Supportive Supervision Report Khandwa, Madhya Pradesh

SUPPORTIVE SUPERVISION REPORT

Dr. Arpana Kullu

Consultant NRHM-1

Ministry of Health and Family Welfare,

New Delhi

Contents ABBREVIATIONS ...... - 4 - List of Tables ...... 5 List of Figures and Graphs ...... 6 Introduction ...... 7 Methodology ...... 8 District Profile ...... 9 Demographic Profile ...... 10 Health Infrastructure in the District ...... 11 Key Findings ...... 12 District Program Management Unit ...... 12 Infrastructure ...... 12 Rogi Kalyan Samiti ...... 16 Referral Transport Services ...... 16 Mobile Medical Unit ...... 16 Human Resource ...... 17 Communitization Processes ...... 18 Service Delivery ...... 21 Inspection of Health Facilities ...... 22 District Hospital, Khandwa ...... 22 CHC, Khalwa ...... 24 PHC, Roshni ...... 26 Sub Health Centre, Kheri ...... 27 Sub Health Centre, Jaswadi ...... 29 CHC Chegaon Makhan ...... 31 PHC Chichgon ...... 32 SHC Deshgaon ...... 33 Way Forward ...... 35 ANNEXURES ...... Error! Bookmark not defined. Annexure 1:Form A: Supportive Supervision Form Yearly Monitoring Format ...... Error! Bookmark not defined. Annexure 2: Sub-Plan for – Khandwa ...... Error! Bookmark not defined.

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Annexure 3: Inspection format for Health Facilities District Hospital, Khandwa ..... Error! Bookmark not defined. Annexure 4: Inspection format for Health Facilities, CHC Khalwa ...... Error! Bookmark not defined. Annexure 5: Inspection format for health facilities, PHC Roshni ...... Error! Bookmark not defined. Annexure 6: Inspection format for SHCs, SHC, Kheri ...... Error! Bookmark not defined. Annexure 7: Inspection format for SHCs, SHC, Jaswadi ...... Error! Bookmark not defined. Annexure 8: Inspection format for health facilities, CHC Chegaon Makhan ...... Error! Bookmark not defined. Annexure 9: Inspection format for health facilities, PHC Chichgon ...... Error! Bookmark not defined. Annexure 10: Inspection format for SHCs, SHC Deshgaon ...... Error! Bookmark not defined.

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ABBREVIATIONS

ANC- Antenatal Care IUD- Intrauterine Device

ANM- Auxillary Nursing Midwife LHV- Lady Health Visitor

ASHA- Accredited Social Health Activist LSAS- Life Saving Anesthesia Skills

AWW- Anganwadi Worker LTT- Laproscopic Tubectomy

BCC- Behaviour Change Communication MMR- Maternal Mortality Rate

BEmONC- Basic Emergency Obstetric and NSV- Non Scalpel Vasectomy Newborn Care PHC-Primary Health Centre BPM- Block Program Manager PNC- Post natal Care CEmONC- Comprehensive Emergency Obstetric and Newborn Care PRI- Panchayati Raj Institution

CHC- Community Health Centre SBA- Skilled Birth Attendant

DCM- District Community Mobiliser SHC- Sub Health Centre

DH- District Hospital SNCU- Sick Newborn Care Unit

DHAP- District Health Action Plan SPMU- State Program Management Unit

DPM-District Program Manager VHND- Village Health and Nutrition Day

DPMU- District Program Management Unit VHSC- Village Health and Sanitation Committee FRU- First Referral Unit

HBNC- Home Based Newborn Care

HMIS- Health Management Information System

IEC- Information Education and Communication

IMNCI- Integrated Management of Neonatal and Childhood Illnesses IMR- Infant Mortality Rate

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List of Tables

Table 1: Blocks and Persons visited for Supportive Supervision

Table 2: Demographic Profile according to Census 2001

Table 3: Currently existing Health Infrastructure in the District

Table 4: Block wise Distribution of Health Facilities

Table 5: Block wise Number of Health Facilities which does not have Govt. building

Table 6: CEmONC and BEmONC Health Facilities in the District

Table 7: Physical and Financial Report against Planned (from April 2009- March 2010)

Table 8: Financial Summary for Rogi Kalyan Samiti for the year April 2009- March 2010

Table 9: Performance of Dindaya Chalit Haspatal

Table 10: SBA Training Status against Planned for 1st April 2009-31stst March 2010

Table 11: IMNCI Trained Personnel in the District for 1st April 2009-31stst March 2010

Table 12: IUD Trained Personnel in the District, 1st April 2009-31stst March 2010

Table 13 (a): ASHA’s in the district (Block wise break up)

Table 13(b): ASHA Selection and Training Status

Table 14: Incentives for ASHA’s as approved in DHAP 2010-11

Table 15: Blockwise number of VHSC’s in the district

List of Figures and Graphs

Figure 1: Rank of Khandwa (East Nimar) District

Figure 2: Labour Board in SHC Kheri

Figure 3(Right): Scrap lying idle in the SHC

Graph 1: District Hospital

Graph 2: CHC Khalwa

Graph 3: PHC Roshni

Graph 4: SHC Kheri

Graph 5: SHC Jaswadi

Graph 6: CHC Chegaon Makhan

Graph 7: PHC Chichgon

Graph 8: SHC Deshgaon

Introduction

For the Supportive Supervision of High Focused Districts, first visit to the district of Khandwa (East Nimar) in Madhya Pradesh from 14th April 2010 to 21st April 2010 was made. The facilities visited and key persons visited for monitoring are enumerated in the Table 1 shown below. The monitoring visit, out of 7 blocks, visit was made to 2 blocks and it included interaction with the Health staff including the Medical Officers, Block Programme Managers , Nursing Staff and few ASHA’s , to gain a better understanding of the processes and difficulties in functioning.

Table 1: Blocks and Persons visited for Supportive Supervision

Date District/ Block Places/Health Persons Visited Activity Facilities Visited 15.06.2010 Khandwa SPMU SPM Data Analyst 16.06.2010 Khandwa DPMU CMHO, DPM,  Baseline data District Hospital Civil Surgeon, collected MO,  Discussions Administrative with the staff staff at the DPMU. at the DPMU about the process and the functioning of the various components of the program.  Inspection of the District Hospital 17.06.2010 Khalwa Village- Jaswadi Beneficiaries, SHC- Jaswadi, ANM’s, MPW, Kheri Staff Nurse’s, PHC, Roshni ASHA’s, MO’s, CHC, Khalwa BPM and Administrative Staff 18.06.2010 Chegaon Makhan Village- Banjhar Beneficiaries, SHC- Deshgaon ANM’s, MPW, PHC, Chichgaon Staff Nurse’s, CHC, Chegaon ASHA’s, MO’s, Makhan BPM and Administrative Staff 19.06.2010 Sector Meeting- ASHA’s, DCM, Monthly meeting Chegaon Makhan BPM with ASHA’s

Methodology

Secondary Data was collected for the structured format from the state and district HMIS data format that was already available at the respective Programme Management Units. Primary data was collected as per the guidelines in the format during interactions with the health staff at the time of visits to the health facilities. Interviews with the patients admitted in the wards and the ones present in the OPD during visits to health facilities and community visits were also conducted to obtain information from the beneficiaries’ perspective about the functioning of the health mission. The health facility format was filled in presence of the facility in charge, in order to communicate the parameters on which they were evaluated and to further bring to their notice the key areas of improvement. In order to ensure that the improvements, identified during the visit are made a copy of the commitment format was also made available to the DPM’s for follow-up.

Health facilities from all the three levels and linked in one referral chain were selected for inspection. One referral chain from two blocks namely Khalwa and Chegaon Makhan were selected after discussions with the Chief Medical Officer and the District Program Manager.

From Khalwa block SHC Kheri, PHC, Roshni and CHC Khalwa were visited and from Chegaon Makhan SHC Deshgaon, PHC Chicgon and CHC Chegaon Makhan. In addition to the District Hospital at Khandwa, SHC Jaswadi from Block Jawar were also visited. To gain insights about the beneficiary’s perspective about the service delivery, community visits and exit interviews were also done. Villages Jaswadi and Banjhar from Chegaon Makhan Block were chosen for community visits.And during the visits to the health facilities the frontline workers including the ASHA’s, LHV and ANM’s were also interviewed . The tools used for collecting the relevant data can be seen in the Annexure section of the report. In the end the section following Inspection of the Health Facilities further is a compilation of actionable points mainly taken from the primary and secondary data collected during the community and health facility visit. The attempt was to find solutions and support the health functionaries in identifying gaps and sensitizing them about the same and then to find areas where action can be taken within their designated capacities.

District Profile

According to the Ranking and Mapping of Districts done by IIPs in 2006 the rank given to Khandwa (East Nimar) was 335 out of the total of 593 districts. The further elaboration of the indicators of the district is given in Figure 2 shown below.

Figure 1: Rank of Khandwa (East Nimar) District, Source: Jansankhya Sthirta Kosh

Demographic Profile

Khandwa District is situated South West of the state of Madhya Pradesh.The District is in Indore Division of Madhya Pradesh. District East Nimar Khandwa is a part of Indore Division of Madhya Pradesh state. The District is bounded on the east by the Betul and Hoshangabad District of Hoshangabad division, and Burhanpur District of Indore Division on south, on the west by West Nimar District of Indore division,and on the north by Dewas District of the Indore Division. It is divided into Five revenue Tehsils and Seven Development Blocks. The 7 development blocks are Khandwa,Chhegaon Makhan,Pandhana, Harsud, Khalwa, Baldi, Punasa. And the 3 tehsils are Khandwa, Harsud, Pandhana. Total number of villages is 798 and the number of Gram Panchayats in te district is 432. And there are a total of 7 towns in the district. Also, Baldi Block HQ has been shifted to Killod, due to submergance of previous area into Indira Sagar Project, Harsud is also a affected block the HQ is decided to be shifted at Chhanera.

Amongst the seven blocks, Khalwa block has maximum proportion of tribal population, the main tribe constitutes of the Korku tribe. Pandhana block is the most inaccessible block, especially in the months of July and August i.e. during the rainy season. Baldi is the worst performing (attatched with Harsud).

Table 2: Demographic Profile according to Census 2001

Gender Literacy Rate Description Total Male Female Density Ration Total Male Female District * 1708170 882371 825799 936 159 867506 538477 329029 Urban * 460332 237773 222559 936 -- 305769 172782 132987 1. Khandwa 171976 88859 83117 915 --- 122701 68238 54463 City 2.Omkareshwar 6616 3562 3054 947 --- 3422 2238 1184 3.Harsud 15869 8301 7568 912 --- 11004 6401 4603 4.Mundi 10667 5541 5126 925 --- 6506 3857 2649 5.Pandhana 10999 5808 5191 894 --- 6989 4245 2744 6.Burhanpur 194360 100031 94329 915 --- 123461 69292 54169 7.Shahpur 18187 9347 8840 916 --- 9804 5915 3889 8.Nepanagar 31658 16324 15334 932 --- 21882 12596 9286

Rural * 1247838 944598 603240 936 --- 561737 365695 196042

1.Khandwa 621120 322114 299006 928 --- 360258 219592 140666 Tehsil 2.Pandhana 129542 66736 62806 941 --- 63354 40796 22561 Tehsil 3.Harsud 321847 166639 155208 931 --- 133577 89754 43823 Tehsil 4.Burhanpur 484554 249419 235135 943 --- 256572 154350 102222 Tehsil 5. Nepanagar 151107 77463 73644 961 --- 53742 33986 19757 Tehsil * In census-2001, the District Burhanpur was not existing as separate district, hence The Data of Khandwa District Includes Burhanpur District's Data, the same are shown blue colour

Source: District Statistical Handbook, 2002 published by District Statistical Office, Khandwa

Health Infrastructure in the District

Health Facility Numbers

District Hospital 1 Community Health Center 6 Primary Health Center 29 Sub Health Center 174 Mobile Medical Unit 1 (Khalwa)

Table 3: Currently existing Health Infrastructure in the District

Key Findings

District Program Management Unit

The DPMU is headed by CMO Dr.Lakshmi Baghel and the management function is supervised by the DPM Mr. Ashutosh Ghute. The office is located in the urban region in the district and Khandwa having a railway station frequently attends to monitoring visits which often keeps a time to time check on the implementation of the mission. The team at the DPMU is equipped with adequate staff to ensure smooth functioning of the health system in the district. The fact that Khandwa has been able to timely update almost 95% of the data on the HMIS web portal is appreciable for which the credit goes to the self motivated staff in position.

Although there were concerns from the DPM and the DCM at the district level and the BPM’s at the block level regarding lack of well defined guidelines about their job description and responsibilities. Also the lack of trainings besides the initial orientation for the above mentioned positions needs to be paid attention in order to build capacities of these administrative staff and further utilize their skills for the benefit of the system as a whole.

Infrastructure Table 4: Block wise Distribution of Health Facilities

Name of the Population CHC PHC SHC Block covered

Khandwa 351130 - 3 21 Pandhana 313885 1 10 33 Mundi 206455 1 10 27 Chaigaon 140980 1 3 20 Makhan Khalwa 203070 1 3 50 Harsud 93408 1 - 15 Killod 36069 1 - 8

Total 12,45,000 6 29 174 Source: District HMIS

The above table shows the block wise distribution of health facilities at each level. As shown in the table there are currently 174 SHC’s and 29 OHC’s for a population of approximately 12,45,000; which implies that according to the IPHS norms of one SHC for a population of 3000-5000 and one PHC for a

12 population of 20,000- 30,000 and one CHC per 80,000- 1,20,000 population which means there is a huge shortfall of approximately 75 SHC’s, 12 PHC’s and 4 CHC’s (these calculations are done by assuming the population of the district to be general and not tribal since the block wise proportion of trial population was not available). Thus the exact requirement of health facilities shall only be more than mentioned above when the calculations are done taking the tribal population in account.

Table 5: Block wise Number of Health Facilities which does not have Govt. building.

Name of the Block CHC’s PHC’s SHC

Khandwa - - 2 Pandhana - - 5 Mundi - - 4 Chaigaon Makhan - 1 2 Khalwa - 1 6 Harsud - - 4 Killod - - 3 Total - 2 26 Source: District Program Management Unit

Currently according to the district MIS data out of the earlier mentioned 174 SHC’s there are 26 SHC’s and 2 PHC’s which do not have a building of their own and are functioning either from a rented building or from a place provided by the Gram Panchayat. Hence such SHC’s face a lot of challenges in terms of space constraints and also they do not get funds for the strengthening of the health facility in with respect to infrastructure which further hampers their the service delivery. At present, construction of building for 1 PHC at Kunasa and 7 SHC’s have been approved and their construction has been initiated.

There are currently 35 SHC’s and 26 PHC’s which are conducting deliveries in the district. And 3 CEmONC and 11 BEmONC centres (mentioned in the table below) in the district. Amongst the 3 CEmONC centres in the district only the District Hospital at present fulfills the criterion for a CEmONC centre, rest of the 2 centres do not have blood storage facility at present.

Table 6: CEmONC and BEmONC Health Facilities in the District

CEmONC BEmONC PHC CHC/ DH PHC CHC District Hospital Chichgon Chegaon Makhan Khandwa CHC, Harsud Piplod Mondi CHC, Khalwa Borgaon Pandhana Gudi Jawar Roshni Beed Mandhala Omkareshwar

3 7 4 Total 14 Source: District Program Management Unit

Though there are health facilities which are designated as CEmONC and BEmONC centres but they do not fulfill the basic requirements for the same. For e.g.CHC Khalwa and PHC Chichgon which are CEmONC and BEmONC centers respectively but during the visit they were found to be lacking in providing services they are expected to as per their designations. The CHC Khalwa did not have Blood Bank facility and the PHC at Chichgon was only conducting on an average hardly 8-10 deliveries per month due to lack of water and electricity supply in the facility.

Stregthening of Health Facilities

Table 7: Physical and Financial Report against Planned (from April 2009- March 2010)

Activity Physical Physical % Budget Budget % Name Plan Achievement Plan Achieved Yearly till March Yearly till March 2010 2010 Strengthening of SHC Untied fund 174 126 72.41 1,740,000 1,039,259 59.73 Rs. 10,000 per SHC per year Contractual 25 11 44.00 1,296,000 629,352 48.56 Appointment of 2nd ANM’s (6000 per month) Maintenance 50 30 0.00 500,000 303,873 60.77 Grant Rs.10,000 per SHC per year

Sub Total 3,536,000 1,972,484 55.78 Intervention

Strenthening of PHC’s Untied Funds 19 19 100 475,000 434,842 91.55 Rs.25,000 per PHC per year Maintenance 19 19 100 950,000 868,787 91.45 Grant

Rs.50,000 per PHC per year

Sub Total 1,425,000 1,303,629 91.48 Intervention

Strengthening of CHC’s Untied Funds 6 6 100 300,000 274,332 91.44 Rs.50,000 per CHC per year Maintenance 6 6 100 600,000 440,736 73.46 grant Rs.1 lakh per CHC per year

Sub Total 900,000 715,068 79.45 Intervention Source: District Program management Unit

The above table shows the Physical and Financial report against planned for the strengthening of the health facilities at each level. A close analysis reveals that out of 174 SHC’s in the district only 126 have been given the untied fund of Rs.10,000/- hence only 72.41% of funds have been allocated which implies that another 48 SHC’s haven’t received the untied fund they are entitled for. In addition the budget plan for the year 2009-2010 was Rs.1,740,000 out of which only Rs. 1,039,259/- has been utilized which forms only 59.73% of the total yearly budget. The annual maintenance grant for the SHC’s which is Rs.10, 000/- has been allocated for 50 SHC’s out of 174 which implies that more than half of the SHC’s were left out and even with the amount allocated only 30 SHC’s were achieved till 31st March 2010 and only 60.77% of the allocated budget was utilized. The sub total intervention for strengthening of SHC’s shows only 55.78% budget achievement till 31st March 2010. The reasons cited by the DPM for which was that many health centers haven’t utilized their funds for the previous years hence further funds were not allocated to them. Thus there is an urgent need to build capacities of the person’s in charge of those facilities which are unable to do so and moreover more hand holding support is required to ensure optimum utilization of available resources. Also the delay in release of funds needs to smoothen so that the funds are utilized within the designated time period.

Table 8: Financial Summary for Rogi Kalyan Samiti for the year April 2009- March 2010

Health Physical Plan Physical Budget Budget % utilized Facility Yearly Achievement Planned Achieved till till March March 2010 2010 District 1 1 5,00,000 5,00,000 100

Hospital

CHC 6 6 600,000 5,37,386 89.56

PHC 29 5 2,900,000 3,91,837 13.51 Source: District Program Management Unit

The subtotal intervention for strengthening of PHC’s and CHC’s is still much better showing 91.48 and 79.45% budget achieved till 31st March 2010. The Financial Summary for Rogi Kalyan Samiti shown in the Table 8 below further emphasizes on the lack of attention to SHC’s wherein the summary shows only 13.51% utilization of the planned budget by SHC’s in the district. Hence when the allocated funds for strengthening the health facility are being grossly underutilized the goal of providing efficient and quality care remains farfetched.

Rogi Kalyan Samiti RKS meetings are held after every 3months at the district level, at the district level the meeting is chaired by the Collector and at the block level the SDM is the chairman of the RKS.

To upgrade facilities in the public health system and with a purpose to provide sustainable quality care with accountability and people’s participation along with total transparency. The RKS is in place in all the health facilities as per the guidelines in the framework. But their meetings do not happen regularly as told by one of the Block Medical Officers and thus utilization of funds for which the RKS was formed is very difficult to mobilise. Therefore currently the funds are not utilised with complete efficiency.

Referral Transport Services  There are no vehicles available at the PHC level. Hence in case of emergencies vehicles are called from the nearby CHC and then the patient is transported to a higher facility.  Transport facility at the district level is in the process of completion, a call centre for the same is being established at the District Hospital wherein tenders for vehicles are in process. It is going to be a referral transport facility for patients in the district , a convenient number shall be provided which would be functional round the clock.

Mobile Medical Unit The district has one mobile medical unit named as “Dindayal Chalit Haspatal”. It provides services only in Khalwa block in the district. It runs for 26 days in a month and on an average visits 56 villages and has a monthly OPD of 1990. The services provided by the mobile medical unit includes, OPD services, Referral facilities, ANC and PNC checkups and Immunization.

Table 9: Performance of Dindaya Chalit Haspatal

No. of Villages Total no. Of Patients ANC Check Health Working covered patients seen referred to Ups done Education Days Healthcare sessions

Institution conducted

312 673 25534 397 4240 915 Source: District Program Management Unit

Human Resource Shortage of staff specifically medical doctors is one of the major problems the district faces, currently 85 positions in the district are vacant. Hence the patients are referred to Indore for treatment of complicated cases. Specialists are arranged from neighboring districts for treatment of patients or else like in many cases patients are referred to private practitioners or to Indore.

Capacity Building

Along with ensuring availability of the health staff in the health centers, NRHM also focuses on building capacities of the existing staff. Various trainings are incorporated in the system which helps the health functionaries to enhance their skill set and provide support to deliver optimum quality of care.

According to the data provided by the district program management unit, trainings for doctors in CEmOC, LSAS and Abdominal Tubectomy (Minilap in the last one year has been nil. And BEmONC Training has been achieved for 4 Medical Officers till March 2010. Thus more attention is required to areas mentioned above in which there are no trained personnel available in the district.

 SBA Training against planned in the year 2009-10 is shown below in Table 10. As shown in the table where the target set for ANM training for SBA is achieved to 100% at the same time achievement of SBA training for Staff Nurses is just 5%, hence it requires attention. The current number of SBA trained personnels in the district is126 which includes12 LHV’s, 76 ANM’s, 26 Staff Nurses and 15 Medical officers.

Table 10: SBA Training Status against Planned for 1st April 2009-31stst March 2010 Staff Nurses LHV’s ANM Target for No of Target for No of Target for No of 2009-10 Personnel 2009-10 Personnel 2009-10 Personnel Trained Trained Trained

20 3 0 0 24 24

 IMNCI Training planned in the DHAP 2010-11 by support from UNICEF and the state. And the current status of IMNCI trained personnel in the district is given below in Table 11. A total of 487 healthcare providers are trained in IMNCI which includes both ICDS and health functionaries in the public health system.

Table 11: IMNCI Trained Personnel in the District for 1st April 2009-31stst March 2010 Health ICDS MO Supervisor ANM MPW CDPO Supervisor AWW

13 7 69 6 0 16 279

 IUD Training- As illustrated in table 12, there are a total of 76 healthcare providers trained in IUD insertions in the district. Which includes 2 doctors, 7 staff nurses and 67 ANM’s. Here we have an opportunity where we can provide more trainings and include more doctors and nursing staff which shall also provide IUD insertion as a family planning method for those have inhibitions regarding surgical procedures for family planning.

Table 12: IUD Trained Personnel in the District, 1st April 2009-31stst March 2010

Target Achievement Participants Total No. of (batch) (batch) Medical Staff ANM Participants Officer Nurse MO/SN/LHV 2 1 2 7 0 9 ANM 9 8 0 0 67 67 Total 11 9 2 7 67 76

Communitization Processes

Community participation is an important component of NRHM for which many strategies have been incorporated in the program, to ensure that the health mission reaches the underserved communities and also involves people in planning process and come up with solutions that are easily accepted by them. Broadly these strategies include Selection of ASHA’s, Village Health and Sanitation Committee and Rogi Kalyan Samiti. Even after five years of NRHM the program has not been able to reach completely up till the community level and create a sense of ownership and accountability towards the public health system amongst people.

I. Accredited Social Health Activists

Table 13 (a): ASHA’s in the district (Block wise break up)

Blocks No. of Villages Population Currently in Sanctioned Shortfall position

Khandwa 97 356264 130 156 26

Pandhana 128 213885 250 276 26

Mundi 161 217905 185 191 6

Chaigaon 86 140980 140 143 3 Makhan Khalwa 147 203073 260 295 35

Harsud 75 76824 75 98 23

Killod 32 36069 60 64 4

Total 726 1245000 1100 1223 123

Table 13 (b): ASHA Selection and Training Status

Name of No. of ASHA’s Refresher the Villages Selected Training Modules Training Institution I II III IV Jawar 97 130 143 120 118 98 32 Pandhana 128 250 178 148 135 121 62 Mundi 161 185 183 150 141 132 54 Chegaon 86 140 124 108 106 101 47 Makhan Khalwa 147 260 224 171 163 152 53 Harsud 75 75 64 55 42 39 34 Killod 32 60 45 36 36 30 18 Total 726 1100 961 788 741 673 300 Source: District Program Management Unit

Table 14: Incentives for ASHA’s as approved in DHAP 2010-11

Incentives (in S.No. Incentives Rs.)

1. For mobilizing ANC and PNC cases for Check Ups on Village Health Day 150 per month 2. For mobilizing RTI/STI cases for checkups in PHC/CHC (max 4 visits per 100 per month month and 2 cases per visit) 3. For promotion of full ANC checkup (3 ANC + TT+ 100/200 IFA Tablets) 100 per case 4. For detection and treatment of malaria 200 per month 5. For detection of Leprosy 100 per case 6. For treatment of Leprosy (MB) 400 per case 7. For treatment of Leprosy (PB) 200 per case 8. For DOTS provision 250

9. For Attending Monthly Meeting for Transportation 50 per month

Source: District Health Action Plan 2010-11

ASHA Incentives –The incentives to ASHA’s are paid by cheques. Although there was a concern expressed by them that when they take a women to a facility outside their block to the District Hospital for delivery they receive their payments are issued from the district bank. And when they deposit their cheques in their bank in the block, the bank charges them a processing fee of Rs.50/- Hence a strategy needs to be developed to ensure such a loss to the ASHA’s.

ASHAs as Depot Holders- the ASHA’s in every village have been provided with drug kits which includes; Chloroquine, Paracetamol, Metrogyl, Oral Rehydration Solution, Bleaching Powder and Chlorine Tablets. And every ASHA is required to put up information outside their houses about the drugs that are available with them. Also ASHA’s provide DOTS medicines to TB patients after their diagnosis is done.

ASHA’s as an Information Resource- ASHA’s collect information about pregnant women, Birth, Death and eligible couples for family planning. Hence they act as a very important source of information to the health providers.

ASHA : A Community Volunteer or a Health Functionary- ASHA’s when inducted in the system they were supposed to be the link between the community and the providers, and support the system to generate demand for the services amongst the people, hence they were chosen as voluntary workers and not regular employees. But now they have become a part of the system, this was substantiated when the ASHA’s who were interviewed and asked about their roles and responsibilities they would reply that they are expected to get all the pregnant women in their village to the health facility for delivery. Also there is an unsaid hope amongst them they would someday become regular employees within the public health system and as mentioned in Table 14 which lists out the approved incentives for them in the year 2010-11 in DHAP this hope is only going to be further strengthened.

II. Village Health and Sanitation Committee

At present there are 616 VHSC’s in the district against the required number of 726. Hence there is a shortfall of 60 VHSC’s. The committees are formed wherever there are ASHA’s thus places where an ASHA is not there VHSC’s are also absent.

Table 15: Blockwise number of VHSC’s in the district

No of No of committees with bank No. of Currently in Blocks Gram Sanctioned accounts Villages position Panchayat

Khandwa 97 60 97 86 86

Pandhana 128 84 128 105 103

Mundi 161 73 161 160 150

Chaigaon 86 59 86 72 62 Makhan Khalwa 147 86 147 108 99

Harsud 75 40 75 56 47

Killod 32 21 32 29 29

Total 726 423 726 616 576

The VHSC’s that are already in place they have a joint bank account in the name of ASHA and the Women representative from the PRI. And the ones formed, almost all of them have bank accounts.

And the fund utilized only requires the signatory to produce a utilization certificate, there is no inbuilt monitoring mechanism is in place to ensure that the money is utilized as per the guidelines.

Also during interactions with ASHA’s at the Monthly sector meeting at CHC Chegaon Makhan many said they did not receive the complete amount of Rs.10,000 instead some received one and some received two installments of Rs.2000 each.

Monthly meetings held on VHND day: Health talks; fewer attempts to penetrate in the community. Objective of Community participation and decentralized planning remains unmet.

In addition since there is no incentive for the members of the VHSC to actively conduct meetings and organize for activities and further the community presence of the health providers is also low there is very little motivation for them to initiate and participate in its functioning.

Service Delivery  Maternal and Child health- Maternal and child immunization tracking yet to be started in the districts as the formats are yet to be sent by the state. Nutrition Rehabilitation Centers set up by support from UNICEF are doing a commendable work in rehabilitating malnourished children.  Janani Suraksha Yojana is one of the major components of NRHM to promote institutional deliveries. The incentives are updated and the benefits are reaching mothers delivering at home with minimal delays.

 Family Planning – emphasis on NSV and LTT hence other alternative methods i.e. spacing methods like contraceptive pills and condoms are not propagated at all.  No fixed day clinics for RTI, STI and adolescents  IEC and BCC activities.(monetary incentives are being used for motivating behavior change)

Inspection of Health Facilities

The following section illustrates the current status of the health centers visited. The approach adopted was to inspect and discuss the gaps and immediate requirements of these health facilities in consultation with the health functionaries. Thus, after much deliberation and discussions and the in the end of a descriptive report about the health facilities, there is a section compiling the Actions to be taken for the betterment of service delivery in the health facilities visited.

District Hospital, Khandwa

The District Hospital at Khandwa is a 400 bedded hospital, in which 70 beds are allocated for Maternity Hospital and rest 330 are in the main hospital building. It cater to a population of 12,45,000 in the district. The services provided at the hospital range from regular OPD and IPD services, emergency care, Basic laboratory investigations, radiological examinations, delivery services including C- Sections. The average number of OPD cases per day is approximately 850. Referred cases are sent to Medical College in Indore and there is a dedicated Ambulance for the same. The performance of DH according to the Health facility inspection Format is represented in Graph 1 shown below.

The SNCU is under construction and is intended to be completed by the end of July 2010. The recruitment process for the SNCU staff is already in process hence it is expected to be functional within this year itself.

The Nutrition Rehabilitation Center set up with the support of UNICEF is functioning well. It is a 20 bedded facility which on the day of the visit was fully occupied. It is well equipped with staff and all the essential supplies to combat malnutrition in the district.

The hospital has a well equipped ICU which on the day of the visit was kept locked and the ICU register showed last entry recorded in the year 2009. Hence it is grossly underutilized, even with the facility available at the hospital the patients are being referred out.

There are no dedicated fixed days for RTI, STI and Adolescent clinics, patients are seen every day in the general OPD.

Waste Disposal practices were not being properly followed. Waste was not segregated in different colored bins. Although needle cutters were present but they were only used to collect the used needles and not for cutting them.

Display of JSY beneficiaries not present, JSY payments were updated till the time of the visits and the ASHA’s who were present at the office had positive responses for the same.

RKS funds in the last year were utilized for appointing security services and for whitewash of few wards.

Since the District Hospital in Khandwa is a big facility with 400 beds its requirement for manpower is also accordingly very huge. There is a severe shortage of nursing staff which is one of the major obstacles in service delivery. There are only 50 staff nurses in the DH against 100 sanctioned positions in the DH and each ward has only one staff nurse deputed for appox.25-30 bedded ward in terms of patient load.

Also there is a huge shortage of doctors and specialists in the DH. There are only 14 doctors in position out of whom one of the doctors has taken voluntary retirement and one more is paralyzed hence he cannot attend to patients.

Actionable Points: (as suggested by the Civil Surgeon of the District hospital)

 As suggested by the Civil Surgeon in the District Hospital to meet the shortage of nursing staff, training centre in the district itself can be one of the solutions to meet the huge demand of staff nurses. Since the hospital is big enough to support such a Training Center for nurses.  Accommodation for Doctors in the premises to ensure their availability.  Action to be taken-  Separate color coded bins for segregation of waste material into infectious and non- infectious material.  Management of Third Stage of labor to be displayed in the labor room.  Cleanliness of the hospital, especially floors with disinfectants to be properly done.

Graph 1: District Hospital Khandwa

CHC, Khalwa

The CHC at Khalwa is a designated FRU of Khalwa block. But it does not provide facilities at the FRU is suppose to at present. The new building for the health centre is under construction since last 3 years. The new building will be a 30 bedded facility.It is a designated CEmONC center but it does not have blood storage facility as of now. The performance

It caters to a population of approximately 2 lakhs. It has 3 PHC’s and 51 SHC’s under it. And currently it has only 6 functional beds. There are no specialists in the CHC, there is only one doctor at present and the other three medical officers who are attached to the CHC are from the PHC’s in the block. There are currently 2 staff nurses and 2 ANM’s out of whom one is from another SHC I the block.

Services provided in the health centre includes, OPD and IPD services, with an average of 70-80 patients per day and 2 patients in the IPD per day with an average length of stay of 24hrs., 24*7 delivery services, outreach activities, immunization, IEC activities, basic routine blood and sputum examination and ophthalmic & radiological examination. The institution conducts on an average 140deliveries per month even with limited number of staff nurses. There are no fixed day clinics for RTI, STI, and Adolescents. LTT camps are conducted weekly on Monday to meet the targets of family planning. The JSY payments to all the eligible women were updated till the last week of the visit.

The Nutrition Rehabilitation Centre in the CHC is well equipped with staff and supplies and functioning quiet well. It has one Feeding Demonstrator, I Cook and one Helper. Although it is a 10 bedded facility at present it has been extended to 26 beds since there were directions from the higher authority to admit all the malnourished children coming to the health centre. Hence the NRC is over- burdened with patients to be rehabilitated thus the staff which is in position for a 10 bedded facility is now insufficient.

Procurement of drugs and supplies is timely available to the facility and all the essential drugs are in enough stock. Although the storage facility for the drugs is not as per the needs the temperature requirement is not fulfilled by the store room at the CHC.

There are no separate toilets for the staff member and the patients. Evan separate toilets for males and females are not present in the facility. There are no provisions of food supplies for the inpatients except for the patients admitted in the NRC.

Water supply and electricity was a major obstacle in delivery of services. Water requirements are immense and are fulfilled by private water tanks on a regular basis.

Waste Disposal was not at all up to the expected standards. A space inside the premises which was built for water storage purpose was being used for dumping waste.

Actions to be taken:

 Immediate attention to provide water supply to the health centre.  Provision of electricity to be made with the installation of a generator at the health facility.  Proper disposal of waste in properly separate color coded bins.

Graph 2: CHC Khalwa

PHC, Roshni

PHC Roshni is a BEmONC health centre under CHC Khalwa in block Khalwa. The PHC caters to a population of approximately 40,000 residing in 40 villages. The facility has 6 beds out of which only 2 are functional and used for delivery purposes. The services provided at the facility includes OPD services with an average OPD of about 30cases per day, 24*7 delivery services conducting on an average 20 deliveries per month. There are 12 SHC’s under PHC Roshni. Other services includes immunization , IEC activities and Routine blood, sputum and malaria parasite examination.

The staff at the facility includes 1 M.B.B.S doctor, 1 AYUSH (Yunani), 2 nursing staff, 1 Supervisor, 1 lab technician and 1 Peon. There are 15 ASHA’s and 30 ANW workers in 40 villages under PHC Roshni. The ANM’s at the facility are SBA trained and are conducting deliveries regularly.

The performance of PHC Roshni on the inspection format for health facilities for Supportive Supervision is illustrated in Graph 3. In majority of parameters the performance of health centre is around 50% except for the services out-sourced and wquipments in the OT where the PHC is severly lacking and requires attention.

Graph 3: PHC Roshni

Actions to be taken:

 The new generator which has already been purchased to be installed with immediate effect.  Provisions for adequate water in the health centre for efficient service delivery.  Proper Waste Disposal.

Sub Health Centre, Kheri

The Sub Health Centre at Kheri caters to a population of approximately 5000 and residing in 5 villages. The health staff has just 1 ANM and the positions of MPW and 2nd ANM remains vacant. Hence all the deliveries are managed single handedly by the ANM currently in position. The other services provided at the SHC are OPD, 24*7 delivery services with an average of 8-10 deliveries per month, Outreach Activities including IEC activities, Polio rounds implementation of other national health programs etc and Immunization along with these services the ANM also has to look after record maintenance and other attend monitoring meetings and workshops. Thus it lays a lot of burden on her.

The SHC has two rooms one is utilized for deliveries and has a labour board which is in a very dismal state, shown below in Figure 2, with no proper bedding and steps climb it up and not even a mackintosh sheet and pad for support the delivering woman. One of the rooms connected to the labor room which can be utilized for patient care currently is dumped with scrap and is occupying space as shown in Figure 3. ANM stays at the SHC which is within the premises of the SHC, across the OPD.

Figure 2(Left): Labour Board in SHC Kheri Figure 3(Right): Scrap lying idle in the SHC

The performance of SHC Kheri on the inspection format for health facilities for Supportive Supervision is illustrated in Graph 4. The SHC scored the least on Bio medical Waste Management, there was no provisions in the health facility for segregation of waste and the needle cutter was being used to store the used needles, which was then collected in a plastic bag and taken to the block level weekly and which further gets disposed from there. There was no burial pit for disposing anatomical waste.

The untied funds for 2009-10 was utilized for purchasing B.P. Instrument and Baby Weighing Machine.

Actions to be taken:

 Arrangement for electricity to be made  Provision of a Newborn Baby Corner

 Other useful items to be bought for the SHC; Ambu Bag, Suction, Mackintosh Sheet and Baby table.

Graph 4: SHC Kheri

Sub Health Centre, Jaswadi

The SHC Jaswadi comes under the block Jawar.The SHC at Jaswadi caters to a population of 5000 residing in 3 villages. The Health staff at the health centre consists of 1 MPW and 2 ANM’s. Services provided are- OPD, 24*7 delivery services, Immunization, Outreach Activities including IEC activities, Polio rounds implementation of other national health programs etc. There are 6 ASHA’s reporting to the health centre. ASHA’s- 6, self motivated and quite aware of their roles and responsibilities, they maintain four records of their villages: Birth, Death, Married Couples and Pregnant Women.

The SHC is functioning from one single room which is divided into two, one side is used for delivery purposes and it accommodates one bed for the delivery mother to lie and a delivery table, the space is very minimal but has been very efficiently utilized. And the other half of the room is used for OPD services and other administrative record keeping. Since the institution is conducting on an average 30

29 deliveries per month there is a need for expanding the current space for labor room and this can be easily done since there is space available in the SHC.

VHND’s are held twice in a week on Tuesday and Friday, thus VHND is conducted once every month in a village. And on the same day meetings for VHSC’s are also conducted. Although, these meetings are conducted regularly but their agenda is limited to promotion of institutional delivery, ANC & PNC checkups, immunization and family planning. The functions of VHSC like the utilization of funds of VHSC for community level activities, creation of community awareness and demand generation are not being taken up at present. Thus there is a need to expand the scope of these meetings and also increase the penetrability into the community.Also, the discussions in the meetings are limited to the members it needs to be scaled up by holding group activities with the people from the community and ensure the presence of the committee in the village.

The SHC at Jaswadi is functioning well for which the prime credit goes to the self motivated staff in position since last 10-12 years. The record maintenance and the micro plan for immunization sessions and outreach community level activities were quite commendable. The JSY payments were also updated till the time of visit. The annual maintenance grant and the untied fund for 2009-10were also efficiently utilized in putting up a shed and and minor civil works for the SHC.

Graph 5: SHC Jaswadi

The performance of SHC Jaswadi on the inspection format for health facilities for Supportive Supervision is illustrated in Graph 5 shown above. Overall the SHC Jaswadi is functioning well and to its complete potential except for the Bio- Medical Waste Management which requires attention.

Actions To Be taken:

 Burial Pit for disposal of waste.

 Color coded bins for segregation of waste.  Newborn Baby Corner for cleaning and weighing the baby immediately after delivery.

CHC Chegaon Makhan

The CHC Chegaon Makhan is a recently constructed facility. The institution was shifted to the new building, 2 month back hence it is still in the process of achieving its full potential and at present requires furnishing. The new building has provision for 30 beds and has a spacious labor room and operation theatre.

The CHC caters to a population of approximately 1.5lakhs residing in 86 villages. It has is designated BEmONC centre which provides normal deliveries 24*7 and the suspected complicated deliveries are referred out to higher facility. On an average 150 deliveries are conducted in the CHC in a month. Deliveries are conducted by 4 trained staff nurses and there are no specialists to provide obstetric and newborn care. There is only one M.B.B.S. doctor in position in the CHC due to which even with the infrastructure and the facilities at the institution it remains grossly underutilized. The family planning surgeries; NSV and LTT are conducted by surgeons from the neighboring districts of Khargaon and Indore. This is facilitated by conducting 3 camps every month in order to achieve the set target for family planning. And in each camp on an average 25 operations are done.

Laboratory services include routine blood examination, sputum investigation, malaria parasite, urine examination and blood sugar. Provision for radiological examination is also available at the institution. And to provide these services there are 2 lab technicians and 1 radiographer in position. The labor room in the health centre has most of the basic requirements and also has a separate newborn corner. The labor room also has an attached toilet to it.

There are 23 SHC’s under the CHC Chegaon Makhan out of which 20 of them have buildings and three are currently functioning from a rented place. also 2nd ANM’s are appointed in only 3 of the SHC’s whereas 13 out of 23 are conducting deliveries in the block. The CHC is also a training centre for ASHA’s and organizes meeting for monitoring of outreach activities in the block. There are 74 VHSC’s in the block.

The Graph 6 shown below illustrates the performance of CHC Chegaon Makhan. The graph shows almost more than 50% performance in majority of the parameters except for services out-sourced and the equipments in the OT which require attention.

Graph 6: CHC Chegaon Makhan

PHC Chichgon

Population covered by the PHC is 40,000 residing in 26 villages. It has 8 Sub Health Centers out of which currently 6 are conducting deliveries.The health centre is a designated Be MONC centre but since last 2months only in case of only urgency like if the mother cannot reach the hospital they are delivered at the facility otherwise they are referred to the nearest CHC at Chegaon Makhan or further to Khandwa. Services provided- OPD services, 24*7 deliveries of urgent cases , immunization, IEC activities, Hb estimation, Sputum collection, Malaria slide preparation, IUD insertion.

PHC does not have a building of its own, it functions from the space given by the Panchayat, it has 2 rooms in the main building one is used for the running OPD and dispensing medicines and the ILR point is also in that same room the other is used as a drug store.

Deliveries are conducted by SBA trained ANM’s. There is no doctor at the facility the staff comprises of 3 ANM’s,1 Dresser, 1 Supervisor, 1 Accountant and 1 Sweeper.OPD is managed by the Dresser since he has been working there since last 12 years.

The labor room is stationed in another building which is approximately half a kilometer away from the main building and is in a very dismal condition, with no proper ventilation, stained and rusted labor table and the equipments (weighing machine) and the materials in the LR were covered with dust.

Electricity and water supply are two major problems due to which the service delivery at the health centre is largely hampered. There are no ambulance facility in the health centre hence when the patient is required to be shifted to a higher facility the transport services has to be either arranged from the block level or private vehicles have to be utilized, which again leads to further delay providing care.

No untied and annual maintenance grants received from the district since the PHC has a proposed building and has not been constructed yet due to land and location disputes between villagers.

SHC Deshgaon

The SHC at Deshgaon caters to a population of 7000 residing in 4 villages. The health staff includes 1 MPW and 2 ANM’s. The services provided at the SHC include, OPD, Immunization, Outreach Activities including IEC activities, Polio rounds implementation of other national health programs etc.

The records are well maintained and service delivery is quite satisfactory with the exception of institutional delivery at the health centre.

The deliveries at the institution are not being conducted since last 2 months due to conflicts between both the ANM’s. Attempts have been made by the CMHO also but the conflict still remains unresolved hence the ultimate effect is seen on the service delivery.

The untied grant and the annual maintenance grant for the previous year 2009-10 was utilized for the purchase of CFL lights for the SHC and making provisions for emergency light for the delivery room and some minor civil works; whitewash.

The performance of SHC Deshgaon as per the parameters set in the inspection for health facilities has been illustrated in Graph 8. The biomedical waste management is the key area which needs attention.

Actions to be taken

 Provision of electricity  Boundary wall required  Resolution of conflict between the two ANM’s

Graph 8: SHC Deshgaon

Way Forward

Recommendations enumerated in the following section have been compiled based on the responses from the community and the health facility visit during the Supportive Supervision Field Visit. Hence they can be scaled up to the rest of the district taking into account the local situations accordingly.

Infrastructure:

 Hand held support is required for better utilization of the annual maintenance grant and the untied grant to the health facilities and more so for the SHC’s.

 Better Waste Disposal system which needs close monitoring also needs attention. And more importantly attention needed for segregation of waste. Cleanliness and hygiene in the health facilities to ensure infection control and not to harm the patients should be the objective.

Human Resource:

 The contractual staff under the mission like the DPM, DCm and the BPM needs to be provided with a framework of their areas of roles and responsibilities for a more effective functioning.

 The lack of specialists and medical officers needs an urgent attention. Support from the neighboring districts need to be gathered to meet the requirement which should be continuously supported by a long term plan for providing specialists in the district.

 Shortage of nursing staff at the District Hospital is another area which has to be looked after. Thus, setting up of a training centre at the district hospital can be a way out.

Service Delivery:

 The target centric approach has for family planning has led to an emphasis on promoting on NSV and LTT, at the same time other methods of contraception also needs to be promoted with the same thrust in order to provide alternatives to the people and help them make an informed choice and actively practice family planning.

Community Processes:

 Communication channels like the ASHA’s need to build a more inter-personal rapport with the community in order to be able to link up the people to the system and increase accountability and responsiveness.

 A monitoring system which can be headed by the District Community Mobilizer for the VHSC’s can be developed to make the presence felt in the community. And the system should be such that it emphasizes on not only conducting meeting of the members but to have more frequent community level activities like a cleanliness drives in the village.