Monitoring Report: Rajasthan
Jan – Mar 2013
EXECUTIVE SUMMARY
The quarterly report for Rajasthan has been put together based of the HMIS data analysis and field visit to Pali district from 06.05.2013 to 09.05.2013. The following key observations and follow up actions are noted based on the monitoring visit conducted:
There are 10 designated FRUs at the district, of which only 4 are functional as FRUs. There is also a severe shortage of specialist manpower – with 85% vacancy for obstetricians and 90% each for paediatricians and anaesthetist – which is a hindrance in the operationalization of the FRUs.
There is a fully functional SNCU and blood bank at the District Hospital. In the month of April, 2013 there had been a total of 187 admissions – 107 inborn and 80 outborn admissions. The case fatality rate was 7.5% which is within acceptable range. There were 18 admissions on the day of visit. The Malnutrition treatment centres (MTCs) are non functional in the district. The MTC at the DH is a 6 bedded facility which did not have any admissions at the time of visit. Referral from AWCs was nil as cited by the district officials. This needs further improvement and referral from the OPD as well as camp based approach may be explored.
State specific schemes like the Mukhyamantri Nishulk Dawai Yojana (MNDY) for provision of free drugs and Mukhyamantri Nishulk Jaanch Yojana (MNJY) for provision of free diagnostics have had a positive impact. The MNDY is functional at all the facilities visited and all the ASHAs and ANMs as well as health care personnel reported adequate supply of medicines. While this is the case, correspondingly the quality of services provided needs to be improved and linked to these schemes. At both the SCs visited there was no Hb testing kit. During the observation of an MCHN day, interactions with the ANM revealed that she did not have any provision for Hb testing of women and had to refer women to higher health facilities for Hb testing. This is also reflected in the fact that only 1.2% of the ANC registrations have been followed up and treated for severe anemia at institutions. In addition to this, the state and district teams should take note of the possibility that ASHAs may be referring the pregnant women for tests at private facilities, which includes ultrasound tests. This needs to be further investigated and action needs to be taken accordingly. Quality and coverage of check-ups at the VHNDs and also at the level of
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PHCs and CHCs needs to be strengthened to ensure that every test that women require is available in government facilities, and referral for such tests is done rationally.
The JSSK scheme is fully operational in the district. Referral transport needs to be further strengthened. 17 of the 20 beneficiaries interacted with reported having incurred out of pocket expenditure on transportation from home to facility.
The JSY scheme is functional at the district and all the benefits under the scheme are being provided to the beneficiaries. While this is the case, interactions with the beneficiaries revealed that the linking of cheques to bank accounts is proving to be a hindrance in their encashing the cheque amounts as most of them do not have bank accounts. Opening of new accounts was a problem for those who did not have any ID proof and maintaining a minimum balance of Rs.500 was an issue.
Referral transport is provided by 13 – 108 ambulances; 8 Janani Express (JE) and 28 facility ambulances in the district. At the time of visit the paramedic staff of 108 ambulances (under contract with “Jigitsa healthcare’’) were on strike for regularization of their posts. Also, the contract between Jigitsa and the State had expired which resulted in a temporary disruption of their services. The DPMU staff were placed on a rotational duty to man the 108 call centre at the CMHO office. Of the 8 JE vehicles, 5 were reported to be non functional and off the road. These were stationed in high delivery load areas where there was no ambulance provision.
There are no ARSH clinics in the district.
“Branding” of the various levels of health care facilities (L1, 2 and 3) is being undertaken by the district. In this, identified health facilities are colour coded as per their levels.
Streamlining tendering processes for ASHA Module 6&7 training - There have been delays in rolling-out the ASHA Module 6&7 training due to the delayed tendering processes for logistics arrangements of training. The district needs to complete the tendering process for next one year before the present tender’s validity is over in July 2013. The state needs to support and monitor districts to ensure timely completion of tendering processes required for ASHA trainings.
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Ensuring Procurement and distribution of HBNC equipments -The state must complete the procurement process for HBNC equipments, namely baby weighing machine, thermometer and digital watch, and provide them to ASHAs, without any further delay.
Provisions to be made for ASHA Diary & other stationary –The state must provide the necessary stationary to help ASHA organize her work, like ASHA Diary and other registers for village survey of families and eligible couples. Also HBNC formats being filled by ASHAs should also be provided in sufficient copies.
Strengthening Support Structures – State must fill the vacancies of block level ASHA coordinators, and also support them with regular capacity building and review mechanisms. The vacant positions of the PHC Health Supervisors also need to be filled on priority basis. State also needs to reconsider the positioning of the PHC Health Supervisors. They should be tasked with the reporting and programme management support at PHC level under NRHM, the kind of role that they are presently doing, and also most of them do not have a background in community level interventions and support. Additionally then ASHA Facilitators should be again selected preferably from among the ASHAs, and placed @ one for every 10 to 20 ASHAs. The district level ASHA support team also needs strengthening, as it has only the District ASHA Coordinator, placed in DPMU, without any separate computer or working space. One computer/data support person and small working space and separate computer is required. The district Chief Medical Officer also very emphatically made a request for such support.
Mapping of the unreached populations - State must do a systematic mapping of the unreached populations to check for left out families and habitations. Gram Panchayats can play the role of consolidating the families being covered by every AWC under the panchayat and do a mapping of left-out families. The state has established a Gram Panahcyat Seva Kendra in every GP, which can be instrumental in conducting this mapping.
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DISTRICT PROFILE The Great Aravali hills link Pali district with Ajmer, Rajsamand, Udaipur and Sirohi Districts. Pali city, the district headquarter, is situated 70 kms away from Jodhpur (the second largest city of rajasthan). There are 10 blocks in Pali District.
Sl.No. Name of Block Distance from District Headquarter Distance Mode of (in Km) Travel 1. Pali ----- Rail/Road 2. Rohit 28 Rail/Road 3. Bali 72 Road 4. Sumerpur 72 Road 5. Desuri 106 Road 6. Rani 83 Rail 50 Road 7. Marwar 31 Rail Junction(Kharchi) 40 Road 8. Sojat 40 Road 9. Raipur 85 Road 10. Jaiaran 111 Road
Pali District Profile
Area (Square Kilometres) 12,369
Population – Male 1,025,895
Population – Female 1,012,638
Population Density 165
Sex Ratio (females per 1000 males) 987
Literacy Rate (per cent) 63.23
Source: Census 2011
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HEALTH INFRASTRUCTURE
The following health facilities are present in Pali District.
Number Number Type of facility As on March As on visit - May 2012* 2013# DH 1 1 SDH 1 1 CHC 16 17 PHC 67 73 SC 432 486 TOTAL 517 578 *Source: RHS 2012, #Source: District MIS
Categorization of delivery points and Levels of MCH: The delivery points across the facilities as confirmed upon visit, is as follows
Facility type No. Level of Facility (L1/2/3) L1 L2 L3 DH 1 1 SDH 1 1 CHC 17 15 2 PHC 73 52 20 SC 486 190 TOTAL 517 243 35 3
The DH is located in Pali District and the SDH in the Sojat block. There has been an addition of 1 CHC, 6 PHCs and 54 SCs since March 2012. The District Hospital and the Sub Divisional Hospitals are Level 3 facilities. Of the 17 CHCs in the district, 10 are identified FRUs, but only 5 facilities – DH Bangad, SDH Sojat, CHC Sadri, CHC Bali and CHC Rani – conduct C-sections. There are 72 PHCs in the district and all are delivery points. Among these 20 facilities are Level 2 and the remaining are level 1 facilities. These facilities are ‘branded’ as per their levels of segregation. In the district, this activity was being undertaken for all the identified levels 1, 2 and 3. At the time of visit, a model SC – Jaden SC (as shown in picture) – had been
Monitoring Report, Rajasthan Page 6 branded – green colour coding for the level 1 SC. There is a fully functional blood bank and SNCU at the DH, Pali. There is a fully functional blood bank at the DH which has been awarded the best performing blood bank in the state.
Facility Visit The monitoring visits were carried out from 06.05.13 to 09.05.13 and following health facilities were visited: Date Facilities Visited/ Activities 06.05.2013 1. Gundoj PHC 2. Sumerpur CHC 07.05.2013 3. Bali CHC 4. Falna PHC 5. Khimel SC 08.05.2013 6. Jaden SC 7. Bangad, Pali DH
SERVICE DELIVERY
Maternal Health
Antenatal Care
The ANC registration against the expected pregnancies is reported to be 144% while the ANC3 registration was 74% as against the ANC registered for the year 2012-13. Duplication in registrations is a reason for the high ANC registrations reported as against the expected pregnancies. Lack of adequate follow up of the women registered for ANC results in the low coverage, 70%, of 3 ANCs. This is also reflected in drop of the 3 ANCs reported as against the ANC registrations from 72% in 2011-12 to 70% in the 2012-13.
The quality of ANC services provided is indicated by the 53% of the ANC women registered who were reported to have Hb less than 11 gm/dl while only 1.3% and 1.2% of ANC registrations were treated at institution for severe anemia and hypertension respectively. Although line listing of the anemia cases is done, the referral and follow-up mechanism is weak at the sub-district level. Interaction with the ANM at an MCHN day held at Rohat, revealed that she did not have any Hb testing kit and had to refer all the pregnant women who were attending their ANC visits to the higher facilities for Hb testing. This is seen in the weak reporting as well as follow-up of anaemia and hypertension cases.
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60.00% 52.41% 50.00% 40.00% 30.00% Percentage against 20.00% reported ANC 10.00% 1.27% 0.41% 1.28% 0.00% Hypertensive Eclampsia ANC women ANC women cases treated cases having Hb having severe at institution managed level < 11 anemia during (Hb<7) delivery treated at institution
Management of complications against reported ANC (Source: District HMIS) Delivery Care The rate of home deliveries has remained constant over 2011-12 and 2012-13 at 6% while institutional deliveries were 94% of the total deliveries reported.
100% 94% 94% 90% 80% 70% 60% 50% Institutional Deliveries 40% Home 30% 20% 10% 6% 6% 0% 2011-12 2012-13
Total No. of institutional and home deliveries (Source: District HMIS) However, there is a marginal decrease in the institutional deliveries reported for the year 2012-13 as compared to the previous year. While there has been an overall decrease in the deliveries in 2012-13, increase in deliveries is observed in the DH and the accredited private hospitals. This was reflected in the visit to the DH where all the 5 labour tables in the labour room were occupied and the corridors were teeming with women who were due for delivery. The DH catered to 11% of the total deliveries in 2011- 12 and 14% in 2012-13. This can be attributed to the higher referrals made to the higher centre and support in terms of better availability of transport for patients. Also, the introduction of state specific
Monitoring Report, Rajasthan Page 8 schemes of providing free drugs and diagnostics at the tertiary level institutions can be attributed to the increased caseload. Facility Deliveries 2011-12 Deliveries 2012-13 DH 4,245 5308 SDH 3,021 2,472 CHC 11,016 10,511 PHC 7,299 7,023 SC 4,243 4,068 Accredited Private Hospital 3,720 4,082 Non Accredited Private 3,901 3,717 Hospital Total 37,445 37,181
35% 29%
30% 28%
25%
19%
19%
20%
14%
11%
15% 11%
11%
11%
10% 2011-12
10%
10% 8%
10% 7% 2012-13 5% 0% DH SDH CHC PHC SC Acc Pvt Non Acc Hospital Pvt. Hospital
% Institutional Deliveries at different levels of health facilities Source: District HMIS
Schemes for promotion of Mother and Child Health
JSSK
Awareness and display of entitlements
The JSSK entitlements along with other benefits for the patients were displayed prominently at all the facilities visited. The state scheme of Mukhyamantru Nishulk Dawai Yojana (MNDY) and Mukhyamantri Nishulk Jaanch Yojana (MNJY) are also widely publicised along with the JSSK display.
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All the patients were aware of the JSSK scheme. 3 patients reported being informed by the Staff Nurse at the facility, 2 reported the ANM and ASHA as the source of information and the remaining 15 beneficiaries interviewed reported ASHAs as their primary source of information.
Out of pocket expenditure Of the women interviewed, all reported out of pocket expenditures – primarily because of transportation charges. User Charges None of the women reported having incurred any user charges for the OPD/IPD services rendered. In addition to the pregnant women, elderly citizen, widows, BPL patients, T.B patients are all exempt from any user charges. Although there were no user charges levied, one beneficiary at the DH reported that they had to make an informal payment of Rs.150 to ‘’someone who had handed over the baby” from the labour room to them.
Drugs and consumables All the drugs and consumables for pregnant women are provided free of cost under the Mukhyamantri Nishulk Dawai Yojana (MNDY) and JSSK schemes. None of the beneficiaries reported being charged for any drugs or consumables. All the facilities visited had adequate stock and an efficient supply chain for indenting and supply of drugs was in place.
Diagnostics
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The Mukhyamantri Nishulk Jaanch Yojana (MNJY) scheme had been launched across all the DHs in the state at the time of visit. Under this scheme, all the patients including pregnant women were exempt from any fees incurred on the basic lab tests. None of the beneficiaries interviewed had incurred any expenditure on diagnostic facilities availed during their pregnancy.
Display of entitlements under the MNJY at DH, Pali Diet Diet facilities for the patients are provided through the Kaleva yojana where food is supplied by NGOs and local women from self help groups in the community empanelled with the hospital. All the beneficiaries, except one interviewed at Gundoj PHC, reported getting a staple diet of milk and biscuits – morning; khichdi/dalia – afternoon and khichdi for dinner. All the facilities except Gundoj PHC had the provision for diet. One of the ASHAs interacted with at Gundoj PHC reported that she had been providing diet to the women under the Kaleva Yojana but had to discontinue doing so due to lack of payments from the PHC.
Referral transport While the provision for referral transport is available in the state, majority of the beneficiaries reported hiring vehicles for their journey from the facility to the hospital. Seventeen of the women reported using either an auto, rickshaw or taxi as a means of transportation. The remaining 3 beneficiaries interviewed had come to the facility in their own vehicles. The main reason for not calling for the ambulance was the waiting time involved between call and arrival of the ambulance. 12 of the respondents said that they did not want to wait for the ambulance hence did not call for it. Of these 5 reported staying near the health facility as a reason for not
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availing ambulance facility. One beneficiary also reported that they were embarrassed about calling an ambulance to their residence as inquisitive villagers gather around. For those who did not use the ambulance facility, reimbursements as per State norms were provided. The norms for reimbursement are as follows:
Distance Amount
0 – 12 kms Rs. 125
12 – 25 kms Rs. 250
Above 25 kms Rs. 7 per km
Grievance Redressal Mechanism
There is no separate mechanism for grievance redressal for the JSSK scheme. Helpline numbers have been displayed for registering any complaints with regards to availability of drugs as were observed at all the facilities.
Helpline no. and Drug Store official’s number displayed at Falna PHC
Records and Registers
All records and registers for JSSK were maintained and up-to-date at all the facilities visited. Details of the beneficiary, records of cheques handed to the patients for reimbursement of transportation charges as well as JSSK drug registers were available.
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Drug Stock register at Falna PHC and JSSK transport register at Bali CHC
JSY and Subhalakshmi Under the JSY scheme, the beneficiary receives an amount of Rs. 1400 (Rural) and Rs.1000 (Urban). Additionally, the govt. of Rajasthan provides Rs.2100 for the birth of a girl child at birth, Rs.2100 at the age of one year and a final instalment of Rs.3100 upon completion of 5 years, thereby making it a total of Rs.7300 for every girl child born. Also, for the BPL families who have institutional deliveries 5 kgs of ghee is provided for the first two deliveries. Records and registers were being maintained for all the schemes. There was minimal backlog of JSY payments in the facilities visited but a problem cited by majority of the beneficiaries interviewed was the difficulty in opening bank accounts for cheque deposits. As a majority of the women did not have bank accounts, many of the cheques were not being cleared. This was a problem cited by the district officials as well. Opening of accounts was proving to be a major hindrance in the benefits being availed by the patients. In some cases, the bank officials were insisting on a minimum balance of Rs.500 to be maintained for opening new accounts which was a problem for the beneficiaries. Also, those who did not have any ID card (such as aadhar, ration card) could not open accounts.
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Maternal Deaths
There were 39 maternal deaths reported in 2011-12 and 40 deaths reported in 2012-13. Maternal death audits and verbal autopsies are carried out for all the reported maternal deaths.
Child Health There is one SNCU - at the District Hospital, Bangad and six NBSUs – at SDH Sojat, CHC Rani, CHC Bali, CHC Sumerpur, CHC Jaitaran and CHC Sadri – in the district. The SNCU is very well maintained and well equipped with 12 radiant warmers and 4 phototherapy units – all of which were functional at the time of visit. There were 18 admissions on the day of visit. The following table highlights the admissions in the year 2011-12 and 2012-13. It is the only SNCU in the district and the number of admissions has increased by 51% in 2012-13. It is also a matter of concern that the number of patients leaving without against medical advice as well as those absconding has increased. There has been a corresponding increase in the number of referrals as well.
2011-12 2012-13 Inborn 744 1028 Outborn 458 796 Total 1202 1824
2011-12 2012-13 LAMA 21 35 Referred 103 311 Expired 124 179 Absconded 3 10
Three oxygen cylinders were present in the SNCU – of which one was non functional. There is a 3 year guarantee for these cylinders and maintenance issues were cited by the nurse in charge. Long delays and poor response from the concerned supplier were reported which was a hindrance in the smooth functioning of the SNCU. The SNCU is staffed by 6 nurses, 5 assistants and a doctor-in-charge. The Principal Medical Officer of the DH is the paediatrician in charge of the SNCU. Malnutrition Treatment Centre
Pali district has 1 six bedded MTC – at the DH and 4 three bedded MTCs – located at CHCs Jaitaran, Rohat, Sadari and Sumerpur. The MTC at the DH was non functional and there were no admissions on
Monitoring Report, Rajasthan Page 14 the day of the visit. It was reported that there is very poor referral of children and uptake of the services offered at the MTC. The other MTCs at the CHC were also reported to be a problem. Referrals from AWCs were nil and as a result there were no admissions in the MTCs.
Immunization Services
The BCG immunization as against the reported live birth is 104%. This can be attributed to duplicity in reporting or underestimated denominator. All the other indicators of immunization for DPT 3, OPV 3, measles are above 90%. The percentage of fully immunized children is 99% as against the reported live births. The drop-out rate from BCG to measles is 14.8%.
106% 104% 104% 102% 100% 100% 99% 98% 96% 94% 93% 92% 92% 90% 88% 86% BCG DPT 3 OPV 3 Measles Fully Immunised
Source: District HMIS
Immunization (%) against reported live births
Family Planning
The total unmet need for family planning is 22.7 – 7.8 for limiting and 14.9 for spacing. In 2012-13, 98% of the reported sterilisations are female sterilisations and only 2% male sterilisations (NSV). Majority of the female sterilisations are laparoscopic (84%) followed by 13% post partum sterilizations. The performance of total sterilizations performed in the district has reduced to less than half in 2012-13. There were 18,308 cases of sterilisation in 2011-12 and in 2012-13 only 7,031 cases were reported.
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Incentives like gas connections were provided for beneficiaries of family planning in 2011-12, resulting in a large number of cases as compared to 2012-13. The district officials cited linking of incentives to the family programme in 2011-12 as being a hindrance in the roll out of the programme for 2012-13. ARSH There are no ARSH clinics in the entire District. One clinic has been proposed for the DH for the year 2013-14.
Referral Transport The district is connected by 108 ambulances (contracted out to Jigitsa Healthcare pvt. Ltd), Janani Express vehicles as well as district ambulances. There are 13 108 ambulances, 8 Janani Express (JE) vehicles and 28 facility ambulances i.e. a total of 49 ambulances in the district. There is a 108 call centre. Of the 8 JE vehicles, 5 were reported to be off-road at the time of visit. The staff of 108 ambulances (1 LT, 1 compounder) in the district and state were on strike demanding regularization of their posts. The contract between the State and Jigitsa Healthcare had also expired, resulting in a disruption of their activities. Consequently, the DPMU staff had been put on a 24 hr rotational duty to operate the 108 call centre.
Bio-Medical Waste Management (BMW) Appropriate segregation of the bio-medical waste was not observed at the facilities. The BMW at PHC Gundoj especially needs attention – at the time of visit, the emergency room had just a tin bucket with discarded plastics and gauze.
State Specific schemes Mukyamantri Nishulk Dawai Yojana (MNDY) - Provision for free drugs
The MNDY scheme was launched across the state on October 2011. The MNDY is functional at all the facilities visited. The scheme has been beneficial in terms of availability of drugs at the facilities. The requisition for the drugs – an online indent - is sent by the facility as per case load to the Block CMO and
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the district drug warehouse (DDW). The drugs are then supplied from the DDW to the District drug centres and through the BCMOs distributed to the various health facilities. All the OPD patients avail their prescribed drugs through the MNDY counter, where a copy is retained by the MNDY staff. The details are entered and stock levels ugraded. A list of the drugs available under the MNDY for the SCs, PHCs and CHC/DH is prominently displayed at all the facilities. Interactions with the ASHAs and ANMs revealed that they did not face any issues in re-stocking or re-filling their drug kits. The stock was received promptly as soon as they were indented for.
List of drugs under MNDY displayed at SC, PHC and DH
Mukhyamantri Nishulk Jaanch Yojana (MNJY) – Provision of free Diagnostics
The MNJY scheme is yet another scheme launched by the State in the last month. At the time of visit, the scheme had been rolled out at the DH and expansion of the same was underway to the CHCs and PHCs. At the DH, all the basic laboratory investigations were provided free of cost to the beneficiaries. In addition to this, all diagnostics except digital X-ray and C.T.Scan were, free of charge.
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Community Processes
ASHA Programme in the district - The district with about 20.38 Lakh population, has 10 blocks, 1 DH, 1 SDH, 17 CHCs, 73 PHCs and 486 SCs. It has 61 delivery points. It has reported 2318 home deliveries and 37181 Institutional deliveries in last FY. The district has total 1445 ASHAs in position and working. Total 205 ASHAs are reported as drop-out in last about three years. Of this 48 are those who have been dropped out of the programme because of being non-functional, by a joint order of Block MO and Block level CDPO (of ICDS dept.) after a due process1. All others have dropped out on their own due to other opportunities. The district has completed the trainings on Module 5 and round one of Module 6&7 training of 5 days. The ASHA programme database has no information on the population being covered by each ASHA. During the recent Module 6&7 training the database of ASHA programme has been updated. As per the ASHA programme structure in the state, ASHAs have been placed at the level of AWCs, so the no. of target ASHAs is equal to no. of AWCs. But during the field visit it was observed that in some villages certain sections of the far-flung habitations are not included in the coverage area of any AWC, so are left out of coverage of ASHA as well on paper. Total 1125 ASHAs have been trained in Module 5, and 1065 trained in round 1 of Module 6&7. Support systems – The district has one District ASHA coordinator in position for last 3 years, who is located in the District PMU. It has only 2 block ASHA Coordinators in position (out of total 10 blocks) and in rest of the blocks BPMs do the role of programme management and support, with the help of PHC Health Supervisors of the neighbouring PHCs who have been given additional responsibility of these blocks regarding the
1 After an ASHA has been found to be non working for 4-5 months, she is given 3 notices, which are sent to her and the panchayat of the village. Second notice is delivered by hand by either PHC level ASHA supervisor or block ASHA Coordinator who also talks to ASHA and tries to understand her problems, if any. After third notice, if ASHA does not respond by joining back her regular work, an order signed jointly by block MO & block CDPO (of ICDS) is sent to her and gram panchayat, informing about ASHAs name being deleted from the list of ASHAs (copies are sent to district CMHO and CDPO of ICDS)
Monitoring Report, Rajasthan Page 18 regular reporting, for which they are expected to spend first 10 days of every month in the block HQ. It has in place, 34 out of total 71 positions of PHC ASHA Supervisors (called PHS) who are now re- christened as PHC Health Supervisors. The PHSs have proved to be ineffective in providing field level support to ASHAs. They have been given responsibility for data entry and reporting for all NRHM programmes at PHC level. Presently they are being used for monitoring of MCHN days and verification of HBNC visits done by ASHAs and forms filled by them, but are not playing any on the job support and mentoring of ASHAs in the field. Module 6&7 training – The district has done the training of ASHAs in round 1 of Module 6&7 for all 10 blocks, and has trained 1065 ASHAs. All trainings were done on residential basis at a training site in a big ‘Dharmashala’ building situated in the middle of the district HQ town. As per the state’s policy the district conducted a tendering process to select agency for logistics arrangements of the training, tendering process was completed in Sep 2012, and one agency was selected based on lowest rates and suitability of venue. The DAC and CMHO felt that the budget of the training, particularly the budget for food @ Rs 100 per person per day was a limiting factor and posed challenges in organizing the training. The trainings were done in 2 or 3 parallel batches at the training venue during Feb and March 2013. The content and agenda of the training was followed as per the training strategy given in the Ajmer TOT. A visit to the training venue was done (no training batch was presently on) and facilities were quite adequate, with 3 big, well maintained, well lighted and airy halls. The two storied building had sufficient number of residential rooms and well kept toilet facilities. The dharmshala was a very safe building. Process of evaluation of ASHAs was done in 4 steps of written tests starting from pre- training, and skill test at the end of the training. ASHAs were scored separately on written and skill tests, and records of the tests and scores were well maintained. Small number of ASHAs who had scored very low were not declared as having failed, but have been identified for further capacity building efforts, including another opportunity to attend the same training. Trainers –
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27 ASHA trainers from the district were trained at State Training site of Ajmer. It included one trainer from an NGO and 2 other freelance trainers with social service background. Others were from among ANMs & GNMs (9), Nurse tutors (2), LHVs (2) and one MO (MBBS). From among the ASHA support team, apart from DAC, it had one BAC and 8 PHC Health Supervisors. All of the trainers were available during the ASHA training, and were used as trainers, except one PHS who had not made the grade in the trainers evaluation done at the state training site. The ASHA trainers had been given trainers manual during their TOT at Ajmer, which were subsequently used by them while conducting ASHA training batches. Training Material and Aids / Modules – The ASHAs have been given copies of only Module 6 as per the instructions of the state. Three last batches of round 1 of Module 6&7 training were not given the copies of Module 6 due to short supply from state. Equipments – The district has not been supplied HBNC equipments by the state, namely – Newborn baby weighing machine, digital thermometer, and digital watch, and baby blanket, and consequently ASHAs have not been given these equipments. ASHAs who had attended IMNCI training in 2009, were given Newborn baby weighing machine and digital thermometer. Many ASHAs have lost them, and some have become non-functional. Digital thermometer in particular has become non-functional with most of the ASHAs. District team reported that state had supplied HBNC training equipments at the training sites. All ASHAs met during the visit said that one set of equipments was provided at the training site and they had practiced the skills on equipments 2-3 times during training. Drugs – Drug supply and replenishment was found to be quite satisfactory in the district. All ASHAs reported having received a package of drug kit after the initial joining, and reported that the drug replenishment process is smooth and they get the required supplies from the PHC as and when required. Nishchay Kits was reported by them as one item not readily available, though it was regularly in demand. Cotrimoxazole has not been included in their supplies. But ASHAs reported having knowledge of Cotrimoxazole and said that they advice families to get it from ANM, with whom it is readily available. The Mukhyamantri Nihshulk Dawa Yojana (MNDY) scheme of the state for making provision of free drugs for all has made a very positive impact on the availability of drugs across the facilities, particularly at PHC level, and has made regular replenishment of ASHA drug kit smooth. All facilities displayed the
Monitoring Report, Rajasthan Page 20 list of about 190 essential drugs available as part of the scheme, with clear ticks on the drugs that were available and those that were not in stock. Knowledge and skills of ASHAs - All ASHAs met were educated upto 8th class, and many of them were 10th class pass also. One ASHA met was studying in BA IInd yr. A no. of ASHAs shared that they are studying for either 10th class or 12 class. Many of them were keen that they should get opportunity to get admission in ANM course. The state at present has no policy of any reservation for ASHAs in ANM courses. In all the 4 group meetings with ASHAs and two village level interactions with ASHAs, most of them were found to be well aware of the skills of weighing the baby and taking the temperature of baby, and could explain the steps well. But most of them did not clearly recall the role of noting the time of birth, and most of them could not relate it clearly to the examination of the baby’s breathing. About the ORS, ASHAs were aware only about the ORS packets and said that they have not been taught the method of making ORS at home. All ASHAs very enthusiastically and rightly explained the steps of Hand-washing. ASHAs were able to explain the steps of HBNC visits and days of the visits in case of both home delivery and institutional delivery. ASHAs have started making HBNC visits and are submitting the filled up forms in the PHC. But they have to get the forms photocopied from the Module 6 book, as they have not been given any copies of the form. During the home visits with ASHA in two villages, one ASHA who had the newborn weighing machine given in the IMNCI training, used it properly and took the weight of the newborn. ASHAs reported that the digital thermometer that some of them had been given, is not working properly either due to discharge of its cell, or due to unknown reasons. No facility or options for its repair or change of cell were reported known by ASHAs.
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ASHAs reported good understanding of how to wrap the baby, but they have not been given baby blanket during the training. Stationary for supporting ASHAs in organizing her work – ASHAs have not been provided any ASHA Diary or such registers or other stationary for helping ASHA organize her work. She maintains her records in copies and plain registers. There is no format provided for monthly consolidation of activities done and payments due by ASHAs. Consequently they submit the vouchers for different activities in a bunch, which also makes it difficult for any cross-check as to whether the full payment has been done to ASHA for her payment claims submitted. ASHAs also shared that they have to even get the photocopies of the Home visit HBNC form done by themselves, and bear the costs. ASHA Monthly Meetings and Payment systems – The payment systems for ASHAs for NRHM related payments have been remarkably streamlined in terms of regularity of payment. The payments to ASHAs are made by the concerned PHC though a consolidated payment system. Each ASHA submits her payment vouchers for every activity and in a consolidated payment voucher total payment due to all ASHAs with the list of activities done by them is listed. In most of the places in the district, this payment is being done through a single cheque payment to the bank. The bank accounts of all ASHAs of the block are in the same branch in which the block’s NRHM account is kept. So by this single cheque payment all ASHAs receive their due payments in their accounts. In some of the blocks this payment is still being done by a cheque being issued to each ASHA for the amount due to her. This consolidated payment system includes incentives of Rs 150 for social mobilization for monthly VHND (called MCHN day in the state), Rs 100 for conducting VHSNC meeting on the same day immediately after VHND, and Rs 100 for attending the monthly block meeting. It also includes all other incentives paid to ASHAs, including those under HBNC, JSY & DOTs and any other incentives paid from NRHM funds. But in a new initiative, the state has recently started a system of payment in which all incentives related to MCHN day and immunization will have to be paid to ASHA by the ANM on the spot at the time of MCHN day. Rs 2500 is being provided to all ANMs as advances for making this payment. But the field level experiences show that this new system is creating delays and problems in payments. At the time when the monthly payment system is being streamlined quite effectively, this new spot payment in cash is creating problems and the district ASHA support team as well as the CMHO were unhappy with the system and wanted it to be discontinued.
Monitoring Report, Rajasthan Page 22
The monthly payment of ASHA-Sahyoginis (as they are called in the state) which comes from the ICDS department is made directly to a separate bank account of the ASHAs meant exclusively for ICDS payment. ASHAs were being paid Rs 1100 per month till 31 March 2013, but it has been raised to Rs 1600 per month since then. The discussions with ASHAs and also a look at the pass-book of some ASHAs showed that this monthly payment is extremely irregular (amounts in one payment were as high as Rs 9000 against a monthly salary of Rs 1100), and also the complete amounts for the whole year have not been paid. ASHAs had no clarity about the amounts paid and deductions made. Services being provided by ASHAs Referral to private hospitals - ASHAs are referring pregnant mothers for ANC check-ups to private hospitals for blood Hb, HIV test & Ultrasound test, costing up to Rs 1300. In two blocks visited Sumerpur and Baali, many of the pregnant women who have been registered and have received ANC at the village level VHND, later get a whole set of tests of pregnancy check-ups done at the private facility at nearby block headquarter town. In some cases this package of tests includes Hb test, Urine test and reportedly also HIV test and costs Rs 300. In some other cases this package of tests would also include the Ultrasound test and would cost Rs 1200-1300. In most of such cases ASHAs accompany the pregnant mother to the private facility, and the doctors in the local government facility were also aware of this practice. On prodding ASHAs say that they help the pregnant mothers by getting these check-ups done and do not get any money or incentive from private facilities for this. Status of VHNDs Only weight of the mothers and TT injections are being done in most of the places. VHNDs BP test is also being done only in some VHNDs. Hb test is not being done in most of the places. The weighing machine for mothers was also not functional in some places. The ANMs admitted to not using the BP instrument at VHND. Status of VHSNCs Systems for support and capacity building of VHSNCs are very weak. Records of the proceedings are almost non-existent. Even the names of the members are not being kept recorded in the VHSNC registers. Also even the ASHAs are not aware of the whole list of the members. In many VHSNCs of the larger villages, with 4 AWCs, all members of VHSNCs except one panch are from among ASHAs (4), AWCs (4) and ANM. In FY 2012-13 no fund has been disbursed to VHSNCs. Both awareness and management of VHSNCs is in very bad shape. Rs 100 is being paid to ASHAs every month for conducting VHSNC meeting from the VHSNC untied funds, and the payment is made directly by the PHC, but ASHA is
Monitoring Report, Rajasthan Page 23 basically conducting a meeting of present women after VHND, with participation of other representatives and members from community being very weak. Performance Monitoring System for ASHA programme - It has not been initiated in the district, no direction from the state has been sent to the district on this. Grievance Redressal System - It has not been initiated in the district, no direction from the state has been sent to the district on this. Coverage of villages / families – Gaps were noticed in the coverage of the families from disadvantaged sections. In one village visited, a habitation of about 125 families from the sheep rearing community is left uncovered by AWC survey, so consequently left out of the coverage of the ASHAs areas as well. District team is not aware of these gaps or this possibility and has no data about the population being covered by each ASHA.
Human Resources The following table highlights the staff position in the district.
Regular Contractual In position In Category/ type Sanctioned In Sanctioned (through position Total in Vacancy of personnel posts position posts state/other from position (%) sources) (E) NRHM st 1 ANM 609 609 104 104 0 713 0% nd 2 ANM 0 0 55 55 0 55 0% MPW/ Male 53 53 0 0 53 53 HW 0% Staff Nurse 277 277 0 0 0 277 total 0% DH - 0 22 22 - 22 0% FRU - 0 40 40 - 40 0% 24X7 PHCs - 0 130 130 - 130 0% Other facilities - 0 154 154 - 154 (Pls. specify) 0% LTs DH FRU - 0 - 0 0 0 24X7 PHCs - 0 5 5 5 10 Other facilities - 0 - 0 0 0 (Pls. specify) Pharmacists 20 20 8 8 0 28 0% MOs total 152 125 2 2 0 127 18% AYUSH MOs 0 0 33 33 0 33 0%
Monitoring Report, Rajasthan Page 24
Regular Contractual In position In Category/ type Sanctioned In Sanctioned (through position Total in Vacancy of personnel posts position posts state/other from position (%) sources) (E) NRHM DENTAL MOs 3 2 0 0 0 2 33% Specialists total 30 5 30 2 0 7 88% Obstetricians 10 3 10 0 0 3 &Gynaecologist 85% Anaesthetist 10 0 10 2 0 2 90% Paediatrician 10 2 10 0 0 2 90% Source: District PIP 2013-14
There is a severe shortage of specialists in the District. Overall, 88% vacancy among the specialists is noted – with 85 % vacancy for obstetricians and 90% vacancy for paediatricians and anesthetists respectively. As a result of this, there are only 4 functional FRUs amongst the 10 designated FRUs. The district officials cited reluctance of personnel to work in the tribal belt as a reason for the shortage of specialists. For e.g. Bali CHC which is a functional FRU, had only one gynaecologist and an anesthetist on call from Sumerpur CHC. Specialist shortage is followed by an 18% shortage of MOs.
Monitoring Report, Rajasthan Page 25
ANNEXURE 1 – HMIS ANALYSIS FROM NATIONAL WEB PORTAL, NHSRC
Rajasthan - Pali- Summary -Apr'12 to Mar'13
ANC
ANC Registration against Expected TT2/ Booster given to Pregnant 84% 95% Pregnancies women against ANC Registration
3 ANC Check ups against ANC 100 IFA Tablets given to Pregnant 70% 120% Registrations women against ANC Registration
Deliveries
Reported Deliveries against Home Deliveries( SBA& Non SBA) 78.2% 4.2% Expected Deliveries against Estimated Deliveries
Institutional Deliveries against Home Deliveries( SBA& Non SBA) 74.0% 5.3% Estimated Deliveries against Reported Deliveries
Institutional Deliveries against C Section Deliveries against 94.7% 2.1% Reported Deliveries Institutional Deliveries( Pvt & Pub)
Births & Neonates Care
Live Births Reported against Newborns weighed against 85.3% 85% Estimated Live Births Reported Live Births
Still Births against reported 1000 live Newborns weighed less than 2.5 26.4 80% Births kgs against newborns weighed
Newborns breastfed within one hr Sex Ratio at Birth 903 87% of Birth against Reported live Births
Child Immunisation( 0 to 11 mnths)
Measles given against Expected Live Measles given against Reported 75% 88% Births Live Births
Fully Immunised Children against Fully Immunised Children against 74% 87% Expected Live Births Reported Live Births
Required numbers of VHNDs per Immunisation Sessions held as 24,944 107% thousand population in 12 mnths percentage of required VHNDs
Family Planning & Abortions
Family Planning Methods Users ( Total Sterilisations ( Male & Sterilisations(Male &Female)+IUD+ 58,749 7,374 Female) Condom pieces/72 + OCP Cycles/13)
MTP up to 12 weeks 312 Abortion (spontaneous/induced) 620
Abortion Rate against Expected MTP more than 12 weeks 42 1.8% pregnancies
Monitoring Report, Rajasthan Page 26
Rajasthan - Pali- Key Performance Indicators -Apr'12 to Mar'13
ANM Related
% ANC Registration in First Trimester % PNC visits within 48 hours and 14 48% 55% against Reported ANC registration days against total deliveries % Three ANC check ups against % DPT3 immunisation against 58% 82% estimated pregancies. Estimated Live Births % Hypertension in pregnancy- detected % Measles Immunization against 1.3% 75% against ANC Reported Estimated Live Births % Severe anaemia (Hb<7) treated gainst % Full immunisation against 1.3% 74% Reported ANC registration Estimated Live Births
ASHA Related
% Newborns weighed at birth against JSY Paid to ASHA as % of reported 72% 19% Estimated live Births Institutional deliveries
% of Newborns having weighed less % ASHAs present during 80% 55% than 2.5 kg against newborns weighed immunisation Sessions
% Newborns visited within 24 hrs of 61% Home deliveries
Facility Related
% C- Section against Institutional OPD per 1000 population 1,174 2.1% Deliveries Abortion Rate against Reported IPD per 1000 population 59 2.2% pregnancies
Total sterilisation done per 1000 eligible Major surgeries per lakh population. 137 21 couples. Institutional deliveries against Total IUD inserted per 1000 eligible 74% estimated deliveries. couples 38.43 Institutional deliveries against 95% Reported deliveries.
Demographic Denominators - Rajasthan - Pali
Eligible Expected CBR - Couple ( IMR of the state Total Pregnancies Expected Deliveries Apr'12 to Rajasthan - 17% of - Rajasthan - Pali Population Apr'12 to Mar'13 Pali total Mar'13 population)
Source AHS -2011 AHS -2011 Census 2011 Derived Derived Derived
55 23.5 20,78,640 53,733 50,191 3,53,369
Monitoring Report, Rajasthan Page 27
Rajasthan - Pali- Deliveries - Apr'12 to Mar'13
Total Population Expected Deliveries - Apr'12 to Mar'13 20,78,640 50,191
Institutional ( Pub & Total Deliveries Unreported Home SBA Home Non SBA Pvt) Reported Deliveries
482 1,610 37,134 39,226 10,965
Total Deliveries Unreported Home SBA % Home Non SBA% Institutional % Reported % Deliveries %
1% 3% 74% 78% 22%
Rajasthan - Pali- Home ( SBA & Non SBA) & Institutional Deliveries against Expected Deliveries - Apr'12 to Mar'13
Unreported Deliveries Home SBA 22% 1% Home Non SBA 3%
Institutional 74%
Monitoring Report, Rajasthan Page 28
Rajasthan - Pali- Home ( SBA & Non SBA) & Institutional Deliveries against Reported Deliveries - Apr'12 to Mar'13 Home SBA Institutional (Pvt) 1.2% Home Non SBA 19.8% 4.1%
Institutional (Pub) 74.9%
Rajasthan - Pali- C sections & Complicated Deliveries Apr'12 to Mar'13
Total Institutional Institutional Deliveries (Public) Institutional Deliveries (Pvt) deliveries
Total Deliveries 29,382 7,752 37,134
C Section 507 287 794
C Section% 1.7% 3.7% 2.1%
Complicated Pregnancies attended 2,362 - 2,362
Complicated Pregnancies attended % 8.0% 0.0% 6.4%
Rajasthan - Pali- C-Section, Complicated & Normal Deliveries against Reported Institutional Deliveries ( Pvt. & Public) Apr'12 to Mar'13 C- section % 2.1% Complicated Pregnancies attended % 6.4%
Normal deliveries % 91.5%
Rajasthan - Pali- Facility wise %ge of C sections & Complicated Deliveries Apr'12 to Mar'13
Monitoring Report, Rajasthan Page 29
Other State PHC CHC SDH/DH Private Facilities Total owned institution Complicated deliveries managed ( 195 359 1,808 - - 2,362 Reported) Complicated deliveries 8.3% 15.2% 76.5% 0.0% 0.0% managed as %ge of total reported C Section (reported ) - 252 255 - 287 794 C Section as percentage of 0.0% 31.7% 32.1% 0.0% 36.1% total reported
Rajasthan - Pali- Complicated Pregnancies & Deliveries Treated - Apr'12 to Mar'13
Reported Deliveries 39,226
Complicated Complicated Pregnancies C - Section PNC Maternal Pregnancies Abortions Still Births Rate Deliveries Complications attended
4.4% 2,362 794 706 620 1,100
Complicated Deliveries Treated with No Of Eclampsia IV No Of severe anemia cases treated Blood cases IV Antibiotics antihypertensive/Magsulph IV Oxytocis Transfusion Treated injection
3,719 541 3,652 1,217 184 575
Monitoring Report, Rajasthan Page 30
Rajasthan - Pali- Stay duration as percentage of Reported Institutional Deliveries - Apr'12 to Mar'13
Stay for more than 48 hrs after delivery 20%
Stay for less than 48 hrs after delivery 80%
Rajasthan - Pali - JSY Paid to Mothers as % of reported deliveries - Apr'12 to Mar'13
%age JSY paid Deliveries JSY Paid to mothers against reported deliveries
Home 3.44% 2,092 72
Institutional (Public) 99.04% 29,382 29,101
Institutional ( 51.43% Accredited - Pvt ) 7,752 3,987
Rajasthan - Pali -JSY Paid to Mothers as % of reported deliveries - Apr'12 to Mar'13
120% 99% 100%
80%
60% 51%
40%
20% 3% 0% Home Institutional (Public) Institutional (Pvt)
Monitoring Report, Rajasthan Page 31
Rajasthan - Pali-ANC Services - Apr'12 to Mar'13
60,000 53,733 53,825
50,000 44,897 44,893 42,704 40,000 31,279 31,811 30,000 21,683 20,000 10,000 - Expected Total ANC ANC ANC 3 ANC check TT1 TT2 or Booster 100 IFA Pregnancies - Registration Registration registration for ups tablets given Apr'12 to within first JSY Mar'13 trimester
Rajasthan - Pali- Management of Complications (Reflecting Quality of ANC )against Reported ANC Registration- Apr'12 to Mar'13 %age against Reported reported ANC Registration Hypertensive cases 568 1.3% detected at institution
Eclampsia cases 184 0.4% managed during delivery
ANC women having Hb 23532 52.4% level<11 ANC women having severe anaemia (Hb<7) 575 1.3% treated at institution
Rajasthan - Pali- Management of Complications (Reflecting Quality of ANC )against Reported ANC Registration- Apr'12 to Mar'13 60.0% 52.4% 50.0%
40.0%
30.0%
20.0%
10.0% 1.3% 0.4% 1.3% 0.0% Hypertensive cases Eclampsia cases ANC women having Hb ANC women having detected at institution managed during delivery level<11 severe anaemia (Hb<7) treated at institution
Monitoring Report, Rajasthan Page 32
Rajasthan - Pali- Post Natal Check up against Reported deliveries -Apr'12 to Mar'13
90% 79% 80%
70% 55% 60% 50% 40% 30% 20% 10% 0% PNC within 48 hours after deliveries PNC between 48 hours and 14 days of Deliveries
Rajasthan - Pali-Births - Apr'12 to Mar'13
60,000
48,848 50,000 41,690 40,000 35,282 36,161
30,000 28,060
20,000
10,000
- Estimated Live Births Reported Live Birth - Newborns weighed at Number of Newborns Newborns breast fed - Apr'12 to Mar'13 Apr'12 to Mar'13 birth having weight less within 1 hour than 2.5 kg
Rajasthan - Pali - Births - Apr'12 to Mar'13
Sex Ratio at Still Birth per 1000 live births ( Live Birth - Males Live Birth - females Live Birth - Total Still Births birth reported)
21,902 19,788 41,690 1,100 903 26.4
Monitoring Report, Rajasthan Page 33
Rajasthan - Pali-Immunisation ( 0 to 11mnths) Against Estimated Live Births- Apr'12 to Mar'13 100% 86% 90% 82% 82% 80% 75% 74% 70% 60% 50% 40% 30% 20% 10% 0% BCG % DPT3% OPV3% Measles % Fully Immunised %
Rajasthan - Pali-Immunisation ( 0 to 11mnths) Against Reported Live Births- Apr'12 to Mar'13
120%
101% 100% 96% 96% 88% 87%
80%
60%
40%
20%
0% BCG % DPT3% OPV3% Measles % Fully Immunised %
Monitoring Report, Rajasthan Page 34
Rajasthan - Pali-Immunisation Sessions- Apr'12 to Mar'13
30,000 26,790
25,000
20,000
14,611 15,000
10,000
5,058 5,000
- Immunisation sessions planned Immunisation sessions Held Sessions where ASHAs were present
Rajasthan - Pali- Adverse Event Following Immunisation(AEFI) - Apr'12 to Mar'13
Abscess 2
Death -
Others 8
Rajasthan - Pali- Immunisation - Dropouts - Apr'12 to Mar'13
Dropout from Dropout from Dropout from DPT3 to Measles BCG to DPT3 BCG to Measles
5% 13% 8%
Rajasthan - Pali - Abortions - Apr'12 to Mar'13
Abortion Rate MTP Less than 12 MTP More than 12 Abortions Abortions in Pvt against weeks weeks (spontaneous/Induced) Facilities expected pregnancies
1.8% 312 42 620 -
Monitoring Report, Rajasthan Page 35
Rajasthan - Pali-Abortions - Apr'12 to Mar'13
MTP less than 12 weeks 32.03%
Abortion (spontaneous/indu ced) 63.66% MTP more than 12 weeks 4.31%
Rajasthan - Pali - RTI Cases - Apr'12 to Mar'13
RTI/STI Total RTI/STI cases Total RTI/STI Total RTI/STI Number of wet mount tests Total OPD cases as %ge - Male cases - Female cases conducted of Total OPD
0.019% 24,40,176 305 170 475 19
Rajasthan - Pali- RTI Cases -Apr'12 to Mar'13
Female 36%
Male 64%
Rajasthan - Pali-Sterilisations - Apr'12 to Mar'13
%age of Reported Reported Sterilisation
Monitoring Report, Rajasthan Page 36
Total Sterilisation 7,374
NSV 2% 117
Laparoscopic 84% 6,169
MiniLap 1% 99
Post Partum 13% 989
Male Sterilisation 2% 117
Female Sterilisation 98% 7,257
Rajasthan - Pali-FP Methods - Apr'12 to Mar'13
%age of All Reported Reported FP Methods Total Reported FP - Method (All types) Users 58,749
Sterilisations 13% 7,374
IUD 23% 13,580
Condom Users 43% 24,980
OCP Users 22% 12,815
Limiting Methods 13% 7,374
Spacing Methods 87% 51,375
Monitoring Report, Rajasthan Page 37
Rajasthan - Pali- Distribution of Family Planning Methods against Total Reported - Apr'12 to Mar'13 Sterilisations OCP Users 13% 22%
IUD 23%
Condom Users 43%
Rajasthan - Pali- Facility wise % of Sterilisations & IUDs - Apr'12 to Mar'13
Private Subcenter PHC CHC SDH/DH Other State owned institution Facilities
NSV as % of total 15.4% 3.4% 81.2% 0.0% 0.0% reported
Laparoscopic as % 66.2% 20.9% 11.2% 0.0% 1.6% of total reported
MiniLap as % of 61.6% 28.3% 10.1% 0.0% 0.0% total reported
Post Partum as % 56.1% 22.2% 9.6% 0.0% 12.0% of total reported
IUD inserted as % 54.4% 25.0% 12.6% 7.9% 0.0% 0.0% of total reported
Rajasthan - Pali- Unmet need ( DLHSIII) met by reported FP Methods - Apr'12 to Mar'13
Unmet need met by Eligible Couples for Reported Estimated total Eligible unmet need- Total reported FP Family Couples ( 17% of Calculated Using Users - HMIS - 3,53,368.80 Planning population) DLHSIII Unmet need Apr'12 to Mar'13 Methods - - Rajasthan - Pali Apr'12 to Mar'13 Unmet Needs 22.7 73% Total 80,215 58,749
Limiting 7.8 9% 27,563 7,374
Spacing 14.9 64% 52,652 51,375
Monitoring Report, Rajasthan Page 38
Rajasthan - Pali- Service Delivery - Apr'12 to Mar'13
Operation Operation major (General minor (No or Adolescent Total OPD Total IPD AYUSH Dental Procedures and spinal local counselling anaesthesia) anaesthesia) services
24,40,176 1,21,853 2,856 4,304 84,439 7,297 4,067 Operation Operation major (General Adolescent minor (No or AYUSH as OPD Visit Per IPD per 1000 and spinal Dental Procedures as %ge of counselling local %ge of 1000 Population population anaesthesia) OPD services as anaesthesia)as OPD per 100000 %ge of %ge of OPD Population OPD
1173.9 58.6 137.4 0.2% 3.5% 0.30% 0.2%
Rajasthan - Pali- Childhood Disease - Vaccine Preventable -Apr'12 to Mar'13
Tetanus Diphtheria Pertussis Tetanus others Polio Measles Neonatorum
0 0 0 0 0 20
Rajasthan - Pali-Childhood Disease - Others - Apr'12 to Mar'13
Number Diarrhoea and admitted with Malaria dehydration Respiratory Infections
1,649 86 2,166
Rajasthan - Pali- Lab Services - Apr'12 to Mar'13
Total Total Total HB tested Total HIV tested Total VDRL Tested Widal Test Blood Smear Examined Population Conducted
20,78,640 65,353 16,728 9,085 6,523 1,03,490 HIV HB test HIV test Widal test HB<7gm positive conducted conducted VDRL test conducted as conducted Blood Smear Examined Total OPD as %age of as %age as %age of as %age %age of OPD as %age of as % of Population HB tested of HIV OPD of OPD OPD tested
2.7% 5.2% 0.7% 1.5% 0.4% 0.27% 4.98% 24,40,176
Monitoring Report, Rajasthan Page 39
Rajasthan - Pali - Mortality Data - Apr'12 to Mar'13
Monitoring Report, Rajasthan Page 40
Rajasthan - Pali - Mortality - Major Causes Group - Apr'12 to Mar'13
Cause-wise deaths Death Groups Reported deaths included in the group
Maternal & Perinatal, Diarrhoea, Communicable Disease , Tuberculosis, Maternal & Perinatal Respiratory (excluding 1,445 TB), Malaria, Other Fever related, HIV/AIDS Heart Disease/ Non communicable Hypertension, disease Neurological including 363 Stroke
Trauma, Accidents,
Injuries Burns, Suicide, Animal 144 Bites
Other known acute diseases, Other known
Others chronic diseases, Other 721 diseases (Causes not known)
Rajasthan - Pali - Mortality - Major Causes Group -Apr'12 to Mar'13
Others 27.0%
Communicable Disease , Maternal & Perinatal 54.1% Injuries 5.4%
Non communicable disease 13.6%
Monitoring Report, Rajasthan Page 41
Rajasthan - Pali- Still Births, Neonatal , Infant ,Under 5 and Maternal Deaths - Apr'12 to Mar'13
Live Births - Reported Live Births -Estimated Still Births Early Neonatal deaths
41,690 48,848 1,100 209
Late Neonatal Deaths Infant Death Under 5 Child Deaths Maternal Deaths
61 347 387 18
Rajasthan - Pali- Still Birth Rate, Perinatal,Neonatal & Infant Mortality Rates - Apr'12 to Mar'13
Against Reported Live Births ( Against Estimated Live Births (
1000) 1000)
Reported Still Birth 26.39 22.52
Reported Perinatal Mortality 31.40 27
Reported Neonatal Mortality 6.48 5.53
Reported Infant Mortality 8.32 7.10
Reported Under 5 Child Deaths 9.3 7.92
Reported Maternal Deaths 43.18 36.85
Rajasthan - Pali - Infant & Child Deaths - Apr'12 to Mar'13 Infant Child Infant Deaths Deaths Deaths Infant Deaths Total between between 1 between 1 Child Deaths between 1yr & Total within 24 hrs of Infant 24hrs & under week & month & under 5years Deaths birth Deaths 1 week under 1 under 1 month year Total Reported 73 136 61 77 347 40 387 % against total deaths 18.9% 35.1% 15.8% 19.9% 89.7% 10.3%
Monitoring Report, Rajasthan Page 42
Infant & Child Deaths against reported Infant & Child deaths - Rajasthan - Pali- Apr'12 to Mar'13
Child Deaths between 1yr& under 5years Infant Deaths within 10.3% 24 hrs of birth 18.9%
Child Deaths between 1 month & under 1 year 19.9%
Infant Deaths between Infant Deaths between 24hrs & under 1 week 1 week & under 1 35.1% month 15.8%
Rajasthan - Pali- Causes of Infant & Child Deaths - Apr'12 to Mar'13 - Total Deaths - 314
Sepsis Asphyxia LBW
Between Between Between 1 Up to 1 Up to 1 1 week 1 week week & 4 Weeks of Total Weeks of & 4 Total Up to 1 Weeks of Birth & 4 Total weeks of Birth Birth weeks weeks birth of birth of birth
9 0 9 16 3 19 35 29 6
Pneumonia Diarrhoea Fever related
Between Between 1 Between 1 Between Between 1 month Between 1 month and month and year & 5 Total 1 year & Total 1 year & Total and 11 11 months 11 months years 5 years 5 years months
8 3 11 5 2 7 6 9 15
Others ( For age upto 4 weks Measels Others( For age from 1 month to 5 yrs) of Birth) Between Between 1 Between 1 Up to 1 1 week Between Between 1 month and month and year & 5 Total Weeks of & 4 Total 1 year & Total 11 months 11 months years Birth weeks 5 years of birth
Monitoring Report, Rajasthan Page 43
82 52 134 84 - - - 58 26
Rajasthan - Pali - Causes of Infant & Child Deaths against total reported infant & child deaths-Apr'12 to Mar'13
Sepsis 3% Asphyxia 6% LBW 11%
Diarrhoea Pneumonia2% 4% Fever related 5% Others 69%
Measles 0%
Monitoring Report, Rajasthan Page 44
Rajasthan - Pali - Known Causes of Infant & Child Deaths against total reported known causes of infant & child deaths -Apr'12 to Mar'13
Fever related Measles 16% Sepsis 0% 9%
Diarrhoea Asphyxia 7% 20%
Pneumonia 12%
LBW 36%
Rajasthan – Pali Maternal Deaths & Causes-Apr'12 to Mar'13
% against total reported Causes Reported % against total reported known causes
Abortion - 0.0% 0.0%
Obstructed/prolonged labour - 0.0% 0.0%
Severe hypertension/fits 1 11.1% 5.6%
Bleeding 8 88.9% 44.4%
High Fever - 0.0% 0.0%
Other Causes 9 50.0%
Total 18
Monitoring Report, Rajasthan Page 45
Rajasthan - Pali - Causes of Maternal Deaths against total reported maternal deaths-Apr'12 to Mar'13
Obstructed/prolonge d labour Severe Abortion 0.0% hypertension/fits 0.0% 5.6%
Bleeding 44.4% Other Causes 50.0%
High Fever 0.0%
Rajasthan - Pali - Known Causes of Maternal Death against total reported Known Causes of maternal deaths -Apr'12 to Mar'13
Obstructed/prolong ed labour Severe High Fever 0.0% hypertension/fits Abortion 0.0% 11.1% 0.0%
Bleeding 88.9%
Rajasthan - Pali - Causes of deaths above 6 yrs of age-Apr'12 to Mar'13
6-14 yrs 15-55 yrs. Above 55yrs Total
Diarrhoeal Diseases - 58 1 59
Tuberculosis 1 14 12 27
Respiratory Diseases (Other than TB) 7 16 54 77
Malaria 2 1 1 4
Monitoring Report, Rajasthan Page 46
Other fever Related 30 14 2 46
HIV/AIDS 1 12 4 17
Heart Disease/ Hypertension related 8 26 49 83
Neurological Disease including strokes 1 2 9 12
Trauma/Accidents/ Burn Cases 106 23 57 26
Suicide - 22 1 23
Animal Bites & Stings 6 2 7 15
Known Acute Disease 100 3 45 52
Known Chronic Disease 205 2 52 151
Causes not known 110 394 14 270
Total Deaths 373 1,168 156 639
Rajasthan - Pali - Known causes of deaths 6 yrs & above against total reported Known causes of deaths 6 yrs & above - Apr'12 to Mar'13
Tuberculosis Known Chronic Disease Diarrhoeal 3.5% Respiratory Diseases 26.5% Diseases (Other than TB) 7.6% 9.9% Malaria 0.5%
Other fever Related 5.9%
HIV/AIDS 2.2%
Heart Disease/ Hypertension related 10.7%
Known Acute Disease Suicide 12.9% 3.0% Neurological Disease including strokes 1.6% Trauma/Accidents/ Burn Animal Bites & Stings Cases 1.9% 13.7%
Monitoring Report, Rajasthan Page 47
Rajasthan - Pali - Cause of deaths 6 yrs & above against total reported deaths 6 yrs & above - Apr'12 to Mar'13
Respiratory Diseases (Other Diarrhoeal Diseases than TB) Tuberculosis Causes not known 5.1% 6.6% 33.7% 2.3% Other fever HIV/AIDS Malaria Related 1.5% 0.3% 3.9%
Heart Disease/ Hypertension related 7.1%
Neurological Disease including strokes 1.0% Known Chronic Disease 17.6%
Suicide 2.0%
Trauma/Accidents/ Burn Known Acute Disease Cases Animal Bites & 8.6%Stings 9.1% 1.3%
Monitoring Report, Rajasthan Page 48
ANNEXURE 2 – FACILITY WISE FINDINGS
Gundoj PHC Infrastructure & Equipments: It is a 24 x 7 delivery point situated at a distance of 20 kms from Pali headquarters. There are 7 SCs under this PHC and it caters to a population of 5804. It is housed in a donated building, a common feature of majority of the hospital buildings across Pali. The emergency room was very dirty and the BMW was very poor. There are two labour table in the labour room. There is one radiant warmer which is functional. There is no ambulance at the facility and referrals are made through 108. The Janani Express is not available here as it is just 20 kms from the district headquarters. There is a deep burial pit for disposal of BMW. There is no generator for power back-up and the invertor was non functional at the time of visit. Night deliveries are conducted with the help of torch light or emergency lamps. There is 24 x 7 provision for water supply. Staff quarters for MO, nurse and a sweeper are available but in poor condition as there has been no repair since 1976. Service Delivery: An average of 25 deliveries per month are conducted at the facility. ANC, PNC family planning services are provided at the centre. Manpower: There is 1 MO, 3 GNM, 1 ANM, 1 LT, 1 LHV and 1 accountant at the centre. The MO was on medical leave at the time of visit. There is no driver and pharmacist. Of the staff, 1 ANM and 1 male nurse were SBA trained, 2 GNMs and 1 ANM had received IMNCI training.
Sumerpur CHC Infrastructure & Equipments: Staff quarters are available. There is provision for power back up and water supply round the clock. There is a 108 and a facility ambulance available. a blood storage unit is present at the CHC but was not functional at the time of visit as the license had expired. Renewal of the license had been applied for. Service Delivery: Delivery services, lab services are provided at the facility. Manpower: There are 5 MO (MBBS) and 1 MO (Ayush) ; 5 GNMs, 1 dentist, 1 LT, 1 pharmacist and 1 driver at the facility. There is a general physician, an anesthetist and an ENT surgeon. The post for gynaecologist is vacant for the last two years.
Monitoring Report, Rajasthan Page 49
Bali CHC Infrastructure & Equipments: The facility is housed in a donated building. The labour room has two tables and a functional radiant warmer. At the time of visit, a short circuit had occurred and repair work was going on in the labour room. The maintenance and repair of equipments was cited to be a problem. Although the equipments are covered in a 2 year AMC, the response from the concerned technicians was poor and most often this period lapses without the problem being resolved. There was no training or operational guidance provided for new equipments which were provided at the facility. This proved to be a hindrance in its functioning when the staff were unsure of its operation. An NBSU is under construction at the facility but there has been no communication of the same to the MO in charge and work has started without any consultations with the doctor in charge which creates problems s The There is a blood storage unit at the facility. There is only 1 ambulance at the facility which has been operational for the last 15 years. 108 facility is used for referrals. Service Delivery: An average of 140 deliveries per month and 120 C-sections annually are conducted at the facility. Minor surgeries as well as family planning services are provided at the CHC. Manpower: There is 1 gynecologist, 1 surgeon, 1 anesthetist, 1 orthopedic, 1 MO, 1 dental MO, 4 GNMs, 2 LHVs, 1 ANM, 14 compounders and 2 LTs at the CHC. The anesthetist has been hired from Sumerpur and is on call at Bali CHC. The post of paediatrician is vacant. Also, of the 14 sanctioned posts only 5 are filled. The remaining posts have been vacant for the last 3-4 years.
Falna PHC Infrastructure & Equipments: This is a 6 bedded 24 x 7 facility housed in a donated building. The labour room has 1 labour table and 1 functional radiant warmer. There is no lab facility. Staff quarters are available. There is no ambulance. Power back up is through a generator and there is provision of water supply round the clock. Service Delivery: An average of 10 deliveries per month is conducted at the facility. Manpower: There are 2 MOs, 3 male nurses, 1 GNM, 1 ANM. The post of pharmacist and LT is vacant. A male nurse under MNDY is employed for the pharmacy. All the nurses are SBA trained and both the MOs have received IMNCI as well as BEmOC training.
Monitoring Report, Rajasthan Page 50
Khimel SC Infrastructure & Equipments: There is a OPD room. Staff quarter is attached with the SC. A separate room has been converted to the labour room. There is no labour table and the ANM has joined two patient cots to convert it into a labour table. The attached toilet which is common for the ANMs quarter is also used by the patients who deliver as there is no separate toilet. Service Delivery: OPD, immunization, family planning services are provided. Deliveries are also conducted at the facility. An average of 3-6 deliveries are recorded per month in the facility. Manpower: There is 1 ANM and 1 GNM at the SC.
Jaden SHC Infrastructure & Equipments: This is a ‘branded’ SC which has been labelled a Level 1 facility. It has been color-coded green. There are signages present for each facility and all entitlements are displayed prominently within the SC. At the time of visit, the ANMs quarter was being constructed. There was no Hb testing kit available at the SC at the time of visit. Service Delivery: OPD, immunization, family planning and delivery services are being provided at the SC. Manpower: There is only 1 ANM at the SC.
Bangad DH, Pali Infrastructure & Equipments: The DH is a 350 bedded hospital. The labour room has 5 labour tables, 3 functional radiant warmers. There is a SNCU operational at the DH. There is a generator for power back up. Staff quarters are available at the facility. There is a fully functional blood bank. There are 3 ambulances in the DH 9 (one is 108 facility). Service Delivery: Delivery, PNC, immunization, family planning, major and minor operations are provided at the DH. The SNCU is also fully operational. Lab and diagnostic services are provided to all the patients free of cost under the MNJY scheme. Manpower: There are 30 MO posts of which 18 are vacant. There are 4 senior specialists, 13 junior specialists. Specialists in anesthesia, medicine, paediatric, gynecology, dermatology, pathology and orthopaedics are available. At the time of visit, the regular staff were on a strike.
Monitoring Report, Rajasthan Page 51