5th Common Review Mission
Andhra Pradesh
9th to 15th November 2011
National Rural Health Mission
Ministry of Health and Family Welfare
Government of India
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Table of Contents
List of abbreviations: ...... 4 Executive Summary: ...... 6 Chapter I – Team – Andhra Pradesh for the 5th CRM ...... 9 Chapter II – Introduction to the State ...... 11 Chapter III - Major findings of CRM ...... 15 Chapter IV Recommendations of the 5th CRM ...... 45 th Annexure 1: Data for the 5 CRM: ...... 49
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3 List of abbreviations:
AH Area Hospital ANM Auxiliary Nurse Midwife APVVP Andhra Pradesh Vaidya Vidhan Parishad ASHA Accredited Social Health Activist AYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy CAO Chief Administrative Officer CAS Civil Assistant SUrgeon CES Coverage Evaluation Survey CFO Chief Finance Officer CHC Community Health Center CHNC Community Health and Nutrition Cluster CPO Chief Programme Officer CRM Common Review Mission DCHS District Coordinator of Hospital Services DH District Hospital DHIS - 2 District Health Information Software - 2 DHS District Health Society DLHS-3 District Level Household Survey-3 DM&HO District Medical and Health Officer DOTS Directly Observed Treatment, Short course DPMU District Programme Management Unit EMRI Emergency Management and Research Institute FDHS Fixed Day Health Services (104) GoAP Government of Andhra Pradesh HDS Hospital Development Society (Rogi Kalyan Samiti) HMIS Health Management Information System HR Human Resources IEC Information Education and Communication IMEP Infection Management and Environment Protection IMR Infant Mortality Rate IPHS Indian Public Health Standards JSSK Janani Shishu Suraksha Karyakram JSY Janani Suraksha Yojana MCTS Mother and Child tracking System MD Mission Director MIS Management Information System
4 MMR Maternal Mortality Ratio MO Medical Officer MoHFW Ministry of Health and Family Welfare, India MPHEO Multi-Purpose Health Education Officer MPHS Multi Purpose Health Supervisor MPW Multi-Purpose Worker (male) NSV Non Scalpel Vasectomy NVBDCP National Vector Borne Diseases Control Programme PC&PNDT Pre-Conception & Pre-natal Diagnostic Techniques PHC Primary Health Center PMU Programme Management Unit RHS Rural Health Statistics RNTCP Revised National Tuberculosis Control Programme SC Sub-Center SPHO Senior Public Health Officer SPMU State Programme Management Unit SRS Sample Registration System TFR Total Fertility Rate VHND Village Health and Nutrition Day VHSNC Village Health Sanitation and Nutrition Committee
5 Executive Summary:
5th Common Review Mission was undertaken in Andhra Pradesh during 9th November to 15th November 2011. The two selected districts were Guntur and Warangal of which Guntur is a better performing district. The key findings of the 5th CRM is as follows:
Infrastructure: The State has in the current phase of NRHM focused on development of facilities and infrastructure at Community Health Centre and Sub-Divisional level. Overall, the infrastructure was found to be good in terms of buildings and at many places community has donated land and buildings for health facilities. However, the District Hospital in Guntur and the CHC at Macherla require major strengthening. Despite of having a dedicated corporation in the state for civil works, there is a huge delay in completion of new works.
Human Resources: There are huge HR crunches in the Specialists, Radiographers, Male Multi- Purpose Workers (male) lab technicians and nursing staff at PHCs and CHCs. There are more than 17% vacancies in the posts of paramedics and lab technicians. No pool of lab technicians is created at the facility-level in secondary care institutions. New posts paramedics are proposed to be sanctioned in the areas with acute shortage. Further, the State is also taking steps to address vacancies due to doctors on PG-LIEN is underway. Compulsory rural service for doctors after completeion of Post-Graduation study is planned to be implemented since 2012.
Training: Only 6.24% of the total intake for nursing and paramedical training in the State is in the Government Institutions. Quality of the training being provided by private institutions is not being ascertained and monitored. Training plan/training calendars are not available. Many trainings like Multi-skilling of doctors(esp. LSAS and EmOC), training for IUD and spacing methods are not taking place.
Service Delivery: Laboratory services in both the districts were highly unsatisfactory. Round the clock lab services were not available in any of the 24x7 facilities or even in the District Hospital of guntur District.
Public facilities remain underutilised particularly at night. Ancillary services, EMRI services were being provided. There is no robust mechanism to redress Grievance in the State. Convergence and coordination with AYUSH is lacking at all levels. There is a shortage of AYUSH drugs and AYUSH equipment at AYUSH facilities visited.
There is no shortage of medicines at most facilities visited. PHCs in Guntur spend up to Rs. 20000 – 25000 per annum on procurement of drugs. No Procurement Manuals/ Guidelines exist in the State.
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Infection Management and Environment Protection: Infection Control measures and Biomedical Waste Management was poor in both the districts.
Reproductive and Child Health: Haemoglobin estimation is being done by paper method in the sub-centres and in many PHCs which is less reliable than the Sahli’s method. Health facilities are not ready for rollout of JSSK. Partograph, AMTSL, essential newborn care protocols not being followed. JSY benefits not being paid in APVVP hospitals with delayed payment in some cases.
TFR goals are prescribed even for the sub-district levels including for Sub-centres. There is an over-emphasis on sterilisation and complete neglect of spacing methods in the State. Safe abortion services are not available in both the districts.
Adolescent anaemia control has not received adequate attention. Convergence of RH with HIV/PPTCT is good. Implementation of PC&PNDT Act needs strengthening. Violations/irregularities in maintenance of F-forms have been taken lightly and charge sheets are not filed.
Disease Control Programmes: There are some vacancies in key supervisory positions in Disease Control Programmes. The quality of blood slide examination needs improvement. The coordination with the sentinel surveillance unit in the Medical College was lacking for diagnosis of dengue. Strengthening of CHCs is required for sustaining efforts for management of lymph - oedema and hydrocele operations. Case detection rate/ cure rate under RNTCP is good.
Programme Management: Well established Programme Management Structures at State and district levels with good coordination between Health Directorate and PMU. However, coordination between the District Medical and Health Office and District Coordinator of Hospital Services (APVVP) is weak. State and Districts are not sending any Reports on HMIS.
Decentralised Local Action for Health: DHAPs are of very bad quality and do not reflect the need of the district. ASHAs are creating demand for Maternal, Child Health and Family Planning services.
Financial Management: Guidelines issued by GOI in December, 2006 on Delegation of Financial & Administrative Powers have not been implemented. The assistants working at Blocks level are not very well conversant with the accounting procedures. AMG and Untied Funds have not been given to each facility on a regular basis. The blocks are not regular in sending the reports (FMR) regularly the same is either sent at the end of the year or whenever there are funds received from DHMO Office.
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Based on the findings, the following areas for improvement are suggested:
Delay in completion of infrastructure projects needs to be checked. Regular monitoring of progress of the projects could be initiated. All health Facilities must be provided with barrier free access for disabled and infirm/old people. Quality of training needs to be ensured including in the private training institutions. Multi-skilling, MTP, IUDs trainings need to be restarted. Performance of CHC, FRUs and 24 x7 PHCs can be further optimized. Strengthening of strategically identified CHCs could be done. This would reduce congestion at secondary and tertiary level facilities. Laboratory services need to be strengthened, particularly in the CHCs, AHS and DHs. Better convergence with AYUSH should be done. Protocols, guidelines, training and facilities for segregation, storage, monitoring and disposal of waste need to be introduced and implemented. Protocols for ensuring asepsis in labor rooms and OTs needs to be introduced. Protocols of Newborn care need to be implemented. New Born Care Corners (NBCC), NB Stabilisation Units (NBSU) and Special Newborn Care Units (SNCU) need to be established in concurrence with the national guidelines. Adolescent anemia control programme needs to be introduced. Safe abortion services need to be provided and made easily accessible. Sub-district TFR goals need to be removed and spacing methods needs to be introduced. Irregularities related to Form F needs to be prosecuted appropriately. Implementation of the guidelines for financial management. Adequate training of all the staff handling accounts needs to be done. District Health Action Plans must be made by bottom up planning. HMIS, MCTS, IT systems and data flow require considerable improvement from peripheral level to district level onwards. Quality Assurance Committees for RCH, District Level Vigilance and Monitoring Committees and District Health Mission are yet to be established, Meetings of DHS and orientation of appropriate authorities in PC-PNDT act implementation is very much required.
8 Chapter I – Team – Andhra Pradesh for the 5th CRM
The 5th Common Review Mission was held between 8th November and 15th November 2011. The team comprised of officials from the Ministry of Health and Family Welfare, representatives from Development Partners and Civil Society as well as Academia. The team of Andhra Pradesh undertook its task under the leadership of Dr. P.K. Prabhakar, Deputy Commissioner, Child Health, Ministry of Health and Family Welfare.
The briefing meeting was held on 9th September 2011 and was chaired by Principal Secretary, Sh. Ratna Kishore, Government of Andhra Pradesh. The Mission visited two districts, Guntur and Warangal. The debriefing session on 15th November was also chaired by Principal Secretary, GoAP.
Guntur is a good performing district and Warangal is one of the 6 high Focus Districts. These districts were chosen by the MoHFW to provide to the team with an opportunity to review both a good performing and a bad performing district in the similar socio-political and economic milieu of the State.
Team Composition of 5th CRM team to AP:
District – GUNTUR District - WARANGAL Dr. P.K. Prabhakar, Deputy Commissioner, Child Dr. P. Padmanaban, Advisor, NHSRC. Health, MoHFW Dr. Dinesh Agarwal, National Programme Officer Dr. H. Sudershan, Karuna Trust. (RH), UNPFA, United Nations Population Fund. Prof T. Mathiyazaghan, Prof. & Head, Deptt. of Communication, NIHFW Dr. Kalpana Baruah, Joint Director (NVBDCP), Sh. V.P. Singh, DS (MS), MoHFW MoHFW Ms.Sujata Sharma, Director, Planning Commission Mr. Anil Garg, Consultant FMG Ms Padmavati, AD (NRHM-II) Mr. Vipin Garg, Consultant Reproductive and Child Health, MoHFW. Dr. Rachana Parikh, Consultant (NRHM), MoHFW Dr. M. S. Mathur, Sr. Regional Director, MoHFW
The teams were accompanied by representative from the State Government of Andhra Pradesh. Dr. Neerada, Dr. Anil Kumar from the Department of Health and Family Welfare of the State Government of Andhra Pradesh and Dr. Reddy from the Regional Evaluation Team had accompanied the National team.
9 Facilities visited during the 5th CRM:
Category Guntur District Warangal District Medical College Government General Hospital Guntur (NICU) GMH, Hanmakonda, CKM Hospital District Hospital DH, Tenali Area Hospital AH Sattenapalli, AH Narsaraopet, AH Mahabubabad CHC CHC Vemuru, CHC Macherla, CHC Ghanpur(Stn), Thorru, Venukonda Wardhannapet, Parkal ANMTC/ Nursing ANMTC & Nursing School, Warangal School PHC PHC Sangam Jagarlamudi, PHC Kolluru, PHC Nellikudur, Regonda,. Shyampet, Nudurpadu, PHC Savlapuram Raiparthy(W) SC SC Angalakuduru, SC Donepaudi, SC Matedu, Kotancha, Bhageerathpet, Nagulavarum, SC Phirangipurum, SC Mailaram, Pathipaka Karnamanchi,SC Cuandala Padu Anganwadi Angalakuduru, SC hamlet at Angalkuduru, centres Koppunur,u (VHND) Karamudu, Villages Kothapalli (104 services), SC Hamlet Matedu, Mailaram (Angalakuduru-SC)
The GOI team would like to acknowledge the efforts made by Government of Andhra Pradesh for facilitating the review and appropriately responding to various issues raised by the CRM members and also thank for the excellent hospitality provided and accommodating even last minute requests for changes in the programme.
10 Chapter II – Introduction to the State
Introduction:
The total population of the State is 846.66 lakh according to the Census 2011. Administratively, it is divided into 23 districts, 78 sub-divisions, 361 blocks, 1124 mandals and 26613 revenue villages (RHS 2010).
Crude Birth Rate for Andhra Pradesh is 18.3 births per 1000 population and Crude Death Rate is 7.6 per 1000 population (SRS 2009). It has a healthy adult sex-ratio of 992 females for 1000 males but the child sex ratio (0-6 years) has shown a decline from 961 girls for 1000 boys in 2001 to 943 girls per 1000 boys in 2011. The total decadal growth rate according to Census 2011 is 11.1% which is much lesser than the national decadal growth rate of 17.64%. Although it is considered to be one of the most progressive States, both male (75.56%) and female (59.74%) literacy rates are below the national average.
Healthcare in the public sector is being provided through a network of 12522 Sub- centres, 1624 Primary Health Centres, 281 community Health Centres, 76 Area Hospitals and 17 District Hospitals and 14 Medical Colleges. According to the data provided by the State, there is one sub-centre for every 4940 population which is according to norm and one PHC for every 37900 population.
800 PHCs (49.26%), 247 CHCs (88%) are functional as 24x7 facilities. There are 156 First Referral Units / Comprehensive Emergency Obstetric and Neonatal Care Centres in the State.
Status of Health Indicators:
Impressive progress has been recorded in the State in the last couple of decades. Infant Mortality Rate has dropped from 106 per 1000 live births in 1971 to 49 per 1000 births in 2009 but it is much higher than the target of 30 for the year 2012. Similarly, Maternal Mortality Ratio from more than 400 per 100000 live births in 1992-93 to 134 per 100000 live births in 2007-09 (SRS). Although, it is lower than the national average of 212, however this is still higher than the target of 100 for the year 2012. Similarly, Total Fertility Rate has also dropped from more than 4.5 in 1971 (SRS) to 1.9 in 2009 (SRS). With a TFR of 1.9 (SRS 2009), the State has already achieved the replacement level of fertility. Institutional deliveries have similarly shown a very impressive rise from about 35% in 1992-93 (NFHS-I) to nearly 95% in 2009 (CES, UNICEF).
Thus, the State is on its way to achieve to millennium Development Goals. It has already achieved the national goal of reducing Total Fertility Rate of 2.1. Important Health Indicators of the State are summarized in the table 1.
11 Table 1 Important health indicators of Andhra Pradesh
Indicators Andhra Pradesh
Institutional Deliveries (as a % of estimated deliveries) - 90.5% HMIS (Apr 2010-Mar 2011) Home deliveries (as a % of estimated deliveries) - HMIS 5.4% (Apr 2010-Mar 2011) C-section deliveries against the Institutional deliveries - 18% HMIS (Apr 2010-Mar 2011) % of deliveries with hospital stay of >48 hrs. (2010-11) 28.68
Still births reported against 1000 reported live births 8
Newborns weighing <2.5 kg against newborns weighed 7%
Fully immunized children against reported live births 97%
Achievements against the goals of NRHM (table 2)
Table 2 Outcomes of the Mission against the set goals
Parameter Expected Outcome Outcome of the Mission Maternal Mortality 100 per 100,000 live births Reduced from 154 (2004-06) to Ratio 134 (2007-09) Infant Mortality Rate 30 per1000 live births Reduced from 59 (SRS 2004) to 49 (SRS 2009) Total Fertility Rate 2.1 Reduced from 2.1 (SRS 2004) to 1.9 (SRS 2009) Malaria Mortality 60% by 2012 Achieved Mission target Reduction Rate Kala Azar Mortality 100% by 2010 and elimination by 2012 Not applicable Reduction Rate Dengue Mortality 50% by 2010 and sustaining that level Achieved Mission target Reduction Rate until 2012 Cataract operations Increasing to 4.6 Million 5.4 lakh cataract operations with 104% achievement Leprosy Prevalence Reduce from 1.8 per 10000 in 2005 to 0.55 per 10000 Rate less than 1 per 10000 thereafter. Tuberculosis Maintain 85% cure rate through entire 87% cure rate and 79% detection mission period and also sustain planned rate case detection rate.
12 Progress of the mission activities in the State
Overall Expenditure under NRHM has increased from Rs. 216.44 crores in 2005-06 to Rs. 405.91 crores in 2006-07, Rs. 505.18 crores in 2007-08, Rs. 700.13 crores in 2008-09, Rs.770.31 in 2009-10 and reported expenditure of Rs.673.31 in 2010-11 against allocation of Rs. 816.38 crores. Thus total expenditures till 2010-11 are Rs. 3271.27 crores against the allocation of Rs. 3560.81 crores which is 92 % of allocated budget. Table 3 summarizes major achievements of NRHM in a nutshell.
Table 3 Activities - wise progress of the Mission in the State (MIS-June 2011)
Activity Status
ASHAs selected 70700 ASHAs have been selected and trained up to 5th Module; training of 6th and 7th module for ASHAs have not yet started. ASHAs with drug kits All the ASHAs have been provided with drug kits
2nd ANMs at SCs Out of 12522 SCs, 10749 are functional with 2nd ANMs.
PHCs with 3 staff nurses 690 PHCs out of 1624 total PHCs have 3 staff nurses.
Contractual appointments 536 Medical Doctors, 1615 Staff Nurses, 712 AYUSH Doctors, 1305 paramedics, 1500 AYUSH paramedical staff, 10749 ANMs & 332 Specialists are positioned under NRHM.
Rogi Kalyan Samiti 2005 facilities (17 DH, 247 CHCs, 117 other than CHC and 1624 PHCs) have been registered with RKS.
Village Health Sanitation & Out of 28123 villages, 21916 VHSNCs constituted. Nutrition Committees (VHSNCs)
13 Action taken on 3rd CRM:
Table 4 Summary of Action taken on the previous CRM reports
Recommendation of 3rd CRM 5th CRM Team observation Major staffing gaps especially of specialists at Multi skilling of Medical Officers is yet to take off. CHCs and hospitals- this can be reduced by Underutilization of medical officers at CHC and 24 x multi-skilling, and reducing mismatches and 7 PHCs. better recruitment policies. Private practice govt. doctors (as allowed) Under utilization of public health facilities is visible. interfering with utilization of services from public Most people prefer to go to private facilities for facilities medical care. More capacity building for systems of financial Accounting systems at lower level facilities needs to management. be strengthened. Need to improve/provide institutional care for Essential and sick new born care services to be new-borns. strengthened. Laboratory bio-safety and biomedical waste Bio Medical Waste Management largely found non- management was lacking generally across all existent in most of the facilities in Warangal and in facilities visited by the team in both districts and Warangal District. Similarly, Infection Control needs to improve Protocols were not being implemented in almost all the facilities in both the districts.
14 Chapter III - Major findings of CRM
This chapter summarizes the findings of the 5th CRM team. It analyses each of the 15 components of the Terms of Reference.
1. Infrastructure Development:
Table 1.1 Status of Health Facilities in the State
Health Facilities Requirem Number of Population Number of Number of ent as per functioning covered per facilities in facilities Census facilities facility Government added during 2001 buildings the Mission (2011) period. Sub-Centres 11697 12522 4940 2841 -122 PHC 1914 1624 37900 1314 48 Area Hospital 76 218300 76 22 CHCs 461 281 281 122 District Hospitals 23 17 52,90,000 15 -4 Medical colleges 14 65,12,000
There is a shortage of PHCs and CHCs in the State according to the current population norms. However, grossly there is an adequate number of Sub-centres in the State. The numbers of sub-centres in the Non-High Focus Districts have declined from 9208 in 2005 to 9086 in 2011 as per the data given by the State (Annexure 1.A). The distribution of facilities is not always according to the population. In the two districts visited, there were a few blocks where the sub-centres catered to a population of more than 5800 namely, Block Cherial in Warangal and Block Ipuru in Guntur district. Similarly, a PHC would cater to more than 40000 people in a number of blocks in both the districts namely, Janagaon, Dornakal, Palakurthy, Parkal, Thorrur and Wardhannapet in Warangal district and Amaravathi, Gurazala, Ipuru, Kollipara, Narasaraopeta, Nizampatnam, P.V.Palem, Sattenapalli and Vinukonda blocks in Guntur district. Most of the health facilities were situated in the village and not on the outskirts as usually happens in many districts. Only 33.7% of all the sub-centres have an ANM residential quarter and all of these are occupied. The State has in the current phase of NRHM focused on development of facilities and infrastructure at Community Health Centre and Sub-Divisional level. This is evident from the above table where 40.3% of all existing Area Hospitals and Community Health Centres were added in the Mission period. Thus currently, more than 76% of the sub-
15 centres do not have a building of their own and are functional in rented buildings. This is true in both the high focus districts and the Non High Focus Districts while majority of the PHCs and all the secondary care hospitals at and above CHC level have their own independent building provided by the Government. Overall, the infrastructure was found to be good in terms of buildings and at many places community has donated land and buildings for health facilities. This is highly appreciable. However, despite having good infrastructures, most of the facilities visited are not optimally utilized especially CHCs and 24 x7 PHCs, there is a general preference to access private sectors. The District Hospital in Guntur and the CHC at Macherla required major strengthening. While the DH was also an under-performing institution, the CHC Macherla which is situated in the relatively backward area of the district Guntur is one of the well performing facilities in the district. Equipments in labor room and OT are largely available; however, newborn care equipments i.e. radiant warmers are not available in most of the places. APHMIDC: The Andhra Pradesh Health, Medical Housing and Infrastructure Development Corporation is Registered under A.P. Public Socities Act. The main function of the Corporation is Construction & Maintenance of Hospital Buildings and Procurement and distribution of Drugs, Surgicals & Consumable and Equipment. In spite of a dedicated Corporation, there is a huge delay in completion of new works.
Progress of Infrastructure Development in the State:
Majority of the new works sanctioned during the entire duration of the Mission are yet to begin. Of the works already undertaken only half of them have been completed (Table 1.2). Essentially there is not much difference in the proportion of all the projects that are under work and not yet initiated in the ‘High Focus Districts’ and the ‘Non High Focus Districts’.
Table 1.2 Progress of New Work in the State:
Completed Under Work sanctioned but not Total Works to yet started be undertaken District Hospitals (DH) 0 0 0 0 Area Hospitals 110 11 0 121 CHCs 2 0 1 3 PHCs 0 0 100 100 Other Health facilities 38 0 0 38 above SC but below block level Sub-Centres 199 335 547 1081 Total 349 346 648 1343
16 However, the completion rate of the new works undertaken is far from satisfactory. Of the 1081 new works of the sub-centers that were to be undertaken in the Mission period, only 199 new works are completed. All the 100 works for PHCs are yet to start. As mentioned earlier, in accordance with the focus on secondary care, the work projects for CHCs and Area Hospitals are essentially complete. One of the factors contributing to the delay in initiating and completion of the works could be that majority of the new works were proposed to be undertaken in the last 3 years only. 100 PHC work and 500 SC constructions were sanctioned in 2010-11 and additional 100 PHC and 250 SC works were proposed and were sanctioned in this year from the GoI. All the 100 PHC works and work of 250 SCs were proposed in this financial year. However, considering that this is the ultimate year of the Mission, it is extremely important that the State focuses on completion of the works. As with the progress of new works in the State, staggering 174 sanctioned projects for renovation and up gradation are yet to start. Further only 10 projects have been completed so far.
2. Human Resources:
Human Resources is onr of the most crucial inputs required in strengtehning on Health Systems. The Implementation Framework of NRHM has provided a unique oportunity to the States to undertake large scale hiring of technical and managerial manpower on a contractual basis. A quick analysis of the RHS 2010 data and data received from the State on Human Resources is summarised in the table 2.1 below.
Motivated Health staff at a sub-centre and the PHC in Guntur District
17 Table 2.1 Status of Human Resources in the State (Service Delivery)
Category Required Sanctioned In Position Vacant Shortfall % posts Diff in vacant of required the and sanctioned sanctioned posts Doctors 5158 5158 4821 337 337 6.5 0 (Allopathic)* Specialists* 883 883 626 257 257 29.1 0 Surgeons at 167 167 110 57 57 34.1 0 CHCs** Ob/ Gyn at 167 167 260 0 0 0 0 CHCs** Physicians at 167 167 20 147 147 88 0 CHCs** Pediatricians at 167 167 90 77 77 46.1 0 CHCs** Nursing staff at 2739 4882 4056 826 16.9 -2143 PHCs& CHCs** MPW* 12453 7552 5792 1760 6661 23.3 4901 ANM* 589 13111 23100 -9989 -22511 -76.2 -12522 LHV** 1570 1614 1564 50 6 3.1 -44 Lab Technician* 7583 7583 6250 1333 1333 17.8 0 Pharmacist** 1737 1686 1614 72 123 4.3 51 Radiographers 167 167 65 102 102 61.1 0 at CHCs** Paramedics* 3991 3991 3303 688 688 17.2 0 * Data provided by the State in Annexure 1 ** Rural Health Statistics (RHS) 2010
Among the frontline functionaries of the health deparment, there is a glaring gap of 4901 between the required and the number of MPW (male) posts sanctioned. Even among the sanctioned posts, there is a vacancy of more than 23% and no new recruitments are currently being made to this cadre. The vacancies in the General Duty Medical Officers and LHVs are low in the state and there are no vacancies in the ANMs and Obstetricians in the State which is appreciable. The low vacancies in the GDMOs may be attributed to their policy of giving additional weightage during selection post-graduation to the Medical Officers who have served in public service and particularly in hard and difficult areas. Many young doctors thus join public service and after a couple of years leave the service to persue higher studies. The posts of these doctors on leave often does not get filled as these doctors go on a leave
18 for studies. Thus, even as this does not get recognised as a vacancy, the doctors are absent at these positions. This remains a challenge for the State. Recently state has sanctioned additional posts in lieu of leave vacancy. There are huge HR crunches in the Specialists, Radiographers, Male Multi-Purpose Workers (male) lab technicians and nursing staff at PHCs and CHCs. • At CHCs, there is a major Human Resources crunch for the following staff. • 88% of the posts of Physicians at the CHCs are vacant • 46.1% of all the posts of Peditricians is vacant. • 34.1% of all the posts of surgeons is also vacant. • Thus overall, nearly 30% of all the posts of the Specialists are vacant. • 61% of the posts of radiographers at the CHCs are vacant. • Further, nearly 17% of the nursing staff posts re vacant at the PHCs and CHCs. Further, there are more than 17% vacancies in the posts of paramedics and lab technicians. No pool of lab technicians is created at the facility-level in secondary care institutions. As a result of which there are practically no facilities providing 24 hour lab services for emergency investigations in both the districts. Efforts are acking for handling this situation and no directed activity was seen to ensure optimum utilisation of the available lab technicians and provision of lab services beyond morning OPD hours. Issues reated to irregular payment of contractual staff were brought to light. This was particularly true for ANMs originally funded by the European Commission. It appears that ANM being charged under this project are not eligible for fixed travel allowance and their salaries are very low. Between the two districts, there was a marked difference in the levels of motivation in the staff. The health staff in Guntur was by far more motivated than in the Warrangal District. The health staff in Guntur enjoyed good support from the community and community leaders. This was evident from the fact that land, buildings were actively donated at many places. Supportive supervision: One of the factors that could have impacted better performace of Guntur District is good supervision by the supervisory cadre i.e., MPHS of the concerned PHCs. There was active supervision by this cadre on the functioning of the sub-centres. Every sub-centre was visited by supervisors atleast once in a week. Further, Medical Officers in Guntur paid regular visits to the sub-centres and undertook monitoring of the sub-centres.
Steps taken by the Government to address the shortage of Human Resources:
Sanctioning of new posts for paramedics in the areas with acute shortage. Addressing vacancies due to doctors on PG-LIEN is underway.
19 Compulsory rural service after completeion of Post-Graduation study is planned to be implemented since 2012. In the sub-centres where MPWs are not present the ANMs are taking care of the activities of the Disease Control Programmes. Recruitment of both MBBS and Specialists were underway in the State at the time of the visit. Recruitment of MPWs is to be initiated soon in the State.
Training:
Training infrastructure for training various categories of health functionaries at different levels seems adequate in the state. A large number of these institutions are private institutions especially for training nurses and other paramedical staff. Only 6.24% of the total intake for nursing and paramedical training in the State is in the Government Institutions. Thus a huge majority of the trainings are taking place in the private institutions. However, availability of trained faculty remains poor at these institutions. Further, the quality of the training being provided by such institutions is not being ascertained and monitored. In the Government training institutions, training plan/training calendars are not available. Many trainings like Multi-skilling of doctors(esp. LSAS and EmOC), training for IUD and spacing methods are not taking place. Life saving Anaesthesia skills training of the Medical Officers isbeing opposed by the Anaesthetist Association in the State and the trainees were denied certification. The State is in process of resolving the issue with the Anaesthetists’ Association. Training for safe abortions, NSSK, F-IMNCI to be strengthened. Similarly, quality of SBA training needs to be improved. During the fied vosots it was noticed that many functionaries who are already trained in SBA were not able to follow protocols properly. Further, high attrition rate of the staff is further adding to the training load in the State. One of the main reasons that was identified for continued high training load in the State was high attrirtion rate of the trained staff. ANM Schools: To improve the quality of ANM training, to raise standards and improve Infrastructure of ANM Schools in Andhra Pradesh, the GoAP has entrusted to make an Assessment of 32 ANM schools in the state to the NGO – ANSWERS, with support from UNFPA. They have submitted a detailed report with the some recommendations on which action is being initiated. Regional Training Centers: They are conducting in-service trainings for all Medical & Paramedical staff including Induction trainings, BCC/IEC trainings, IMNCI trainings and ARSH trainings. Regional Training Center faculty is trained in all ToTs and they will train MOs, SNs and other staff
20 at Regional and District Levels. The faculty is linked to PO-DTT of the districts concerned with that RTC. As per the GO. Rt.No.1484, Dt.24.08.2011, 4 RTCs will be shifted to other Districts to ensure equitable district allocations and will be accommodated in already existing Indian Population Project-VI (IPP-VI) buildings. The RTCs are renamed as Co- Educational Training Centers under the administrative control of the Director, IIHFW, Hyderabad, to the extent of Academic and Training activities. Health Management Courses: The Indian Institute of Public Health, Hyderabad undertakes PG Diploma is Public Health Management and PG Diploma in Biostatistics Management. In 2010-11, 23 students undertook the Diploma course in Public Health Management and 9 students undertook the Diploma course in Bio-Statistics Management.
3. Health Care Services Delivery: Comment [h1]: This is too detailed and may not be required. The Out-patient attendance in the health facilities in the public sector has increased from 2.499 Cr in 2006-07 to 2.768 crores in 2010-11. Thus, on an average an annual increase of 2.6% increase in the out-patient attendance was recorded in the State. Normal delivery and C-section performances of the FRUs is very poor (Warangal) in spite of availability of adequate number of specialists. E.g., in CHC Parikal & CHC Wardhanapet rarely any C-sections are performed and deliveries range from 8-10 deliveries in a month. In Guntur district, the District Hospital performance was not found up to the expected level. Laboratory servcies: Laboratory services in both the districts were highly unsatisfactory. Round the clock lab services were not available in any of the 24x7 facilities or even in the District Hospital of guntur District. This is a major area which has not received adequate attention in the mission period. Guntur District: There are 1332 beds in the public sector in the Guntur district. Thus, there is one bed in the public sector for more than 2300 people in the district. In 2010- 11, there were 23.9 lakh OPD patients and 99210 IPD patients. 74.5 patients per bed have been admitted in Guntur in 2010-11. 30.7% of all the beds (409 beds) are allocated to maternal care in the district. Public health facilities remain underutilised. This is evident from the fact that out of the 88200 pregnant women in the district, only 13474 (15.3%) delivered in the public facilities in 2010-11. Utilisation of the facilities at night (between 8 pm and 8 am) might not be up to the mark as only 18.5% of all the public sector deliveries are conducted at night. Warangal District: There are 1076 beds in the district. In 2010-11, there were 10.2 lakh OPD cases and 12.7 lakh IPD cases in the district. Calculation of bed occupancy ratio is
21 not possible from the available information. However, there have been 113 patient admitted per bed in 2010-11 in Warangal which is much better in Warangal than in Guntur. Only 8.9% of the beds in the district are allotted to maternal care. There is a gross underutilization of these facilities, particularly at night. In the PHCs, only 30 of the 823 (3.6%) deliveries are conducted at night. There is a lack of well defined BCC strategy plans at state and district level. This is resulting in ad hoc IEC activities, which are ad hoc and lack a focus on behaviour change.
Facility Maintenance, Ancillary services, Transport and citizen’s rights:
Facilitiy Maintenance: Overall facility maintenance was good in the visited districts except in CHC Macherla in the Guntur District where the faciltiy was very overcrowded and not maintained very well. The wards and toilets were maintained well in most of the facilities visited. Separate toilets and wards were maintained but not in all facilities. In both the districts, admission of both male and female patients in the same ward was seen in some facilities. Thus privacy and gender sensitivity was compromised in both districts.
Well maintained facility (PHC) in Guntur district)
Ancilliary Services: Diet services were being given to all the pregnant women who were admitted for natal care. It was being purchased as there was no kitchen facilities in the PHCs. Drinking water facilities were available for patients. In secondary care facilities, areas to cook and wait for the attendants were available. Thus, ancilliary services were in place in the facilities visited to make stay in hospital easier. EMRI: There are 752 Emergency Transport Service Vehicles running in the state under a PPP initiative between GVK-EMRI and NRHM. The target group is pregnant women, infants, children and people with chronic diseases. Average response time is 24 minutes. These 108 EMRI services are provided for free and are popular in the State. However, may pregnant women had commuted to the hospitals by private transport like
22 autorickshaws and even public transport like buses. Similarly, some of the beneficiaries were dependent on the ANM to call the ambulance. Out of Pocket Expenditure: While accessing services in the public hospitals, out of Pocket expenditure was minimum and practically nil among the pregnant women. The satisfaction level among the patients seeking services at the public hospitals was found to be high at all levels. This is very encouraging. Documentation and records: As far as documentation at the visited facilities is concerned, case sheets are not being filled up properly. In most of the cases, separate case sheet for the baby was not being maintained. Regular doctor’s notes were not being enetered. Condition of mother, fever/ intake-output chart, etc were not maintained. Similarly, referral registers were not being maintained propoerly in all facilities. Citizn’s rights and Grievance Redressal: Citizen’s charter was displayed at many institutions but not all the institutions. However,Grievance redressal mechanism is not set up and functional in the state. Laboratory services: At the PHCs and at designated centres, Hb, urine sugar and albumin, malaria and tuberculosis diagnosis was being done. However, the laboratories at the secondary care hospitals which are primarily under the APVVP are very rudimentary. None of the hospitals visited provide any emergency lab services. Many patients were noted to have been tested outside. Pooling of LTs and provision of quality lab services has not taken place. User fees for laboratory services was being charged from the paients. There was a shortage of reagents at many facilities visited. AYUSH: There is a good network of AYUSH colocated fcilities in both the visited districts. AYUSH doctors were not being used as a substitute to allopathic doctors. This was conducive to preserve the nature of their practicie and provide choice to the patients. However, many of these AYUSH practitioners have not been provided with equipments relevant to the practice. AYUSH doctors have also not been receiving salaries regularly. Gross shortage of drugs was found at many facilities. The AYUSH is being implemented and managed by a separate Commisionerate. Convergence with this commissionerate is not sufficient to ensure smooth functioning and coordiantion between health department and AYUSH at district level and below.
Infection Management and Environment Protection:
Infection Control protocols were not being followed in the state at any level including Operation theatres. BMW guidelines not displayed and not being used. Knowledge of the staff was highly limited as far segragation and disposal of Biomedical Watse is concerned. Intensive training is therefore required regarding IMEP.
23 Segragation of Biomedical waste and disposal is a serious problem in the State even in the secondary care facilities where it was outsourced. Thus, there is a need to implement protocols of IMEP and monitor the agencies to which it is outsourced. Further, there is no mechanism for storage before disposal. Sharp and burial pits were available only at some places. None of the visited OTs in Guntur district, had a OT fumigation register or an autoclave register. No signalac tape or any such indicator for effectiveness of autoclave was being used in the district. The washing areas in the OT were not clearly marked and maintained. State Polluntion Control Board may also like to review waste disposal methods used by Common Treatment Facility (CTF).
Soiled linen and body parts outside the Place outside Mortuary where Biomedical main theater in an Area Hospital in Guntur Waste of the District Hospital was kept District before disposal.
4. Outreach Services:
Sub centres Functioning:
Sub centers visited had adequate space and were well maintained clean facilities. However, None of the SCs visited are conducting deliveries. Availability of drugs at SCs was satisfactory. ORS packets were generally available but not with Zinc. Training The staff required re-orientation on diarrhea prevention. The main activity performed by ANM is to conduct immunization session (every Wednesday) ANC and PNC. Sub-Centre micro plans for immunization were available at all the facilities visited. However, alternate Vaccine delivery system not in place. Either ANM/ ASHA have to go nearest PHC one day prior to collect the vaccines. This affects their service delivery.
24 Quality of ANC needs to be ensured particularly, the quality of hemoglobin esimation. ANMs are using paper method of hemoglobin estimation. The method is less reliable as compared to Sahli’s method.
Village Health and Nutrition Days (VHND):
VHNDs are organized by ANM & AWW on every 2nd Saturdays either at AWC or in the village. ANMs were giving counseling on Immunization, nutrition, breast feeding, ANC, PNC & Family planning. Nutritional supplementation (Take-home Rations) was given to less than 3 years old children & pregnant and lactating women. Involvement of ASHA, LHV & male supervisors was good at VHNDs. VHNDs were being monitored by VHSNC members and MO-IC. Village Health Nutrition Days and immunization activities are planned through common micro plans of ANMs, AWW and ASHAs. There is good inter-sectoral linkage with ICDS.
VHND at an anganwadi centre A child enjoying gruel at the Anganwadi centre
Mobile Medical Units:
There are 475 Mobile Health Units of the Fixed Day Health Services (104) are providing outreach services in the State which was formerly run as a PPP with the Health Management Research Initiative, Hyderabad. A team of 1 Medical Officer, 1 Pharmacist, 1 Lab technician, 1 driver and 1 data entry operator provides medical examination, laboratory services, and referral support at the village level. Each sub-centre is visited once in a month and the vehicle covers 1-2 villages in a day. Blood tests like Hb, RBS, Urine albumin/ sugar as well as screening for chronic diseases like hypertension and diabetes is being done by the FDHS.
25 Medical Oficers from the concerned PHCs accompany the MHU in the villages and thus providing quality clinical servcies at the village level which was one of the earlier concerns with FDHS. FDHS in turn has improved mobility and supervision by the MO of the field staff and sub-centres. However, huge cost is involved in maintaining the huge fleet of vehicles which are stationed and managed at the CHNC (block) level. Evaluation of FDHS conducted by NHSRC has brought out crucial observations regarding quality of services and integration with the primary healthcare system. State may thus like to undertake a cost-benefit analysis of this scheme before extending for next year.
5. Accredited Social Health Activist:
There are 70700 ASHAs in the State and all are trained upto 5th module. Training on 6th and 7th module for Home based new born care is initiated in 11 districts. Average take home amount per month per ASHA is Rs. 600. ASHAs were involved in promoting ANC, institutional deliveries, family planning, DOTS and organizing VHNDs. ASHAs were actively involved in identifying and promoting delivery of contraceptives. They were also maintaining daily diaries. Training of ASHAs in promoting “Menstrual Hygiene Programme” is initiated in the state. ASHA support system is in place in the State at the ground level which also functions as a grievance redressal mechanism for ASHAs. ASHA Days are being held at the PHC level throughout the State on every first Tuesday of the month. ASHA nodal officers or coordinators conduct these ASHA days and further meet at the district level on every Thursday for review. However, attrition rate of ASHAs is very high nearly 800 per annum due to seasonal labour, economic and personal reasons. In Warangal it was found that the claims of incentives for ASHAs were being sent to the district head-quarters for verification which was casuing undue delay in payments. Prompt payments need to be made to ASHAs to retain them into the system.
6. Reproductive and Child Health
Maternal Health:
ANC and PNC services are regularly provided by ANMs and MOs and ASHAs are creating good demand for MH, CH, FP and Immunization services. However, linkages between service delivery and demand generation need to be improved. Hemoglobin estimation was being done by paper method in almost all SCs and also in majority of CHCs. The quality of the reference indicators used in the prevalent paper method appeared highly unreliable. Since anemia is very high in the State like in the rest
26 of the country, urgent attention is required towards standardisation of hemoglobin estimation and promotion of more reliable testing methods like Sahli’s method in the periphery. Coupled with a poorly developed laboratory services at all levels, addressing the issue becomes significant.
Hemoglobin estmation by paper method. Note the colour of the reference strip in the 2nd last or 6.3 gm% which is darker than the reference for 78 gm%.
Preparedness for JSSK: Although funds have been approved for the JSSK, health officials need to be oriented towards the objectives and entitlements available under JSSK. The health facilities are not prepared to roll out the programme in very near future. User fees are still being charged for laboratory servcies although out of pocket expenditure for natal care is almost nil. System needs assessment and planned upgradation needs to be undertaken to ensure availablity of quality services at all levels. Many of the C-sections and Hysterectomies conducted in the hospitals were understood to be unnecessary and the indications were not found to be convincing. The surgical menopause thus introduced could be prevented in many women.
Operation Theatres and Labour rooms:
The infrastructure in labor rooms and OTS was good with good wall and floor conditions except at the DH. Toilets attached to the labor rooms were present in majority of the hospitals visited.Visual privacy was compromised at places.Equipments were also found to be adequate and largely in working condition in most of the facilities except at the AH Sathenapalli where both the available Boyle’s apparatus were leaking and needed repairs. In majority of the PHCs visited, spot lights were not present or not in working
27 condition. Routine and Emergency drugs were available in all facilities which is appreciable. Partographs are not being used in any of the visited facilities. At many secondary care faciltities, partographs were displayed in labor rooms, but were not being used at all. Knowledge of its use and significance was alsofound to be inadequate. Acute Management of Third Stage of Labor is critically important in preventing PPH. But it was not being followed in majority of the facilites.
Partographs displayed in the labor room of a CHC
Infection Control Protocols were found to be lacking in all the OTs and Labor rooms visited.
Janani Suraksha Yojana:
An important concern is that APVVP centres do not provide JSY benefit to the women delivering in their CHCs, AHs and DHs. This needs to be checked and payment of the JSY benefit at the institution of delivery needs to be ensured in accordance with the national guidelines. Delayed JSY benefit payment by upto 2-5 months was observed in some cases. The scheme needs to be better monitored well and random varification of the beneficiaries needs to be done.
Newborn care:
Newborn Care Corners were not identified and set-up in most of the places where deliveries was taking place in both PHCs and in highr centres. Wherever established, knowledge and protocols of essential newborn care and neonatal resuscitation were not being followed. For eg, a newborn care corner was established in AH Sathenapalli but it was largely unused and was set-up outside the labor room.
28 A SNCU is sanctioned at the DH, Guntur. However, it is not yet set-up according to guidelines. Presently, a separate room is identified and 2 Incubators are kept in the room. The room is integrated with the labor room complex and connected to the pediatric ward. Access is not restricted and infection control protocols are not being followed. In view of a full fledged SNCU/NICU at the Government General Hospital at Guntur just 20 km away NBSU with 4 beds may be established at the DH where the deliovery load is also relatively less. SNCUs are functioning at Medical College hospitals in both districts. These need to be expanded and strengthened as per as per GOI guidelines. Protocols for maintaining asepsis need to be put in place.
Child Health:
Immunization coverage is nearly 100%. All vaccines available and there is no stock out. The cold chain is well maintained at all levels. Temperature charts are well maintained. Immunization outreach plan is available at the sites and is being followed. Outreach sessions are held on every Wednesday and Saturday. Due list of pregnant women and children is maintained by ASHAs and ANMs. Tickler’s bag is no longer being used in most of the places and due lists are being prepared with the help of the Immunization register. Disposal of AD syringes and needles after use remains a problem and there is no mechanism for their safe disposal. Often they are disposed by burning/ dumping outside the village. Zero OPV dose was being given in most of the facilities visited, but BCG doses were not given before discharge and were given only on fixed days for immunization at the Sub- centres and not at the facility. This was true even in the DH.
Family Planning
Sterilization services are routinely available at peripheral facilities. Client segmentation is very well organized. Minilap acceptors are being discharged early in about 4 hours time which needs to be prolonged. Guntur district had projected its target as TFR of 1.3. This is far below the replacement level. Similar targets have been handed down up to sub centre level. Though new
29 population policy emphasizes; on spacing on ground still obsession with sterilization targets. IUDs and other spacing methods are generally not offered to couples in the State. Service providers and programme managers are ignorant about period protection offered by IUDs. EC pills were also not found in the facilities visited.
Safe abortion:
Safe abortion services were not available widely in either of the districts visited. Only 1 to 2 facilities per district offered safe abortion services. Further, as no trainings in Medical Termination of Pregnancy (MTP) have been organized in the State and Districts there was very poor capacity for providing safe abortion services in the State. Dilation and Curettage is most commonly done for MTPs; Manual and Vacuum Aspiration was not available in any hospital in the public sector in the district.
Adolescent Health and School Health Programme:
There is no special programme for addressing adolescent anemia. School Health Programme is running successfully through a dedicated team of health staff in all the govt and govt.-aided schools up to high school level. Medical check-ups are done twice in a year. The programme provides for referrals to high centres. However, special referral cards are not being maintained in the districts visited. Inclusion of dental component in the School Health Programme is appreciable.
Convergence of RH with HIV/ PPTCT:
Convergence between ARSH and NACP is planned to provide Adolescent Health Services in tribal PHCs/CHCs. Pregnant women are being routinely screened for HIV and NACO protocols are being adhered. ANMs have been trained for pre test counselling and conducting spot tests. Colour coded kits for syndromic treatment of RTI/STI was being regularly supplied and well utilised. Female condom use in TI sites visited was highly encouraging. Barrier method use promoted amongst sero-discordant couples. Sex workers can also access the public services and not discriminated in the PHCs. However, other reproductive health needs of sex workers and PLHAs require attention and provision of MTP and dual method must be ensured. HIV positive deliveries are also being done in the Health facilities without any discrimination. PPK and PEP kits are available
30 7. Preventive and Promotive services including Nutrition and inter-sectroal convergence
Good coordination among AWW, ANM and ASHA for VHNDs. Hot cooked meals are provided to eligible children and pregnant mothers at AWCs. VHSCs have been renamed VHSNCs in the State. VHSNC funds are being utilized. They are particularly being utilised for sanitation purposes. Zilla Mahila Samakhyas and Self Help Groups in Guntur District - There are nearly 1000 such groups at the village levels. They conduct monthly meetings with the villagers and discuss about health sanitation, nutrition, hygiene among other issues of poverty, education and employment. The Anganwadi Worker and the ASHA of the village are also members of the SHG and this helps in better synergy between them. Activities like Mass Relation Bandhan (Mamta programme) are also used as a platform for integrating various departments. On such events distribution of pensions, ration cards, sanctioning of houses are announced. Simultaneously, issues related to women and children including health also get discussed.
8. Gender Issues & PC-PNDT
State, District and Sub-District Appropriate Authorities have been notified under the PC & PNDT Act. There are 41 mobile clinics are registered and constantly monitored. Violations/irregularities in maintenance of F-forms have been taken lightly and chargsheets are not filed. This was found to be true in the Guntur district. Display of names of tubal ligation acceptors on notice board is a serious violation of privacy. Display of IEC/BCC messages on PC-PNDT was good at all the facilities. Facilities needs to be more gender sensitive in terms of privacy, separate toilets (Warangal) and implementation of Vishakha guidelines.
9. Disease Control Programmes:
National Vector Borne Disease Control Programme (NVBDCP)
Among vector borne diseases, Malaria, Dengue, Chikungunya, Japanese Encephalitis and Filariasis are prevalent in the State. Kala-azar is not reported till date.
Malaria All 23 districts are endemic. The surveillance in the state is good (ABER 11.87% in 2010) however target oriented. Hence, slide positive rate is only 0.37%. In comparison to 2010 cases are increasing in 2011 as 35020 cases reported till October in 2011 against 28327
31 cases reported till December 2010. However, deaths are reduced in 2011 as only 2 deaths have been reported till October against 20 deaths in 2010. Pf % is also increasing in 2011(72%) in comparison to 2010(67%). Six high endemic districts namely Adilabad, East Godavari, Khammam, Srikakulam, Vishakhapattanam and Vizianagaram have been included under World Bank Assisted National Vector Borne Disease Support Project for additional inputs to intensify malaria control activities. Additional inputs like Rapid Diagnostic kits for early diagnosis, ACT for effective treatment of P. falciparum cases and LLINs to prevent transmission are provided to these districts. In these districts and in the state HQ additional manpower have been provided for strengthening the programme implementation. For supervision and monitoring mobility supports are also provided. Guntur District - Pl vivax is the predominant species (88.1% in 2010 and 96.4% in 2011 till Oct). Due to low P falciparum prevalence the district has not been provided RDTs, LLINs and ACT. The ABER is 11.72%; however, slide positive rate is only 0.07%. Out of 118 Lab Technicians post 52 (44.1%) are vacant. Similarly, 41.8% of MPHA (Male) and 72% of Field worker posts are also vacant. The National drug policy 2010 has clearly articulated for not providing presumptive treatment in the passive collections where diagnosis facilities are available or results can provided within 24 hours to stop indiscriminate use of Chloroquine and increasing trend of resistance. Since passive collection is more than active the State needs to review the policy in the light of current national guidelines. In some PHCs monocular microscopes are still being used. Sufficient quantity of logistics (Chloroquine tablets, Primaquine tablets, Micro slides, Lancets, JSB stains) and insecticides were available as per the record of DMO.
Dengue All 23 districts are endemic for Dengue. During 2010, 4 districts namely Guntur, Krishna, Prakasam and Warangal were worst affected. In 2011 till 31st October total 672 cases and 3 deaths have been reported from 20 districts. Maximum cases were reported from Warangal (181) followed by Krishna (117) wherein in 2010, 20 districts have reported total 776 cases and 3 deaths.
Chikungunya In 2011 till 31st October, total 94 clinically suspected Chikungunya cases and nil death have been reported from 8 districts. Maximum cases were reported from Medak (30) followed by Adilabad (22). In 2010, 116 clinically suspected Chikungunya cases and nil death reported of which MB Nagar reported maximum cases (27) followed by West Godavari (25).
32 For augmenting diagnostic facilities for Dengue and Chikungunya in the state 25 Sentinel Surveillance Hospitals (SSH) with laboratory support have been identified and linked with Institute of Preventive Medicine, Hyderabad which is Apex Referral Laboratory, with advanced diagnostic facilities. NIV Pune has been entrusted the supply of IgM ELISA test kits. The state has been asked to procure ELISA based Dengue NS1 kits as per technical requirement out of the funds provided by NVBDCP for decentralized procurement. GoI provides contingency grant @ Rs. 50,000/- per year to each Sentinel Surveillance Hospital and Rs. 1.00 Lakh Apex Referral Laboratory to meet the operational cost. The SSH are not conducting the diagnostic tests on time due to which preventive vector control measures are not implemented in the affected areas on time allowing transmission to continue. The State Programme Officer and DMOs need orientation on Mid Term Plan strategies for prevention and control of Dengue and Chikungunya.
Filariasis Sixteen districts are covered under Mass Drug Administration of which except three districts significant reduction in Mf to be less than 1% has been achieved. Mf rate in Guntur district have been reported to be 0.2 %. Although Government of Andhra Pradesh has initiated action for management of lymphoedema and surgical operation of Hydrocele, strengthening of CHCs would be required to sustain such interventions.
Acute Encephalitis Syndrome(AES)/Japanese Encephalitis(JE) For surveillance purpose, JE is reported under the heading of AES as per national guidelines. Nineteen districts are endemic for Japanese Encephalitis in the state of Andhra Pradesh. However, since vaccination of the affected districts 2006 onwards the incidence of JE has been reduced significantly. In 2011, till 31st Oct, 59 AES (4 confirmed JE) cases and one death have been reported in comparison to 139 AES cases and 7 deaths reported in 2010.For augmenting diagnostic facility in the state , six sentinel centre with laboratory support has been identified. IgM Elisa test kits are provided to these albs through NIV Pune. JE Vaccination of children between 1-15 years have been carried out in total 10 districts which are Warangal, Kurnool, Krishna, Nellore, Medak, Adilabad, Khammam, Nalgonda, Mahabubnagar and Nizamabad.
Revised National Tuberculosis Control Programme (RNTCP)
Entire state of Andhra Pradesh is under RNTCP since February, 2004; covering a total population of 847.35 Lakh in 24 districts (23+1 Bhadrachalam additional DTC). The State has 178 tuberculosis units and 918 Designated Microscopy Centres. Overall
33 performance of the state is consistently improving. During 2011 till Sep, 28,077 cases detected of which 12,600 were New Smear +ve cases. The new smear positive case detection rate is 79%; Sputum conversion is 92% and cure rate of 87% in new smear positive cases. Till Sep, 2011, total 2607 MDR Suspects tested, 901 diagnosed, put on treatment 718. Staffs are available. NGOs, Anganwadi Workers & ASHAs are involved as DOT providers. Guntur district has case detection rate of 70% and is achieving 85% cure rate. Drugs for category I, II & III are available in the PHCs and for MDR TB in Area Hospitals and CHCs. The lab technicians of RNTCP at PHC were maintaining the records properly and during the visit observed that LTs received instructions to provide the services for other programmes (e.g. Malaria). TB-HIV coordination committee formed on30/10/2005 in the district 52 ICTCs are functioning in collaboration with NGOs. All ICTC Nurse Practitioners, Lab technicians and NGOs are trained.
Integrated Disease Surveillance Project (IDSP)
IDSP was launched with World Bank (WB) support in Nov 2004 to detect and respond to outbreaks of epidemic prone diseases. District Surveillance Officers are in position at all districts; 16 Epidemiologists, 3 Microbiologist, 1 Entomologist is positioned at State Surveillance Unit. Data Managers and Data Entry operators are in position in districts. All districts report weekly disease surveillance data through portal and email. 68 outbreaks were reported from January – October 2011. Majority of them were Acute Diarrhoeal disease and Food Poisoning. Analysis of data has to be strengthened for predicting the early warning signals. In Guntur District Surveillance Officer (DSO), Epidemiologist, Data Manager and Data Entry operator are positioned at District Surveillance Unit. Training of DSO, Medical and Para medical staff completed. IT Equipments are installed and functional. Weekly diseases surveillance data are being reported through portal. 96% of blocks report weekly disease surveillance data through portal. S forms are reported by 98.6%, P forms by 90.7% and L forms by 95.8% of the reporting units. The RRT and monitoring teams and staffs are present. The data entry in excel and portal thus not match. . Due to late reporting of Dengue cases by the diagnostics labs (>15 days) cases are not included in L forms. Two outbreaks (Food Poisoning and Viral Hepatitis) were reported from January –October 2011. In Warangal DSO, Epidemiologist, Data Manager and Data Entry operator are positioned. Training has been completed. 62% of blocks report weekly disease surveillance data through portal. 7 outbreaks (Acute Diarrhoeal disease, Dengue, Viral Fever and Viral Hepatitis) were reported from January –October 2011.
34 National Leprosy Elimination Programme (NLEP)
There are 9 recognized centres providing reconstructive surgery services to leprosy affected persons with disability (1 Govt. institution and 8 NGO institutions). The State has achieved the goal of elimination that is less than 1 case per 10,000 at the State level by March, 2005.Total cases registered as on August 20-11 is 4670 against 6323 during march 2005.The new cases detected rate in 2010-2011 is 10.4%. The new child case rate of 14.7% in 2010-2011 is alarming. Drugs are available in all health facilities.
National Iodine Deficiency Disorder Control Programme (NIDDCP)
At State level iodised salt consumption is only 31%. Not much information was available at State as well as in the districts. Except Karmanchi SC in Guntur District, Iodine testing kits are not available in any other facilities. Community sensitization is needed for use of iodised salt.
National Programme for Control of Blindness (NPCB)
Three eye banks have been established with GOI support at Warangal, Kurnool and Vijayawada. As per State record 250823 cataract operations have been conducted till August in 2011. However, except Narsaraopet area Hospital no activity was observed in either Guntur or Warangal District. Funds are not made available to NGOs at time for conduction of camps.
10. Programme Management
The Programme Management structures are well established at both state and District level. There were no major vacancies at the DMPUs in the State.
Coordination between DPMU and Health Directorate
Good coordination between the Health Directorate and the Programme Management Unit was seen at Guntur District whereas the case in Warangal is different. In Warangal, the contractual employees of the DPMU are burdened with work of regular employees. The DPMU at Guntur is also better established than that at Warangal district. The State has recently deputed a senior regular employee of the health department to head the DPMU after training in Public Health Management at Indian Institute of Public Health, Hyderabad. This may prove helpful in bringing about balanced dynamics between the District Health Directorate and DPMU. However, the State must caution that this might not necessarily improve dynamics between the regular and contractual
35 employees and a serious dissatisfaction in job may be prevalent among the contractual employees of the DPMU and below.
Coordination between the District Medical and Health Office and District Coordinator of Hospital Services (APVVP):
Coordination between these two authorities is weak. This is a weak link in overall implementation and monitoring and supervision of programmes of NRHM in secondary care hospitals.
Community Health and Nutrition Cluster:
Community Health and Nutrition Cluster (CHNC) have been established in all the districts of the state. It functions as a block level monitoring and supportive supervision structure. The office of the CHNC is situated at the identified secondary care hospital and a Senior Public Health Officer (SPHO) is in-charge of the CHNC. The SPHO along with other officers and supervisors of the CHNC undertake thorough monitoring of functioning of the Primary Health Centres, Sub-centres and other public sector hospitals in its area. They also undertake financial monitoring of the various funds released to these hospitals under NRHM.
11. Procurement System:
Drugs and Equipments are procured centrally at the State by the APHMIDC. Additionally District Headquarters also have powers to procure medicines form the Central Drug Store if required. The State follows differential supply of medicines to its facilities. A quarterly budget is allotted to each of the facilities and the facilities then prepare an indent against this budget. The drugs are supplied from the District Central Drug store. Further, the State provides flexibility to the facilities to purchase drugs from open market from the Rogi Kalyan Samiti Funds if not available in the Central Drug Store. Primary Health Centres in Guntur District spent upto 20000 to 25000 from the Rogi Kalyan Samiti funds annually on purchase of drugs from open market last year. Most commonly these were found to be some brands of antacids, multivitamins, antibiotics and others.
36 PHC Pass book for procurement of drugs from the Central Drug store
Whereas this type of system supports the general observation of the team regarding no major shortage of supply of medicines in any of the facilities visited in both the districts, it is certainly leading to purchase of drugs worth a significant sum from the private sector. There is no monitoring of this purchase of drugs directly from the private sector. The purchasing patterns of the facilities could be studied by the Districts and change indenting patterns accordingly to reduce such purchase of drugs. There is only 1 Jeevan Dhaara store situated at the Government General Hospital attached to the Medical College which provided subsidised medicines to people in Guntur. The store has 121 generic drugs which cater to 305 commonly prescribed drugs. It is easily accessible and runs 24x7. The cost borne by the patients is 1/5th to 1/10th. Nearly 200 patients benefit from it daily.
The Jeevan Dhaara Jan Aushadhi Store at Medical College in Guntur District
37 12. Effective Use of Information Technology:
The State has now shifted to data entry from the facility level. Integration of MCTS, HMIS, MDR – TB tracking, School Health Programme all of which are of current importance to the State administration is being done using DHIS -2 software, which is being introduced in the State. The State is undertaking orientation training of its staff to use DHIS-2. But institutionalisation is taking time. However, this has caused irregular data entry into the national HMIS portal. Information on MCTS is uploaded at the district/cluster level, however data uploading is not up to date and the staffs require orientation/training on MCTS. In most of the centres visited, the computer facility was not available and wherever it is available, not put to use. The collected information was not being utilized for tracking and monitoring.
13. Decentralised Local Health Action:
The quality of Decentralized Health Action Plans is very poor in the State. Situation analysis and bottom-up planning is missing in district health action plans. Targets and activities for districts are assigned by the State. Community Participation through VHSNCs is largely taking place. Funds are available with these committees and are being utilized for sanitation (purchase of bleaching powder). ASHAs are creating demand for Maternal, Child Health and Family Planning services.
14. Financial Management
Presently the Financial Management is being managed under the close supervision of the Commissioner (Family Welfare) with the support of one Chief Finance Officer and other support staffs at State and District Accounts Manager and one assistant at district level. The whole financial management system was analyzed and activity wise report is as under:
Manpower: The post of Director (Fin. & Accounts) at State Level is held by Chief Finance Officer and at District Level DAM is in place, whereas F&A personnel at levels below the districts are not well aware of the Accounting & Reporting. Staffs at Blocks need more orientation and training. It is also suggested that State should have one Professional Chartered Accountant at State Level for more efficient and professional approach. Electronic Funds Transfer: Electronic funds transfer system being used in the State and the extent to which it is used and the bank used for electronic fund transfer.
38 Tally ERP 9 software: Comment on usage of Customized version of Tally ERP 9 software up to District level only is being used. Release of Funds & Utilization: Funds are being released from the State activity-wise and similarly from districts to Blocks activity-wise only. Auditing Procedures: Statutory Audit under NRHM is still in progress. Audit Team was doing auditing at District – Warangal during our visit. It was noticed that Auditor appointed under NRHM is not conducting audit of vertical programmes as against the Terms of Reference of Audit to cover all the programmes including NDCPs. Delegation of Financial & Administrative Powers: It is noticed that guidelines issued by GOI in December, 2006 on Delegation of Financial & Administrative Powers have not been implemented. For this reason all the cheques are being signed by the District Collector which takes time and extra efforts for releasing the funds from Districts to Blocks. When there is approved District Action Plan duly approved by the State and also in the DHS meeting, there should not be any need of getting signed each and every cheque. Looking to the number of activities under each programme of NRHM including NDCPs and the number of releases each year it is advisable to review the authorization for cheques signing to reduce the time and efforts needed. Training measures: It has been observed that the assistants working at Blocks level are not very well conversant with the accounting procedures and therefore a comprehensive training programme is needed for all the F&A personnel at block level. In addition the Medical Officers in charge at Blocks should also be provided orientation training on Finance & Accounts. HMIS: State and Districts are not sending any Reports on HMIS. Maintenance of Records & MIS: Books of accounts etc. maintained at District Level are being maintained on Tally and Manual also whereas at Blocks the same are maintained manually only. It was also noticed that blocks are not regular in sending the reports (FMR) regularly the same is either sent at the end of the year or whenever there are funds received from DHMO Office. Integration of Financial Management Processes with NDCPS: Integration of bank accounts at state/district level and integrated reporting system has not taken place. The report is sent by the District Programme Officers of NDCPs to their respective programme officers at the State Level. There is no common bank account for all funds received under NRHM i.e. along with RCH & NRHM Additionalities funds of NDCPs. Thus the vertical programmes are considered as not a part of NRHM at State and District level. Model Accounting Handbooks: Model Accounting Handbooks for sub-district level finance staff as issued by NRHM-Finance Division have not been rolled out in the State to bring about uniformity in books of accounts.
39 Procurement: No Procurement Manuals/ Guidelines exist in the State. Pendency of UCs: UCs for the years 2009-10 and 2010-11 amounting Rs. 346.20 crore and Rs. 242.10 crore under RCH and Mission Flexible-Pool respectively are pending which will be settled along with the Audit Report yet to be submitted for the year 2010- 11. Advances: Amounts released by Districts to Blocks is shown as Advances with Blocks but the utilization report of the advances is lagging behind. Block Medical Officers needs orientation for improving the utilization of unspent balances. AMG & Untied Funds: Funds for AMG and Untied Funds are being released to blocks etc. but not regularly as the utilization are poor. There is lack of knowledge amongst the Medical Officers in-charge for the effective utilization of such funds. Funds Utilization: The status of funds utilization for the year 2011-12 under various programmes is summarized as under:
State: Andhra Pradesh Programme Target for 2011- Expenditure till % of Expenditure on 12 October, 2011 Target NRHM 106557 31720 29.77 RCH 37530 5843 15.57 Mission 27266 6512 23.88 Immunisation 1906 236 12.38 Pulse Polio 1917 66 3.44 NVBDCP 4030 518 12.85 RNTCP 2183 797 36.51 NPCB 2500 827 33.08 NIDDCP 26 0 0.00 NLEP 216 43 19.91 IDSP 285 139 48.77 Total for NDCPs 9240 2324 25.15 Direction & 28698 16739 58.33 Administration.
District: Guntur Programme Target for 2011-12 Expenditure till % of October, 2011 Expenditure on Target NRHM 1808 662 36.62 RCH 1231 266 21.61
40 Mission 426 394 92.49 Immunization 77 2 2.60 Pulse Polio 74 0 0.00
District: Warangal Programme Target for 2011-12 Expenditure till % of October, 2011 Expenditure on Target RHM 2030 662 32.61 RCH 1426 266 18.65 Mission 463 133.24 28.78 Immunization 77 1.7 2.21 Pulse Polio 62 0 0.00
The above tables show very low level of expenditure at State and districts level. State should identify the reasons and take the remedial actions. Procedure for payment of JSY and ASHA Incentives: It is seen that the procedure followed by the district for payment of JSY Beneficiaries and its related payment of ASHAs needs a correction so that payment to be made to the beneficiaries and ASHAs are made on timely basis. Actually, the ANM gets completed the necessary formalities in the preparation of the list of beneficiaries and ASHA incentives which after the approval of Nodal Officer sent the statement to DMHO Office, who in turn after its checking release the funds to PHC/CHC for onward to be given to JSY Beneficiaries and ASHAs / or for the disbursement to ANM of the Sub-Centre under which the beneficiary resides. RKS constitution, fund utilization and the accountability: RKS is named as Hospital Development Society (HDS) which was found existed at all the places but funds are not being provided regularly in full due unspent balances lying with them. Minutes were found maintained at PHC and Sub-Centre levels. Comment on fund flow: The process of release of funds from the State and further from District to Blocks/ PHC/CHC need to be reviewed as sometimes it takes a lot of time. Release of Funds from the State is made on the proposal of the Programme Officers. If there is no proposal no funds are being released. Even salary of 2nd ANM, Staffs Nurses and Medical Officers got delayed due to this system. The proposal for release of salary of 24X7 and CEMONC Staff for the m/o February and March, 2011 is still pending. During the year 2010-11 the numbers of proposals that were made for release of funds were 38 times for RCH, 37 times for Mission Flexible Pool, 26 times for routine immunization; a total of 101 times. For each release first approval for the release of funds is accorded by the Commissioner (FW) and then funds are
41 released. Thus for each sanction the file goes two times to the Commissioner thereby 202 times file are moved for the release of funds to the districts under three components only.
Other remarks with regard to flow of funds are as under:
Delay in Payment of JSY: Payment to JSY beneficiaries at Warangal District is delayed and being made by ANM of the Sub Centre. Many a times request is made by PHC/ CHC to DMHO for release of funds along with the Statement and then on receipt of funds from District payment of JSY takes place. For making Payment of JSY cheques are also given to ANM and then ANM is issuing cheques to JSY beneficiaries. No JSY payments is being made for deliveries being done in urban and semi-urban areas. Delay in Payment of ASHA Incentives: As per the system prevalent in the district a statement of ASHA incentives is made for each facility by the facility nodal officer which is sent to the PODTT of the District, who after verifying the consolidated statement gives to DAM for releasing the funds. In this way the payment to ASHA gets delayed from 3-4 months. AMG and Untied funds: AMG and Untied Funds have not been given to each facility on a regular basis. AMG for SC in a government building have not been released for the year 2011-12. Lack of funds for essential programme components- At PHC/ CHC Medical Officer in charge are not well aware of various programme activities and due to lack of this are not demanding the funds for such activities. State Contribution: State has received State Share contribution for the year 2010-11 totaling Rs. 183.65 crore in the year 2011-12 whereas the same for earlier years Rs.303 crore is outstanding. Other observations: Since the formation of DHS, Warangal in 2006 the meeting of the Governing Body at District has been held only once in March, 2011. Govt. of India in December, 2006 issued guidelines for Financial & Administrative Powers for decentralization which has not been implemented.
15. Overall Outcomes of the Mission:
The Mission has enabled the State to undertake strengthening of Health Systems and has improved provision of Maternal and Child Healthcare Services. This was evident from the FGDs and informal interaction the team had with the patients and users of the public system in both the districts. It was widely held that in the last 5 years, the health
42 facilities had improved, outreach had improved and facilities for women and child care have improved.
“MCH Mission” at a CHC in Guntur District
The availability of 108- EMRI emergency transport services was seen to be one of the most important developments in the public system. However, it was also thought that there was a narrow focus on women and child care and a holistic approach was hence felt to be lost and therefore services related to men, older children and adolescents have suffered. Throughout the mission period the State has made good use of the flexibility provided by NRHM and has undertaken significant steps in improving service delivery and public health management. State, District Programme Management Units have been developed and are functioning well. Similarly, the State has introduced a new structure called the Community Health and Nutrition Cluster which acts as a Block Level Programme Management unit. Large scale infrastructure development and upgradation is undertaken in the State. However there are major issues in taking up of the sanctioned works and completing of ongoing works. Similarly, large number of contractual staff is appointed under NRHM to tackle the acute shortage of Human Resources for service delivery. However, simultaneously robust human resources policy and training policy was not developed. As a result, there remains a serious doubt about the quality of the human resources in the State. Training infrastructure and capacity remains very weak in the State.
43 As far as facility development and maintenance is concerned, focus has been again on developing the facility to provide maternal and newborn child care services. Even the newborn care has received recent attention. As a result, Laboratory services, Infection Management and Environmental Protection, ancillary services, facility management, procurement and supply chain maintenance have remained weak and underdeveloped. NRHM has provided a broad platform to engage communities in health services delivery through ASHAs, Village Health Sanitation and Nutrition Committees and Rogi Kalyan Samitis. Although NRHM has a right’s based approach, protection of citizen’ rights and effective grievance redressal mechanism is not established. Decentralization although conceptualized very well, is not being implemented well in the State. The State remains the hub of all planning activities. The quality of District Health Action Plans is very poor. They are practically reduced to budget sheets. Similarly, although financial guidelines were conceptualized very well, there are delays in releasing of funds and auditing mechanisms remain weak. Inter-sectoral Convergence with other departments although envisaged very well is not being carried out. As a result, impact of NRHM on prevention and health promotion remains poor and it does not contribute significantly in addressing the determinants of health. Quality is another area which requires major emphasis in the next phase of the Mission. Standardization of protocols and implementation of the protocols is of utmost importance.
Thus, areas that require greater emphasis in the next five year plan are: Planning for infrastructure development at all levels and setting up of effective monitoring mechanism. Development of policy for human resources at State level Training infrastructure and quality Infection management and Environment Protection Laboratory services Decentralization Inter-sectoral convergence Grievance redressal Community Monitoring
Areas which have not been addressed during conceptualization of mission: Infection Management and Environmental Protection Development of training infrastructure and capacity Grievance redressal Laboratory services
44 Chapter IV Recommendations of the 5th CRM
Recommendations:
Based on the observations outlined above, the following recommendations are suggested for the State:
1. Infrastructure Development: Ongoing constructions may be expedited and completed. Sanctioned new works and projects need to be taken up and all efforts should be made to finish the in the current financial year. Optimum utilization of existing/ donated infrastructure needs to be ensured. - Routine Monitoring of the new works undertaken need to be undertaken by the department of health. - All health Facilities must be provided with barrier free access for disabled and infirm/old people. The AMG may be used for strengthening these gaps. 2. In order to ensure provision of round the clock Comprehensive Emergency Obstetric services, strengthening of strategically identified CHCs could be done by undertaking infrastructure strengthening and providing adequate number of Specialists on a priority basis and simultaneously to these facilities. Performance of FRUs could be monitored by number of C-Sections and Blood transfusions conducted at night. 3. Equipments: NBCC/SNCU equipments need to be optimally utilized in many Area Hospitals and District Hospitals (Wardhanapet, DH Tenali, AH Sathenapalli). 4. Laboratory Services: Laboratory services need to be strengthened, particularly in the CHCs, AHS and DHs. These hospitals must at least be provided with a semi-auto analyzer for conducting biochemical tests. - The crude paper method for estimating hemoglobin needs to be replaced with Sahli’s method in the peripheral facilities like Sub-centres and PHCs. Wherever there is a significant workload a semi-auto redressal analyzer should be installed for blood tests. - User fees for diagnostics and blood transfusion for pregnant women and newborn babies should be abolished. - Supply of lab reagents must be streamlined. 5. Infection Management and Environment Protection: None of the facilities followed proper protocols for BMW management and people handling the waste are ignorant of the protocols. In all the labor rooms, OTs the protocols for washing, draping and disposal of soiled linen, used gloves, body parts needs to be set and enforced. - Training for disposal of Biomedical Waste Management needs to be started. Guidelines for the same needs to be shared with the District Administration and facilities. Regular supply of all consumables for effective disposal of BMW needs to be ensured.
45 - Monitoring of the disposal of waste to be done stringently. Facilities for storage of waste up to disposal and record keeping of the waste disposed needs to be maintained. 6. Human Resources: - Quality of training needs to be ensured including in the private training institutions. Skill labs could be set up at District Hospitals. A training calendar needs to be set-up and many of the presently interrupted trainings need to be restated at State and District level. - Multi-skilling of doctors in LSAS and CEmONC can bridge the gap of unavailability of Specialists and needs to be taken seriously by the State. - Delay in payments to the HR employed on contract needs to be addressed. - Enabling environment for motivated staff should be created. 7. Maternal and Child Health: High risk pregnancies should be monitored and Partographs and Active Management of Third Stage of labor need to be introduced in all facilities. - IMEP protocols need to standardized and implemented in labor rooms and OTs. Similarly, protocols for asepsis need to be followed strictly in the NICUs too. - NBCCs should be operationalized and equipments to be provided along with skilled staff at all labor rooms and OTs to provide essential newborn care. - NBSUs may be operationalized in all CHCs/ FRUs and in District Hospitals of those districts where NICU/ SNCUs are already operational in the Medical Colleges. 8. Safe abortions and MTP: Safe abortion of services in accordance with the MTP Act needs to be provided. Medical Officers need to be trained and the State must ensure that MTP by Vacuum Aspiration, Emergency Contraceptives, etc are available and easily accessible. 9. Janani Suraksha Yojana: Disbursement procedures in the Medical Colleges and APVVP hospitals need to be established. Backlogs in JSY payments need to be addressed and random verification of JSY beneficiaries needs to be done in accordance with JSY guidelines. 10. Adolescent anemia: Considering that maternal anemia is very common and women start bearing children soon after their marriage which also happens to be at an early age, a special programme to address adolescent anemia should be introduced and implemented. 11. Family Planning: State need to develop work plans to implement new population policy. TFR targets should be withdrawn from sub district level as it is a complex demographic calculation and beyond the skills of the ANM. - State needs to give more focus to spacing methods including post-partum IUDs. State could consider incentivizing ASHAs for promoting spacing methods in young couples.
46 12. ASHA: Uniform guidelines for providing incentives to ASHA for taking the women to private facilities needs to be established. In Warangal, the claims of incentives are sent to the District for verification which results in undue delay in payment. The ASHA days, ASHA coordinators and the ASHA support system need to be strengthened. 13. PCPNDT & Gender issues: State level teams should visit facilities for ensuring implementation of PCPNDT Act. Irregularities related to Form F needs to be prosecuted appropriately. - Names of acceptors of termination method of family planning should not be displayed at the health facilities. - Gender wise disaggregation of data for all National disease control programmes need to be done. 14. Use of SHGs to deal with misuse of technology: Given that there is wide spread misuse of technology such as un-necessary C-section, rampant hysterectomy & aggressive promotion of sterilization at a very young age, state should consider of SHGs in making women aware about consequences of rampant misuse of such invasive techniques. 15. Disease Control Programmes: - The vacancies of key supervisory positions in NVBDCP and lab technicians should be filled up. The monocular microscopes need to be replaced with binocular microscopes. - Quality of blood slide examination needs to be monitored. - The sentinel surveillance unit at Guntur Medical College needs to conduct tests as and when samples are received. 16. Financial Management: - It is seen in the previous years that Auditors have been unable to issue a true & fair view on the Books of Accounts. To overcome the lack in accounting, reporting and internal controls, State should have one Chartered Accountant as State Accounts Manager at State level and one or two experienced accountant at each district level with the prime responsibility of supervising the work related to the proper maintenance of books of accounts at each facility and sub-centers levels under the guidance of the District Accounts Manager. - Some suggestions for ensuring complete utilization of funds related to the major components under RCH and Mission Flexible Pool are as follows: a. Salary: Make payments on monthly basis from DHS directly into the bank account of payees on receipt of Statement from each PHC/CHC b. JSY: Assess the requirements for a month and park the funds with each facility. Make it mandatory to submit the report of expenditure every month. Make payment at the time of delivery.
47 c. ASHA: Payment should be made by the respective facility under which ASHA works within the shortest period of time. d. HDS/ VHSC/SCs: Make an assessment for the year by each PHC/ CHC etc. and after approving in the meeting of HDS funds can be transferred to respective units. e. Untied Funds: Medical Officers in-charge and ANM should be oriented to know the areas where the funds can be utilized. - State should review the procedure and system for release of funds. Presently, the proposals are moved by the programme officers and after the approval of the same by the Commissioner (FW) the same is again approved by Finance Wing for the release of funds which takes a very long time. It is suggested that the State may release the funds as per the approved activities in the RoP. The State Programme Officers and District Medical & Health Officers could be made accountable and responsible for the proper and effective utilization of funds. 17. Decentralization: - DHAP: The state needs to ensure that the District Health Action Plans are prepared by bottom-up planning and needs assessment is done effectively. The plans must reflect targets for the year and indicators to monitor progress in accordance with national guidelines. 18. Quality Assurance: Quality Assurance Committees for RCH, District Level Vigilance and Monitoring Committees and District Health Mission are yet to be established, Meetings of DHS and orientation of appropriate authorities in PC-PNDT act implementation is very much required. 19. Computers should be provided at all facilities at and above PHC level. 20. Evaluation studies: Evaluation of 104 FDHS and 108 EMRI periodically should be undertaken for cost-effectiveness and cost-benefit analysis.
48 Annexure 1: Data for the 5th CRM:
Name of the State/ UT: ANDHRA PRADESH Infrastructure Upgradation A 1. Overview of Health Infrastructure and achievements in the Mission - High Focus Districts Number of High Focus Districts in the State = ___6___ Required Number of facilities Number of facilities Numb Total no. as per functional in 2005 (i.e. at the functional as of 30th er of of populatio start of Mission) September 2011 new facilities n norms faciliti which (census es will be 2001) under functiona constr l at the uction end of the Health Mission Facility period Govt. Rented No. Govt. Rented No. building building function building building function ing in ing in other other bldgs bldgs without without paying paying rent* rent* 1 2 3 4 1+2+3+4 District 6 4 0 0 3 0 0 0 3 Hospitals (DH) Sub- 0 15 0 0 20 0 0 0 20 Divisional Hospitals and other hospitals above CHC CHCs 116 46 0 0 82 0 0 0 82 PHCs 513 386 62 0 366 70 0 0 436 Other Health facilities above SC but below block level (may include APHC etc.) Sub-Centres 3165 735 2701 0 796 2640 0 0 3436 * Facilities functional in other buildings like Panchayat buildings/ voluntary/ social organization, etc.
49 Name of the State/ UT: ANDHRA PRADESH Infrastructure Upgradation A 2. Overview of Health Infrastructure and achievements in the Mission - Non High Focus Districts Number of Non High Focus Districts in the State = __17____ Required as Number of facilities Number of facilties functional Number Total per functional in 2005 (i.e. at as of 30th September 2011 of new number population the start of Mission) facilities of norms under facilities (census constru- which 2001) ction will be functiona l at the Health end of the Facility Mission period Govt. Rented No. Govt. Rented No. building building functioning building building functioning in other in other buildings buildings without without paying paying rent* rent*
1 2 3 4 1+2+3+4 District 17 15 0 0 12 0 0 0 0 Hospitals (DH) Sub- 0 41 0 0 58 0 0 0 58 Divisiona l Hospitals and other hospitals above CHC CHCs 345 113 0 0 199 0 0 0 199 PHCs 1401 1001 121 0 948 240 0 0 1188 Other Health facilities above SC but below block level Sub- 8532 2142 7066 0 2045 7041 0 276 9086 Centres * Facilities functional in other buildings like Panchayat buildings/ voluntary/ social organisation, etc.
50 Name of the State/ UT: ANDHRA PRADESH A. 3 Status of Block-wise Availability of Health Facilities (Information to be collected only at District Level) Name of District: WARANGAL No. of Health No. of Sub- facilities above Divisional SC but below Hospitals and block level other other than hospitals No. of PHCs (may above CHC No. of District Sr. Name of Populat Sub- include APHC No. of No. of but below level hospitals No Block ion centres etc.) PHCs CHCs District Level if any We are having 3 hospitals under DME Control (MGM,CKM,G 1 Jangaon 173869 43 4 1 1 (AH) MH) 2 Mahbubabad 186114 39 5 1 1 (AH) 3 Bachannapet 82963 18 3 1 4 Cherial 70540 12 2 1 5 Chityala 126802 29 5 1 6 Dornakal 109238 27 2 1 7 Eturunagaram 92077 34 5 1 8 Gudur 127668 40 6 1 9 Mulugu 156399 41 6 1 1 (AH) 10 Narsampet 169576 43 6 1 1 (AH) 11 Palakurthy 152355 30 3 1 12 Parkal 220317 43 4 1 13 Stn. Ghanpur 190573 43 6 1 14 Thorrur 258253 51 4 1 15 Wardhannapet 233471 46 4 1 16 Hanmakonda 174088 51 5 1
51 Name of the State/ UT: ANDHRA PRADESH B. Information on Progress of New Constructions taken up under NRHM in the State (cumulative till 30th September 2011)
Progress of New Constructions
New Construction Health sanctioned under Under Sanctioned but Yet Remarks/ Facility NRHM so far Completed Construction to start Shortcomings
Non Non Non Non High High High High High High High High Focus Focus Focus Focus Focus Focus Focus Focus Districts Districts Districts Districts Districts Districts Districts Districts
District Hospitals - - - - - (DH) Sub- Divisional Hospitals and 39 62 36 74 3 8 0 0 other hospitals above CHC CHCs 0 2 0 2 0 0 0 1 PHCs 18 82 0 0 0 0 18 82
Other Health facilities above SC but below block 13 25 13 25 0 0 0 0 level (may include APHC etc.)
Sub- 278 748 58 141 59 276 161 386 Centres
52 Name of the State/ UT: ANDHRA PRADESH
C. Information on Progress of Upgradation of Health Facilities under NRHM in the State (cumulative till September 2011)
Progress
Upgradation Health sanctioned under Under Sanctioned but Remarks/ Facility NRHM so far Completed Construction Yet to start Shortcomings
Non Non Non Non High High High High High High High High Focus Focus Focus Focus Focus Focus Focus Focus
District Hospitals 0 2 0 2 0 0 3 10 (DH)
Sub- Divisional Hospitals 1 3 1 3 0 0 25 72 and other hospitals above CHC CHCs 1 3 1 3 0 0 17 43 PHCs
Other Health facilities above SC 1 3 but below block level (may include APHC etc.) Sub- Centres
53 Name of the State/ UT: ANDHRA PRADESH D. Sources of Funds for Health Care Infrastructure: (Rs in lakhs) 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 NRHM 35637.27 39462.24 39939.69 64266.52 79043.31 38870.42 Other Central Ministry 21153.57 21066.04 21175.97 25963.91 30515.63 35660.88 Funds
State Budget 15895.81 19995.81 26887.54 18306.74 20593.78 47514.28 Donor funds -- -- 11700.00 12700.00 13294.00 -- Financial Commission Grants ------
Other sources ------Total 72686.65 80524.09 99703.20 121237.17 143446.72 122045.58
54 Name of the State/ UT: ANDHRA PRADESH E. Human Resources augmentation under NRHM at all facilities Required Required as In Position as per per IPHS Contractual IPHS (Sept 2011) (March 2005) NRHM Other Category Sanctioned Regular Funds Sources
Mar Sept Mar Sept 2005 2011 2005 2011
Doctors (Allopathic) 5158 5158 4674 147 AYUSH doctors 663
Specialists 883 883 545 81 0
Paramedics 3991 3991 3019 284 Staff Nurses 7025 7025 5951 1163 51 MPW 7552 7552 2108 3684 ANM 589 13111 10330 10613 2157 LHV
Lab Technician 7583 7583 5172 1078
Pharmacist
AYUSH Paramedics X-Ray Technician Ward Staff 1593
Cleaning Staff 1590 ASHA Facilitators 70700 -- 70700 -- -- 64827 --
ASHA Co- ordinators
55 Name of the State/ UT: ANDHRA PRADESH
F. Training requirement and training institutions in the State
Sr. Category Annual Annual Institutions and Annual Intake capacity no training Training Govt. Govt. Private Private if any - require- require- (Sept 2011) (added during (Sept 2011) (added during ement in ment in Mission Mission March Sept 2011 Period) Period) 2005 No Intake No Intake No Intake No Intake 1 ANM Schools 14 560 294 8820 2 LHV Schools 3 180 -- -- 3 GNM Schools 14 840 248 10874 MPHW 4 10 400 -- -- Schools Post Basic B.Sc. 5 -- -- 5 200 (Nursing)- College B.Sc. 6 (Nursing)- 8 480 216 11181 College M.Sc. 7 (Nursing)- 3 90 42 784 College 8 D.Pharm 11 590 52 2988 9 B.Pharm -- -- 124 7440 Lab. 10 Technician -- -- 143 1924 (DMLT) Lab. 11 Technician (Degree) Others 12 (Pl specify)
56
Name of the State/ UT: ANDHRA PRADESH
G. Achievements of training of Health Functionaries Type of Cumulative number of functionaries trained (2005 to September 2011) Training LHV/AWW/C MO Specialists ANM Staff Nurse DPO/Others IUCD 126 - - 116 118 NSSK 1151 111 - 948 NIL SBA - 279 1876 NIL IMNCI 1633 1648 160 NIL F-IMNCI NIL 82 NIL NIL NIL IUCD BeMOC 60 NIL NIL NIL NIL LSAS NIL 24 NIL NIL NIL MTP/MVA NSV 236 - - - Minilap 159 - - 159 CCSP Laproscopy 132 132
Communicable Diseases Others / ASHA Module 6&7 385 ToT
57 Name of the State/ UT: ANDHRA PRADESH H. Information on ASHA I. Checklist for ASHA
Districts Number Number Number Number Number of ASHA trained Number of ASHA of of of up to following Modules till of required ASHA ASHAs ASHAs date ASHAs Selected dropped in place with out drug 5th 6th 7th kits
Srikakulam 3326 3326 434 2892 2892 Vizianagaram 2596 2596 56 2540 2540 Visakhapatnam 5188 5188 0 5188 5188 East Godavari 4289 4289 316 3973 3973 West Godavari 3260 3260 170 3090 3090 Krishna 3347 3347 425 2922 2922 Guntur 3275 3275 371 2904 2904 Prakasam 3031 3031 300 2731 2731 SPSR Nellore 2291 2291 178 2113 2113 Chittoor 3230 3230 717 2513 2513 Kadapa 2548 2548 161 2387 2387 Ananthapur 3057 3057 127 2930 2930 Kurnool 3243 3243 417 2826 2826 Mahabubnagar 4543 4543 743 3800 3800 Rangareddy 1712 1712 140 1572 1572 Hyderabad 1140 1140 105 1035 1035 Medak 2129 2129 1 2128 2128 Nizamabad 2154 2154 246 1908 1908 Adilabad 2979 2979 198 2781 2781 Karimnagar 2880 2880 171 2709 2709 Warangal 3477 3477 161 3316 3316 Khammam 3712 3712 279 3433 3433 Nalgonda 3293 3293 157 3136 3136
58 Total 70700 70700 5873 64827 64827
Name of the State/ UT: ANDHRA PRADESH I. Mother and Child Tracking System Other than Other CHC at or Health above block facilities level but Area above SC below Hospitals Sub- but below District / General centres block level PHCs Level CHCs Hospitals DHs No. of Data Entry Points 360 CHNCs No. of facilities reporting on MCTS 12522 ------portal No. of facilities where DEOs are deployed for 360 CHNCs data entry No. of facilities where ANMs/ DEOs are trained for data 12522 capturing on MCTS formats and uploading on MCTS portal
No. of facilities where At present data entry has been initiated from Districts only, because of lack of computers with internet infrastructure at block level. State is in the process of equipping all 360 blocks connectivity available with computers and internet facilities. No. of faciltiies using CSC (Common Service Centre) SWAN centes ------for data entry on MCTS portal No. of facilities generating and using All the facilities are in the process of generating work plan of MCTS work-plan of MCTS No. of facilities doing verification of data to reduce errors and ------anomalies occurred at the time of data capturing and entry
59 Name of the State/ UT: ANDHRA PRADESH
J. Information on Programme Management Units Level No. of Regular No. of contractual Staff in No. of contractual Total Number Staff important positions like support staff such as of Staff in Programme managers and programme assistants/ SPMU Consultants who have been DEOs/ typists/ peons employed for their technical expertise
SPMU 7 2 72 81 DPMU 15 45 119 179 BPMU - Total 22 47 191 260
60 Name of the State/ UT: ANDHRA PRADESH K. Information on Delivery Points
S.No Indicator Number
1 Total No. of SCs 12522
a No. of SCs conducting >3 deliveries/month 85 2 Total No. of 24X7 PHCs 800 a No. of 24X7 PHCs conducting > 10 deliveries /month 243 3 Total No. of any other PHCs 824 a No. of any other PHCs conducting > 10 deliveries/ month 70 4 Total No. of CHCs ( Non- FRU) 159 a No. of CHCs ( Non- FRU) conducting > 10 deliveries /month 30 5 Total No. of CHCs ( FRU) 122 a No. of CHCs (FRU) conducting > 20 deliveries /month 72 b No. of CHCs (FRU) conducting C-sections 23 6 Total No. of any other FRUs (excluding CHC-FRUs) 58 No. of any other FRUs (excluding CHC-FRUs) conducting > 20 a 52 deliveries /month
b No. of any other FRUs (excluding CHC-FRUs) conducting C-sections 52
7 Total No. of DH 17 a No. of DH conducting > 50 deliveries /month 17 b No. of DH conducting C-section 17 Total No. of District Women And Children hospital (if separate 8 11 from DH) No. of District Women And Children hospital (if separate from DH) a 11 conducting > 50 deliveries /month No. of District Women And Children hospital (if separate from DH) b 11 conducting C-section 9 Total No. of Medical colleges 14 a No. of Medical colleges conducting > 50 deliveries per month 14 b No. of Medical colleges conducting C-section 14 10 Total No. of Accredited PHF 2081 a No. of Accredited PHF conducting > 10 deliveries per month 1334 b No. of Accredited PHF conducting C-sections 1108
61 Name of the State/ UT: ANDHRA PRADESH L. Other Indicators A Infrastructure As on 01.04.2005 As on 31.03.2011 1 Blood Storage Units 75 2 Blood Banks 16 3 SNCUs 44 4 NBSU 156 5 NBCC 1372 6 Total Number of Beds Bed population Ratio (No. of beds per 7 thousand population) 8 Number of Facilities functioning as per IPHS As on 01.04.2005 As on 31.03.2011 Total No of Functioning Total No of Functioning
Facilities as per IPHS Facilities as per IPHS DH 19 17 CHC 117 281 PHC 1570 1624 Sub centre 12522 12522 No. of facilities having Total No. of Facilities more than 50 % receiving grants in 2010- B Utilization of United Grants utilization in 2010-11 11 Utilization of RKS Grants 1822 1822 Utilization of United Funds 14270 14270 Utilization of Annual Maintenance Grants 1570 1570 Amount of funds spent Total Expenditure under on NGOs/ PPPs NRHM cumulative till cumulative till 2010-11 2010-11 C PPP /NGOs Total Annual OPD in Percentage increase over D the District/ State previous year 2005-06 2006-07 24992482 3.00 2007-08 25771888 3.12 2008-09 26717330 3.67 2009-10 26972694 0.96 2010-11 27681343 2.63 E Lab Services 1.04.2005 31.03.2011 No of patients tested for any ailment in labs at the PHCs 36325000 No of patients tested for any ailment in the labs at CHCs % of 24x7 facilities where 24X7 lab services are available 100 100
62 CHECK LIST FOR REVIEW OF IMPLEMENTATION OF PC&PNDT ACT
A STATE LEVEL:
SL Key points Yes No Remarks No 1 2 3 4 5 1 A multi-member state level appropriate Yes Through G. O. Ms. No. 156; authority appointed by notification in the HM&FW (D1) Dept; Dated official gazette 13.05.2003 the Govt of AP has been constituted the State Level Multi-Member Appropriate Authority for PC&PNDT Act for the whole of the State. It is under reconstitution and relevant proposal has been submitted by this office to the Government on 22.09.2011. The draft GO has been circulated by the Government to the Hon’ble Minister; HM&FW; AP; Hyderabad for approval 2 A State Supervisory Board constituted Yes Through G. O. Ms. No. 207; HM&FW (D1) Dept; Dated 09.06.2003 the Government of AP have constituted the State Supervisory Board for PC&PNDT Act and later certain amendments have carried out through ) G. O. Ms. No. 120; HM&FW (D1) Dept; Dated 20.04.2006
The validity period of operationlisation of the Board have been extended for two years by the Government of AP, through G. O. Rt. No. 379; HM&FW (D1) Dept; Dated 21.03.2007 2.1 If response to S. No. 2, it yes – How many Till 21.03.2007, all Board meetins meetings of State Supervisory Board have convened as per stipulated period. been organized during 2010-2011 (State Board should have meeting once in four The government has reconstituted months) of the Board vide GO 1837 HM&FW; AP; Hyderabad
2.3 Availability of minutes of the meeting Yes Till 21.03.2007, all Board meetings convened as per stipulated period and accordingly minutes are available 3 A State Advisory Committee constituted. Yes A State Level Advisory Committee has been constituted by the
63 SL Key points Yes No Remarks No 1 2 3 4 5 Government of Andhra Pradesh through G. O. MS. NO. 280; HM&FW (D1) Dept.; Dated 10.07.2001 and certain amendments have been carried by the Government through G. O. Ms. No. 408; HM&FW (D1) Dept; Dated 24.06.2005 in respect of nomination of members under Legal Expert category and IEC Expert category.
The Government has issued orders vide GO 1836 for reconstitution of the State Level Advisory Committee on 05.11.2011. 3.2 Availability of minutes of the meeting Yes 3.3 Availability of action taken reports on minutes of meeting 4 A State Level PC&PNDT Cell constituted Yes The State Appropriate Authority was constituted for State Level and District Level PC&PNDT Cell vide GO 1834 dt 5.11.2011.
4.1 If response to Sl. No. 4 is yer, who are the It is proposed to have the following member of the State PC&PNDT Cell (Verify machinery to work at State and from order / circular) District Level PC&PNDT Cell
a) State Level – State PC&PNDT Cell:
1) Additional Director (MCH) / State Appropriate Authority for PC&PNDT Act 2) Supporting Officer (Additional Director (Special) PS & SP) 3) Legal Consultant - (Proposed) 4) Asst. Programme Officer 5) Senior Assistant 6) Data Entry Operator (Proposed) b) District Level – District Level PC&PNDT Cell – Proposed 1) Legal Consultant (Part-
64 SL Key points Yes No Remarks No 1 2 3 4 5 time) – Proposed 2) Data Entry Operator – (Proposed)
4.2 Has the State constituted a State Inspection Yes The Government of Andhra and Monitoring Committee Pradesh have been constituted a State Level Inspection & Monitoring Committee for PC&PNDT Act through G. O. Ms. No. 107; HM&FW (D1) Dept; Dated 06.04.2005;
The Government has r reconstituted the State Level Inspection and Monitoring Committee vide GO 1838
4.2.1 In response to 4.2 is yes – who are the The members list of State Level members of the State Inspection team Inspection and Monitoring Committee are detailed in the GO.
4.2.2 How many independent inspection of USG No Clinics have been done by the state leel inspection team during 2010-2011 4.2.3 Record of follow up actions available on No important observation of inspection of USG Clinics 5 Total number of cases in the state filed in the No There are no reports from District court during 2010-11 Appropriate Authority in the State regarding cases filed in the court during 2010-11
5.1 Total number of cases filed (cumulative) Yes There are 16 cases filed by the District Appropriate Authority for PC&PNDT Act and District Medical & Health Officer, Ranga Reddy and Hyderabad. Out of them 13 cases for non-registration, violation of provisions of Act (non-maintenance of records) and 3 cases are filed against manufacturer, who are supplied US Machines to non-registered facility in the District. .
5.2 Out of 5.1 – total number of cases dismissed No No updated status report submitted with key reasons by the District Appropriate
65 SL Key points Yes No Remarks No 1 2 3 4 5 Authority, concerned.
5.3 Out of 5.1 – total number of cases where No No updated status report submitted charge sheets have been framed by the District Appropriate Authority, concerned
5.4 Out of 5.1, total number of convictions No Cases are pending at Hon’ble courts. No. updated information submitted by the District Appropriate Authority concerned.
5.5 Total number of registration of doctors No No updated information submitted suspended by the state medical council after by the District Appropriate framing charge sheets against them or after Authority concerned. conviction 6 Not received from the GOI 7 Total number of appeals, action have been No No appeals were received by the taken (verify from records) State Appropriate Authority 7.1 On how many appeals, action have been taken No Does not arise (verify from records) 7.2 How many appeals received have been No Does not arise` disposed of by state appropriate authority within 60 days of receipt of appeals? 8 As per Rule 16 (3) has the state appropriate No authority published the list of registered genetic counseling centres, genetic laboratories, genetic clinics, ultrasound clinics and imaging centres and findings from the reports and other information in their possession, for the information of the public and for use by the experts in the field (verity from records) 9 As per Rule {3 A, (2)} are the suppliers / Yes The State Appropriate Authority providers of such machines / equipment to has been receiving the list of any person / body registered under the Act, customers of manufacturers are sending the State Appropriate Authority, regularly once in three months. once in three months, a list of those to whom the machine / equipment has been provided If any such violation has been done by the manufacturer, the District Appropriate Authority, Hyderabad and Ranga Reddy have filed 3 cases against the accused for non- supply of US Machines / equipment to the un-registered facility in their jurisdiction.
9.1 If response to 9 is NO - what action / s have If any such violation is observed
66 SL Key points Yes No Remarks No 1 2 3 4 5 been taken by the State AA against the by the State Appropriate Authority suppliers will address the manufacturers, who are non-submitted the list of their customers directly and accordingly warding / appeal press notification is being proposed to publish in all leading news papers in all editions with the help of State Information and Public Relations Department duly submitting proposal to the Government
If any such violation has been done by the manufacturer, the District Appropriate Authority, Hyderabad and Ranga Reddy have filed 3 cases against the accused for non- supply of US Machines / equipment to the un-registered facility in their jurisdiction
10 Availability of annual state action plan for Yes PC&PNDT related activities 10.1 Budget sanctioned for 2010-11 for Yes A Budget sanctioned under RCH / implementation of various activities NRHM - PIP exclusively from state level for implementation of the Act An amount of Rs. 16.10 lakhs (Rs. 70,000/ per each district = Rs. 16.10 lakhs) has been sanctioned under NRHM to undertake certain IEC Activities. The reports are awaited from District Appropriate Authorities.
B. Funds sanctioned from state budget
No budget has been sanctioned from the State Government for PC&PNDT Activities.
10.2 % utilization of budget sanctioned. No A. Reports are awaited from District Appropriate Authorities in the State.
B. Does not arise
67 SL Key points Yes No Remarks No 1 2 3 4 5 11 Periodical reports from State PCPNDT Cell to Yes GOI submitted in time and copies available 12 Suggestions from state level authorities for better addressing sex selection issues and concerns and implementation of PCPNDT Act
68 CHECKLIST
IMPLEMENTATION STATUS OF JANANI SHISHU SURAKSHA KARYAKARAM (JSSK): STATE LEVEL State/ UT: ...... No. of districts: ...... No. of Blocks: ………… Reporting Month/Year: …………… State Nodal Officer in place (Y/N): ……..…………. State Grievance Redressal Officer in place (Y/N): ………………….. No. of District Nodal Officers in place: ….………… No. of District Grievance Redressal Officers in place: …………….. A) ENTITLEMENTS: CASHLESS SERVICES & USER CHARGES Sno Provision for Cashless deliveries for all pregnant women Whether G.O. Month when started / No. of districts . and sick newborns at all public health facilities issued (Y/ N) proposed timeline implementing 1. Provision of Free drugs/ consumables Yes 22-10-2011 23 fromNov-11 2. Provision of Free Diagnostics Yes 22-10-2011 23 fromNov-11 3. Provision of Free Diet Yes 22-10-2011 23 fromNov-11 4. Provision of Free blood (inclusive of testing fee) Yes 22-10-2011 23 fromNov-11 5. Provision of free treatment to Sick newborns up to 30 days Yes 22-10-2011 23 fromNov-11 6. Free Referral Transport for PW (to & fro, 2nd referral) Yes 22-10-2011 23 fromNov-11 7. Free Referral Transport for Sick newborns (to & fro, 2nd referral) Yes 22-10-2011 23 fromNov-11 8. Exemption from all user charges for all PW and sick newborns Yes 22-10-2011 23 fromNov-11 9. Empowerment of MO in-charge to make emergency purchases Yes 22-10-2011 23 fromNov-11 NOTE: Pls. provide a copy of relevant Govt. Order(s)(provide one time, and when any updation/ revision is done) B) ENTITLEMENTS: REFERRAL TRANSPORT (RT) Sno. Referral transport services State owned EMRI/ PPP Other EMTS 1. Total number of ambulances/ referral vehicles in the State/ UT 390 752 - - 2. Whether vehicles fitted with GPS (specify no.) No No - - 3. Call centre(s) for the ambulance network: Districts (no.s) - …108…………………… State (Y/N): 108 YES 4. Toll free number (provide number, if available): ………………108……………………….. C) IMPLEMENTATION: CASHLESS SERVICES Sno Provision for Cashless deliveries for all pregnant women and sick newborns at all Govt. health facilities Status . 1. No. of districts where free entitlements are displayed at all health facilities- 2 2. No. of districts where free diet is available to PW (at all facilities 24x7 PHC and above level)-T-H & FRU’s 23 Except 24 X 7 PHCs 3. No. of districts where lab is functional for basic tests for PW (at all facilities 24x7 PHC and above level)- 23 3a. No. of districts where any facility has stock outs of lab reagents / equipment not working - 4. No. of districts where any facility has stock outs of essential drugs / supplies for PW and sick newborns - 5. No. of districts where any facility has user charges for PW / sick newborns for: i. OPD Nil ii. Admission / delivery / C- Nil section iii. Lab tests / diagnostics Nil iv. Blood Nil 6. Total no. of govt. medical colleges in the State 14 7. Total no. of govt. medical colleges not levying any type of user charges 14
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D) SERVICE UTILISATION: REFERRAL TRANSPORT (RT) Sno Referral transport services State vehicles EMRI/ EMTS PPP Other . 1. No. of PW who used RT services for: 16585 i. Home to health institution 14097 ii. Transfer to higher level facility for complications 2488 iii. Drop back home Nil 2. No. of sick newborns who used RT services for: 2322 i. Home to health institution 1394 ii. Transfer to higher level facility for complications 928 iii. Drop back home Nil
E) GRIEVANCE REDRESSAL Sno. Grievance redressal Status detail 1. No. of complaints/ grievance cases related to free entitlements One 2. No. of cases addressed / no. of cases pending
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