(NRHM) in Punjab – a Rapid Appraisal in Patiala District

National Rural Health Mission (NRHM) in Punjab – A Rapid Appraisal in Patiala District

July 2009

Population Research Centre Centre for Research in Rural and Industrial Development Sector 19A, Madhya Marg, Chandigarh 160 019

ational Rural Health Mission (RHM) in Punjab – A Rapid Appraisal in Patiala District

(Report Submitted to the Statistics Division, Ministry of Health and Family Welfare, Government of India)

Population Research Centre Centre for Research in Rural and Industrial Development Sector 19A, Madhya Marg CHADIGARH 160 019 Website: www.crrid.res.in

ACKNOWLEDGEMENTS

The project “ National Rural Health Mission (NRHM) in Punjab – A Rapid Appraisal in Patiala District ” could not have been successfully completed but for the co-operation of many organizations and individuals. We express our indebtedness to them all.

We, as a team, are grateful to Statistics Division, Ministry of Health and Family Welfare (MoHFW), Government of India for assigning and funding the study to Population Research Centre (PRC) at the Centre for Research in Rural and Industrial Development (CRRID), Chandigarh. We are thankful to all senior officers including Dr. V.K. Malhotra, Additional Director General, Dr. Rattan Chand, Chief Director, Shri Parveen Srivastava, Director, and Shri Rajesh Bhatia, Joint Director in the MoHFW for their continued support, valuable inputs till the completion of the report. Without this, smooth completion of this project would not have been possible.

We are equally grateful to the officers in the Department of Health and Family Welfare, Government of Punjab for rendering active co-operation when required for the study. Thanks are specially due to Dr. C.L. Bhatia, State Nodal Officer for NRHM and Shri Gulshan Kumar, Senior Research Officer for finding time to act as resource person during the training for field investigators/supervisors at CRRID. In the field, Dr. Kuldip Kaur, Civil Surgeon, Patiala district extended full cooperation to the team along with her medical officers (in-charge) at the different selected health facilities (district, CHC and PHC level). The para-medical staff also deserve our appreciation for their help during the field survey in the district.

The selected households in the rural areas of the district were the major source of information to whom the study owes a lot. They participated selflessly and spontaneously in the interview in peak winter months without any direct expectation. We are indeed thankful to them.

At CRRID, we are thankful to Dr. Rashpal Malhotra, Director General/Executive Vice Chairman, for his encouragement for the study. The advice rendered by Dr. S.K. Mangal, Senior Adviser, CRRID from time to time is also gratefully acknowledged. The varied and valuable contributions by CRRID staff including administration, library, computer, secretarial cell and others, is also thankfully acknowledged.

The members of the study team at CRRID were appreciative of the importance and value of National Rural Health Mission, and worked hard for setting the tone of the study in a very short span of time. For this, I specially thank Dr. Rajesh Kumar Aggarwal, Shri Sunil Bansal, Ms. Monica Munjial, Ms. Poonam Kaushik, Dr. Shaik Iftikhar Ahmed, Shri Sunil Agnihotri, Ms. Bindu and Mr. Sandeep for fully responding to the call of duty and making the assignment a success. All these colleagues have made significant contributions, according to their respective roles, to the understanding of the National Rural Health Mission in a wider and holistic perspective. I earnestly hope that the report will go a long way in strengthening the Scheme.

Aswini Kumar Nanda Professor and Head PRC/CRRID Chandigarh July 2009

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Abbreviations Used

ACFA: Assistant Controller of Finance and Accounts AIDS: Acquired Immunodeficiency Syndrome ANC: Ante Natal Care ANM: Auxiliary Nurse Midwife APL: Above Poverty Line ARI: Acute Respiratory Infection ASHA: Accredited Social Health Activist AWC: Anganwari Centre AWW: Anganwari Worker AYUSH: Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy BEE: Block Extension Educator BP: Blood Pressure BPL: Below Poverty Line CHC: Community Health Centre CSSD: Central Sterile and Supply Department DDK: Disposable Delivery Kit DOTS: Directly Observed Treatment Short Course DRA: Dark Room Assistant EDD: Expected Date of Delivery EMOC: Emergency Medical and Obstetric Care FHW: Female Health Worker FRU: First Referral Unit GP: Gram Panchayat GOI: Government of India HIV: Human Immunodeficiency Virus ICPD: International Conference on Population and Development ICU: Intensive Care Unit IFA: Iron and Folic Acid IMR: Infant Mortality Rate IPHS: Indian Public Health Standards IUCD: Intra Uterine Contraceptive Device IUD: Intra Uterine Device JSY: Janani Suraksha Yojana LHV: Lady Health Visitor LPG: Liquefied Petroleum Gas MCH: Maternal and Child Health MMR: Maternal Mortality Rate MO: Medical Officer MOU: Memorandum of Understanding MPHW (M): Multi Purpose Health Worker (Male)

MPHW: Multi Purpose Health Worker NACO: National AIDS Control Organization NCMP: National Common Minimum Programme NGO: Non-Government Organization NHP: National Health Policy NMBS: National Maternity Benefit Scheme NPA: Non-Practicing Allowance NPP: National Population Policy NRHM: National Rural Health Mission OBC: Other Backward Caste ORS: Oral Rehydration Solution PGI: Post Graduate Institute PHC: Primary Health Centre PHN: Public Health Nurse PPP: Public-Private Partnership PPTC: Prevention of Parent to Child Transmission Centres PRC: Population Research Centre PRI: Panchayati Raj Institution PWC: Patient Welfare Committee RCH: Reproductive and Child Health RKS: Rogi Kalyan Samiti RMP: Registered Medical Practitioner RTI: Reproductive Tract Infection SA: Statistical Assistant SC: Sub Centre SHC: Subsidiary Health Centre SHG: Self Help Group SMO: Senior Medical Officer SPMU: State Programme Management Unit SLI: Standard of Living Index ST: Scheduled Tribe STI: Sexually Transmitted Infection TT: Tetanus Toxoid TV: Television VCT: Voluntary Counseling Test VCTC: Voluntary Counseling and Testing Centre VHND: Village Health and Nutrition Day VHSC: Village Health and Sanitation Committee

COTETS

Chapter Title and Content Page No. 1 State Profile 1 Population characteristics Estimated population Status of NRHM interventions Status of health infrastructure and facility up-gradation under NRHM Rogi Kalyan Samitis (RKSs) Implementation of Janani Suraksha Yojana (JSY) Financial mechanism at the state including transfer of untied funds Survey period for different categories of schedules List of facilities covered with names Coverage 2 District Profile 17 Background The district Part A Population characteristics Infrastructure Rogi Kalyan Samiti Janani Suraksha Yojana Financial mechanisms Part B District hospital Location of the hospital Status of IPHS Physical infrastructure Human resources Other framework and structural issues Conclusions 3 Community Health Centres 51 Background Coverage and availability of infrastructure Availability of staff Availability of specific services Status of specific interventions Status of residential facilities Laboratory facilities Status of performance of OT Performance of labour room Availability of equipments and drugs Availability of specified services Service outcome Observations and suggestions 4 Primary Health Centres 69 Selection of sample Coverage and facilities

Availability of infrastructure Staff position Status of training of personnel Labour room and its performance Availability of laboratory and its performance Status of specific interventions Availability of equipments Availability of drugs Service outcome Conclusions and suggestions 5 Sub Cen tre s 93 Introduction Methodology Sub Centres schedule Sub Centres Infrastructural status Human resource Status of deliveries conducted at sub-centre Availability of equipments and drugs Performance of ANM at sub-centre Status of record maintenance at sub-centre Status of JSY scheme at sub-centre Utilization of untied funds Suggestions for proper implementation of NRHM Suggestions for improvements of services at sub-centre Conclusions 6 Household Characteristics 127 Introduction Methodology and design Household schedule Respondent’s background Household characteristics Awareness about the programmes under NRHM Janani Suraksha Yojana (JSY) Registration of JSY beneficiaries JSY card Role of ASHA in JSY Deliveries under JSY Satisfaction of beneficiaries at health facility Home deliveries: Prevalence and reasons Cash incentive under JSY Utilization of health services Client satisfaction User fees Facilities for BPL patients Outbreak of diseases Preventive measures for selected diseases Family planning awareness Awareness about HIV/AIDS Suggestions for improvement of services at the village level Conclusions

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7 Status and Performance of ASHA 163 Status of ASHA Method of selection Training of ASHAs Role and performance of ASHA Average incentive received Types of difficulties faced Kind of support required Distribution of ASHAs by reported awareness on different aspects Initiating breastfeeding Conclusions 8 Role, Awareness and Involvement of Gram 169 Panchayats Status of Gram Panchayats Covered Level of awareness and involvement of Gram Panchayats Information, Education and Communication (IEC) Village health committees Janani Suraksha Yojana (JSY) Difficulties faced during implementation of activities under NRHM Conclusions 9 Quality of Care and Client Satisfacti on 175 Introduction Methodology Indoor patient department (IPD) Background characteristics Purpose of admission Waiting time Satisfaction regarding waiting time Behaviour of staff Unique/innovative measure taken to improve the staff behaviour Privacy Patient-doctor/provider communication Cleanliness of the facility Satisfaction regarding cleanliness of the facility Crowding in the facility Amenities provided by the hospital Continuity of treatment Outdoor patient department (OPD) Background characteristics Purpose of visit Waiting time Satisfaction regarding waiting time Behaviour of staff Privacy Patient-doctor/provider communication Satisfaction regarding cleanliness of the facility Satisfaction regarding crowding in the facility Continuity of treatment Concl usion s PROJECT MEMBERS 201

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List of tables

Table No. Title R1 Area-wise and caste-wise population, Punjab, 2001 R2 Area-wise and caste-wise projected population, Punjab, March 2008 R3 Status of health infrastructure and Upgradation under NRHM in Punjab (As on 30.6.2008) R4 Status of Rogi Kalyan Samitis (RKS), Punjab R5 Public Private Partnership in Janani Suraksha Yojana (JSY) , Punjab R6 Classification on the basis of socio-economic basis of JSY cases in Punjab, (2007-08) R7 Financial Mechanism at the State level and transfer of untied funds D1 Selected Health Infrastructure in Patiala district D2 Nature of Facilities for Delivery in Patiala D3 Types of Human Resources in Patiala district D4 Progress of JSY in Patiala district (2007-08) D5 Availability of specialized medical manpower in Patiala district D6 Availability of para-medical manpower in Patiala district D7 Availability of administrative manpower in Patiala district C1 Coverage and Availability of Infrastructure in selected CHCs C2 Position of Medical Staff and Paramedical Staff in selected CHCs, Punjab C3 Availability of Specific Services in Selected CHCs C4 Status of Specific Interventions C5 Status of Residential Facilities for Doctors and Other Staff C6 Availability of Laboratory Facilities C7 Number of laboratory tests done in selected CHC C8 Number of surgeries performed during 2007-2008 in selected CHCs C9 Reasons for not conducting surgeries at selected CHCs C10 Status of performance of labour room during 2007-08 at selected CHCs C11 Reasons for not conducting deliveries at selected CHCs C12 Status of availability of equipments & drugs at selected CHCs C13 Availability of specific services at the selected CHCs C14 Service Outcome (based on data for last three months, September-November 2008) P1 Coverage and facilities of Primary Health Centre P2 Primary Health Centres by Infrastructure P3 Staff Position in selected Primary Health Centres P4 Status of training of personnel at Primary Health Centre P5 Availability of Labour Room in Primary Health Centre P6 Status of performance of Labour Room during 2007-2008 P7 Availability of laboratory testing in PHC P8 Number of tests done in PHC in last three calendar months P9 Status of Specific Interventions P10 Availability of selected equipments in PHC P11 Status of Availability of Drugs P12A Service Outcome (based on data for last three months) P12B Service Outcome (based on data for last three months) P12C Service Outcome (based on data for last three months) P12D Service Outcome (based on data for last three months) P13 Status of record maintenance (Yes:1; No: 0)

S1 Sub Centres coverage S2 Sub-Centre infrastructure S3 Sub Centres with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre quarter S4 Sub Centres with Staff in Position S5 Availability of Labour Room in Sub Centre S6A Number of deliveries performed during 2007-2008 S6B Sub-Centres with arrangement for deliveries S7A Sub Centres with availability of equipments S7B Percentage of SCs with functional equipments S8 Status of availability of drugs S9 Status of Specific Skills and Procedures S10 Service Outcome (based on data for last three months) S11 Status of Record Maintenance S12A Status of Awareness of ANM about JSY Scheme S12B Status of procedure under JSY Scheme S13 Status of performance of ANM under JSY Scheme S14 Status of Untied Grants H1 Characteristics of the respondents. Percent distribution of respondents by background characteristics H2 Characteristics of the household. Percent distribution of households by their background characteristics H3 Percent distribution of households by their waste disposal, stagnation of waste water and mosquito breeding around the house and system of medicine preferred by them H4 Percent distribution of household respondents by their information about availability of health worker, health facilities and transport used to take serious patients H5 Percent distribution of household respondents by their knowledge about NRHM, ASHA and her activities, VHND, VHSC and JSY H6 Percent distribution of JSY beneficiaries by their background characteristics H7 Timing, person and place of registration for JSY scheme H8 Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the beneficiary in getting the JSY card H9 Role of ASHA during the pregnancy of the beneficiaries H10 Place of delivery and reason for opting institutional delivery H11 Transport of the beneficiaries to reach the Health Institution H12 Waiting time at the health facility, type of delivery, amount spent at the health facility and satisfaction regarding services available in the health facility H13 Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives being available under the JSY Scheme H14 Cash incentive received by the beneficiary under JSY scheme H15 Utilization of government health facility in last six months H16 Characteristics of the respondents who have availed the services in government health facility in last six months H17 Type of health facility visited, purpose of visit and client satisfaction regarding behaviour of health worker, privacy and availability of medicines H18 User fees and extra charges H19 Services for the BPL patients H20 Outbreak of selected diseases (Malaria, Measles, Gastroenteritis, Jaundice and Other Diseases) in the respondents’ area in the last six months

H21 Action to be taken for selected diseases (diarrhoea, high fever, persistent cough, loose motion, persistent cough and breathing problems for a child) H22 Awareness about spacing methods and ideal gap between 1 st and 2 nd child H23 Awareness about modes of getting AIDS, source of information about AIDS and awareness about VCTC A1 Status of ASHA A2 Role and Performance of ASHA A3 Distribution of ASHAs by reported types of difficulties faced and kind of support required A4 Distribution of ASHAs by reported awareness on different aspects G1 Status of Gram Panchayats covered G2 Level of awareness and involvement of Gram Panchayats I1 Background characteristics of the in-patients I2 Purpose of admission in the health institution I3 Waiting time I4 Satisfaction regarding waiting time I5 Behaviour of Staff I6 Unique/innovativ e measure taken to improve the staff behaviour I7 Privacy at the facility I8 Patient -Doctor/Provider communication I9 Cleanliness of the facility I10 Satisfaction of patients regarding cleanliness of the facility I11 Crowding in the facility I12 Amenities provided by the hospital I13 Continuity of treatment O1 Background characteristics of the patients O2 Purpose of visit to the health institution O3 Waiting time at the facility O4 Satisfaction regarding waiting time O5 Behaviour of staff O6 Privacy at the facility O7 Patient-Doctor/Provider communication O8 Satisfaction of OPD patients regarding cleanliness of the facility O9 Satisfaction of OPD patients regarding crowding in the facility O10 Continuity of treatment

List of Annexure Annexure No. Title 1.1 Health facilities selected in the district Patiala 1.2 Schedule (S): Filled -in State Schedule 2.1 Patiala District: Basic Data Sheet 2.2 Schedule (D): Filled -in District Schedule

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