Monitoring Visit Report –Andhra Pradesh Quarter 4, 2012- 2013 Public Health Planning (PHP) Unit, NHSRC Contents Maps of Districts Executive Summary of Report Monitoring Visit Report Annexures - Monitoring Visit - Tour Schedule - Photographs of Facilities 1 2 3 Andhra Pradesh Integrated Monitoring Report Executive Summary The integrated program monitoring visit for the first quarter of 2013 has covered the high focus districts of Visakhapatnam (Vizag) and Vizianagaram in 3 days. Visit Findings and Critical Issues in facilities needing interventions: Caseload of the facilities is varied. The caseloads in both the district hospitals of Anakapalle and Ghosha is very high, particularly the maternity OPD and IPD. Women from far flung interior areas visit these hospitals. Additional manpower to match the caseload, systems for OPD management, creating space for waiting areas with some minimum amenities are the need of the hour in the DHs. Caseloads in CHC Kotapadu and 24x7 PHC Devarapalli are relatively less. Grievance redressal mechanism, privacy in maternal wards, biomedical waste management need attention. In the JSSK component, information availability / dissemination to the community in regard to the complete entitlements and transportation facilities to & from the Facility need to be streamlined. Diet provision services need to be reviewed and revamped for optimum utilization of services by the beneficiaries in both districts. Some of the issues related to these facilities are non-availability of documentation (registers/ books) in an orderly and systematic manner (particularly those related to JSSK), lack of orientation to the concerned staff on the same, virtually non-functional laboratories at the Facilities e.g., the 24X7 PHC Pusapati Rega, absence of line-listing of JSSK beneficiaries in all the facilities, etc. NBSUs and SNCUs are not properly put in place with a number of functional bottlenecks and some of them being only partially operational. The air-conditioners are not working in SNCUs (e.g.: DH Anakapalle & CHC Kotapadu, where there were two new-borns at the time of the visit); the staff is not oriented with regard to the requirement of proper ventilation and ideal temperature to be maintained for the infants in NBSU. In the DHs, though scanners and other diagnostic equipment are available, they are underutilized due to non-availability of operating manpower on a consistent basis e.g., DH Anakapalle. Washrooms in maternity wards are available but dysfunctional in many cases such as 24x 7 PHC Pusapati Rega and PHC Devarapalli. Similarly, referral transport is not available in some facilities such as the 24x7 PHC Pusapati Rega and PHC Devarapalli. IPHS formats are not filled in at any of the facilities. Laboratory systems need to be streamlined in terms of hygiene maintenance; records, addition of service components (such as blood grouping in some facilities) and bio-medical waste management should get strengthened. 4 Andhra Pradesh - Detailed Report on Monitoring Visit Purpose Monitoring & Technical Assistance to high focus districts for planning and implementation of NRHM activities To assess the status of implementation of free and cashless services for delivery and referral transport for pregnant women and children under JSSK Profile of the Districts - Geographical and Health The integrated program monitoring visit for the first quarter of 2013 has covered the high focus districts of Visakhapatnam (Vizag) and Vizianagaram for three days. Details of Monitoring Program schedule is given in Annexure 1. Exit interview tools, facility checklists, interviews, and district level data are used to analyse the present status. Vizianagaram Vizianagaram District is bounded on the North by Chhattisgarh, on the South partly by Visakhapatnam District and partly by the Bay of Bengal, on the West partly by Odisha State (north- west) and on the East by Srikakulam District. The Sex Ratio is 1016 Females per 1000 Males. Scheduled Tribes account for 18% of the population in the district. Visakhapatnam Visakhapatnam (Vizag) District is one of the North Eastern Coastal districts of Andhra Pradesh. It is bounded on the North partly by the state of Odisha and partly by Vizianagaram District, on the South by East Godavari District, on the West by Odisha State and on the East by the Bay of Bengal. The Sex Ratio is 1003 Females per 1000 Males. The District has a Population Density of 384 per sq. km. Agency area shows lesser population density and plain area, higher density. 39.9%of the population resides in the 10 Hierarchic urban settlements while the rest of the population is distributed in 302 villages. Scheduled Castes constitute 7.6% of the population while Scheduled Tribes account for 14.55% of the population in the district. Demographic and Health Indicators Major demographic data and key Maternal & Child Health parameters are presented in Tables 1 and 2 below. 5 Table 1 - Demographic Fact Sheet for Visakhapatnam & Vizianagaram Districts Visakhapatnam Vizianagaram Particulars / Parameters District District Persons 4,288,113 2,342,868 Population - Census - 2011 Male 2,140,872 1,161,913 Female 2,147,241 1,180,955 Population in the Persons 429,234 231,021 Age Group 0-6 - Male 218,923 118,149 Census - 2011 Female 210,311 112,872 Sex Ratio ( No. of Females per 1000 Males) 1,003 1,016 Sex Ratio 0 - 6 years 961 955 IMR (per thousand live births) 43 12.31 MMR( per one lakh population) 131 84.07 TFR 1.98 1.7 Persons 67.70 59.49 Literacy Rate (%) Male 75.47 69.04 - Census - 2011 Female 60.00 50.16 Population Density per sq. km 384 358 Table2 - Indicators in Maternal & Child Health Visakhapatnam Vizianagaram Indicators (DLHS III) District District ANC ANC Check-up in First Trimester 59.7 57.8 3 or More ANC Check-up 76.4 82.6 Deliveries Institutional Delivery 59.8 56.9 Home Delivery 39.4 42 Home Delivery by SBA 1.3 7.4 New Born & Post Natal Care PNC within 48 Hours of Delivery 58.4 70.8 Immunisation Full Immunisation 60 55.4 Health Care Infrastructure: Major infrastructure facilities / amenities available in the two districts is shown in Table 3. Table 4 shows the position vis-à-vis filled posts of ASHAs in the two districts. 6 Table 3 - Health Sector Infrastructure in Visakhapatnam and Vizianagaram Districts Sl. No. Facility Visakhapatnam Vizianagaram 1 District Hospital 1 1 2 Area Hospital 1 1 3 No. of CHNCs 15 12 4 No. of CHC s 13 11 5 No. of PHCs 85 68 6 No. of Sub-centres 584 - 7 No. of 24 Hrs. PHCs 34 32 8 No. of Blood Banks 1 5 9 No. of BSUs 4 3 10 No. of ARSHs 59 31 11 No. of Ayush doctors 12 8 Source: DMHO/ DPMO Office, Visakhapatnam, Vizianagaram Table 4 – ASHAs Visakhapatnam District Vizianagaram District Description Sanctioned In Position Vacant Sanctioned In Position Vacant Non-Tribal 3082 2628 - - - - Tribal 3106 3106 - - - - Total 6188 5734 454 2596 2450 146 Source: DMHO office Vizianagaram, Visakhapatnam It is clear that more number of positions of ASHAs are vacant in Visakhapatnam. Blood Banks & BSUs Two Blood Banks are available in Visakhapatnam district (DHs Anakapalle & KGH) and 4 BSUs in Araku, Paderu, Narsipatnam and Chintapalli Mandals. In Vizianagaram district, Blood Banks are available in MR DH, Indian Red Cross Society facilities (at Vizianagaram and Parvathipuram), MIMs, and a Private facility. BSUs are available at CHCS of Saluru, Chipurupalli and S. Kota. Key Observations 7 Facilities visited in Vizianagaram district are CHC Bhagapuram, PHC Pusapati Rega, SC village Tallapeta and DH Ghosha Hospital in Vizianagaram town. In Visakhapatnam district, the facilities visited are CHC Kotapadu, 24x7 PHC Devarapalli, sub-centre Chinna Gangavaram village, District Hospital in Anakapalle town and a normal PHC in Tallapalli Mandal. All facilities are in Government buildings. Caseload of the facilities is varying. The caseloads in both the District Hospitals of Anakapalle and Ghosha is very high, particularly for the maternity OPD and IPD. Women from far flung, interior areas visit the hospital because specialist doctors and SNCU are available in these facilities. In the DH Anakapalle, gynaecology caseload is around 500 to 550 per day with about 10 deliveries and 3 C sections being conducted per day. During April 2012 - March 2013, a total of 2,085 normal deliveries, 1004 LSCs, and 434 sterilizations were conducted in the DH Anakapalle. The situation is more or less same in the DH Vizianagaram. The physical infrastructure such as waiting rooms, washrooms, basic equipment, etc.as well as the Human resources are not adequate to meet the caseload in both the District hospitals. CHC Bhagapuram in Vizianagaram district has considerably high case load, with a general OPD of 250 to 300 per day, gynaecology caseload of minimum 30 per day, 45 to 50 deliveries per month and at least 3 to 5 C Sections per month. One fulltime Gynaecologist is available, with 2 other doctors on contract basis. The caseload in 24X & PHC Pupapati Rega is 80-100 general OPD, and 15-18 deliveries per month. At the time of visit there are no inpatients in the maternity wards. The NBSU is newly renovated and yet to be made operational. Sub-Centres: Sub-centre, Tallapalli village under CHC Bhogapuram was visited and interviews with delivered women revealed that complete information about JSSK is lacking and post-delivery local dietary practices are different from the diet provided in the Facility. CHC Kotapadu and CHNC Kotapadu in Visakhapatnam reported caseload of 30-40 deliveries per month and a general OPD caseload of 100 per day, which is relatively less. One of the In-patients wards is mixed for men and women. The caseload due to GE outbreak (at the time of visit) was quite high and as there was no separate ward available.