at the SC level.
Our detailed discussion with the members of the VHSC revealed that once the untied funds were received by the BMOs, ANMs were directed to open a joint bank account with Sarpanch/Chowkidar/Mukhia/ of the village. The ANMs took their signatures/thumb impressions on the application forms. Some respondents also mentioned that they accompanied the ANM at the time of opening the bank account. Once the joint bank account was opened, a cheque book was issued which is under the custody of the ANM. Respondents were not sure about the amount that has been transferred in this account. However, the respondents have some vague idea about the purpose of the fund and most of them mentioned that it is for the development of infrastructure at the SC especially furniture and white wash/paint. Respondents also mentioned that they are not consulted for the utilization of this fund. Instead decisions about the utilization of the funds are taken by the BMO in consultation with ANMs. BMO after collecting information from the ANMs about the requirements of the SCs places orders for the purchase of furniture and other items. Once the items are received by the SCs, ANMs show the bills of the items supplied to the VHSC member and take their signatures on the cheque to be issued to the supplier. Thus in this whole process the role of the members of the VHSC is limited to signing of cheques.
ASHA As mentioned earlier that NRHM envisages promoting access to improved healthcare at household level through the female Accredited Social Health Activist (ASHA) chosen by and accountable to the panchayat to act as the interface between the community and the public
149 health system. Our respondents reported that they had no role in the selection of ASHA in their villages. The ASHAs were selected by the BMOs and they were not consulted. In fact they came to know about ASHA scheme only after their selection.
Though, ASHAs have been selected in almost every village but information collected from the selected VHSC members indicate that there are 55 percent of Panchayats where ASHA was selected but have stopped working. Respondents opined that ASHAs had the impression that they would be regularized and get regular honorarium like Anganwadi workers in addition to the incentives under JSY. But despite the hard work done by the ASHAs, they are not even getting the incentive under JSY not to speak of regularizing their services. Therefore, some of them have stopped working.
JSY Awareness about JSY was universal as all our respondents had knowledge of JSY. But respondents were confused whether or not any benefits under JSY are currently given to women. Two of our respondents attributed this confusion to the hoardings of the Directorate of Family Welfare and RCH placed in different health institutions of the district, wherein one hoarding does not show any amount, another shows Rs. 500 and yet another shows Rs. 1400. Only 55 percent of the respondents were aware about the benefits of JSY. All the respondents who are aware of JSY mentioned that cash incentive for institutional delivery is given to women. But none of them is aware that money is available for transportation or it is also available for women opting for home deliveries.
It was reported by majority of our respondents that women generally preferred to deliver at home. However, JSY brought about a dramatic change in this preference and they started to opt for institutional deliver mostly at District Hospital Rajouri. Since most of the women who preferred institutional delivery were not given any incentive under JSY, therefore, the enthusiasm generated by JSY got a setback. Another reason for preferring a home delivery is non availability of roads and transport facility. Respondents also complained of poor quality of services, non availability of gynecologists at the CHCs and DH that deter women to go for institutional delivery. Though all our respondents mentioned of the practice of corruption in the DH at various stages of delivery but 6 of our respondents mentioned that there is no fun to go for institutional delivery for claiming Rs. 1400 when you have to pay a minimum of Rs. 2000 3000
150 to the surgeon only for attending a cesarean section delivery and an additional amount of Rs. 1000 is to be incurred on transportation.
Problems in implementing RHM National Rural Health Mission was launched to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. The Goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children. In order to ascertain the perception of Village representatives regarding the impact of NRHM, we asked them whether NRHM has brought about any improvement in their area. Surprisingly, the respondents do not see any perceptible improvement in their villages so far as delivery and utilization of health care services are concerned. They mentioned that they do not have much information how untied funds are spent. Though ASHAs have been selected, but they are unable to carry out their activities due to non availability of JSY funds. SCs, PHCs and CHCs have been painted and they have been equipped with equipments and other supplies but there are no doctors available in these health institutions. Vehicles have been provided to PHCs/CHCs but they are not available when needed most.
Respondents were also asked to express the problems faced by them in implementing NRHM and multiple responses were recorded. It was mentioned by 82 percent of the respondents that ANMs do not seek their cooperation in running the affairs of SCs. More than 80 percent attributed the tardy implementation of NRHM to irregular and inadequate funding. Another problem mentioned by 72 percent of the respondents is non availability of doctors. Almost all the respondents expressed that ANMs do not attend the SCs regularly on the pretext of meetings and household visits, which hampers the implementation of health programmes in the villages. Fifty five percent of the respondents believe that low qualification, inadequate training and technical incompetence of ASHA hamper the implementation of NRHM. Another 73 percent of the respondents mentioned that an inadequate facility for institutional deliveries is also a big hurdle in proper implantation of NRHM.
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Finally, we requested our respondents to mention the kind of support which they require to implement NRHM more effectively. It was mentioned by almost all the respondents that responsible community members should be involved in running the affairs of SCs and they should be delegated powers to control and utilize the money received under untied funds and annual maintenance grants. Besides, 82 percent mentioned that more funds are required for maintenance and functioning of SCs. It was also suggested by 73 percent of our respondents that ASHA and Community members be given adequate training on issues related to health sanitation, nutrition and disease prevention.
Thus it may be concluded that community participation in the implementation of NRHM in the rural areas is almost nonexistent. Though, the VHSCs have been constituted but practically they are not involved in the functioning of SCs in the District.
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Table G1. Status of Gram Panchayats Covered Status of Gram Panchayats Covered value A. Number of Gram Panchayats covered in the District 11 B. Average population of Gram Panchayat covered Schedule Caste 10.5 Schedule Tribe 1313.2 Total 5654.5 C. Average number of households in the Gram Panchayat covered Schedule Caste 0.9 Schedule Tribe 172.7 Total 735.5 D. Average number of BPL families in the Gram Panchayat covered Schedule Caste 0.5 Schedule Tribe 130.5 Total 331.9
Table G2: Level of awareness and involvement of Gram Panchayats Level of awareness and involvement of Gram Panchayats Percent A. Percentage of Gram Panchayat reporting regular availability of ANM 45.5 B. Percentage of Gram Panchayat reporting timely services provided by Sub Centre to the patients 18.2 C. Percentage of Gram Panchayat reporting role of Gram Panchayat in conducting/finalizing IEC programme in Gram Panchayat 0 D. Percentage of Gram Panchayat reporting existence of VHSC in their Gram Panchayat 54.5 E. Percentage of Gram Panchayat reporting regular meetings of VHSC 16.7 F. Percentage of Gram Panchayat reporting Village Health Plan been prepared by VHSC 0 G. Percentage of Gram Panchayat reporting that VHSC has received any Untied Fund 0 H. Percentage of Gram Panchayat reporting ASHA worker in position 54.5 Continued
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Table G2: Level of awareness and involvement of Gram Panchayats Level of awareness and involvement of Gram Panchayats Percent I. Percentage of Gram Panchayat reporting awareness of the benefits under JSY scheme 54.5 J. Percentage of Gram Panchayat reporting that NRHM brought about any improvement in their area 0 K. Distribution of Gram Panchayats covered by type of improvement reported due to NRHM Funds available for maintenance of Sub Centres - Community support is available as ASHA worker - Funds/facilities are available under JSY - Better facilities are available for CHCs/PHCs for referred patients - Transport facilities are available - Other - L. Distribution of Gram Panchayats by type of difficulties faced in implementing programme activities under NRHM Funds not available in time 81.8 Decision making with community leaders are difficult 9.1 ANM does not seek their cooperation 81.8 ASHA has not been adequately trained 54.5 Adequate facility for institutional deliveries are not available 72.7 ANMs are not always present in the Sub centre 100.0 M. Distribution of Gram Panchayats by kind of support required to implement programme more effectively More funds are required for maintenance/ effective functioning 81.8 Gram Panchayat should be given direct control over funds 90.9 More training is to be arranged for ASHA and Community members 72.7 Level of awareness and involvement of Gram Panchayats Any other 27.3 Number of Gram Panchayat covered in the district 11
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CHAPTER 9 Client Prospective
The Government of India has launched the National Rural Health Mission (NRHM) on 12th April, 2005 for a period of seven years (2005 2012) to improve access of people, especially the poor women and children, to quality primary health care services. NRHM in basically a strategy with an objective to provide accessible, approachable, accountable, effective and reliable health care, especially to poor and vulnerable sections of the population in rural areas. The mission provides on overarching umbrella, subsuming the existing programme of the Central Health Ministry. NRHM is operational over the entire country with special focus on 18 states which includes the state of Jammu and Kashmir also. The JSY has generated considerable amount of speculation in increasing the number of institutional deliveries in order to reduce MMR and IMR to a desired level. But to what extent NRHM has improved the service delivery is not known. How has the community reacted to this new programme remains to be examined? The objective of this chapter is to answer some of these questions. The chapter starts with a description of the demographic and socio economic characteristics of the interviewed men and women and goes on to discuss the household details, knowledge about National Rural Health Mission (NRHM), Janani Suraksha Youjana (JSY), utilisation of antenatal services, post natal services, child health services followed by incentive money received under JSY. An attempt has also been made to analyse the knowledge of the respondents about family planning methods and HIV/AIDS. Finally, opinions of the respondents regarding the quality of services delivered by public health institutions under NRHM in the district have also been analysed.
Background characteristics of household respondents The information on characteristics of the respondents presented in Table H1 reveals that of the total 1,196 interviewed respondents, 85 percent are female and 15 percent are male. The table further shows the percentage distribution of respondents by age. Almost fifty percent of our respondents were less than 30 years of age and 31 percent were 30 39 years. The percentage of respondents who were more than 40 years was 17 percent. So far as marital status of the respondents is concerned 80 percent of the respondents were currently married, 10 percent were unmarried, 2 percent were widowed, and the remaining less than 1 percent were divorced or separated.
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An important feature of the health seeking behaviour is the level of education especially of the women. Since 85 percent of the respondents are women, therefore, the educational distribution of the respondents reveal that more than one half (53 percent) are illiterates, 26 percent have completed middle, 17 percent have at least high school education or more, and 4 percent have attained less than primary level education.
The information in Table H2 on household characteristics reveals that almost all the respondents (97 percent) in Rajouri are Muslim and only 3 percent are Hindus. Thirty six percent of the respondents belong to scheduled tribes, 27 percent belong to other backward classes and less than 1 percent belongs to scheduled castes. Remaining 36 percent of the respondents do not belong to any of the above mentioned groups. Half of the households in Rajouri have the below poverty line (BPL) status.
Information was also collected regarding some of the important housing characteristics like type of house, electricity, telephone, TV, cooking gas, toilet, piped water supply, agricultural land, and standard of living. The information collected on type of house reveals that 28 percent of the respondents are living in pucca houses and the remaining households have either a semi pucca or a kuccha house. The availability of sanitary facilities is an important determinant of the health status of household members, particularly of children. Lack of availability of sanitary facilities possesses a serious health problem. The data collected on this aspect reveals that only 13 percent households have some toilet facility, where as rest of them reported to have no toilet facility and are defecating in open spaces. Therefore, there is a large scope in the district to start a campaign for construction of public toilets.
More than ninety percent of the households reported to have at least some agricultural land; but most of this land is not irrigated due to the lack of irrigation facilities. Eighty six percent of the households are having access to electricity. Nearly half of the households (48 percent) have mobile phone facility and 25 percent posses a television set. Twenty nine percent of the households use liquid petroleum gas for cooking purposes. However, fridge, computer, tractor, scooter and washing machines are not so commonly available in the district.
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Sons and daughters born The data was also collected on the number of living children in the household born during last five years prior to survey. Information presented in Table H2 reveals that of the total number of 1,196 households surveyed, 744 mentioned that there was at least one live birth in their household during the last 5 years. Of these 744 births, 197 (26 percent) were born in health institutions. Thus, even after implementing NRHM in the district, still three fourth of the births are delivered at home.
Waste disposal and system of medicines preferred Pools and streams of wastewater are common scenes in rural areas. If not disposed properly, waste water can breed mosquitoes. Stagnated water is also a prime cause of morbidity and mortality. Under NRHM, ASHAs are being trained to raise awareness on hazards of indiscriminate waste water disposal and household waste and educate community members about proper waste water management. In the present survey an effort was made to ascertain the health and sanitation situation in the households. The data given in Table H3 reveals that 88 percent of the household throw the household waste in open space, 9 percent burnt it and another 3 percent bury it in a pit. Higher percentage of households living in non Sub Centre villages throw the waste in open than the households who are located in Sub Centre villages. As far as stagnation of waste water around the houses is concerned, 8 percent of the respondents reported that the waste water stagnated around their houses. Of the households who reported stagnation of waste water around their houses, 95 percent also reported that there are instances of mosquito breeding.
The respondents were further posed a question to report the system of medicines they usually prefer in case of illness and multiple responses were recorded. Allopathic system is generally preferred by all, as almost all the respondents showed their preference for it. Allopathic system is followed by traditional healing (16 percent) and 1 percent each reported for Ayurveda and Unani system of medicines respectively. None of the respondents reported for Siddha, Yoga and Naturopathy. Further this needs to be mentioned that are no difference in preference among respondents belonging in sub centre villages or non sub centre villages.
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Information about health worker, health facility and transport used for serious patients NRHM survey included a series of questions on knowledge of respondents regarding male and female health workers, visits by health workers, type of health facility available at the time of need and type of health facility where serious patients are taken. The results presented in Table H4 reveals that 57 percent respondents have heard about ANM and 48 percent have heard of Male Health Worker. However, the knowledge regarding health workers was more among the respondents who were living in the sub centre village (62 percent) than those who belonged to non sub centre villages (53 percent). Health workers are expected to visit households for IEC activities. But it was found that Health workers do not perform this activity as per the guidelines. During the last one month prior to survey they have not visited about 75 percent of the households. Another important finding which emerges from the present study is that even if Health workers visit households, they prefer to visit the households located in the Sub Centre villages and avoid households located in non sub centre villages. A health worker posted at the health centre should normally be available at the SC when needed by the community members. However, large majority of the respondents reported that Health Workers are not available when they require their services. In fact they mentioned that ANMs come to the SCs once or twice a week and most of the time they remain absent from the SCs on the pretext of meetings, household surveys, IEC activities, immunization, etc.
All the respondents were also requested to mention name of the health facility which is available to them when they are in need. Multiple responses were recorded. More than one half (53 percent) mentioned that they visit to district hospital, 46 percent visit to a Primary Health Centre (PHC), 13 percent go to a private clinics, 8 percent visit a CHC and 10 percent go to a SC. Thus, most of the households prefer to bypass the CHCs, PHCs and SCs and prefer to visit District Hospital even for the treatment of minor ailments. One of the reasons for this state of affairs is non availability of staff at the SCs, PHCs and CHCs. There is not much difference in preference of health facilities among households who live in a SC village and those who do not belong to a SC village. Enquiries were also made regarding health facilities where the serious patients are taken. Here also some respondents reported multiple places of treatment. But large majority of the households (95 percent) take serious patients directly to district hospital, followed by 15 percent who take their patients to a PHC. Nearly 5 percent each of the households take their patients to a CHC or consult a private doctor. Once again CHCs are not preferred for the treatment of serious patients in
158 the district. One of the prime reasons for preferring PHCs to CHCs is the inconvenient location of CHC Darhal.
Respondents use a variety of modes for transporting patients to a health facility. Due to the terrain topography, the patients have either to foot the distance upto the road or have to use a cot to bring the patient up to the road. In fact more than 70 percent of the respondents mentioned that due to the non availability of road connectivity they have to first bring the patients either on the back or use a cot. Public transport is used to carry the patients by 66 percent and private transport by 40 percent. This is important to note that use of ambulance for shifting serious patients to health facility was reported by only 1 percent respondents. The above information reveals that the level of health facilities has not changed so far even after the introduction of NRHM.
Knowledge about RHM, ASHA, VHSC and JSY. Lack of knowledge of any health programme can be a major obstacle to its use. During the present survey each respondent was asked about the knowledge regarding NRHM in general and about some of its components in particular. Table H5 reflects that only 10 percent of the respondents have heard about NRHM. So far as the sources of knowledge of NRHM are concerned, 63 percent of the respondents have heard of NRHM from radio/television, followed by 32 percent who had come to know about NRHM from friends/relatives. News papers were reported to be a source of knowledge by 16 percent, while as ASHA and panchayats have virtually played no role in disseminating the knowledge regarding NRHM. If we look at the data collected lesser percentage of respondents from sub centre villages have heard about NRHM as compared to those who belong to non sub centre villages. This information indicates that a lot is to be done for the proper implementation of NRHM especially by the health department itself.
The respondents were supposed to get health education on personal hygiene, sanitation, mother and child care and other related health issues at gross roots level through ASHA. Therefore, NRHM survey asked the respondents whether they are acquainted with the name of ASHA or not. Table H5 shows the percentage distribution of respondents by their knowledge about ASHA and the type of services provided by them. Though wide publicity has been given to ASHA but only 30 percent of our respondents had heard of ASHA. Respondents who knew about ASHA were further asked to report the services that are delivered by ASHAs. It was reported by 56 percent of the respondents that ASHA carries a medical kit, and another 29 percent mentioned that
159 common medicines are provided by ASHA free of cost. Since ASHAs are supposed to educate community about sanitation, hygiene and proper waste disposal, therefore, respondents were specifically asked whether ASHAs performs these roles. But it was found that all the ASHAs do not perform all these activities. The topics most frequently discussed by ASHA with respondents are hand washing (17 percent), safe drinking water (16 percent) and construction of household toilets (12 percent).
Under NRHM each and every village had to constitute a Village Health Sanitation Committee (VHSC) to look after the health, nutrition, sanitation and drinking water affairs of the villages. Though the health officials at the district and block level informed us that VHSCs have been formed in each village but surprisingly only 1 percent of our respondents had knowledge about the existence of VHSC in their villages. It appears that the health officials at the village level have not given much publicity to VHSCs. Besides, VHSCs have not done anything concrete in improving the health and sanitation of the villages, therefore, formation of VHSCs has remained confined to papers only. Similarly, when the respondents were asked about Village Health Nutrition Days in villages, only 1 percent of our respondents had heard about VHND. Thus, VHND also remains to be a neglected issue even under NRHM.
Overall, these findings suggest that implementation of NRHM in Rajouri district has not been well integrated. Major health related awareness topics under NRHM are rarely discussed during visits to a health facility with the respondents. Indeed, in the process of providing health and childcare services, health workers in general and ASHA workers in particular are missing the opportunity to discuss various issues with masses. It is also evident that the provision of advice and information on safe motherhood practices to pregnant women and mothers with young children is very limited.
Janani Surakshya Yojana Janani Suraksha Yojana (JSY) under the umbrella of NRHM has replaced the existing National Maternity Benefit scheme (NMBS) which was basically linked to provision of better diet for pregnant women from BPL families, but JSY integrates the cash assistance with ANC during the pregnancy period, institutional care during delivery and immediate post partum period in a health centre by establishing a system of coordinated care by field level health worker. The JSY is a fully centrally sponsored scheme. The basic aim of the JSY is to reduce the infant
160 mortality rate and maternal mortality rate and increase the institutional deliveries from 47% to 80% during the given period of time.
The JSY envisages that the benefit of the Yojana would be extended to all the BPL families of ten (10) low performing states namely 8 EAG states (Utter Pradesh, Uttaranchal, Medhya Pradesh, Chattisgarh, Rajisthan, Bihar, Jharkhand and Orissa) and the state of Assam and Jammu and Kashmir. However, the benefit is due to mother even after the third birth, if she of her own accord chooses to undergo sterilization in the health facility where she delivered, immediately after the delivery. This needs also to be noted that the benefit is also due to such pregnant women falling in the above category even though she is not registered under JSY previously but needs institutional care for delivery.
In order to implement JSY the state government reacted positively and geared up all necessary machinery and resources to implement this new benefit scheme. The JSY has generated considerable amount of speculation in increasing the number of institutional deliveries in order to reduce MMR and IMR to a desired level. But to what extent this scheme has been implemented and what are the experiences of services seekers is not known. In this section an attempt has been made to know experiences of the community regarding JSY.
All the respondents were enquired whether they are aware of a yojana called JSY. Table H5 shows that only 43 percent of the respondents have heard about JSY. Respondents have heard about JSY from a variety of sources. Doctors as a source of information was reported by 30 percent of the respondents. Sixteen percent of the respondents had heard about JSY from Radio/TV. ASHA as a source of knowledge was reported by only 15 percent. Hoardings at PHCs/CHCs had also helped 11 percent of the respondents to know about JSY. The data also shows 7 percent of the respondents had heard about JSY through ANM and 4 percent from Anganwadi Worker. Other sources such as relatives, friends, and family members had disseminated information to 40 percent of the respondents, where as Panchayats, NGOs and SHGs have played no role in disseminating information regarding JSY. When the respondents were asked to mention whether there is any woman who is a beneficiary of JSY, it was found that only 17 percent of the households who had heard about JSY had at least one JSY beneficiary. It needs to be mentioned that in the present survey a household was considered to be a JSY beneficiary if the respondent or any other women in the household was registered under JSY irrespective of the fact whether she had received monetary incentive under JSY or not. 161
Background characteristics of JSY beneficiaries Table H6 presents information about various social, economic and demographic characteristics of JSY beneficiaries in Rajouri district. As mentioned above that only 90 households had JSY beneficiaries and if a household had more than two JSY beneficiaries, information was collected regarding the women who had delivered recently. Of the 90 beneficiaries, 89 are Muslims. In Jammu and Kashmir, JSY has been extended to all women irrespective of economic status and parity. The distribution of members by type of social category shows that nearly half of the beneficiaries belong to general caste, 32 percent are from other backward classes and 18 percent belong to schedule tribe category.
Table H6 also presents the distribution of beneficiaries by age and parity. The proportion of beneficiaries in five year age group increases from 9 percent in the age group less than 20 years to 33 percent in the age group 20 24 years and then further increases to 36 percent in the age group 25 29, and then steadily fall to 16 percent, 6 percent and 1 percent in the consequent age groups respectively. So far as the parity is concerned, percentage of JSY beneficiaries increases sharply with parity. Seventeen percent of the beneficiaries were of parity one and 39 percent were of second parity and 44 percent were of higher order parities (3 or more).
According to the information given by the respondents, slightly less than one half (47 percent) of the beneficiaries belong to BPL families. The data on standard of living index (SLI) reveals that 36 percent each of the beneficiaries belong to households with low and medium SLI and remaining 29 percent belong to households with high SLI. Table H6 also shows that slightly more than one half (52 percent) of the women registered under JSY have delivered their most recent birth in a health institutions and remaining 48 percent were delivered at home.
Timing, person and place of registration In order to avoid the risks of pregnancy and child bearing the antenatal care is an essential link between women and the health system in all respects. A pregnant woman, therefore, is supposed to visit the health centre for her check up at the early stage of pregnancy. This enables the health worker to evaluate any abnormality of the pregnancy or the deficiency so that he/she can take the necessary measures at the appropriate time to manage the complications and ensure safe delivery. To know whether women are registered under JSY and provided services as per JSY guidelines, all the women who had heard about JSY were asked a series of questions. The first questions put
162 to the women was whether they had heard about JSY before being pregnant or during pregnancy. Table H7 shows that 63 percent had heard about JSY during pregnancy and 37 percent had heard about it before their pregnancy. The second question tried to ascertain whether women knew the stage of pregnancy when they were registered under JSY scheme. It was reported by about two third of the women that they were aware of the stage of pregnancy when they got registered under JSY. All the beneficiary women who knew the stage of pregnancy were asked to report the month of registration of their pregnancies. Though ASHAs are supposed to register women for JSY soon after the pregnancy is confirmed, but 46 percent of the women reported to have been registered after 5th month or after that. .It was reported by 27 percent that they were registered in the 3rd month, and another 15 percent in the 4th month. The percentage of women who were registered in the first or second month of pregnancy was 12 percent. However, it was reported by most of the health workers that the pregnant women are usually registered when they come to receive the first dose of tetanus toxide injection. Most of the beneficiary women reported to have been registered by doctors (40 percent) followed by ASHA (29 percent) and ANM/FHW (27 percent). Large majority of the women (38 percent) reported to have registered themselves at the PHC and a substantial proportion were registered at District Hospital (31 percent) and sub centres as place of registration was reported by 24 percent. Surprisingly, none of the women reported CHC as a place of registration.
Role of ASHA and difficulties faced by beneficiaries in getting JSY card ASHA is a health activist in the community who has to create awareness on health and its social determinants and mobilise the community towards local health planning and increased utilisation and accountability of the existing health services. ASHA has to mobilise the women and facilitate them in accessing health and health related services, such as immunisation, Ante Natal Check up (ANC), Post Natal Check up and other services provided by the government. Keeping in view the above mentioned responsibilities of the ASHA, she is supposed to guide, help and even accompany the pregnant women at the time of her registration and also ensure that she gets the JSY card without facing any difficulty. Table H8 shows the different types of formalities which the beneficiaries have to fulfill for getting benefit under JSY. Multiple responses were recorded and the information reveals that out of 90 beneficiaries only 64 percent reported to have received JSY cards and out of these beneficiaries 38 percent were helped by ASHA to obtain a JSY card. So far as the problems faced by the women to obtain a JSY cards is concerned, a larger proportion of beneficiaries (95 percent) opined that the procedures followed for
163 procuring cards are not difficult at all and only 5 percent found them somewhat difficult. Sixty seven percent of the beneficiaries who found the procedures difficult mentioned that the formalities for making cards are too cumbersome. One respondent each related it to non availability of cards and bribery.
Role of ASHA during Pregnancy ASHA is supposed to mobilize the community and facilitate in accessing health and health related services available at sub centres, primary health centres, such as immunization, antenatal care, post natal checkup etc. ASHA is also supposed to accompany pregnant women and even children requiring treatment or admission at the nearest pre identified health facility like primary health centre, community health centre or first referral unit.
The women who received help from ASHA during registration and procurement of JSY cards were further asked to reveal whether they have received any advice regarding the health related issues from ASHA during the course of pregnancy. The data given in Table H9 on some specific types of help provided to beneficiary at the time of her last pregnancy reveals that only 23 percent of the beneficiaries reported that they were helped by ASHA. Regarding the type of help 19 percent women were given advice on breastfeeding, 16 percent were given advice on danger signs, followed by 13 percent each on diet and delivery care respectively. The other issues such as, information on new born care and family planning was also provided to 11 percent each of the beneficiary women. Another 22 percent respondents reported that the ASHA have stopped working in their villages.
In order to avoid complications at least three antenatal checkups are necessary for a pregnant lady. Besides women should know the dates and place of next check up, place and date of delivery and place of referral in case of complications. ASHA and health workers are supposed to provide detailed information to pregnant women on each of these aspects. To what extent ASHAs are performing these activities, we asked a series of questions to women who were registered under JSY and the same is presented in Table H9. More than one half (53 percent) of the women were informed about next check up and 60 percent of them were also informed about the place of next check up. Date of expected delivery and place of delivery was also communicated to 32 percent and 29 percent of the pregnant women respectively. The information on place of referral during complications was reported by only 16 percent
164 beneficiaries (Table H9). Thus, it appears that pregnant women are not given complete information regarding various components of antenatal and natal care services by the ASHA and health workers.
Place of delivery and reasons for opting institutional delivery Another important thrust of the NRHM is to encourage deliveries under proper hygienic conditions under the supervision of trained health professionals. The goal is to reduce the IMR from 58 to < 30 by 2010. The MMR which is presently around 400 and is proposed to be reduced up to 100 and the institutional deliveries to go up from 47 percent to 80 percent during the given period of time. NRHM encourages institutional deliveries and lots of inputs are being put in place to motivate women to deliver in health institutions. During the survey an effort was made to know the percentage of women utilizing institutional deliveries and the reasons for preferring home deliveries. Table H10 shows that 55 percent of the births took place in public health institutions and 45 percent took place at home. Women prefer District hospital for delivery as more than 80 percent of the institutional deliveries take place at District Hospital and 14 percent at PHCs. Surprisingly, the services of CHCs have not been utilized by the respondents for delivery purposes. Thus, there appears to be some serious problem with the working of CHCs. The respondents who opted for institutional deliveries where further probed to mention reasons for opting institutional deliveries. Multiple responses were recorded and are presented in Table H10. It was mentioned by 29 percent of the women that they opted for an institutional delivery because better care for mother and child is available at the health institutions than at home. Another 22 percent of the respondents preferred an institutional delivery for monetary reasons under JSY and another 22 percent mentioned that they have a better access to health institution for deliveries. Nearly 20 percent cited the reason that their previous child was born in an institution. ASHA was considered as a support for institutional deliveries by 12 percent, followed by 7 percent respondents who mentioned that they have the provision of services in their own area. None of the respondents mentioned that assistance for transport facility was motivating force for opting for institutional deliveries.
Transport facility For any type of health services, existence of a suitable transport facility is essential. In fact, availability of transport is more important for the poor because they cannot afford it easily. To mitigate the problems of poor women who cannot pay for transportation, NRHM has tried to
165 solve this problem by giving incentives to pregnant women through JSY scheme which includes money for transportation also. This survey made an effort to collect information from the beneficiaries to ascertain whether the money is reaching the needy or not. ASHAs are supposed to help the pregnant women in arranging transportation at the time of delivery. ASHA/ANM is also supposed provide a referral slip to pregnant women to access delivery services, but 93 percent of the women mentioned that they did not received any referral slip from ASHA/health personnel. In fact 41 percent of the women expressed that they faced difficulties in reaching health institutions at the time of delivery. One of the main problems in reaching the health institution was non availability of transportation. It was reported by 12 percent of the women that they had insufficient money to bear the delivery costs. Other problems in reaching the health facility were non availability of male members, non cooperation of ASHA worker and odd timing to visit a health facility.
Table H11 also shows that that on an average the distance from residence to ultimate place of delivery was reported to be 21 kilometers and the mode of transport to reach the place of delivery was reported to be a private vehicle by 68 percent of the respondents. The services of government ambulance were used by 17 percent and 15 percent covered the distance by foot/cot. The transportation was arranged by relatives for 95 percent of the women and in case of 5 percent women ASHA/ANM helped in arranging transportation. Village Health Committees are not involved in arranging transportation for delivery cases. The average cost on transportation during delivery was Rs. 520. The payments for the transport were borne by the respondents and none of the beneficiaries had received any transportation assistance under JSY from the government. Under NRHM the ASHA is supposed to accompany pregnant lady to health facility where the delivery is expected to take place. But the data shows that most of the pregnant ladies (90 percent) were accompanied by their relatives and only 10 percent women reported that they were accompanied by the ASHA.
Type of delivery and amount spent The health services required by pregnant women at the time of delivery are other important dimensions of the maternal and child health services because the natal care is closely associated with the survival status of the mother and child. All the 41 beneficiary women who delivered in a health facility reported that on an average they had to wait at the health facility for 27 minutes before someone attended them. Commenting on the type of delivery 51 percent
166 deliveries were reported as assisted (Forceps, Vacuum) deliveries, 44 percent were normal deliveries and 5 percent delivered by caesarian section. Eighty five percent of the beneficiaries had to pay for the services at the heath facility and average amount paid was reported as Rs. 2, 246. It was reported by all the women that paying tips to the hospital staff for availing services is considered to be a routine. Women have to pay for each service like occupying bed, changing bed sheets, lab services, delivery, bathing, immunization etc. Women who had to deliver through cesarean section have even been forced to pay an amount of Rs. 2000 4000 to the Doctors for caesarean section. All the beneficiaries mentioned that on an average each one of them had to spend two da at the health centre.
The beneficiaries were asked to mention whether they are satisfied with the services provided to them at the public health facility. Most of the service seekers (83 percent) were satisfied or somewhat satisfied with the services provided to them and 17 percent showed their dissatisfaction. Those respondents who showed their dissatisfaction with the services were further asked to mention the reasons for their dissatisfaction. The higher proportion of beneficiaries (43 percent) was upset with rude behavior of staff, 29 percent complained for poor quality of services and another 14 percent said that facility was not clean (Table H12). So far as higher level of satisfaction with the quality of services is concerned, respondents expressed that since they do not have any better alternatives available therefore, they have to be satisfied with whatever service is provided to them, even if they are forced to pay for most of the services. Reasons for home delivery The respondents who opted for home delivery were asked to mention the reasons for home delivery and the responses are shown in Table H13. Seventy one percent of the women who had delivered at home mentioned that they could not visit a health facility for delivery because of non availability of road transportation. Another 23 percent of the women preferred a home delivery because they think that the behaviour of medical/paramedical staff is indifferent and another 23 percent mentioned that they do not have the financial resources to bear the costs involved in institutional delivery. It was also mentioned by 17 percent of the women that it is not customary to deliver in hospitals as they have had no problems in earlier deliveries. These results suggest that there is still a need to improve the services in the health institutions, change the attitude of the medical and paramedical staff and stop the prevalence of corruption in the District Hospital.
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Receipt of cash Incentive JSY guidelines envisage that cash incentive should be given to women soon after the delivery. However, in Jammu and Kashmir, though JSY scheme was implemented but cash incentives to women were stopped during 2007 08. It was reported by the BMOs that once the funding under JSY was stopped to them they only used to register women under JSY, prepare the JSY cards and provide them services but do not pay any cash incentives. This is the main reason about 94 percent of the JSY card holders had not received any cash incentive under JSY after delivery, however, only 6 percent of the beneficiaries reported to have received cash assistance under JSY. All these women had received the assistance before JSY funding was stopped. Though, a woman is supposed to receive Rs. 1400 under JSY, but in Rajouri district women on an average had received Rs. 940. Besides, this amount was to be paid in a single installment but 20 percent of the women reported to have received it in 2 3 installments. As per NRHM norms a pregnant lady should normally get incentive money when she is admitted for delivery or soon after the delivery. But the information collected from the beneficiaries reveals that this money is not paid as per the guidelines. Beneficiaries are compelled to visit the BMO office a couple of times to get the money. This is substantiated by the fact that 40 percent of the women had received the amount within a week after delivery. Twenty percent of the respondents received payment through ASHA and others reported from doctor, LHV and ANM/FHW. Eighty percent payments were made at primary health centres and the remaining 20 percent at district hospital. Eighty percent of the respondents did not face any difficulty in getting money. However, those who faced difficulty in getting money related it to the demand for bribe.
Client satisfaction In 1996, the existing family welfare programme was transformed into the new Reproductive and Child Health (RCH) Programme. This new programme integrates all family welfare, women and child health services with the explicit objective of providing beneficiaries with .need based, client centered, demand driven, high quality integrated RCH services (Ministry of Health and Family Welfare, 1998b:6). The strategy for the RCH Programme shifts the policy emphasis from achieving demographic targets to meeting the reproductive needs of individual clients (Ministry of Health and Family Welfare, 1996). The present study included several questions on the quality of care of health and family welfare services provided in the public sector. This section first describes the sources of health care for households then presents data for home visits by health and family planning workers and examines several different aspects
168 of visits by respondents to health facilities, including source of care and quality of care. Though we covered 1196 households under the rapid appraisal survey but information regarding the client satisfaction was collected only for those households who availed health services from the government health facility in last 6 months prior to survey. If the services were availed by the children below 16 years of age, information regarding the quality of care was collected from the adult household member who accompanied the child to the health facility.
Of the 1196 households covered under the study, members of 60 percent of the households had visited a government health facility to avail health care services (Table H15). This percentage is slightly higher in case of households who belong to SC villages than non SC villages. Table H16 gives the some socio economic and demographic characteristics of respondents who visited the public health facility. Three fourth of the respondents who had visited a health facility were female and only 25 percent were male. The proportion of respondents by age reveals that 48 percent were between age 20 39 years, 26 percent were less than 19 years and another 27 percent were 40 years or more. An important component of the health seeking behaviour is the level of education. The distribution of respondents by educational reveals that more than one half of them (55 percent) were illiterate, 29 percent have completed less than 10 years of schooling and 16 percent have completed 10 or more years of school education. Ten percent of our respondents were unmarried, and 5 percent were widowed/separated/divorced. Scheduled tribes accounted for 37 percent of our respondents and OBCs accounted for 26 percent. Large majority f our respondents (98 percent) were Muslims and 2 percent were Hindu. Data on the standard of living of the respondents shows that 52 percent belong to below poverty category (BPL). Further households by SLI shows that 51 percent belonged to households who had a low SLI and 32 percent belonged to households with a medium SLI and 17 percent belonged to households with a high standard of living.
Type of health facility visited All the respondents were asked to mention the health institution where they availed the services. Table H17 shows that a higher proportion of respondents (64 percent) have visited district hospital, 24 percent visited a PHC, 7 percent availed the services from CHC and 4 percent reported to have visited a sub centres. When the respondents were asked to report the purpose of visit to the health facility it was mentioned by 47 percent of them that they visited the health
169 facility for the treatment of minor ailments, 5percent for ANC services, 24 percent for immunisation of children, 23 percent for the treatment of other major diseases.
One of the important components of quality of care is the behaviour of the staff. When asked about the behavior of the health staff at the time of treatment, 55 percent opined that the behaviour of the staff was courteous, 41 percent termed it casual/indifferent and 4 percent said it was insulting/derogatory. Respondents were asked to express whether the doctor/staff listened to his/her health complaints patiently. Majority of the respondent (59 percent) mentioned that the doctor/health staff listened to their complaints patiently, 38 percent said that they somewhat listened patiently and 3 percent felt that the health staff did not paid any attention to their health problems. Sixty three percent opined that women patients were treated in privacy but 63 percent revealed that patients with chronic diseases do not get medicines regularly from the health facilities. So far as the private practice by the doctors is concerned it was reported by about 80 percent of the respondents that the doctors posted at the government health facilities were doing private practice during and after working hours. Finally respondents were asked to report whether they were satisfied with the overall services and the behavior of the staff at the government health facility visited by them. About one third of the respondents were fully satisfied with the services availed by the respondents and another 38 percent were partly satisfied. The percentage of respondents who were not satisfied with the services was 30 percent. Similarly, 35 percent were satisfied with the behaviour of the staff and 27 percent were not satisfied. A substantial proportion of respondents were partly satisfied with the behaviour of the staff at the government health facilities.
User’s fees and extra charges The information was collected from the respondents who have availed the services from government health facility and were asked to express their opinion on the user fee charged by the government health facilities. It was reported by 92 percent of the respondents that government health facilities are charging user fees from the patients (Table H18). Of the respondents who mentioned charging of user fees, 98 percent mentioned that it is charged for registration (OPD Ticket). User charges for X rays were mentioned by 12 percent, for ultrasound by 6 percent and lab tests by 15 percent. Eighty one percent reported that proper receipts are given for fees charged for different services mentioned above. However, 28 percent
170 of the users recorded that in addition to above listed services extra money is also charged for availing various other services as well.
Services for BPL patients Under the NRHM the patients who belong to BPL category are supposed to get subsidized services in public sector health facilities when they are under treatment at these facilities. The BPL patient’s are provided subsidies on medicines, tests, etc. How far these services are available and availed at these health facilities, information was collected from the respondents and are presented in Table H19. Eighty five percent respondents denied that BPL patients are getting any subsidized services, 11 percent did not know whether or not government health facilities provide any free/subsidized services to BPL patients and only 4 percent accepted that BPL patients are provided free and subsidized services. The Rogi Kalyan Samities (RKS) are supposed to help BPL patients in completing the formalities like filling of forms etc. and getting them attested from concerned authorities. Therefore, those respondents who responded in affirmative were further asked to reveal whether BPL families are facing any problems in completing the paper work and whether RKS facilitate in completing these formalities. Information collected on these aspects show that 11 percent of the respondents opined that BPL families face problems in paper work and only 1 percent said that RKS is facilitating the paperwork for BPL patients to obtain free/subsidized services from government health facilities.
Outbreak of diseases Information was also collected from the respondents regarding the outbreak of various diseases like malaria, measles, gastroenteritis, jaundice or any other disease during the last 6 months. The responses collected from the respondents are tabulated in Table H20. It was mentioned by 15 percent of the respondents that there was an outbreak of malaria in their area during the last 6 months. Similarly outbreak of measles was reported by 25 percent of respondents, 21 percent reported outbreak of jaundice and 15 percent reported gastroenteritis and 4 percent reported outbreak of other diseases like skin problem etc.
Action taken for diseases NRHM has a strong IEC component. Health workers as well as ASHA are supposed to provide health education and Information on various disease preventive measures. However, it is not
171 known as to what extent are people aware of various diseases prevention measures. It was mentioned by 15 percent of the respondents that diarrhea can be prevented by ensuring regular hand washing. Similarly14 percent also mentioned that we should use covered containers to store drinking water and 2 percent suggested that garbage needs be disposed properly to prevent diarrhea.
This survey also collected information regarding the actions taken by the family members when any of the family members have malaria, persistent cough, loose motions or persistent cough and breathing problems. When the respondents were asked to report the actions they take in case a family member has fever, it was reported by 11 percent of the respondents that they consult a RMP. But large majority the respondents take the patient to a health facility, 16 percent use home remedy and 10 percent consult other people like peer, hakim etc. People generally do not go for blood test for malaria unless advised by the doctor. As far as persistent cough is concerned, once again higher percentage of patients (85 percent) are generally taken to a health facility. Few households also try home remedies or consult a RMP but sputum testing is generally not undertaken in case of persistent cough. Once a person has loose motions, he needs to be given oral rehydration salts. But, only 2 percent of the respondents reported that they start giving ORS to a person having loose motions. However, large majority of respondents (88 percent) prefer to visit a health facility for the treatment of loose motions. Home remedies are also tried by about 20 percent of the households. Oral foods /liquids are generally not stopped to treat loose motions. In case of persistent cough and breathing, 13 percent mentioned that they try home remedies. However more than 85 of the households consult the nearest health facility and 7 percent visit a RMP. The above findings clearly show that large majority of the respondents (more than 85 percent) generally rely on the health facilities for the treatment of the above mentioned diseases. However, they do not directly go for lab tests unless advised by a health professional. Home remedies are also tried by about 10 15 percent. Use of ORS is uncommon. However, it is surprising to record that none of the respondents mentioned that they contact ASHA in case of sickness which in other words show that ASHAs are not active in their respective villages.
Family planning Information about knowledge of family planning and use of contraceptive methods is of practical use to policy makers and programme administrators for formulating policies and
172 strategies. Though knowledge of family planning methods is nearly universal in India, but use of contraception is relatively very low. Sterilization is the most commonly accepted method in the country and spacing methods have not become so popular in the country. Inadequate knowledge about spacing methods, side effects, lack of expertise to handle the side effects, low quality follow up services are a few reasons responsible for the low level of acceptance of terminal methods. ANMs/ASHAs are supposed to provide adequate information to the eligible women regarding various methods of family planning, place of availability, how to use them, their side effects and follow up services.
During the NRHM survey, all the respondents were asked to report whether they are aware of the family planning methods, if the answer was in affirmative then they were probed to report about spacing methods and the ideal gap between 1st and 2nd child. Table H22 depicts that nearly 78 percent of the respondents were aware of at least one method of family planning. Respondents were generally aware of female sterilization but knowledge about various spacing methods is limited. Among the respondents who are aware of family planning methods, 55 percent reported knowledge of oral pills, 26 percent IUD, 22 percent condom and 18 percent reported knowledge of other methods like withdrawal and safe method etc. There were 25 percent of the respondents who reported knowledge of spacing methods but could not mention name of any such method.
Awareness of getting HIV/AIDS and counseling centres A set of questions were asked to all the respondents related to HIV/AIDS. All the respondents were first asked if they had ever heard of an illness called HIV/AIDS. Respondents who had heard of AIDS were further probed to mention the source of information. Table H23 shows that 55 percent of the respondents reported to have heard of an illness called HIV/AIDS.
As part of its AIDS prevention programme, the Government of India has been using mass media, especially electronic media, extensively to create awareness among the general public about AIDS and its prevention. The respondents were further questioned regarding the modes of getting HIV/AIDS. The most important mode of getting HIV/AIDS was mentioned as unsafe sexual contacts by 61 percent of the respondents. A substantial proportion of respondents (35 percent) related it to sharing of needles/syringes, while as 33 percent told that blood transfusion can cause HIV/AIDS. Fifteen percent were of the opinion that AIDs can transfer from mother to child.
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Earlier there were a lot of misconceptions regarding the mode of transmission of HIV/AIDS. The present survey shows that the misconceptions regarding the mode of transmission of HIV/AIDS have declined. Less than 5 percent of our respondents perceive that HIV/AIDS is transmitted by sneezing, shaking and insect bite.
Sources of Knowledge The Government of India has been using mass media extensively, especially electronic media, to increase awareness of AIDS and its prevention in the general population. Rapid appraisal of NRHM asked respondents who had heard of AIDS to identify the sources from which they learned about AIDS; results are presented in Table H23. Radio is by far the most common source of information on AIDS, reported by 53 percent of respondents who have heard of AIDS. A substantial proportion of respondents (33 percent) have received information about AIDS from the TV. The next most frequently reported sources after television and radio are health workers (13 percent), posters (11 percent) and newspapers/magazines (9 percent). Other sources such as relatives, friends etc were also mentioned by one third of respondents reporting HIV/AIDS knowledge.
A good number of voluntary counselling and testing centres have been established in all the states. In fact there is now a VCTC in each of the districts in Jammu and Kashmir. The information collected from the field regarding the knowledge of HIV/AIDS Counselling Centres/VCTC centres is very poor as less than 7 percent of the respondents having knowledge of HIV/AIDS have heard about HIV/AIDS Counselling Centres/VCTC. All the respondents who had heard of a VCTC were asked to mention the location of VCTC. But it was found that only two third of them had a correct knowledge about the location of VCTC.
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Table H1. Characteristics of the respondents Characteristics of the respondents Number Percent Age < 30 years 591 49.4 30-39 years 373 31.2 40-49 years 199 16.6 50-59 years 16 1.3 60 years or more 17 1.4 Sex Male 184 15.4 Female 1012 84.6 Years of Schooling Illiterate 635 53.1 1-5 Years 49 4.1 5-9 years 305 25.5 10 years of more 207 17.3 Marital status Unmarried 118 9.9 Currently Married 1050 87.8 Divorced/Separated 5 0.4 Widowed 23 1.9 Total number of respondents 1196 100.0
Table H2. Characteristics of the household
Characteristics of the household Number of living children born in last five years: Total 744
Institutional Delivery: Total 197 % of children born in Health Institutions during last five years: Total 26
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Table H2. Characteristics of the household Characteristics of the household Number Percent Social category Scheduled caste 5 0.4 Scheduled tribe 434 36.3 OBC 327 27.3 Others 430 36.0 Religion Hindu 32 2.7 Muslim 1164 97.3 Christian 0 0.0 Sikhs 0 0.0 Other 0 0.0 Households having BPL status Yes 593 49.6 No 603 50.4 Household living in pucca house Yes 340 28.4 No 856 71.6 Households with electricity Yes 1028 86 No 168 14 Households with toilet facility Yes 160 13.4 No 1036 86.6 Households with piped water supply Yes 393 32.9 No 803 67.1 Households using LPG/Biogas for cooking Yes 348 29.1 No 848 70.9 Household with own agricultural land Yes 1123 93.9 No 73 6.1 Households have a mobile phone Yes 570 47.7 No 626 52.3 Households own a colour/B&W TV Yes 299 25 No 897 75 Households with low standard of living index Yes 612 51.2 No 584 48.8 Total number of respondents 1196 100.0
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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 Households located Households Characteristics in Sub Centre HQ located in other Village Village All Method of waste disposal by the household Number Percent Number Percent Number Percent Thrown in the open 518 86.3 539 90.4 1057 88.4 Buried in a pit 16 2.7 14 2.3 30 2.5 Burnt 66 11.0 43 7.2 109 9.1 Other 0 0 0 0 0 0 Stagnation of waste water around the household Yes 53 8.8 41 6.9 94 7.9 No 547 91.2 555 93.1 1102 92.1 Instance of any mosquito breeding Yes 49 92.5 40 97.6 89 94.7 No 4 7.5 1 2.4 5 5.3 System of medicine preferred: Allopathic Yes 597 99.5 592 99.3 1189 99.4 No 3 0.5 4 0.7 7 0.6 Ayurveda Yes 8 1.3 9 1.5 17 1.4 No 592 98.7 587 98.5 1179 98.6 Yoga and Naturopathy Yes 0 0 0 0 0 0 No 600 100.0 596 100 1196 100 Unani Yes 1 0.2 7 1.2 8 0.7 No 599 99.8 589 98.8 1188 99.3 Siddha Yes 0 0 0 0 0 0 No 600 100.0 596 100 1196 100 Homeopathy Yes 1 0.2 0 0 1 0.1 No 599 99.8 596 100 1195 99.9 Traditional healing Yes 78 13.0 110 18.5 188 15.7 No 522 87.0 486 81.5 1008 84.3 Any other Yes 10 1.7 8 1.3 18 1.5 No 590 98.3 588 98.7 1178 98.5 None Yes 0 0 0 0 0 0 No 600 100.0 596 100 1196 100 Total Number of Households 600 100.0 596 100.0 1196 100.0
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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 Households located in Sub Households Centre HQ located in other Characteristics Village village All Heard about ANM Number Percent Number Percent Number Percent Yes 369 61.5 317 53.2 686 57.4 No 231 38.5 279 46.8 510 42.6 Heard about male health worker Yes 301 50.2 277 46.5 578 48.3 No 299 49.8 319 53.5 618 51.7 Visited by a Health Worker in last one month Yes 168 28.0 141 23.7 309 25.8 No 432 72.0 455 76.3 887 74.2 Health worker available at the time of need Yes 133 22.2 136 22.8 269 22.5 No 467 77.8 460 77.2 927 77.5 Available health facility in need: RMP Yes 7 1.2 8 1.3 15 1.3 No 593 98.8 588 98.7 1181 98.7 Private clinic/NGO Yes 90 15.0 65 10.9 155 13 No 510 85.0 531 89.1 1041 87 Sub Centre Yes 48 8.0 71 11.9 119 9.9 No 552 92.0 525 88.1 1077 90.1 PHC Yes 295 49.2 256 43 551 46.1 No 305 50.8 340 57 645 53.9 CHC Yes 28 4.7 71 11.9 99 8.3 No 572 95.3 525 88.1 1097 91.7 Other Yes 283 47.2 352 59.1 635 53.1 No 317 52.8 244 40.9 561 46.9
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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 Households Households located in Sub located in other All Characteristics Centre HQ Village village Facilities where serious patients taken: Number Percent Number Percent Number Percent RMP/Private clinic Yes 63 10.5 42 7 105 8.8 No 537 89.5 554 93 1091 91.2 NGO hospital/clinic Yes 10 1.7 2 0.3 12 1 No 590 98.3 594 99.7 1184 99 PHC Yes 77 12.8 100 16.8 177 14.8 No 523 87.2 496 83.2 1019 85.2 CHC Yes 24 4.0 36 6 60 5 No 576 96.0 560 94 1136 95 District/ Sub Divisional hospital Yes 566 94.3 572 96 1138 95.2 No 34 5.7 24 4 58 4.8 Other Yes 16 2.7 35 5.9 51 4.3 No 584 97.3 561 94.1 1145 95.7 Mode of transport for serious patient: Bullock cart Yes 0 0.0 0 0 0 0 No 600 100.0 596 100 1196 100 Bus Yes 394 65.7 395 66.3 789 66 No 206 34.3 201 33.7 407 34 Private vehicle Yes 241 40.2 240 40.3 481 40.2 No 359 59.8 356 59.7 715 59.8 Ambulance Yes 6 1.0 6 1 12 1 No 594 99.0 590 99 1184 99 Other Yes 408 68.0 426 71.5 834 69.7 No 192 32.0 170 28.5 362 30.3 Total number of household 600 100.0 596 100.0 1196 100.0
179 respondents
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Table H5. Percent distribution of household respondents by their knowledge about NRHM,ASHA and her activities, VHND, VHSC and JSY Households located in Sub Centre HQ Households located Village in other village All Characteristics Number Percent Number Percent Number Percent Have heard of NRHM Yes 50 8.3 74 12.4 124 10.4 No 550 91.7 522 87.6 1072 89.6 Source of information about NRHM: ASHA Yes 1 2.0 0 0 1 0.8 No 49 98.0 74 100 123 99.2 Radio/television Yes 33 66.0 45 60.8 78 62.9 No 17 34.0 29 39.2 46 37.1 Newspaper Yes 9 18.0 11 14.9 20 16.1 No 41 82.0 63 85.1 104 83.9 Panchayat Yes 1 2.0 1 1.4 2 1.6 No 49 98.0 73 98.6 122 98.4 Community member Yes 3 6.0 4 5.4 7 5.6 No 47 94.0 70 94.6 117 94.4 Other Yes 13 26.0 26 35.1 39 31.5 No 37 74.0 48 64.9 85 68.5 Respondents heard about ASHA Yes 204 34.0 158 26.5 362 30.3 No 396 66.0 438 73.5 834 69.7 ASHA carries a kit Yes 78 66.7 38 42.7 116 56.3 No 39 33.3 51 57.3 90 43.7 ASHA provides common medicine free of cost Yes 41 35.0 18 20.2 59 28.6 No 76 65.0 71 79.8 147 71.4 ASHA held discussion about: Hand washing Yes 21 17.9 14 15.7 35 17 No 96 82.1 75 84.3 171 83 ASHA held discussion about: Construction of household toilets Yes 14 12.0 11 12.4 25 12.1 No 103 88.0 78 87.6 181 87.9 ASHA held discussion about: Safe drinking water Yes 20 17.1 14 15.7 34 16.5 No 97 82.9 75 84.3 172 83.5 Village Health and Nutrition Day being organized in the village Yes 10 1.7 4 0.7 14 1.2 No 590 98.3 592 99.3 1182 98.8 Presence of village health and sanitation committee in village Yes 13 2.2 4 0.7 17 1.4 No 587 97.8 592 99.3 1179 98.6
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Table H5. Percent distribution of household respondents by their knowledge about NRHM,ASHA and her activities, VHND, VHSC and JSY Households Households located in Sub located in other All Characteristics Centre HQ Village village Frequency of Village Health and Nutrition Number Percent Number Percent Number Percent Weekly 6 60 1 25.0 7 50 Monthly 1 10 1 25.0 2 14.3 Quarterly 1 10 0 0.0 1 7.1 Annual 2 20 2 50.0 4 28.6 Don't know 0 0 0 0.0 0 0 Number of respondents aware about the JSY scheme Yes 270 45 247 41.4 517 43.2 No 330 55 349 58.6 679 56.8 Radio/Television Yes 37 13.7 44 17.8 81 15.7 No 233 86.3 203 82.2 436 84.3 Pamphlets Yes 5 1.9 6 2.4 11 2.1 No 265 98.1 241 97.6 506 97.9 Hoardings at SC/PHC etc. Yes 28 10.4 29 11.7 57 11 No 242 89.6 218 88.3 460 89 ASHA worker Yes 42 15.6 34 13.8 76 14.7 No 228 84.4 213 86.2 441 85.3 Anganwadi Centre/Worker Yes 13 4.8 5 2.0 18 3.5 No 257 95.2 242 98.0 499 96.5 ANM Yes 21 7.8 13 5.3 34 6.6 No 249 92.2 234 94.7 483 93.4 Doctor Yes 81 30 73 29.6 154 29.8 No 189 70 174 70.4 363 70.2 Gram Panchayat Yes 0 0 0 0.0 0 0 No 270 100 247 100.0 517 100 NGOs/SHGs Yes 0 0 0 0.0 0 0 No 270 100 247 100.0 517 100 Others Yes 91 33.7 117 47.4 208 40.2 No 179 66.3 130 52.6 309 59.8 Any one of household is JSY beneficiary Yes 48 17.8 42 17.0 90 17.4 No 222 82.2 205 83.0 427 82.6 Total number of household respondents 270 100.0 247 100.0 517 100.0
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Table H6. Percent distribution of JSY beneficiaries by their background characteristics Characteristics Number Percent Age < 20 years 8 8.9 20-24 years 30 33.3 25-29 years 32 35.6 30-34 years 14 15.6 35-39 years 5 5.6 40-44 years 1 1.1 45-49 years 0 0 Parity 0 0 0 1 15 16.7 2 35 38.9 3 & 3+ 40 44.4 Social category Scheduled caste 1 1.1 Scheduled tribe 16 17.8 OBC 29 32.2 Others 44 48.9 Religion of the household Hindu 0 0 Muslim 90 100 Christian 0 0 Sikhs 0 0 Other 0 0 SLI of the household Low 32 35.6 Medium 32 35.6 High 26 28.9 BPL household Yes 42 46.7 No 48 53.3 Place of last delivery Household 43 47.8 Health Institution 47 52.2 Total number of JSY beneficiaries 90 100.0
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Table H7. Timing, person place of registration for JSY scheme Characteristics Number Percent Timing of hearing about JSY scheme Before being pregnant 33 36.7 During pregnancy 57 63.3 Whether know about the stage of pregnancy when beneficiary registered under JSY scheme Yes 59 65.6 No 31 34.4 Stage of pregnancy when beneficiary got registered for JSY scheme 1st 2 3.4 2nd 5 8.5 3rd 16 27.1 4th 9 15.3 5th and above 27 45.8 Person who registered the beneficiary for JSY scheme Doctor 36 40 LHV 0 0 ANM/FHW 24 26.7 Anganwadi worker 2 2.2 ASHA worker 26 28.9 Other 2 2.2 Place where the beneficiary was registered for JSY District/Sub-District Hospital 28 31.1 Community Health Centre 4 4.4 PHC 34 37.8 Sub-Centre 22 24.4 Anganwadi Centre 1 1.1 Pvt. Hosp. accredited by the Govt. 0 0 At home 1 1.1 Other places 0 0
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Total number of JSY beneficiaries 90 100.0
Table H8. Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the beneficiary in getting the JSY card
JSY Card Number Percent
JSY card received by the beneficiary
Yes 58 64.4
No 32 35.6
Total number of JSY beneficiaries 90 100.0
ASHA worker helped the beneficiary in getting JSY card
Yes 22 37.9
No 27 46.6
Not applicable 9 15.5
Beneficiary faced difficulty in procuring JSY card
Yes 3 5.2
No 55 94.8
Problem faced in procuring JSY card:
Cards were not available
Yes 1 33.3
No 2 66.7
Formalities in making card were too cumbersome
Yes 2 66.7
No 1 33.3
Asked to pay money for card
Yes 1 33.3
No 2 66.7
Other
Yes 0 0
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No 3 100
Table H 9. Role of ASHA during the pregnancy of the beneficiaries Characteristics Number Percent ASHA worker provided any specific help to beneficiary in last pregnancy Yes 21 23.3 No 49 54.4 Not Applicable 20 22.2 Beneficiary received advice from ASHA-Diet Yes 12 13.3 No 78 86.7 Danger signs Yes 14 15.6 No 76 84.4 Delivery Care Yes 12 13.3 No 78 86.7 Breastfeeding Yes 17 18.9 No 73 81.1 Newborn care Yes 10 11.1 No 80 88.9 Family Planning Yes 10 11.1 No 80 88.9 Not applicable (ASHA not appointed in the village) Yes 20 22.2 No 70 77.8 Information given to the beneficiary - Date of next check-up Yes 48 53.3 No 42 46.7 Place of next check-up Yes No Yes 54 60 No 36 40 Date of expected delivery Yes 29 32.2 No 61 67.8 Place of delivery Yes 26 28.9
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No 64 71.1 Place of referral if complications arise Yes 14 15.6 No 76 84.4 Total number of JSY beneficiaries 90 100.0
Table H 10. Place of delivery and reason for opting institutional delivery Characteristics Number Percent Place of delivery and reason for opting institutional delivery Place of delivery District/Sub-District Hospital 34 45.3 Community Health Centre 0 0 PHC 6 8 Sub-Centre 1 1.3 Trust/NGO Hospital 0 0 Private Hospital 0 0 Pvt. Hosp. accredited by the Govt. 0 0 At home 34 45.3 Total number of JSY beneficiaries 75 - Reasons for opting Institutional Delivery: Money available under JSY scheme Yes 9 22 No 32 78 Better access to institutional delivery Yes 9 22 No 32 78 Better care for mother and new born child Yes 12 29.3 No 29 70.7 Services in the area Yes 3 7.3 No 38 92.7 Support provided by ASHA Yes No Yes 5 12.2 No 36 87.8 Availability of transport assistance Yes 0 0 No 41 100 Previous child was born in an institution Yes No
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Yes 8 19.5 No 33 80.5 Others Yes 14 34.1 No 27 65.9 Total number of JSY beneficiaries 41 100.0
Table H 11. Transport of the beneficiaries to reach the Health Institution Characteristics Number Percent Process of Transport Received referral slip from ASHA/health personnel to access delivery services Yes 3 7.3 No 38 92.7 Faced difficulty in reaching Health Institution Yes 17 41.5 No 24 58.5 Faced difficulty in reaching Health Institution: It was late in the night Yes 6 35.3 No 11 64.7 Did not have insufficient money Yes 2 11.8 No 15 88.2 Transport was not immediately available Yes 15 88.2 No 2 11.8 Male members in the household were not present Yes 1 5.9 No 16 94.1 ASHA was not readily available Yes 1 5.9 No 16 94.1 Others Yes 1 5.9 No 16 94.1 Average distance to the ultimate place of delivery from the beneficiary residence 20.6 Average Kmts Mode of transport used by the beneficiary to reach the ultimate place of delivery Government Ambulance 7 17.1 Private Vehicle 28 68.3 Vehicle arranged by Local Health Committee 0 0
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Others 6 14.6 Persons facilitated in arranging the transport ASHA 1 2.4 ANM 1 2.4 Village Health Committee 0 0 Others 39 95.1 Continued
Table H 11. Transport of the beneficiaries to reach the Health Institution Beneficiary had money to pay for the transport services Yes 35 85.4 No 6 14.6 Average amount spent on transport (in Rs.) Average 0 Average amount of transport assistance received under JSY scheme Average 520.1 Person accompanied beneficiary to the health institution ASHA 4 9.8 Relatives 34 82.9 Others 3 7.3 Total number of JSY beneficiaries 41 100.0
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 Characteristics Number Percent Average waiting time at the facility until someone attended the 26.6 beneficiary (in minutes) minutes Type of delivery Normal 18 43.9 Assisted (Forceps Vacuum) 21 51.2 Caesarean 2 4.9 Average number of days spent in the facility till discharge Average 1.8 days Percent beneficiary who have to pay at the health centre Yes 35 85.4 No 6 14.6 Average amount paid at the health centre (Rs.) Average Rs.2245.7 Satisfied with the services at health centre Satisfied 17 41.5 Somewhat satisfied 17 41.5 Not satisfied 7 17.1
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Reason for not satisfied Others Staff was rude 3 42.9 Facility was not clean 1 14.3 Poor quality of services 2 28.6 Others 1 14.3
Table H13. Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives being available under the JSY Reasons for home delivery: Number Percent Home delivery is more convenient Yes 7 20.6 No 27 79.4 Fear of stitches/caesarean Yes 1 2.9 No 33 97.1 Indifferent behaviour of medical/paramedical staff Yes 8 23.5 No 26 76.5 Cultural/social reasons Yes 3 8.8 No 31 91.2 Transport not being available Yes 24 70.6 No 10 29.4 Can't afford Yes 8 23.5 No 26 76.5 Others Yes 6 17.6 No 28 82.4 Total number of JSY beneficiaries under Home Delivery 34 100.0
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Table H.14 Cash incentive received by the beneficiary under JSY scheme Characteristics Number Percent Beneficiary received cash incentive under JSY scheme Yes 5 5.6 No 85 94.4 Total number of JSY beneficiaries 90 100.0 Average amount received by beneficiary as cash incentive Average Rs.940 Received the cash incentive In one go 4 80 In 2-3 installments 1 20 Timing of the receipt of the cash incentive by beneficiary At the time of registration 0 0 At the time of antenatal check up 0 0 Much before delivery 0 0 Within a week before the EDD 0 0 Immediately after the delivery 1 20 Within a week of delivery 1 20 Much later 2 40 Not received yet 0 0 Other 1 20 Do not know/ Husband knows 0 0 Person who delivered the cash incentive to the beneficiary Doctor 1 20 LHV 1 20 ANM/FHW 1 20 Anganwadi worker 0 0 ASHA worker 1 20 Other 1 20 Place where the cash incentive received by the beneficiary District/Sub-District Hospital 1 20 Community Health Centre 0 0 PHC 4 80 Sub-Centre 0 0 Anganwadi Centre 0 0 Pvt. Hosp. accredited by the Govt. 0 0 At home 0 0 Other 0 0 Faced any difficulty in getting money Yes 1 20 No 4 80 Type of difficulty faced by the beneficiary 0 0 Was asked to pay the bribe 1 100 Was paid by cheque/draft 0 0 Others 0 0 Total number of JSY beneficiaries 1 100.0
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Table H 15. Utilization of government health facility in last 6 months Households Percent of household who located in Sub Households availed health services in Centre HQ located in other government health facility in Village village All last 6 months Number percent Number Percent Number Percent Yes 372 62.0 352 59.1 724 60.5 No 228 38.0 244 40.9 472 39.5 Total number of households 600 100.0 596 100.0 1196 100.0
Table H. 16 Characteristics of the respondents who have availed the services in government health facility in last 6 months Characteristics Number Percent Age <16 years 130 19.2 16-19 years 44 6.5 20-29 years 172 25.4 30-39 years 151 22.3 40-49 years 100 14.7 50-59 years 35 5.2 60 years or more 46 6.8 Sex Male 172 25.4 Female 506 74.6 Years of schooling completed Illiterate 371 54.7 1-5 years 30 4.4 6-9 years 166 24.5 10+ years 111 16.4 Marital status Unmarried 66 9.7 Currently married 576 85 Divorced/Separated 4 0.6 Widowed 32 4.7 Social category of the household Scheduled caste 4 0.6 Scheduled tribe 265 36.6 OBC 192 26.5 Others 263 36.3 Religion of the household Hindu 16 2.2 Muslim 708 97.8 Christian 0 0 Sikhs 0 0 Other 0 0 BPL Household Yes No 350 48.3 Standard of Living Index
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Low 371 51.2 Medium 228 31.5 High 125 17.3
Table H.17 Type of health facility visited, purpose visit and client satisfaction regarding behaviour of health worker, privacy and availability medicines Characteristics Number Percent Type of health facility where service availed District/ Sub district hospital 436 64.3 CHC 50 7.4 PHC 164 24.2 Sub Centre 28 4.1 AYUSH 0 0 Purpose of visit to health facility Treatment of minor ailment 321 47.3 ANC care 33 4.9 Child care 163 24 Immunisation 14 2.1 Other 147 21.7 Behaviour of staff at health facility Courteous 373 55 Causal/Indifferent 279 41.2 Insulting/Derogatory 26 3.8 Listening of complaints by Doctor/staff Listened to complaints 397 58.6 Somewhat listened 259 38.2 Not listened 22 3.2 Cannot say 0 0 Women patient were treated in privacy Yes 429 63.3 No 226 33.3 Do not know 23 3.4 Patients with chronic disease get regular medicines from health facility Yes 78 11.5 No 426 62.8 Do not know 174 25.7 Private practice of the doctors during and after the duty hours Yes 538 79.4 No 83 12.2 Do not know 57 8.4 Satisfied with overall services and staff of Govt Health Facility Satisfied 214 31.6 Somewhat satisfied 257 37.9 Not satisfied 207 30.5
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Satisfied with the behaviour of staff at Govt. Health Facility Satisfied 236 34.8 Somewhat satisfied 256 37.8 Not satisfied 186 27.4
Table H.18 User fees and extra charges Characteristics Number Percent Total respondents who have availed the services in government health facility in last 6 months 724 - User fees charged from the users Yes 625 92.2 No 53 7.8 If user fees charged type of user fees: Registration Yes 612 97.9 No 13 2.1 X-ray Yes 77 12.3 No 548 87.7 Ultrasound Yes 40 6.4 No 585 93.6 Lab test Yes 91 14.6 No 534 85.4 Others Yes 20 3.2 No 605 96.8 Receipt given for the user fees Yes 508 81.3 No 117 18.7 Extra money charged for any services Yes 178 28.5 No 409 65.4 Do not know 38 6.1 Total respondents 625 100.0
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Table H19. Services for the BPL patients Characteristics Number Percent BPL patients provided free / subsidized services Yes 14 4.4 No 269 84.9 Do not know 34 10.7 BPL patients faced any problem in paper work for free/subsidized services Yes 35 11 No 141 44.5 Do not know 141 44.5 RKS facilitated the paperwork for BPL patients Yes 3 0.9 No 103 32.5 Do not know 211 66.6 Total BPL respondents 317 100.0
Table H 20. Outbreak of selected diseases in the respondents' area in the last six months Number Percent Malaria in last six months in the area Yes 181 15.1 No 960 80.3 Do not know 55 4.6 Measles in last six months in the area Yes 299 25 No 860 71.9 Do not know 37 3.1 Gastroenteritis in last six months in the area Yes 190 15.9 No 958 80.1 Do not know 48 4 Jaundice in last six months in the area Yes 255 21.3 No 902 75.4 Do not know 39 3.3 Other disease in last six months in the area Yes 43 3.6 No 1080 90.3 Do not know 73 6.1 Total number of household respondents 1196 100.0 195
Table H 21. Action to be taken for selected diseases Characteristics Number Percent Prevention of diarrhoea: Hand washing 189 15.8 Use of safe food and water 391 32.7 Use of covered container 166 13.9 Proper disposal of garbage 25 2.1 Other 39 3.3 Don't know 738 61.7 Action for high fever: Blood test for malaria 6 0.5 Taken to RMP 130 10.9 Taken to nearest govt health facility 1019 85.2 Consult ASHA 1 0.1 Try home remedies 192 16.1 Other 120 10 Don't know 19 1.6 Action for persistent cough: Taken for sputum testing 6 0.5 Taken to RMP 137 11.5 Taken to nearest govt health facility 1034 86.5 Consult ASHA 0 0 Try home remedies 194 16.2 Other 120 10 Don't know 5 0.4 Action for loose-motions: Stop giving oral fluids/food etc 15 1.3 Start giving ORS 29 2.4 Taken to RMP 89 7.4 Taken to nearest govt health facility 1046 87.5 Consult ASHA 0 0 Try home remedies 233 19.5 Other 99 8.3 Don’t know 10 0.8 Action for persistent cough and breathing problem: Try home remedies 159 13.3 Taken to RMP 86 7.2 Taken to nearest govt health facility 1048 87.6 Consult ASHA 1 0.1 Other 104 8.7 Don't know 13 1.1 Total number of household respondents 1196 100.0
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Table H 22. Awareness about spacing methods and ideal gap between 1st and 2nd child Characteristics Number Percent Aware of family planning methods Yes 927 77.5 No 269 22.5 Total number of household respondents 1196 100.0 Ideal gap between first and second child 1 year 10 1.1 2 year 213 23 3 and more year 704 75.9 Spacing method: IUD Yes 242 26.1 No 685 73.9 Oral Pills Yes 511 55.1 No 416 44.9 Nirodh/Condom Yes 202 21.8 No 725 78.2 Any other Yes 164 17.7 No 763 82.3 Don't know Yes 229 24.7 No 698 75.3 Total number of household respondents 927 100.0
Table H23. Awareness about modes of getting AIDS, source of information about AIDS and awareness about VCTC Characteristics Number Percent Heard about: HIV/AIDS 656 54.8 Total number of household respondents 1196 - Mode of HIV/AIDS: Sexual contact 397 60.5 Blood transfusion 217 33.1 Sharing of needled/springs 231 35.2
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From mother to child 98 14.9 Shaking hands 22 3.4 Sneezing 6 0.9 Insect bite 6 0.9 Kissing 2 0.3 Others 22 3.4 Source of information on HIV/AIDS: Radio 346 52.7 TV 216 32.9 Health worker 87 13.3 Poster 74 11.3 News paper 60 9.1 Other 228 34.8 Aware of HIV/AIDS counseling centre/VCTC nearby Yes 43 6.6 No 613 93.4 Location of counseling centre PHC 4 9.3 CHC 3 7 District Hospital 29 67.4 Sub District Hospital 7 16.3 Private Hospital 0 0 Total number of household respondents 43 100.0
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CHAPTER 10
Perception of IPD and OPD Patients
Out patients This chapter deals with the perception of the beneficiaries with the utilization of the services availed from government health institutions in Rajouri district. It also presents their opinion regarding the quality of services delivered by these health institutions. We had a plan to interview a minimum of 10 respondents each from the selected Primary Health Centres, Community Health Centres and also from District Hospital Rajouri. These interviews were conducted on the day of our visit to the concerned health centre. Interviews were conducted with both male and female respondents age 16 years or more. However, if the patient was less than 16 years, interviews were conducted with the adult member accompanying the patient. A total number of 73 respondents were interviewed during the course of field work. These include 31 male and 42 female.
Socio economic and demographic characteristics of the respondent Table OP1 presents some of the socio economic and demographic characteristics of the interviewed respondents. Majority of the respondents (40 percent) were age 20 29 years, and a considerable number of respondents (19 percent) belong to age groups 30 39. Nine percent of the respondents were more than 60 years old. The younger respondents were considerably small in size (15 percent). Seventy seven percent of the respondents were currently married. Unmarried respondents accounted for 18 percent and remaining 5 percent were divorced/separated. So far as the place of residence is concerned, 96 percent of the interviewed were from rural areas. Of the 73 respondents, 10 were interviewed from District Hospital Rajouri, 25 from Community Health Centres and 38 from Primary Health Centres.
Purpose of visit All the respondents were asked to mention the main reason for visiting the health facility and the findings are presented in Table OP2. It was mentioned by 58 percent of the respondents that they visited the health facility for the treatment of minor illness. Another one third of respondents (34 percent) had visited the health facility for the treatment of child sickness. Only 1 respondent each had come for antenatal and post natal care. Thus it appears
199 that large majority of respondents visit the government health facilities in the district for the treatment of minor illness or child illness. It appears that the government health facilities in the district have not yet generated the demand for ANC/PNC, family planning and other available services in these health institutions.
Waiting time and satisfaction with the waiting time
We tried to collect information regarding the time for which the patients have to wait to utilize various services. The average waiting for registration in various health institutions in the district is 14.4 minutes (Table OP3). It is highest in case of CHCs (23.2 minutes) and lowest in case of PHCs (7.3). Patients on an average have to wait for 20 minutes for registration at the district hospital. Mean waiting time to see the doctor was about one hour at the DH, 40 minutes at CHC and 10 minutes at PHC. Time to get injection was also some what lower the PHC than at CHC. Thus, the waiting time for availing various services is the lowest at PHC than CHC or DH. This is due to the fact that large majority of patients skip the PHCs/CHCs even for the treatment of minor illness and prefer to avail the services from DH, which increases the work load of DH in the district.
How do the clients view the waiting time to avail various services? It can be seen from Table OP4 that 71 percent of the respondents perceive waiting time for registration to be appropriate and 23 percent perceive it to be too long. Even though the registration time at DH was reported to be 20 minutes but still 80 percent of the patients considered it to be appropriate. The reason for this type of response is that there are no better alternatives to avail the services. Similarly, two third of the respondents found waiting time for the doctors examination to be appropriate. Surprisingly none of the patients at the DH mentioned to have received any injections or medicines from the district hospital. In fact all the patients are advised to buy the medicines from the market.
Behaviour of the staff
The utilization of health services and their quality to large extent depends on the behaviour of the staff at the health centres. In this connection all the contacted respondents were asked a few questions regarding the behavior of the staff. When the respondents were asked
200 whether the doctor greeted them in a friendly manner, it was mentioned by only 48 percent of them that the doctor greeted them in a friendly manner. Not even a single respondent from DH gave such response. Twenty percent of the respondents from DH expressed that the greeting from doctor was unfriendly. So far as the behaviour of the Doctor is concerned, 82 percent expressed it was good/reasonable and 16 percent reported it to be very kind. None of the patients who had availed the services from DH had very good image of the behavior of the doctors. Though large majority of the respondents who had visited the health facilities had no interaction with Dispenser, Technician and Nursing staff but none of the respondents who had interaction with these people complained of their behaviour. Overall, respondents who had visited a PHC had a better image of the behaviour of the staff than the patients who had visited CHCs (Table OP5). None of the patients who visited a DH had any interaction with nursing staff and dispenser.
Privacy
Among respondents who said they needed privacy during their visit to a health facility, a large majority of them (45 percent) were not satisfied with the presence of privacy at the place of examination (Table OP6). At DH, 9 out of 10 respondents said that there was no privacy at the place of examination.
Patient Doctor interaction
All the respondents were asked a number of questions to ascertain their perception of the interaction that took place between them and the service provider during their most recent visit to a health facility. Specific dimensions covered were whether the doctor listened to description of ailment patiently, whether doctor allowed the patient to ask questions, whether doctor responded to questions, whether doctor discussed about ailment, recovery etc. The responses of the patients are presented in Table OP7. Eighty two percent of the respondents mentioned that doctor listened to the description of the ailment patiently and also allowed them to ask questions. About 75 percent mentioned that doctor responded to their questions and discussed about the ailment. Nearly two third of the patients reported that doctors talked about recovery and 33 percent also mentioned that doctors gave them other advice such as avoiding certain foods, precautions, preventive measures, date of
201 follow up etc. Respondents interviewed from PHCs were highly appreciative of their communication with doctors than the respondents interviewed from CHCs. On the other hand respondents who had availed the services from DH were critical of the interaction that took place between them and the service provider. Overall it can be concluded that the quality of services were perceived to be poor at the DH and good at CHC and very good at PHC.
Satisfaction with cleanliness
The utilization of the services also depends on the cleanliness of various facilities in the health institutions. Therefore, information was collected regarding the cleanliness of OPD rooms, examination rooms, dispensary, laboratory, injection room and dressing room. Thirty five percent of the respondents rated the OPD room as clean and 45 percent rated examination room as clean (Table OP8). Higher proportion of respondents interviewed perceived PHC to be cleaner than CHCs. Facilities at the DH were perceived to be untidy by about one fourth of the respondents.
Crowding
Perception of the respondents with the availability of space (crowding) in different sections of the health institutions is presented in Table OP9. The responses show that DH is the most crowded followed by CHCs and PHCs. More than 70 percent of the respondents perceive that the space in OPD and examination rooms in the DH is inadequate. Space in the laboratory was perceived to be inadequate by 50 percent and 33 percent of the respondents who visited a CHC and PHC respectively.
Continuity of treatment
Respondents were asked whether they were satisfied with their visit to the health facility. It was found 41 percent were satisfied with their visit, and another 33 percent were partially satisfied. About one fourth of the respondents were dissatisfied with their visit to a health facility. The dissatisfaction level was highest in case of DH (70 percent), followed by CHC (32 percent). Only 10 percent of respondents who visited a PHC were not satisfied with their visit to PHC.
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Respondents who were not satisfied with their visit to health facility were asked to mention the main reason for dissatisfaction. Large majority of these respondents (95 percent) attributed it to lack of proper facilities at the health institutions and another 5 percent mentioned that they had bad experience with the doctors. The reasons do not vary by the type of institution they had visited. When the respondents were asked whether they would prefer to visit the health institution again if they fell sick, it was mentioned by about half of the respondents they will again visit the same facility and another 3 percent were not sure. A higher proportion of respondents from DH (80 percent) mentioned to revisit the DH than the patients who had visited a CHC (48 percent) or PHC (42 percent). Finally all the respondents were asked whether they would recommend the health facility they had visited to other people or not. It was found that 93 percent of our respondents expressed their desire to recommend this facility to other people. Almost all the respondents who had availed the services from a PHC mentioned that they would like to recommended the PHC to other patients as compared to 92 percent and 80 of the respondents who had availed the services from a CHC and DH respectively. In Patients At the start of the survey we had planned to interview a minimum of 10 patients each who were admitted in the District Hospital and selected PHCs and CHCs. Though the team successfully interviewed 10 indoor patients in District Hospital Rajouri but it was not possible to interview any of the indoor patients at the selected PHCs or CHCs. Though wards for indoor patients are available in all the selected PHCs and CHCs but it was found that patients are not admitted in these institutions mainly because of non availability of staff and other facilities like electricity, heating, food etc. The Medical Officers, however, mentioned that they admit some patients during day time for administration of dextrose and in the afternoon the patients are either discharged or referred to District Hospital. As mentioned above that indoor facilities in actual practice are not available in any of the selected CHCs or PHCs. However, some patients are admitted during day hours for 1 or 2 hours, especially those who need dextrose infusion but do not stay in the hospital after working hours. Such patients were not considered as IPD patients in the survey and no interviews were conducted with such patients. Thus information regarding inpatients is based only on 10 patients from the district hospital. Of these 10 patients, 4 were male and 6 were female. Half of them were below age 30 and married patients also accounted for half of the patients (Table IP1).
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Purpose of admission Though the patients in the hospitals are admitted for various services but 9 out of 10 interviewed patients were admitted in the hospital for different surgeries and one patient was admitted for delivery. Average waiting time for different services shown in Table IP2 and IP3 shows that registration of the patients takes about 15 minutes, patients have to wait for doctor’s call for about half an hour and doctors examination takes roughly about 20 minutes. Admission in the ward takes another 38 minutes and the average time taken to get services was noted to be 47 minutes. Mean time taken to get discharged from the hospital takes 41 minutes. Thus the waiting time to get various services in the district hospital is very high. Satisfaction with waiting time How do the indoor patients view the waiting time to avail various services. It can be seen from Table IP4 that 80 percent perceive waiting time for registration to be appropriate and 20 percent perceive to be too long. Even though the doctors call at the DH takes about half an hour but still 78 percent of the patients considered it to be appropriate. Similarly, 80 percent of indoor patients found waiting time for the doctors examination to be appropriate and 60 percent found waiting time to get services as appropriate. Discharging time from the hospital was viewed to be too long by 90 percent of the patients.
Behaviour of the staff
All the indoor patients were asked to give their opinion regarding the behaviour of the medical and paramedical staff. Only 40 percent of the respondents mentioned that the Doctor greeted them in a friendly manner. The behaviour of the doctor was rude in case of 1 patient, it was reasonable or good in case of 90 percent. Four out of 10 patients mentioned that the behaviour of the Nurse was rude, it was reasonable in case of half of our respondents. The behaviour of the Technical staff towards patients seemed to be reasonably good in all the cases but Ayah and Ward boys seem to be negligent in case of 90 percent and 40 percent of the cases respectively. All the patients mentioned that behaviour of the Counter clerk was good (Table IP5). Our informal discussions with the patients however shows that that patients have a poor image about the behaviour of staff. Patients were more critical about the behaviour of the Nurses. They added that once they tip the officials, they start caring for the patients.
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All the interviewed patients were asked to mention whether in their opinion the hospital authorities have taken any innovative measures to improve the staff behaviour. All he respondents expressed that keeping in view their past experience, there is no indication that the hospital authorities have taken any innovative measure to improve the staff behaviour. On the contrary, the patients and the attendants continue with the old system of bribing the staff to get the services from the hospital (Table IP6).
Privacy
Providing privacy to the patient during examination is an important components of quality of health care services However, it was found that the concept of providing privacy during examination seems to be unknown to DH Rajouri. All the respondents mentioned that there was no privacy neither at the place of examination nor in the wards (Table IP7).
Patient Doctor interaction
All the selected indoor patients were asked a number of questions to ascertain their perception of the interaction that took place between them and the service provider during their most recent visit. Specific dimensions covered were whether the doctor listened to description of ailment patiently, whether doctor allowed the patient to ask questions, whether doctor responded to questions, whether doctor discussed about ailment, recovery etc. The responses of the patients are presented in Table IP8. Fifty percent of the respondents mentioned that doctor always listened to the description of the ailment patiently and 40 percent mentioned that doctor always allowed them to ask questions. Only 30 percent mentioned that doctor always responded to their questions. It was mentioned by 60 percent of the respondents that doctors did not discuss with them about the ailment. None of the patients mentioned that the doctors talked about their recovery with them. Similarly other advices such as avoiding certain foods, precautions, preventive measures, follow up were also not discussed by the doctors with any of the patients interviewed by us.
Observation
After completing the interviews with the in patients we were surrounded both by the patients as well as the attendants who complained that corruption in the hospital is rampant. They have to pay for each service they get from the hospital. Unless they tip the staff, their attitude towards them is indifferent and once they pay the tip, their attitude is friendly.
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Satisfaction with cleanliness
The utilization of the services also depends on the cleanliness of various facilities in the health institutions. Therefore, information was collected regarding the frequency of cleaning floor, toilet/bathrooms/changing patients uniform and changing bed sheets. When the respondents were asked to mention the frequency of cleaning floor, 60 percent mentioned that it is cleaned once a day, generally in the morning before the doctors take a round of the wards. Twenty percent each mentioned that cleaning of the ward takes place twice or thrice a day. All the respondents mentioned that toilet and bath rooms are not cleaned daily. They mentioned that toilets and bath rooms are cleaned on alternate days.
As far as patient’s uniform is concerned all the patients mentioned that uniform is not provided in the hospital. Even the patients who had undergone surgery had not been provided any uniform. All the respondents also expressed that once they are admitted in the hospital they get a bed sheet which is not changed till they are discharged (Table IP9).
Respondents were asked to express whether they were satisfied with the cleanliness of the hospital. It was found hat majority of the patients were not satisfied with the cleaning of floor (Table IP10).
Observation
Sweepers generally clean the hospital premises and the wards in the morning daily. Operation theatres, labour room and Blood Bank is cleaned twice or thrice a day. The toilets and bath rooms of the hospital were found to be unhygienic and it appeared that they are not cleaned daily. Though the patients complained of inadequate toilet/bath room facilities in the hospital but we observed that one of bathrooms/toilets is being used for storing dextrose and other fluid. It was also found that bed sheets are not changed regularly. Bed sheets are generally changed at the time of admission and are not changed till the patient gets discharged. However, patients expressed that they pay money to get the bed sheets changed. Others mentioned that they use their personal bed sheets.
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Crowding
A set of questions were asked to the patients to know their perception about the crowding in the hospital. The first question was regarding the availability of cot/bed at the time of admission. Eighty percent of the patients mentioned that they got a cot/bed immediately after admission and only one out of 10 patients could not get a cot immediately after admission but got it on the same day (Table IP11). The second question asked in the series was whether the bed/cot was available with the patient till his discharge. It was mentioned by 90 percent of them that bed was available with them till they were discharged from the hospital. The third question was regarding the adequacy of space in the ward. Eighty percent of our respondents expressed that the space in the ward is inadequate. As far as satisfaction with ward arrangement is concerned, 90 percent were not satisfied with the arrangement of wards in the hospital. Similarly, 70 percent of the respondents mentioned that the space in the IPD is inadequate.
Amenities
Information was also collected about the availability of facilities like television, canteen, medical shop, telephone ambulance and accommodation. Television and canteen facilities, telephone for patients and accommodation for relatives is not available in the district hospital. The availability of medical shop was reported by 70 percent and availability of ambulance facility was mentioned by all the 10 respondents. But only 86 percent of the respondents who mentioned availability of medical shop were satisfied with it. Satisfaction level was low in case of ambulance (Table IP12).
Observations
Telephone facility is not available in any of the wards in the hospital. Telephone is available in the Medical Superintendants room and is exclusive for office use. Similarly medical shop is operating in the hospital premises but the rates of medicines and drugs are no different than other shops in the market. The hospital does not have a canteen facility or a kitchen while attendants can at least cook meals.
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Continuity of treatment
Respondents were asked whether they were satisfied with their visit to the health facility. It was found that 80 percent of the patients were not satisfied with the services provided to them in the hospital. The remaining 20 percent were partially satisfied. Respondents who were not satisfied with their visit to health facility were asked to mention the reason for dissatisfaction. All the respondents attributed their dissatisfaction to lack of proper facilities at the district hospital. When the respondents were asked whether they would prefer to visit the district hospital again if they fell sick, it was mentioned by 30 percent of them that because of not availability of a better alternative they are constrained to continue visiting the same facility for treatment but large majority of the respondents were unsure about continuing visiting the health institution in future (Table IP13). Finally, all the respondents were asked whether they would recommend district hospital to other patients or not. Surprisingly, all the patients mentioned that the quality of services in the district hospital is so poor that they would not like to recommend this facility to other people.
Overall it may be said that the patients admitted in the district hospital were not satisfied with the services provided by it.
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Table OP1:Background characteristics of the out-patients Background Characteristics of the Out-Patients Percent Age < 20 years 15.1 20-29 years 39.7 30-39 years 19.2 40-49 years 12.3 50-59 years 4.1 60 years or more 9.6 Sex Male 42.5 Female 57.5 Marital status Unmarried 17.8 Currently married 76.7 Divorced/Separated - Widowed 5.5 Place of residence Rural 95.9 Urban 4.1 Type of Health Facility District Hospital 13.7 CHC 34.2 PHC 52.1 Total no. of out-patients interviewed 73
Table OP2: Purpose of visit to the Health Institution Purpose of visit District Hospital CHC PHC All Minor illness 30 52 68.4 57.5 FP services 0 0 0 0 Antenatal care 10 0 0 1.4 PNC 10 0 0 1.4 Eye check up 0 0 0 0 MDT-DOTs 0 0 0 0 Child illness 40 44 26.3 34.2 Other 10 4 5.3 5.5 Total no. of out-patients interviewed 10 25 38 73
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Table OP3: Waiting time for various services
Type of Health Facility District Waiting time for Hospital CHC PHC All Registration Number of patients availed the service 10 25 38 73 Average waiting time (in minutes) 19.5 23.2 7.3 14.4 Doctor's examination Number of patients availed the service 10 25 38 73 Average waiting time (in minutes) 54 38.8 10.4 26.1 Injection Number of patients availed the service 0 4 9 13 Average waiting time (in minutes) 0 6 4.2 4.8 Getting medicines Number of patients availed the service 0 6 23 29 Average waiting time (in minutes) 0 3.7 4.3 4.2 Dressing Number of patients availed the service 0 0 1 1 Average waiting time (in minutes) 0 0 3 3 Paying bill Number of patients availed the service 0 11 18 29 Average waiting time (in minutes) 0 2.2 2.1 2.1
Table OP4: Satisfaction regarding waiting time
Type of Health Facility (% of patients) Satisfaction District Hospital CHC PHC All Registration Too long 20 40 13.2 23.3 Appropriate 80 60 76.3 71.2 Too short - - 10.5 5.5 Can't say - - - - Number of patients availed the services 10 25 38 73 Doctor's examination Too long 50 60 5.3 30.1 Appropriate 50 40 89.5 67.1 Too short - - 5.3 2.7 Can't say - - - - Number of patients availed the services 10 25 38 73 Continued
210
Table OP4: Satisfaction regarding waiting time Satisfaction Type of Health Facility (% of patients) District Hospital CHC PHC All Too long - - - - Appropriate - 100 88.9 92.3 Too short - - 11.1 7.7 Can't say - - - - Number of patients availed the services - 4 9 13 Getting medicines Too long - 16.7 - 3.4 Appropriate - 83.3 100 96.6 Too short - - - - Can't say - - - - Number of patients availed the services - 6 23 29 Dressing Too long - - - - Appropriate - - 100 100 Too short - - - - Can't say - - - - Number of patients availed the services - - 1 1 Paying bill Too long - - - - Appropriate - 100 77.8 86.2 Too short - - 22.2 13.8 Can't say - - - - Number of patients availed the services - 11 18 29
Table OP5: Behaviour of staff Type of Health Facility (Percent) District Staff Behaviour Hospital CHC PHC All Doctor greet in a friendly manner Not friendly 20 - - 2.7 Yes somewhat 80 44 44.7 49.3 Yes - 56 55.3 47.9 Did not interact/ Not applicable - - - - Behaviour of Doctor Rude - - - - Reasonable 100 36 21.1 37 Good - 56 50 45.2 Very kind - 8 26.3 16.4 Did not interact/ Not applicable - - 2.6 1.4 Continued
211
Table OP5: Behaviour of staff Staff Behaviour Type of Health Facility (Percent) District Hospital CHC PHC All Rude - - - - Reasonable - 12 26.3 17.8 Good - 32 44.7 34.2 Very kind - 4 18.4 11 Did not interact/ Not applicable 100 52 10.5 37 Behaviour of Dispenser Rude - - - - Reasonable - - 10.5 5.5 Good - 24 36.8 27.4 Very kind - - 10.5 5.5 Did not interact/ Not applicable 100 76 42.1 61.6 Behaviour of Technician Rude - - - - Reasonable 10 - - 1.4 Good 10 8 - 4.1 Very kind - - - - Did not interact/ Not applicable 80 92 100 94.5 Total no. of out-patients interviewed 10 25 38 73
Table OP6: Privacy Type of Health Facility (Percent) Privacy District Hospital CHC PHC All Patients reporting presence of privacy at the place of examination 10 52 50 45.2 Total no. of out-patients interviewed 10 25 38 73
212
Table OP7: Patient-Doctor/Provider Communication
Type of Health Facility (Percent) Patient-Doctor Communication District Hospital CHC PHC All Doctor listened to description of ailment patiently Yes somewhat 70 12 5.3 16.4 Yes always 20 88 94.7 82.2 No - - - - Did not interact/Not Applicable 10 - - 1.4 Doctor allowed to ask questions Yes somewhat 60 24 - 16.4 Yes always 30 68 100 79.5 No - 8 - 2.7 Did not interact/Not Applicable 10 - - 1.4 Doctor responded to questions Yes somewhat 60 20 2.6 16.4 Yes always 10 72 92.1 74 No - 8 - 2.7 Did not interact/Not Applicable 30 - 5.3 6.8 Doctor discussed about the ailment Yes 40 56 97.4 75.3 No 60 44 2.6 24.7 Did not interact/Not Applicable - - - - Doctor talked about the recovery Yes 10 56 94.7 69.9 No 90 40 5.3 28.8 Did not interact/Not Applicable - 4 - 1.4 Doctor gave 'other advice' Yes 10 20 47.4 32.9 No 90 80 52.6 67.1 Total no. of out-patients interviewed 10 25 38 73
213
Table OP8: Satisfaction of OPD patients regarding cleanliness of the facility Type of Health Facility (Percent of patients) Satisfaction regarding cleanliness in the facility District Hospital CHC PHC All OPD Room Not clean 30 16 0 9.9 Partially clean 70 64 44.4 54.9 Clean 0 20 55.6 35.2 No. of patients availed the services 10 25 36 71 Examination Room Not clean 22.2 4 0 4.5 Partially clean 77.8 64 33.3 50.7 Clean 0 32 66.7 44.8 No. of patients availed the services 9 25 33 67 Dispensary Not clean 0 0 0 0 Partially clean 0 33.3 33.3 33.3 Clean 0 66.7 66.7 66.7 No. of patients availed the services - 6 27 33 Laboratory Not clean 0 0 0 0 Partially clean 0 0 50 25 Clean 0 100 50 75 No. of patients availed the services - 2 2 4 Injection Room Not clean 0 0 0 0 Partially clean 0 33.3 35.7 35.3 Clean 0 66.7 64.3 64.7 No. of patients availed the services - 3 14 17 Dressing Room Not clean 0 0 0 0 Partially clean 0 0 0 0 Clean 0 0 100 100 No. of patients availed the services - - 1 1
214
Table OP9: Satisfaction of OPD patients regarding crowding in the facility Type of Health Facility (Percent of Satisfaction regarding crowding in patients) the facility District Hospital CHC PHC All OPD Room Not adequate 77.8 - 5.7 13 Somewhat adequate 22.2 76 48.6 55.1 Adequate - 24 45.7 31.9 Not applicable - - - - No. of patients availed the facility 9 25 35 69 Examination Room Not adequate 71.4 - 5.6 10.3 Somewhat adequate 28.6 68 38.9 48.5 Adequate - 32 55.6 41.2 No. of patients availed the facility 7 25 36 68 Dispensary Not adequate - - - - Somewhat adequate - 42.9 31 33.3 Adequate - 57.1 69 66.7 No. of patients availed the facility - 7 29 36 Laboratory Not adequate - 50 33.3 40 Somewhat adequate - 50 33.3 40 Adequate - - 33.3 20 No. of patients availed the facility - 2 3 5 Injection Room Not adequate - - 13.3 11.1 Somewhat adequate - 66.7 40 44.4 Adequate - 33.3 46.7 44.4 No. of patients availed the facility - 3 15 18 Dressing Room Not adequate - - - - Somewhat adequate - - 100 100 Adequate - - - - No. of patients availed the facility - - 1 1
215
Table OP10: Continuity of treatment Continuity of treatment Type of Health Facility (Percent) District Hospital CHC PHC Total Satisfaction with the visit to the health facility Dissatisfied 70 32 10.5 26 Somewhat satisfied 30 36 31.6 32.9 Satisfied - 32 57.9 41.1 Reason of dissatisfaction if dissatisfied Lack of facilities 100 87.5 100 94.7 Bad experience with doctors - 12.5 - 5.3 Poor quality of services - - - - Charges are exorbitant - - - - Other - - - - Visit again to the facility (if fell sick) Yes 80 48 42.1 49.3 No 10 4 - 2.7 May come/unsure 10 48 57.9 47.9 Recommend this hospital to others Yes 80 92 97.4 93.2 No 20 8 2.6 6.8 Total no. of out-patients interviewed 10 25 38 73
216
Table IP1: Background characteristics of the in-patients Background Characteristics of the In-Patients Number Percent Age < 20 years 2 20 20-29 years 3 30 30-39 years 2 20 40-49 years 1 10 50-59 years 1 10 60 years or more 1 10 Sex Male 4 40 Female 6 60 Marital status Unmarried 5 50 Currently married 5 50 Divorced/Separated 0 0 Widowed 0 0 Residence Rural 10 100 Urban 0 0 Type of Health Facility District Hospital 10 100 CHC 0 0 PHC 0 0 Total no. of in-patients interviewed 10 100
Table IP2: Purpose of the admission in the Health Institution Purpose of admission in Health Institution Percent Minor illness 0 FP surgery 0 Delivery 10 Cataract surgery 0 Child admitted 0 Other 90 Total no. of in-patients interviewed 10
Table IP3: Waiting time Average waiting time for: Minutes Registration 15.5 Doctor's call 28.3 Doctor's examination 19.5 Admission to ward 38.5 Getting services 47.5 To get discharged 41.5 Total no. of in-patients interviewed 10
217
Table IP4: Satisfaction regarding waiting time Waiting time for/Satisfaction Percent Registration Too long 20 Appropriate 80 Too short 0 Doctor's call Too long 22.2 Appropriate 77.8 Too short 0 Can't say 0 Doctor's examination Too long 20 Appropriate 80 Too short 0 Can't say 0 Admission to ward Too long 40 Appropriate 60 Too short 0 Can't say 0 Getting services Too long 40 Appropriate 60 Too short 0 Can't say 0 To get discharged Too long 90 Appropriate 10 Too short 0 Can't say 0 Total no. of in-patients interviewed 10
218
Table IP5: Behaviour of Staff Staff Behaviour Percent Doctor greet in a friendly manner Yes 40 Somewhat 60 No - Behaviour of Doctor Rude 10 Reasonable 60 Good 30 Very kind - Behaviour of Nurse Rude 40 Reasonable 50 Good 10 Very kind - Behaviour of Technical Staff Rude - Reasonable 100 Good - Very kind - Behaviour of Ayah Negligent 90 Arrogant - Indifferent - Good 10 Behaviour of Ward Boys Negligent 40 Arrogant - Indifferent 30 Good 30 Behaviour of Counter Clerk Negligent - Arrogant - Indifferent - Good 100 Total no. of in-patients interviewed 10
219
Table IP6: Unique/ innovative measure taken to improve the staff behaviour Staff Behaviour Percent Unique/innovative measure taken to improve the staff behaviour Yes - No - Don't know 100 Total no. of in-patients interviewed 10
Table IP7: Privacy maintained at District Hospital at the place of examination Privacy Percent Patients reporting presence of privacy at the place of examination 0 Total no. of in-patients interviewed 10
Table IP8 : Patient-Doctor/ Provider Communication Patient-Doctor/ Provider Communication Percent Doctor listened to description of ailment patiently Yes somewhat 50 Yes always 50 No 0 Did not interact with doctor 0 Doctor allowed to ask question Yes somewhat 50 Yes always 40 No 10 Did not interact with doctor 0 Doctor responded to question Yes somewhat 60 Yes always 30 No 10 Did not interact with doctor 0 Doctor discussed about ailment Yes 40 No 60 Did not interact with doctor 0 Doctor talked about the recovery Yes 0 No 100 Did not interact with doctor 0 Doctor gave 'other advice' Yes 0 No 100 Did not interact with doctor 0 Total no. of in-patients interviewed 10
220
Table IP9: Cleanliness of the facility Type of facility/ Frequency of cleaning Percent Floor Thrice a day 20 Twice a day 20 Once a day 60 Less than once a day - Not applicable - Toilet/ Bathroom cleaning Thrice a day - Twice a day - Once a day - Less than once a day 100 Changing patient's uniform Twice a day - Once a day - Less than once a day - Not changed 100 Not applicable - Changing bed-sheets Twice a day - Once a day - Less than once a day - Not changed 100 Not applicable - Total no. of in-patients interviewed 10
Table IP10: Satisfaction of patients regarding cleanliness of the facility Type of facility/ Satisfaction Percent Floor cleaning Satisfied 30 Somewhat satisfied 10 Not satisfied 60 Toilet/ Bathroom cleaning Satisfied - Somewhat satisfied - Not satisfied 100 Changing patient's uniform Satisfied - Somewhat satisfied - Not satisfied 100 Changing bed sheets Satisfied - Somewhat satisfied - Not satisfied 100 Total no. of in-patients interviewed 10
221
Table IP11: Crowding in the facility Crowding in the facility Percent Availability of cot Immediately 80 Not immediately but same day 10 Next day 0 After more than a day 10 Never got the cot 0 Availability for cot/bed till the time of discharge Yes 90 No 10 Adequacy of space in the ward Adequate 0 Somewhat adequate 20 Not adequate 80 Satisfaction with the ward arrangement Satisfied 0 Somewhat satisfied 10 Not satisfied 90 Adequacy of space in IPD Adequate 0 Somewhat adequate 30 Not adequate 70 Total no. of in-patients interviewed 10
Table IP12: Amenities provided by the hospital Percentage of in-patients reporting availability/ % reporting satisfaction Percent Availability of amenities Television - Canteen - Medical shop 70 Telephone - Accommodation for relatives - Ambulance 100 Satisfaction among those who said the amenity is available Television - Canteen - Medical shop 85.7 Telephone - Accommodation for relatives - Ambulance 40
222
Table IP13: Continuity of treatment Continuity of treatment Percent Overall satisfaction on visiting to facility Dissatisfied 80 Somewhat satisfied 20 Satisfied - Reason of dissatisfaction Lack of facilities 100 Bad experience with doctor - Poor quality of services - Charges are exorbitant - Other - Would like to come again in case fell sick Yes 30 No 10 May come/unsure 60 Whether recommend this hospital to other Yes - No 100 Total no. of in-patients interviewed 10
223
SCHEDULE (S): STATE SCHEDULE
Block A. Identification Details (Information to be collected from State Health Department) Q. o. 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. o. 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. Total 3977652 3649410 1383274 1133364 5360926 4782974 10143700 Block B. Population of the State (As on March, 2008) (Information to be collected from State Health (II) Department) Rural Urban Total Source Code (Population Projection – Q. o. Category 1; State Male Female Male Female Male Female Estimate – 2; ot 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. Total 4773182 4379292 1659928 1360036 6433111 5739568 12172440
224
Block C. Infrastructure (Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) Q. o. S114. Name of the Respondent S115. Designation of the Respondent Public Health Total ew Total o. of Infrastructure Existing Buildings umber facilities (In os.) Under where IPHS where IPHS (As on Construction facility Upgradation 30.6.2008) (In os.) survey completed (As on completed (As on 30.6.2008) (As on 30.6.2008) 30.6.2008) S116. Sub Centre 1907 INA 1907 S117. PHC 375 375 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 os.) (As on 30.6.2008) S125. Hospitals (More than INA 30 bedded) S126. Nursing Homes (Less INA than 30 bedded) Block D. Rogi Kalyan Samities (RKS)(Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) Q. o. How many facilities have Rogi Kalyan Samities (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 ot existing
S132. Addl. PHC ot existing
225
Block E. Janani Suraksha Yojana(JSY)(Information to be collected from Programme Manager in State Programme Management Unit (SPMU)) Q. o. Response Category Skip S133. Whether any PPP Yes initiative undertaken in
the state for the implementation of JSY > Q. S135 Scheme? S134. If yes, number of 07 private health facilities accredited for JSY scheme
Q. o. Total Institutional Total number of Out of total number Deliveries Registered JSY of Registered JSY Reported during Women during Women, number of 2007 08 2007 08 women opting for Institutional Delivery during 2007 08 At Govt. Facilities S135. Scheduled I A I A I A Caste S136. Scheduled I A I A I A Tribe S137. General I A I A I A S138. BPL I A I A I A S139. APL I A I A I A S140. Total 151144 151144 I A At Private Facilities (Wherever accredited for services) S141. Scheduled I A I A I A Caste S142. Scheduled I A I A I A Tribe S143. General I A I A I A S144. BPL I A I A I A S145. APL I A I A I A S146. Total I A I A I A
226
Block F. Financial Mechanisms (Information to be collected from Finance Manager in State Programme Management Unit (SPMU)) Q. o. Response Category Skip S147. Name of the Respondent S148. Designation of the Respondent S149. Have all the vertical health Yes societies created under different programmes merged in to State > Q. S151 Health Society under NRHM? S150. How many districts have 14 merged registered health societies? S151. Is there a common bank account No for 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 Health action Plans have been District Action Plans for the prepared in 2007 2008 current year (2008 09)? S154. Have these plans been approved Yes by the state society? S155. How are the funds being Activity wise allocated to the districts Flexi pool funds Size of district (Encircle all applicable options) Previous years expenditute S156. Are the funds being transferred Yes electronically by the State to the district? >Q S158 S157. If yes, then to how many 22 districts is 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
227
SCHEDULE (D): DISTRICT SCHEDULE
The interviewer is expected to interact with District NRHM society (Part A) member for collection of district level information and follow this up with a visit to the district hospital (Part
B)
Part A
Block A. Identification Details (Information to be collected from District RHM Society) Q. o. Questions D101. Name of the District Rajouri D102. Total Number of Blocks in the District 4 (Four) D103. Total Number of Census Villages (2001 census) in the 395 District D104. Name of the Respondent Asif Iqbal Mir D105. Designation of the Respondent DPM
Block B. (I) Population of the District (As on 2001 as per Population Census) Rural Urban Total Total Q. o. Category Male Female Male Female Male Female D106. Scheduled 18764 17942 952 868 19716 18810 38526 Caste D107. Scheduled 83373 74749 1095 782 84468 75581 160049 Tribe D108. Others 135811 118940 17341 12617 153152 131557 284709 D109. Total 237948 211681 19388 14267 257336 225948 483284 Block B. (II) Population of the District (As on March, 2008) (Information to be collected from State Health Department) Rural Urban Total Total Source Code (Popul ation Q. o. Category Male Female Male Female Male Female Project ion –1 Estima te – 2; D110. Scheduled 22543 21555 1142 1041 23686 22596 46231 2 Caste D111. Scheduled 100164 89698 1314 938 101361 90697 192058 2 Tribe D112. Others 162973 142728 20809 15140 183782 157868 341650 2
228
D113. Total 285537 254017 23265 17120 308803 271137 579940 2
Block C. Infrastructure [Information to be collected from Chief Medical Officer (CMO) Office] Q. o. D114. Name of the Respondent Manjit Singh D115. Designation of the Respondent CMO Public Health Total ew Total o. of facilities Infrastructure Existing Buildings umber where IPHS (In os.) Under where IPHS Upgradation (As on Construction facility completed (As on 30.6.2008) (In os.) survey 30.6.2008) (As on 30.6.2008) completed (As on 30.6.2008) D116. Sub Centre 143 12 0 0 D117. PHC 22 03 22 INA D118. 24x7 PHCs 02 00 2 2 D119. CHC 07 02 7 1 D120. First Referral Units 02 00 0 0 (FRUs) D121. Mobile medical units 00 D122. Sub Divisional Hospitals 03 00 0 0 D123. District Hospitals 01 01 1 0 D124. AYUSH 00 00 0 0 Private Health Infrastructure Total Existing (In os.) (As on 30.6.2008) D125. Hospitals (More than 30 bedded) o D126. Nursing Homes (Less than 30 bedded) 1 Facilities available in the district for delivery Facility Number of Facilities Total Operational Providing With CeMOC With New Born existing in 24x7 BeMOC (having Blood Care Unit the District Storage, (As on Anaesthetist and 30.6.2008) Gynaecologist) D127. District 01 01 01 01 01 Hospital D128. Sub Divisional 03 03 02 01 02 Hospital D129. CHC 04 03 00 00 00 D130. PHC 22 02 00 00 02 D131. Public 00 00 00 00 00 Maternity Homes 229
D132. Others Public 00 00 00 00 00 (ESI, Railways etc.) D133. Others Private 01 01 00 00 00 D134. Private 00 00 00 00 00 accredited for JSY
Block D. Human Resources Available in the District (Information to be collected from Chief Medical Officer (CMO) Office) Q. o. Category o. Regular in Contractual Total in sanctioned Position Recruits Position D135. Medical Officer 130 46 22 62 D136. Gynaecologist 07 05 00 05 D137. Anaesthetist 06 04 00 04 D138. Paediatrician 05 02 00 02 D139. Other Specialists 18 14 00 14 D140. Staff Nurses 74 52 14 66 D141. ANM 208 197 46 261
Block E. Rogi Kalyan Samities (RKS) Information to be collected from District Programme Management Unit (DPMU) Q. o. D142. Name of the Asif Iqbal Mir Respondent D143. Designation of the DPM Respondent Number of facilities having Rogi Kalyan Samities (RKS) Registered? Total functioning o. with Registered RKS D144. District Hospital 01 01 D145. Sub Divisional Hospital D146. CHC 07 07 D147. PHC 22 22
230
Block Janani Suraksha Yojana(JSY) (Information to be collected from District Programme F. Management Unit (DPMU)) Q. o. Response Category Skip/Remarks D148. Whether any PPP initiative being undertaken in the No > Q D151 district for the implementation of JSY Scheme? D149. If yes, number of private health facilities accredited for JSY scheme D150. Which of the following Lab services…………….…..A Not Applicable as areas are covered under PPP Diagnostics like Ultrasound & X none of the initiatives (Encircle all Rays………………….…..B private health applicable options) facility is Bio Medical waste Disposal..C accredited. Sanitation……………..……D Security……………………..E Hiring of specialist services….F Procurement of Drugs/ Equipment…………………...G Providing transportation facility for delivery & referral cases....H Other...... I Q. o. Total Institutional Total number of Out of total number Deliveries Registered JSY of Registered JSY Reported during Women during Women, number of 2007 08 2007 08 women opting for Institutional Delivery during 2007 08 At Govt. Facilities D151. Scheduled Caste 461 1263 461 D152. Scheduled Tribe 1324 4425 1324 D153. General 3956 13232 3956 D154. APL INA INA INA D155. BPL INA INA INA D156. Total 5797 18920 5797 At Private Facilities (Wherever accredited for services) D157. Scheduled Caste NIL NIL NIL
231
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 INA=Information Not available
Block G. Financial Mechanisms (Information to be collected from Finance Manager in District Programme Management Unit (DPMU)) Q. o. D163. Name of the Respondent Sukhvir Singh D164. Designation of the Respondent Dist. Accounts Manager Response Category Skip D165. Have all the vertical health societies created under different programmes merged in to a District Yes >Q D167 Health Society? D166. Whether the merged district health Yes society is registered?
D167. Is there a common bank account for No all programmes in District Health Society D168. Whether the district has prepared Action Plan prepared for 2007 08 District Action Plan for the current >Q D170 year? 2008 09 D169. If yes, has the plan been approved Yes by the district society? D170. How are the funds being received Flexi Pool from the State in the district (Encircle all applicable options) Activity wise
Last years expenditure
D171. Are the funds received were transferred electronically by the State Yes D172. How many Sub Centres have Operational Joint Bank Account of ANM and Sarpanch? 175
232
No. of centres for which Untied 143 o of Centres Grant for the current year transferred? 2008 09 D173. CHC/SDH 7,00,000 7 D174. PHC 11,00,000 22 D175. Sub Centre 28,60,000 143
DISTRICT SCHEDULE Part B
District Hospital The infrastructure details to be supported by digital photographs of the facility and other areas like operation Theater, wards, pharmacy, lab etc
Block A. Identification Details (Information to be collected from the Office Of Medical Superintendent of the Hospital) Q. o. Questions (for both Male/Female) D176. Name of District Hospital Dist. Hospital Rajouri D177. Name of the Respondent Dr. D.S. Salathia 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 25 01 D180. Farthest CHC in the coverage area 60 03 D181. Distance of District Hospital from the nearest bus stop (in < 0.5 Km.………….A Kms.)
D182. Has the IPHS facility survey been carried out in the No District Hospital Block B. Physical Infrastructure (Information to be collected from the Office Of Medical Superintendant of the Hospital and supplemented by observation) Q. o. Questions Response Category 8000 D183. Area of the Hospital (in Sq. mtrs.) 100 D184. Number of indoor beds available Yes D185. Is the hospital located near residential area?
D186. Is necessary environmental clearance obtained from No Pollution Control Board by the Hospital?
233
D187. Whether hospital building is disable friendly as per No 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 No D193. Treatment Room Yes D194. Pharmacy (Dispensary) Yes 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) No D201. Hospital Laundry No Yes D202. Medical and General Stores
D203. Engineering Services Backup No Ventilation (Natural or mechanical exhaust) in the No D204. wards D205. Water coolers / Refrigerators o D206. Round the clock water supply No Overhead water storage tank with Pumping and Yes D207. boosting arrangements D208. Provision for fire fighting No Proper drainage and sanitation system for waste water, No D209. surface water, sub soil water and sewerage Buried ……….…….A How is the Bio Medical Waste disposed? (Encircle all Thrown in open…….D D210. applicable options)
Is Bio Medical Waste segregated in three different D211. No bins?
234
umber of Residential Quarters available for all o. o.
medical and Para medical staff Available Occupied D212. Medical Staff 08 08 D213. Para medical staff 10 10 D214. Parking place Yes D215. Medical Records Section Yes Is the disease classification being carried out as per No D216. protocols Yes D217. Availability of telephone
D218. Availability of Fax equipment No D219. Availability of Computers No D220. Availability of Internet services No
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 Kulsooma Akhtar D222. Designation of the Respondent FMPW Response Category Skip D223. Is there a separate Ward for Female Yes Patients? >Q D224 D224. If Yes, the number of beds 18 D225. Bed Occupancy Rate in the last 12 INA months (As on March 31, 2008) D226. Total OPD in last 3 calendar months 3298 D227. Total deliveries in last 3 calendar 484 months D228. Is there a separate OT available for Yes Gynaecology & Obstetrics Procedures Carried Out Particulars Availability of Services If Yes, umbers in 2007 2008 2241 D229. Total deliveries conducted D230. Caesarean section deliveries Yes 198 Yes INA D231. Caesarean section for JSY
Yes 1976 D232. Assisted Delivery
235
Yes 67 D233. Forceps delivery
Yes 676 D234. MTP
D235. Mid trimester Abortion Yes INA D236. Ectopic Pregnancy Yes 02 Yes INA D237. Retained Placenta D238. Eclampsia No Yes INA D239. PPH
Yes 87 Sterlisation D240. D241. Suturing Cervical Tear No D242. Hysterectomy Yes 36 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 Ashok Kumar D245. Designation of the Respondent Theater Supervisor No. of Surgical OPD in last three months: 2025 D246. Female INA D247. Male INA No. of Surgical IPD in last three months: 425 D248. Female INA D249. Male INA
Availability of Services Response Category If Yes, umbers in last 3 months 67 D250. Emergency (Accident & other Yes emergency) (Casualty) D251. Pancreas Surgery No D252. Spleen and Portal Hypertension No Surgery D253. Yes 93 Abdomen Surgery
D254. Breast Surgery Yes 03
236
D255. Leprosy Reconstructive surgery No
Medical Section (Information to be collected from the Sister In charge of Medical ward & supplemented by Observation) D256. Name of the Respondent Fehmeeda D257. Designation of the Respondent FMPW Medical OPD in last three months 3852 D258. Female INA D259. Male INA Medical IPD in last three months 700 D260. Female INA D261. Male INA Availability of Services Response Category If Yes, umbers in last 3 months Dermatology and Venerology D262. No (Skin & VD) RTI / STI D263. Services under NLEP No D264. Yes INA Pleural Aspiration
D265. Pleural Biopsy No D266. Bronchoscopy No D267. Lumbar Puncture No D268. Pericardial tapping No D269. Skin scraping for fungus / AFB No D270. Bone Marrow Biopsy No D271. Endoscopic Specialized Procedures No D272. Psychiatry Services No
Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D273. Name of the Respondent Dr. M.K. Koul D274. Designation of the Respondent B. Grade Pediatrician Pediatric OPD in 2007 2008 umbers: 7215 D275. Female INA
237
Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D276. Male INA D277. Designated/identified Beds for Yes >Q D280 newborns available? D278. If yes, no. of beds 8 Pediatric Patients admitted in umbers 2007 2008 D279. Total Admitted INA D280. Neonates admitted INA D281. Other Infants (0 1 years) admitted INA D282. Children under 5 yrs admitted INA Services Available D283. Yes Asphyxia Management
D284. Management of severe Yes malnourished children D285. Management of Neo Natal Sepsis No D286. Management of Dehydration and Yes Diarrhoeal Cases D287. Management of Respiratory Tract Yes / Pneumonia Cases Available? If available, whether Equipment Available working? D288. No Yes………………….1 Cradle No…………………..2 D289. Yes No Incubator
D290. Yes Yes Radiant Heat Warmer
D291. Yes No Phototherapy Unit
D292. Yes Bag with Mask
238
Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) 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. No Vitamin A Solution
D299. No Iron folic Acid Syrup
D300. No Pediatric Antibiotics
Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation) D301. Name of the Respondent Mohmmad Zubair D302. Designation of the Respondent X ray Technician Diagnostic OPD in last 3 months D303. Female 0 D304. Male 0 Availability of services Response Category If Yes, umber carried out in last 3 months D305. X Ray Yes 2494
D306. Ultrasound Yes 573
D307. Ultrasound guided Biopsy No D308. ECG Yes 273
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Lab Services (Information to be collected from the Lab Technician & supplemented by Observation) D309. Name of the Respondent Dr. Abdul Hakim D310. Designation of the Respondent Pathologist Number attended in last 3 months INA D311. Female INA D312. Male INA Availability of services Response Category If Yes, umber carried out in last 3 months CLI ICAL PATHOLOGY D313. Hematology Yes 6870
D314. Urine Analysis Yes 980
D315. Stool Analysis Yes 06
D316. Semen Analysis (morphology, Yes 06 count)
D317. CSF Analysis (Cell count, culture Yes 04 sensitivity etc., gram staining)
D318. Aspirated fluids (cell count Yes 03 cytology)
PATHOLOGY D319. PAP smear No D320. Split Skin Smear Examination for leprosy No D321. Sputum Yes 199
D322. Histopathology No D323. Microbiology No D324. Serology Yes 94
D325. Biochemistry Yes 680
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Lab Services (Information to be collected from the Lab Technician & supplemented by Observation) 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 Dr. D.S. Salathia D328. Designation of the Respondent Med. Superintendent Category of Personnel Sanctioned Regular Contractual Total In Position In Position D329. Hospital Superintendent 01 01 00 01 D330. Medical Specialist 02 02 00 02 D331. Surgery Specialist 02 02 00 02 D332. Gynaecologist 03 00 00 00 D333. Gynaecologist (short term trained 00 02 00 02 MO) D334. Paediatrician 01 01 00 01 D335. Anesthetist 02 02 00 02 D336. Anesthetist (short term trained 00 00 00 00 MO) D337. Radiologist 01 00 00 00 D338. General Duty Doctor 16 08 00 08 D339. Public Health Manager 00 00 00 00 D340. AYUSH Physician 00 00 00 00 D341. Pathologists 01 01 00 01 D342. Psychiatrist 00 00 00 00 D343. Dermatologist / Venereologist 00 00 00 00 D344. ENT Surgeon 01 01 00 01 D345. Opthalmologist 01 01 00 01 D346. Orthopaedician 02 02 00 02 D347. Microbiologist 00 00 00 00 D348. Dental Surgeon 02 01 00 01 Para Medicals D349. Staff Nurse 13 13 00 13 D350. Hospital worker (OP/ward +OT+ 03 03 00 03 blood bank) D351. Sanitary Worker 00 00 00 00
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Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) 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 01 01 D354. ECG Technician 01 01 00 01 D355. Audiometrician 00 00 00 00 D356. Laboratory Technician ( Lab + 05 05 00 05 Blood Bank) D357. Laboratory Attendant (Hospital 01 01 00 01 Worker) D358. Dietician 00 00 00 00 D359. ANM 06 06 00 06 D360. LHV 00 00 00 00 D361. PHN 00 00 00 00 D362. Radiographer 00 00 00 00 D363. Pharmacist 06 06 00 06 D364. Matron 00 00 00 00 D365. Physiotherapist 00 00 00 00 D366. Medical Records Officer / 00 00 00 00 Technician Administrative Staff D367. Manager (Administration) 00 00 00 00 D368. Junior Administrative Officer 00 00 00 00 D369. Office Superintendent 01 01 00 01 D370. Accounts Manager 02 02 00 02 D371. Driver 00 00 03 03 D372. Peon 16 14 `02 16
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
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Block D. Other Framework and Structure Related Issues (Information to be collected from the Office of Medical Superintendent of the 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 …Personal…Acquaintance………E applicable options) D378. How do RKS generate additional Donation…………….……A one resources other than govt. grants? User fees…………..……..B (Encircle all applicable options)
D379. How is the money generated used? Retained within the facility for local (Encircle all applicable options) use…A
Half Transferred to district Accounts………….…….C
D380. Is display board put up in Hospital No showing number of members, number of meetings of RKS etc? D381. How feedback is taken for No feedback mechanism .....D one grievance redressal by RKS?
D382. Any Other Special Ward/ Procedures not covered above ______D383. Any other remarks by MS of the hospital/ Other members which have not been captured in the questions above but are relevant ______D384. Any other remarks or suggestions for improvement of services by Observer which have not been captured in the questions above but are relevant ______
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______If the patient has availed service either in (OPD or IPD) the observer to go to Exit Interview Schedule D D M M Y Y B.A.Bhat/Jaweed Ahmad
Date ame of the Investigator Signature of the Investigator
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