Yadgir - PIP Report
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NRHM-PIP Monitoring for Yadgir District, Karnataka
C M Lakshmana C Yogananda
Population Resarch Centre Institute for Social and Economic Change Bangalore-560072
November, 2013
NRHM-PIP Monitoring for Yadgir District, Karnataka 1 November, 2013
Executive Summary
This report is a part of PIP monitoring work under NRHM, assigned by the Ministry of Health and Family Welfare. As per the guidelines and instruction given by the Ministry of Health and Family Welfare, the field work has been conducted in Yadgir District of Karnataka during mid November, 2013. Information on various health issues and service delivery parameters was collected from the selected health institutions in Yadgir District of Karnataka. Specified check lists and questionnaires have been used to gather information on various health care delivery services at different set of health institutions in the district. Based on the information provided by the designated health staff in the selected health institutions the major findings and recommendations have been made on the available components of NRHM in PIP as well as the general health services in the visited health centres of Yadgir District
Findings and Observations
The performance of health care service delivery is relatively better at the lower level health institutions like PHC and CHC compared to the higher level institutions like SDH and DH.
So far, the district hospital does not have its own land and building. The previous Taluk Hospital of Yadgir is now working as District Hospital, but, the status is remained the same in terms of available beds, service delivery and physical infrastructure as well as the human resource.
Overall physical infrastructure in terms of buildings is insufficient in DH and SDH of Shahpur.
Unavailability of equipments in district hospitals creates many problems. On the other hand health equipments are available at SDH/CHC. But many of them under repair. Hence, it is observed that the functioning of health services is affected by several factors.
Almost 98 per cent of health institutions are located in government buildings in the district.
Electricity with power back up, running 24/7 water supply is not available in CHC/PHC.
Separate toilet for Male/Female is available in the visited health centres. However, cleanness was very poor in case of DH and SDH.
SNCU is not available in DH of Yadgir. Interestingly, there is no single paediatrician either in district hospital or CHC/PHC.
NBSU is functioning in SDH of Shahpur without having necessary requirements.
New born care corner and new born stabilization units are available in CHC but, the service delivery and proper management is not at all good.
Staff quarters are not sufficient at the selected health institutions and almost 50 per cent shortage in staff quarters in the district. 2 So far, the District Surgeon post is not sanctioned by the government. No Health specialists like Anaesthetist, OBG, and Surgeons are available in DH. There is huge shortage of SNs not only in DH but also in the entire district.
The overall shortage of health staff in the total sanctioned post in Yadgir District is 40 per cent. The vacant position of health specialists of OBG, Podiatrist, Surgery, and Anaesthetist is about 78 per cent in the sanctioned post. 24 per cent of General Physician, 40 per cent of Staff Nurses, 59 per cent of LHVs posts are vacant. And vacant posts of Chief Pharmacist, Pharmacist and Laboratory Technician are 28, 23 and 24 per cent respectively.
Available health staff in SDH/CHC/PHC is not as per the norms, these centres have been up-graded form lower level to higher level. Even though, the functioning status is remained the same.
The trained man power in the district at all level is quite low. There are no trained health staffs in EmOC, BeMOC and SBA. However, the training status among health staff in SDH, CHC and PHC is quite moderate.
Blood Bank/Blood storage units are not functioning in DH. The health equipments are found available in DH, but many of them are not in use or under repair.
Emergency/Trauma care is not available in DH, though emergency cases being referring to Gulbarga, Raichur or Hyderabad.
There are serious problems with supply of essential drugs to various health institutions in the district. There is a shortage of drugs for hypertension, diabetes and other common ailments in district hospitals. Zink tablets are not supplied to CHC and PHC. There is partial supply of OCPs and EC pills in the district. Supplying of essential consumables like Gloves Pads and gauze are sufficient in the selected health institutions.
Lab services are available in the district hospital but not performing well. Liver function test (LFT) is not available in DH.
There is huge crowd in DH at the OPD, but except few patients in IPD in the wards the most of the wards are empty in DH. It is a common sight in all the visited health facilities in the district.
The percentage of reported institutional deliveries in the district in the total deliveries was 96 per cent, of which about 75 per cent deliveries were conducted in public and 25 per cent in private facilities respectively. Roughly around 3-4 per cent of deliveries were found as C section deliveries in the total institutional deliveries of the district.
Due to non availability of Anaesthetist and surgeons at SDH, CHC, majority of the C- section deliveries are presently being referring to District Hospital of Gulbarga/Raichur and also to the private facility.
Due to non availability of health specialists, high risk pregnancies and Sick neonates are presently referred to private hospitals, district hospital of Gulbarga and Raichur.
3 Maintenance of registers like OPD, IPD, ANC, PNC, Drug stock and referral etc., are found properly maintained in the selected health institutions, but up-to date service information is not seen in CHC of Saidapur.
The expenditures like AMC, untied funds and RKS are good (almost 100 per cent) at PHC and SC level as compared to DH and SDH (80 per cent).
Transport facility (Referral linkages in last two quarters in the district) under JSSK has been properly utilized in the district for various purposes. Majority of the service (98 per cent) was used for medical purposes, of which about 56 per cent of service was provided to pregnant women.
As per the protocol, IEC Display materials have been posted at the selected health centres in the district. However, excepting citizen charter and list of services available under JSSK entitlement, the remaining materials were not seen in PHC and CHC. Only few IEC display were found at SC. No suggestion box is provided at all the selected health institutions.
Additional support services such as Regular Fogging, Washing service, are not being properly done at the selected health institutions. The overall cleanness is very poor in DH as well as in SDH of Shahpur. However, by and large the maintained cleanness in CHC/ PHC is quite well as compared to DH/SDH.
The FRU services are not seen at SDH of Shahpur. It has been demoted from FRU status due to non availability of requisite services.
Regular supervisory visits were found and reported in the selected health intuitions in Yadgir District. But overall service delivery is moderate. The respective medical officers were not found at selected health centres. We found some negligence and irregularities in order to provide health services in the visited health centres in the district.
4 NRHM-PIP Monitoring for Yadgir District, Karnataka
1. Introduction
The District of Yadgir was basically carved out from the erstwhile Gulbarga District of Karnataka in 2009. It is also one among the backward districts of Karnataka, located in the northern part of the state. However, in order to monitoring and evaluate the implementation of PIP/NRHM programmes in Yadgir District, health information on physical infrastructure, human resource as well as the various service delivery parameters such as maternal health, child health, Family planning, community services, JSSK, JSY and quality health care etc., have been collected from the selected health institutions in Yadgir District. We gathered information from the designated health staff like, District Programme Managing Officer (DPMO) of Yadgir, in charge District Surgeon of Yadgir, senior medical officer of SDH of Shahpur, the available health staff in CHC of Saidapur, PHC/SC of Madawar in Shahpur Taluk. The findings and recommendations have been drawn up based on the field work observations. Please refer Table 1 for general information on selected health facilities in Yadgir District.
2. State Profile and District Profile
Karnataka State is located on the southern part of India. Geographically, it has four natural regions such as northern maidan, southern maidan, west and coastal regions. The total geographical area of the state is 1,91,791 sq.kms. As per 2011 census the state has 30 administrative Districts and 177 blocks (Taluks) with a total population of 61.09 million (Table 2). The total literacy rate of Karnataka is 75.36 per cent; density and sex ratio are 943 and 319 respectively. Yadgir District is one among the backward districts of Karnataka, located on the northern part of the state, also known as Hyderabad-Karnataka region (Fig 1).
Fig 1: Location Map of Yadgir District in Karnataka-India
It has 10,954.97 sq.kms of geographical area comprising of 7 sub divisional administrative blocks, and the total number of villages of 876. As per 2011 census, the total population of Yadgir is 11, 74,271, of which majority of the population i.e. 81 per cent is residing in rural. There are 984 females per every 1000 males; the density of population is 224, which is below the state average of 319. The District has 2.69 per cent geographical area and 1.92 per cent of the State’s population.
As per 2011 census, the average literacy rate of Yadgir District is 52.36 per cent, and Child sex ratio of 942 which is lower than the general sex ratio of 984 at 42 percentage points. The proportion of male/female population is almost equal in the total population. The share of SCs and STs in the total is more than a quarter with 35.78 per cent. And similarly the share of child population (below 6 years) in the total is about 15.81 per cent. The percentage of working population is 46.64 per cent of the total population. There are total 111 public health institutions in the district which includes 5 the district hospital has served the population of 10579 by each health institution.
3. Key Health and Service Delivery Indicators
According to SRS (2011), the total fertility rate (TFR0 of Karnataka was 2, and the reported CBR, CDR, IMR, NMR and MMR had shown slightly below the national average of 21.8, 7.1, 44, 31 212 respectively. During the decade 2001-2011, the CBR has declined from 22.2 in 2001 to 18.8 in 2011. Similarly the CDR declined to 6.9 in 2011 from 7.6 in 2001. Although, there has been a gradual decline of IMR, with 35 per 1000 live births in the year 2011 as compared to 58 in 2001. Even though, the MMR also declined from 228 in 2001 to 178 in 2011. However, achieved health aspects of CBR, CDR and TFR in Yadgir District are below the state average. The district CBR, CDR and TFR was 26, 9 and 3.5 respectively. On the other hand, the reported IMR and MMR of Yadgir District is 20.61 and 166 respectively. Interestingly the reported IMR and MMR are below the state average of 35 and 178 respectively. But, the reported TFR is higher (3.50) than the state average of 2. Please refer Table 3 for relevant information on the other health care service delivery utilization of Yadgir District.
Table 2: State and District Profile.
Source: RHS, 2012 and Census of India 2011
4. Health Infrastructure
According to the field observation as well as the information provided by the designated health staff in Yadgir District has seen that the available space in CHC/ PHC is sufficient, but in case of SDH of Shahpur and DH of Yadgir is still required. However, the existing facilities in the upgraded SDH and DH are not as per the norms. Hence, there is urgent need to construct a new building for SDH as well as DH in Yadgir. Although, as per the information provided by DPMO, except few sub centres (SCs) about 98 per cent of health institutions in Yadgir are running under government buildings. However, the existing building in the district hospital is old; and hence the overall building quality is poor. However, the available building in terms of space and quality is relatively good in the selected CHC and PHC. Further, it is important to note that the district as a whole the shortage of staff quarters is 50 per cent. On the other hand, staff quarters are available in the sub- divisional hospital and also in CHC, but, the staff quarters are still required. Electricity with power
6 back up and 24/7 water supply is available in DH and SDH. SNCU is not available in DH/SDH. New born care corner and New born Stabilization unit are functioning there. But, we found some negligence and malpractice in the respective health centres.
The cleanness/neatness in DH and SDH of Shahpur is too bad. There is no regular washing fumigation etc. Though, separate toilets for males and females are available, but there is no regular maintenance of cleanness. This is a common problem in all the visited health centres. Functioning of clean labour room, clean wards, mechanisms for biomedical waste management etc., are not being managed well in the visited health centres. NRC is available at SDH of Shahpur, but it has locked at the time of our visit due to non-availability of patients. Further, we observed that the negligence and irregularities by the health staff in managing the new born care at Shahpur. ARSH clinics are not functioning properly in the visited health centres. BB and BBU are not available both at DH and SDH.
5. Human Resource
The sanctioned posts of health staff in Yadgir District were 494. Of this, the filled posts by the respective health department are 300 (Table 4). It is surprised to note that the district does not have a single government paediatrics either in DH or SDH. There is huge shortage of human resource, not only at lower level health institutions but also at higher level health institutions. The overall, shortage of health staff in the district is around 40 per cent. Coming to a particular issue with regard to specialists doctors like OBG, Paediatrics, Surgery and Anaesthetist is about 78 per cent.
Table 3: Key Demographic and Health service delivery indicators of Karnataka and Yadgir District (2001 and 2011).
Source: DLHS -II 2004 and DLHS- III (2008) Fact sheet.SRS Bulletin 2001 and 2011 and EPW, Fertility at the dist level in India, Guilmoto, S Irudaya Rajan, June 8, 2013 Note: SL No. 7 to 12, HMIS. This position was 24 and 40 per cent in case of General Physician and Staff Nurses respectively. The shortage of Chief Pharmacist, Pharmacist, and Laboratory Technician is 28, 23 and 24 per cent respectively. Vacant position of LHVs and ANMs is about 59 and 40 per cent in the total sanctioned posts. Further, the available health staffs under NRHM were 230 in the district. The filled posts of health staff under NRHM were 220, which is close to 99 per cent (Table 4.1). Please refer Annexure 1 for detail understanding of working position of health staff in the selected health centres of Yadgir District.
Further, it is found that there is no separate staffs been appointed to look after the HMIS/MCTS in the visited health centres. Similarly, there are no separate staff for New born care. Hence, it should be noted that in the selected health institutions each staff is handling more than one responsibility. It is due to shortage of health staff. This is due to non availability of necessary health facilities in the upgraded health centres. available health staff is not working as per the norms.
7 However, it has informed by the available health staff in the visited health centres that increased work load due to shortage of health staff has caused to negative impact on acquiring requisite/advanced skills in the health profession by attending health training/programmes.
Table 4: Status of Human Resource in Yadgir District of Karnataka (2013)
Sl.No Human Resource Sanctioned Filled and Vacant Position Posts Working (in Percentage) 1 Specialists* 31 7 78 2 Doctors(General 50 38 24 Physician) 3 Doctors (Dentist) 6 2 33 4 Staff Nurses 89 54 40 5 Chief Pharmacist 2 0 28 6 Pharmacist 57 41 23 7 Laboratory 55 42 24 Technician
8 LHVs 27 11 59 9 ANMs 177 105 40 Total 494 300 40 Source: DHO, Yadgir District. Note: * OBG/Paediatrician/Surgery/Anaesthetist etc.
It was observed that due to non-availability of health specialist especially General Physician and Paediatrics even in DH and SDH, the counselled patients in OPD are being referring to either DH of Gulbarga/Raichur or to private health facilities. Hence, during our visit, there were no in- patients in the wards in DH/SDH/CHC. As per the information gathered by the public it should be note that some government doctors are running their own private hospitals/nursing homes and clinics. Hence, the counselled patients are being referring to their own clinics/nursing homes.
Table 4.1: Working Status of Health Staff under NRHM
Health Staff Since 2009-10 till 2013-14 (upto last month)
8 Sanctioned Filled Specialists (Gyane & 3 1(Gyana Obs/Paed/Surgery/Anaesthetis ecologist t etc. ) Doctors (General Physician) 1 nil
Doctors (Dentist) 0 nil Doctors (AYUSH) 29 26
Staff Nurses 147 147 Laboratory Technician 3 3
ANMs 47 44 Total 230 220
Source: DPMO, Yadgir District.
It is important to note that the entire district has witnessed for huge shortage of health staff. Under this circumstance there were no duty doctors as well as health staff at different level health centres during the time of our field visit. Hence, it is suspect that the routine work at health institutions has been taking place some kind of mutual understanding in managing their respective work among the health staff in DH/SDH/CHC. Further, we had observed the irregularity at NBSU and new born stabilization unit in the visited health centres.
6. Other Health Issues Inputs
Emergency medical care and the services like cardiology, surgery etc., are not available either in SDH or in DH. There is no exclusive maternal and child health hospital or any super speciality hospital in the district. Services like Blood Bank and Blood storage facility are not available. AYUSH service is just in a paper, it has not been implemented effectively in the district. But, as per the information provided by the DPMO, there are 26 AYUSH doctors are working under NRHM with a fixed salary of Rs. 14 thousand per month. But the perception of health choice by the people is still Allopathic. In DH and SDH Rs. 2/- and 20/- has been collecting as users fee and charges for OPD. But, the user fee has not been collecting by CHC/PHC. However, as per the guidelines Rs 15 has been collecting for issuing a medical certificate, and Rs. 200 has been collecting for new registration at OPD in SDH as well as in DH. Management of high risk pregnancies, caring for sick neonates and correctly administering vaccines at the district hospital are in serious problem.
7. Maternal Health
7.1 ANC and PNC
In the year 2012-2013 the expected ANC registration in Yadgir District were 34153, and the actual registered ANCs were 20071. The overall achievement was 58.77 per cent in the target. During the 9 same period the documentation of follow up service of TT2 and IFA tablets had given to pregnant women at ANC in the district was 51.81 per cent and 71.39 per cent respectively in the target. Documentation of severely anaemic is not reported systematically in the district, however, it was reported by DPMO that generally, about 10 per cent and 2 per cent of women had identified as severely anaemic of the total women registered for ANC and PNC respectively. Similarly among the total weighted babies in the district (17799) during the same period about 20.26 per cent of babies had identifies as low weight babies. However, report on hypertensive, B.Sugar, U-Sugar and protein tests of women was not available in the district.
The trend of OPD and IPD registration in the district hospital between the last two quarters has seen an increasing trend at 12.85 and 10 per cent respectively. However, the registered trend of OPD between the two quarters was shown increasing in SDH as compared to DH. But, IPD has shown negative trend between the two quarters with -12.41 per cent. The trend of ANC coverage at SC level has also seen increasing trend with 50 per cent. Coverage of ANC at PHC level has reported as negative trend with -16 per cent. Over a period of time, the number of pregnant women given IFA has also seen negative both at SC, PHC and CHC (except in DH). (See Annexure 2 to 5 for further details).
7.2. Institutional Deliveries
The expected deliveries in the district in the year 2012-2013 (April 2012 to March 2013) were 31095 and the actual reported deliveries were 17142. Hence, the reported delivery in terms of percentage was 55 per cent. However, the expected deliveries in the district were 31790 in the next year of 2012-2013 and the reported deliveries were 18189. The achievement was about 57.22 per cent. However, in the total deliveries conducted at various health institutions in Yadgir District has confirmed that about 97 per cent of deliveries were reported as institutional deliveries. In which majority of the deliveries i.e. 78 per cent had been conducted by public facility and 22 per cent by private facility. With respect to institutional deliveries a similar observations is reported in all the taluks of Yadgir district. Of the total institutional deliveries there is about 5-7 per cent of C section deliveries reported in the district. The reported deliveries in DH of Yadgir in the first quarter (April- June, 2013) and second quarter (July-Sep, 2013) were 31 and 25 respectively. (See Annexure 2 to 5 for further details).
7.3 Maternal Death Review
The maternal death review has been regularly monitoring and reporting by the DHO of Yadgir District. The updated information is available in its monthly as well as quarterly report. According to the maternal review, during the year 2011-12 (April to March) there were 28 maternal deaths were reported in the district and more or less the same numbers of maternal deaths were reported in the next year of 2012-2013 during the same period. However, a higher number of maternal deaths were reported in the taluks of Shorapur and Shahpur as compared to Yadgir Taluk in the district. According to our observation there is no reduction of Maternal Deaths in the district during the period of 2012 and 2013. The major reasons for maternal deaths in the district are Eclampsia and
10 PPH Puerpereal Sepsis and Anaemia. The reported anaemia among ANC women is about 10 per cent and it is 2 per cent among PNC registered women in the district. Lack of awareness about the intake of nutritional food especially among BPL women is the prime cause for anaemia.
7.4 JSSK
JSSK is not yet implemented fully in the entire district. Unfortunately, the knowledge on JSSK among the interviewed mothers is absolutely zero. However, 108 Ambulance transport service has been provided to delivery services for women under JSSK. The information gathered by the interviewed women at various facilities during our visit has confirms that no diet being given to delivered women at the visited health centres. First of all, excepting one woman in CHC, we did not see any delivered women at the visited health facility in CHC and PHC. Most of the beds in maternal ward were empty due to non availability of required services. The available information on JSSK beneficiaries in DH and PHC is presented in Annexure 6.
7.5 JSY
JSY has been implemented in the district. As per the government order dated 08-5-2013 payments have been made available to the beneficiaries. Rs. 500 for home delivery, Rs. 700 and Rs. 600 for institutional delivery for rural and urban woman respectively has been given to JSY beneficiaries. In case of C section delivery woman gets Rs. 1500. The payments have been done through A/C cheque. However, there is un-solved problem in this regard is found in the district. Opening of ZERO balance account is a major issue in both private and public banks. It is important note that so far, only 10 per cent of the issued cheques had gets cleared from banks. And the remaining 90 per cent of cheques are not yet cleared and money has not been paid to the respective beneficiaries from various banks. On the other hand, 30 per cent of the cheques are still with the respective health institutions. Hence, the government should take note this important point to resolve the problem. Though, even private bank and public banks are not allowed to zero balance. In this circumstance, the beneficiaries who received cheques are not yet cleared for payments. Further, it leads to some problem of account management for the respective financial year in various health facilities. However, the lead bank authority of Yadgir District and respective health authority jointly wrote a request letter to all public and private banks in order to open zero balance account to enable payment for JSY beneficiaries. The JSY beneficiaries in this regard could be seen in Annexure 7.
8. Child Health
8.1. SNCU and NRC
It has seen and confirmed that the SNCU is not working in the District Hospital due to non- availability of paediatrician. However, NBSU is working in all the SDH in the district. But, as per our observation, there is no proper care has been taken by the health staff in SDH. The quality of treatment as well as the cleanness at NBSU in Shahpur is poor. We had not seen the health staff either staff nurse or ANMs at NBSU during our visit. Similarly NRC is also not working properly at DH and SDH of Shahpur. During the time of our visit NRC was locked, there were no patients in the ward. No separate staff being employed to perform duty at NRC. In the year 2012-2013 about 258 SAM cases have been identified and referred to DH of Gulbarga and Raichur.
11 8.3 Immunization
According to the DPMO of Yadgir there is a shortage of immunization and no surplus in this regard. However, immunization coverage is somewhat good in the entire district. The overall coverage of immunization at SDH level is 96 per cent, and it is 70 per cent at PHC level. The increased level of immunization in the period of April-June (2013-2014) was highest with 12 per cent in Shahpur. A similar increase has witnessed in the remaining taluks of Yadgir and Shahpur(Table 5). In this regard, half yearly progress report of immunization coverage has been presented in Table 5.1. The Immunization achievement in Yadgir district was 53.91 per cent in the year 2012-2013, it increased to 56.91 per cent in the next year (2013-14). The taluk of Shahpur has achieved highest immunization coverage as compared to other taluks in the district in both the years. However, there were no deaths due to Measles in the district as a whole. However, the immunisation sessions conducted were slightly lower than the planned sessions in both the quarters. ARS committees have been constituted and performing their duties accordingly in all the health centres in the district.
Table 5: Immunization Coverage in Yadgir District
Immunization Taluk/ 2013-14 District 2012-13 (April- Increased (April-June) June) Coverage % District Total 6462 6856 394 6.10 Shahpur 2075 2150 75 3.61 Shorapur 2081 2331 250 12.01 Yadgir 2306 2375 69 2.99
Source: DHO, Yadgir District
8.4. Knowledge and Awareness on Child Health (Families with 0-6 years Children)
During the time of our visit to various health institutions in Yadgir District, we assessed the knowledge and awareness on child health from families with 0-6 year’s children. Nine out of twelve of interviewed mothers (75 per cent) were aware about the need for breast feeding within an hour after birth, and four out of twelve mothers (58 per cent) showed adherence to starting Breast Feeding within an hour of birth. Though, there are many reasons cited for not breast feeding the child within an hour after delivery. The practice of shifting delivered mothers into the ward only after 2-3 hours is one of the reasons. Also, most of the mothers were unaware of the fact that that the New born could become sick if not breast-fed within the first hour of delivery. 10 out of 12 (83 per cent) mothers were aware about exclusive breast feeding for six months and continued it till 2 years. The remaining mothers were unaware of the need of exclusive breast feeding for six months continued BF till 2 years. 9 out of 12 mothers (75 per cent) were aware about complementary feeding practices for child from 6 months onwards, and 50 per cent of mothers continued with complementary feeding practices from 6 months onwards. 7 out of 12 mothers (58 per cent) were aware about Diarrhea and 7 out of 12 mothers acknowledged the availability of
12 ORS through ASHSs. There was no awareness about the danger signs of Pneumonia among interviewed mothers.
Table 5.1: Fully Immunized Children in Yadgir District by Taluk
(Half yearly progress during April-September, 2012 and 2013) 2012 2013 Sl No. Taluk Target Achievement % Target Achievement % 1 Shahpur 9225 5097 55.26 9389 5542 59.03 2 Shorapur 10589 5716 53.98 10740 5946 55.36 3 Yadgir 11281 5951 52.75 11661 6604 56.63 4 Total District 31095 16764 53.91 31790 18092 56.91 Source: HMIS, Yadgir District
All interviewed mothers at various health institutions were reported that the MCP card was being regularly filled. And most of the interviewed women told that the quality of ANC is poor and inadequate. However, all interviewed women were aware about Birth Preparedness. And almost 50 per cent of the pregnant women do not have knowledge about JSY. Interestingly, all interviewed women do not have the knowledge about JSSK. All interviewed women told that they do not have the call centre or referral transport telephone number, but about 87 per cent of interviewed woman reported that they are having telephone number of ASHAs and ANMs.
9. Family Planning
In general, the progress of Family Planning programme in Yadgir District seems to be quite neglected and failed to create awareness on the modern family planning methods. Family planning related activates such as paintings, posters, electronic and print media were not seen much in the visited health centres. Expectedly, over the years, modern family planning methods have become popular among married couples. Non-availability of health specialists particularly Anaesthetist, Surgeons and OBGs in Taluk Hospitals as well as in CHCs, the respective health centres did not performed any Tubectomy. Such cases have been referring to either DH of Raichur or DH of Gulbarga and also to private health facilities. In this regard, detailed information on coverage of modern family planning methods in Yadgir District is presented in Annexure 8. The targeted sterilizations for the period of April to September (half yearly, 2012-2013) were 13595, of which the half yearly achievement was 48.65 per cent. The achieved sterilizations in the next year during the same period were around 60 per cent. However, the overall trend of acceptance of modern family planning method in Yadgir district shows that in the recent period, the number of users of CC in terms of percentage has increased from 53 per cent in 2012 to 64.76 per cent in 2013. Similarly IUD users were also increased from 39.5 per cent in 2012 to 47.3 per cent in 2013. At the same time, the numbers of OP users were also increased from 32.6 per cent to 52.3 per cent (See further details in Annexure 8).
10. ARSH Clinics
13 The ARSH programme is not implemented in the district. DPMO in this regard told that this programme is still in paper, no efforts have been done to implement this programme effectively in the district. .
11. Quality in Health Services
11.1 Infection Control
According to our personal observation and investigation on the cleanness and neatness in the visited health institutions to be say that it is totally bad. Generally, the maintenance quality in order to keep cleanness and neatness at the selected health institutions is very poor. More or less the protocols with regard to posting of JSSK entitlement are available at the health centres, but the incentives are not being reached to the eligible beneficiaries. A list of JSY facilities available and family welfare programmes etc., have seen at the selected health centres. Further it was informed by the health staff that the washing and cleaning is the only a routine mechanism to keep cleanness at the visited health centres. Fumigation, disinfection and autoclave are not being performed at the selected health institutions to control infection.
11.2 Biomedical Waste Management
Biomedical Waste Management has been managing in the district by PARISARA ASSOCIATION OF YADGIR, according to the information provided by the health staff at DH, the bio-medical waste has been clearing every day, and it is once in a week at CHC/PHC, and once in three days in SDH. However, the cleanness both in DH and SDH is very poor. There is too much of stinking. However, the cleanness in CHC/PHC is comparatively better than the DH and SDH. Maintained routine work of bio- waste disposal is not satisfactorily by the health staff. Segregation of bio- medical waste in specified colour bins is not followed accordingly, and overall awareness on waste management among health staff in the district is average. The main reason for this is the shortage of D group health staff.
11.3 IEC
All protocol IEC display such as Citizen Charter, MCH and FP related IEC, essential drug list entitlements of JSSK and JSY have been found posted at the District Hospital as well as in Taluk Hospitals, though, it is not strictly adhered at the CHC, PHC and SC level institutions. The Citizen Charter chart and List of services available under JSSK entitlements were not found at CHC. However, except Citizen Charter, the remaining posters were found at PHC and out of 10 IEC Display, a few posters were seen at SC. The suggestion box was not provided at CHC/PHC and SC.
12. Referral Transport and MMUs
There are only three 108 vehicles (Arogya Kavacha) available in the district. Hence, it shows that the available ambulance is less than the norms of one lakh population, as per 2011 census, the total population of the district is 11,74,271. The district authority has not purchased any ambulance vehicle under NRHM budget. However, the call centre for referral transport is operating in the district. Emergency calls received for medical purpose in the district in the year 2011-2012 (March –April) were 31,499; it increased to 12805 in the year 2012-2013. In this regard figure 2 shows that during April-June, 2011-2012 the use of transport for the medical purpose was 87.7 per cent, it 14 increased to 98.19 per cent in the next year (2012-2013) in the same period. The vehicle used for pregnancy was 68.36 per cent in the year 2011-2012, it decreased to 56.12 per cent in the year 2012-2013. On the other hand, the vehicle used for other purposes like Respiratory, Acute Abdomen, cardiac etc., has increased over time. The responding time for Ambulance service is 30 minutes for rural and 15 minutes for urban. Please see further information on transport delivery in figure 2 and Table 6.
13. Community Process
13.1 ASHA
Currently the available ASHAs in the district were 800 and further requirement as per the norms per 1000 population is 100. Skill development among ASHA is quite good; about 70 per cent of them are trained. The meetings and ANC registration were held at various health institutions. But still training is required for ASHA’s. Drug kit replenishment and payment issues are currently being sorted out by the respective authorities. But Drug kit replenishment has not been done for ASHAs in the district due to non-supply of kits. However, as per the information provided by the DHO, there is some hindrance in regard to payment for ASHA workers due to the excess payments made in the previous year. There were no any NGOs works for the betterment of health issues in the district.
14. Disease Control Program
According to DPMO, over a period of time, there was a decline of Malaria cases approximately about 70 per cent. However, during the years 2012 and 2013, about 482 and 289 Malaria cases had been identified and treated in the district respectively. Numbers of deaths due to Malaria in the year in Yadgir District were nil. Staff availability for Malaria control programme in the district is inadequate. The expected number of patients undergoing sputum examination for diagnosis (TB) in Yadgir District for the year 2012 was 705. And the number of cases identified and treated cases were 66. The target in this regard was 705 in the year of 212-2013. In which 50 cases had identified and treated. However, out of three taluks there are highest Malaria cases as well as TB cases were reported in Shorapur Taluk as compared other two taluks of Shahpur and Yadgir. As per the report available with DPMO of Yadgir the villages of Kakera and Rajan Kollur of Shorapur have witnessed for higher incident of Malaria. It is due to stagnation of water around the villages. TB cases have been increased over time in the district. This is because of resistance to drugs. Drugs and staff availability for TB programme is quite good. However, about 10 per cent of deaths in the total identified cases were reported in Yadgir District.
Except Gastro enteritis (GE) there were not any such Communicable Diseases in Yadgir District. In the last one year, there were no cases of death due to communicable diseases in the district. Further, as per the information provided by the health staff, Non Communicable Diseases are under control. However, NCD clinics are yet to be started in DH as well as in SDH.
15 Fig 2: Utilization of transport service by 108 ambulances in Yadgir District (in two qua
Table 6: No. of Cases Free Referral Transport Provided in DH of Yadgir and PHC of Madawar (in August (DM) and during April to August 2013 (CT).
No. of cases shifted from FRU to DH or other higher facilities
Emoc Other cases Facility Day Night Total Day Night Total
7am-8pm 8pm-7am DM CT 7am-8pm 8pm-7am DM CT DH 115 93 57 208 84 80 18 164 PHC 2 6 8 8 5 5 10 30 DM – During the month and CT-Cumulative total
15. HMIS/MCTS
HMIS/MCTS information has been regularly uploading to the HMIS portal at various levels of health institutions. However, due to net work problem in CHC of Saidapur the data has been up- loading from DH. The uploading process being performed either by ANMs or other health staff at the respective health centres. The overall quality of HMIS data is relatively good, and the data processing and validation mechanism has been regularly monitoring by the respective MOs in the respective health institutions.
16. Key Conclusions and Recommendations
16 The available health service in Yadgir District is inadequate both in terms of physical as well as human resource is concerned. Hence, there is a need for immediate attention to provide necessary health services to this newly carved district from Gulbarga. Due to non availability of health specialist especially Paediatrics, OBG and surgeons, in DH and SDH the IPD is totally inactive. NBSU is not working properly. Hence, there is urgent need to provide staff quarters to ensure quality of health services as well as to ensure emergency health care services.
Due to shortage of health staff both at the District Hospital and SDH in general and specialist doctors in particular the reduction level of IMR and MMR is not progressive in the District. The efforts made by the health department to promote institutional deliveries through private hospital tie up under Thayi Bhagya scheme is a good sign of development. And the implementation of NRHM and Thayi Bhagya scheme together has significantly increased the number of institutional deliveries in the district as a whole. Inadequate space and shortage of health staff have resulted in providing poor quality of services. Staff availability is much below accepted norms in all the visited health institutions. The working status of the health staff in upgraded health institutions status is remained the same.
Trained health staff in the district is quite weak. This deficiency is found to adversely impact maternal and child health services in the district. Due to shortage of doctors as well as excess work- load at the district hospital, the quality of care is seriously affected. Therefore, there is a felt need to provide district hospitals with all the necessary facilities and manpower. There is need to provide full-fledged facilities of SNCU to the DH as well as to SDH in order to ensure quality of service and promote child health. In the present circumstance the district required a training centre as well as a maternal and Child hospital in the district. Un-equal distribution of funds across district was affecting the shortage of drugs as well as to maintain the other health management in the district.
The drug centre is not opened at the DH so far. The supply of immunization drops/vaccines and drugs are not sufficient. However, according to DPMO, the JSSK has helped a lot to purchase the emergency drugs and other things at the various health institutions. There is need to find a permanent solution to resolve the issue of JSY payments. Hardly 10 per cent of issued cheques are being cleared and 30 per cent of cheques still with health staff clerks at various health institutions. Maintains of records are available in the visited health centres. But, the updated information is not up to the mark.
References
1. District at a Glance of Yadgir and Gulbarga District (2011-2012).
17 2. IIPS and ISEC. DLHS II (2004) and DLHS III (2008). District Fact sheet (Karnataka), Mumbai.
3. Guilmoto, S Irudaya Rajan, “Fertility at the District Level in India, Lessons from the 2011 Census, June 8, 2013, EPW, Vol. XLVIII No. 23.
4. ISEC and IIPS, 2002. District Level Household Survey (DLHS, 2002 and 2008), Gulbarga District.
5. Karnataka at a Glance (2011-2012), Government of Karnataka, Bangalore.
6. Sample Registration System (SRS), 2001 and 2011. Registrar General & Census Commissioner, Government of India, New Delhi.
7. HMIS portal Data for Gulbarga District and Karnataka (2011).
18 Annexure 1: Working Status of Health Staff at Various Health Institutions of Yadgir District.
Working Status SL.No Category DH SDH CHC PHC SC Ma Yadgi Saidapu Madawa daw r Shahpur r r ar 1 OBG 1 1 2 Anaesthetist 3 Paediatrician 4 General Surgeon 1 1 5 Other Specialists 4 4 6 Mos 1 4 2 1 7 SNs 19 23 2 3 8 ANMs 2 2 1 2 9 LTs 3 3 1 1 10 Pharmacist 1 1 2 1 11 LHV 12 Radiographer 1 1 13 RMNCHA+ counsellors 1 14 Others 6 1
Source: DPMO, Yadgir District.
Annexure 2: Service Delivery in last two quarters Q1 (April 13 to Jun-13) & Q2 (Jul-13 to Sep-13).
19 Service (DH) SL.No Utilization Yadgir (SDH) Shahaur Parameter
Q1 Q2 q1-q2 Trends Q1 Q2 q1-q2 Trends
1 OPD 19645 22169 2524 12.85 7252 10250 2998 41.34
2 IPD 4409 4848 439 9.96 2627 2301 -326 -12.41
Expected number of Pregnancie 3 s 269 267 -2 -0.74
MCTS entry on percentage of women registered in the first 4 trimester 85 80 -5 -5.88
No. of pregnant women 5 given IFA 427 359 -68 -15.93 156 178 22 14.10
Total deliveries 6 conducted 533 576 43 8.07 365 368 3
No. of assisted deliveries (ventouse/ 7 Forceps) 48 68 20 41.67
No. of C section 8 conducted 31 25 -6 -19.35 5
Number of obstetric complicati ons managed, pls specify 9 type 2 1 -1 -50.00
No. of neonates initiated breast feeding within one 10 hour 364 365 1
11 Number of children screened
20 for Defects at birth under RBSK
RTI/STI 12 Treated 504 561 57 11.31 362 435 73 20.17
No of admissions in NBSUs/ SNCU, whichever 13a available 201 153 -48 -23.88 41 37 -4
13b Inborn 142 144 2 1.41 41 34 -7 -17.07
13c Outborn 59 9 -50 -84.75 3
No. of children admitted 14 with SAM 8 10 2 25.00
No. of sick children 15 referred 4 11 7 175.00
No. of pregnant women 16 referred 88 121 126 5
ANC1 17 registration 528
ANC 3 18 Coverage 690
21 Annexure 2 cont…..
19 ANC 4 Coverage No. of IUCD Insertions 20 18 1 1 No. of Tubectomy 21 136 8 10 2 25.00 No. of Vasectomy 22 No. of Minilap - 23 136 383 334 -49 12.79 No. of children fully 24 immunized 408 Measles coverage 25 No. of children given ORS + 26 Zinc No. of children given 27 Vitamin A 408 No. of women who accepted - post-partum FP services 100.0 28 1 -1 0 No. of MTPs conducted in 29 first trimester No. of MTPs conducted in 30 second trimester Number of Adolescents 31 attending ARSH clinic 46 48 2 4.35 Maternal deaths, if any 32 Still births, if any 33 5 1 1 Neonatal deaths, if any 34 Infant deaths, if any 35
22 Annexure 3: Service Delivery Utilization in last two quarters Q1 (April 13 to Jun-13) & Q2 (Jul-13 to Sep-13).
Service CHC SL.No Utilizatio Saidapur n Q1 Q2 q1-q2 Trends Paramete 1 OPDr 7300 8335 1035 14.18 2 IPD 403 510 Expected number of Pregnanci 3 es 72 74 2 2.78 MCTS entry on percentag e of women registered in the first 4 trimester 51% 47% No. of pregnant women 5 given IFA Total deliveries 6 conducted 110 126 16 14.55 Number of obstetric complicat ions managed, pls specify 7 type No. of neonates initiated breast feeding within 8 one hour 92 103 11 11.96 Number of children screened for Defects at birth under 9 RBSK 23 RTI/STI 10 Treated 17 15 -2 -11.76 No of admission s in NBSUs if 11 available No. of sick children 12 referred 8 6 -2 -25.00 No. of pregnant women 13 referred 20 19 -1 -5.00 ANC1 registratio 14 n 51 ANC 3 15 Coverage 51 ANC 4 16 Coverage 118 No. of IUCD 17 Insertions 21 23 2 9.52 No. of Tubectom 18 y No. of Vasectom 19 y No. of 20 Minilap 57 50 -7 -12.28 No. of children fully immunize 21 d 79 76 -3 -3.80 Measles 22 coverage 79 76 -3 -3.80 No. of children given ORS + 23 Zinc 45 51 6 13.33 No. of children given Vitamin 24 A 79 76 -3 -3.80 25 No. of 21 23 2 9.52 women who accepted post-
24 partum FP services No. of MTPs 26 conducted Maternal deaths, if 27 any Still births, if 28 any 2 1 -1 -50.00 Neonatal deaths, if 29 any Infant deaths, if 30 any
Annexure 4: Service Delivery in last two quarters Q1 (April 13 to Jun-13) & Q2 (Jul-13 to Sep-13).
Service Utilizatio PHC Madawar SL.No n Paramete r Q1 Q2 q1-q2 Trends 1 OPD 783 1087 304 38.83 2 IPD 79 90 11 13.92 Expected number of Pregnanci 3 es 178 148 -30 -16.85 MCTS entry on percentag e of women registered in the first 4 trimester 30% 30% No. of pregnant women 5 given IFA 178 148 -30 -16.85 Total deliveries 6 conducted 143 153 10 7 Number
25 of obstetric complicat ions managed, pls specify type No. of neonates initiated breast feeding within 8 one hour 143 153 10 Number of children screened for Defects at birth under 9 RBSK RTI/STI 10 Treated 60 70 10 16.67 No of admission s in NBSUs if 11 available No. of sick children 12 referred 10 20 10 100.00 No. of pregnant women 13 referred 7 14 7 100.00 ANC1 registratio 14 n 178 148 -30 -16.85 ANC 3 15 Coverage 178 148 -30 -16.85 ANC 4 16 Coverage 178 148 -30 -16.85 No. of IUCD 17 Insertions 18 26 8 44.44 No. of Tubectom 18 y 11 10 -1 -9.09 No. of Vasectom 19 y
26 No. of 20 Minilap 39 42 3 No. of children fully immunize 21 d 110 297 187 170.00 Measles 22 coverage 110 297 187 170.00 No. of children given ORS + 23 Zinc 9 12 3 33.33 No. of children given Vitamin 24 A 110 297 187 170.00 No. of women who accepted post- partum FP 25 services No. of MTPs 26 conducted Maternal deaths, if 27 any Still births, if 28 any 1 2 1 100.00 Neonatal deaths, if 29 any 3 Infant deaths, if 30 any
Annexure 5: Service Delivery in last two quarters Q1 (April 13 to Jun-13) & Q2 (Jul-13 to Sep-13).
SC Madawar SL. Service Utilization Parameter No Q1 Q2 q1-q2 Trends 1 Number of estimated pregnancies 43 30 -13 -30.23
27 2 MCTS entry on percentage of women 85% 85% registered in the first trimester 3 No. of pregnant women given IFA 43 30 -13 -30.23 4 Total deliveries conducted at SC 5 Number of deliveries conducted at home 3 2 -1 -33.33 6 No. of neonates initiated breast feeding 19 40 21 110.53 within one hour 7 Number of children screened for Defects at 2 1 -1 -50.00 birth under RBSK 8 No. of sick children referred 9 No. of pregnant women referred 5 3 -2 -40.00 10 ANC1 registration 43 30 -13 -30.23 11 ANC 3 Coverage 43 30 -13 -30.23 12 ANC 4 Coverage 8 10 2 25.00 13 No. of IUCD Insertions 12 9 -3 -25.00 14 No. of children fully immunized 38 40 2 5.26 14a Measles coverage 38 40 2 5.26 15 No. of children given ORS + Zinc 20 22 2 10.00 16 No. of children given Vitamin A 225 218 -7 -3.11 17 No. of children given IFA Syrup 18 No. of Maternal deaths recorded, If any 19 No. of Still birth recorded, if any 2 2 0 0.00 20 Neonatal deaths, recorded, if any 21 Number of VHNDs attended 3 3 0 0.00 22 Number of VHNSC meeting attended 23 Service delivery data submitted for MCTs 30 68 38 126.67 updating
Appendix 6: JSSK Beneficiaries in Yadgir Dist
DH PHC JSSK beneficiary components 1st 2nd 1st 2nd Quarter Quarter Quarter Quarter 1. No. of beneficiaries received drugs 143 153 369 339 for normal delivery 28 2. No. of beneficiaries received drugs for - - 45 32 c-section delivery 3. No. of beneficiaries received diagnostics 143 153 693 719 service 4. No. of beneficiaries received blood - - 71 125 5. No. of beneficiaries received diet 143 153 369 449 6. No. of beneficiaries received referral 31 57 7 14 transport 1st Quarter (April-June, 2013) 2nd Quarter (July-September 2013
Appendix 7: No. of Women Who Received JSY Incentives in the Visited Facilities during two quarter 2013 in Yadgir district.
DH PHC Items 1st 2nd 1st 2nd Quarter Quarter Quarter Quarter 37 37 JSY 225 289 Beneficiaries 1.Non-SC/STs 154 187 28 32
2.SCs 54 59 6 4
3.STs 17 43 3 2
Total 37 37
Total Deliveries 533 576 143 153
Annexure 8: Coverage of Modern Family Planning Methods in Yadgir District.
Sterilization IUD OP CC Year Achi Achi Achi Achi Targe eve- Targe eve- Targe eve- Targe eve- t ment % t ment % t ment % t ment % (Apri l- Septe mber, 1359 2012) 5 6614 48.7 6507 2571 40 3795 1238 33 7048 3739 53.1 29 (Apri l- Septe mber 1251 2013) 1 7255 59.2 6641 3143 47 4182 2187 52 7502 4858 64.8 Source : DPMO, Yadgir
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