Monitoring Report for Uttar Pradesh; Jan – Mar 2013

National Health Systems Resource Center, New Delhi

The quarterly report of Uttar Pradesh is based on the HMIS data analysis and field monitoring visits to the high priority district of Faizabad

State and District Profile

UP is the most populous state of the country with the population of 19,95,81,477 as per the census 2011. State has 18 divisions, 72 districts and 821 blocks. The Total Fertility Rate of the State is 3.6 (AHS, 2011). The Infant Mortality Rate is 57(SRS, 2012) and Maternal Mortality Ratio is 440 (SRS 2004 - 2006) which are higher than the National average. The Sex Ratio in the State is 904 (as compared to 933 for the country)

Faizabad is one of the high-focus districts of the state with highest IMR (98) and MMR (faizabad mandal – 451) as per the AHS 2011. Faizabad has a population of 24,68,371 and CBR of 25.5. Faizabad district has 11 blocks with 3 DH, 11 CHCs, 27 PHCs and 248 SCs. There are 37 SCs which are conducting more than 3 deliveries/month, six 24x7 PHC and 8 APHCs conducting more than 10 deliveries per month. District indicators are –

Comparative Indicators Indicator Uttar Pradesh Faizabad 3 ANC 75% 79% % of women given 100 IFA 66% 36% tablets Institutional delivery rate 36% 44% Home delivery rate against 62% 69% reported deliveries C-section rate 3% 4% Fully immunized Children 82% 62% Low birth weighed Children 22% 19% Female Sterilization** 17.5% 12% Male Sterilization** 0.2% 0.2% IUD insertion** 1% 0.3% *HMIS 2012-13 ** AHS 2010-11

Public Health Infrastructure

Over the years under NRHM, the state has nominal increase in number of health facilities. As per RHS statistics, no new SCs and PHCs are constructed by the state. State has constructed only 143 new CHC and upgraded some of the facilities.

Shortfall of health infrastructure is highly evident as per the population norms in district Faizabad. There is shortfall of 50% of SCs, 67% of PHCs and 54% of CHCs.

Faizabad District Facilities Expected facilities as per census Existing facilities Shortfall 2011 population norms SC 493 248 245 PHC 82 27 55 CHC 24 11 13 DH 3 3 0

State has issued a government order in 2010 stating, all the BPHCs are to be upgraded to CHCs and all APHCs should have nomenclature as PHCs. Out of total 06 BPHCs – 4 are completed and handed over to concerned in-charge and 2 are under construction (BPHC Mawai has been upgraded to CHC (30 beds) in September 2012 but it is not operationalized yet as furniture and adequate HR is not available). Infrastructure construction is outsourced to a private agency, whose construction process is very slow and results in hindrance in handing over newly upgraded facilities.

All the APHCs have been named as PHCs but facilities provided by APHC are not up to the par as PHCs. Their bed strength even after the change in nomenclature remains same as 2 beds .

Facilities Sanctioned Existing Under Existing in Existing in government Construction rented building building SC 248 246 48 48 198 PHC 06 06 0 0 06 CHC 05 05 0 0 05 DH 03 03 0 0 03 SDH 01 0 1 0 01 APHC 27 27 0 0 27 Tertiary care 01 0 1 0 1 Hospital Urban Health 05 05 0 0 5 Post It has been identified that, 100% of PHCs, CHCs and DH are functional in government building and 19% of SCs are functional in rented building (SC under rented building are under construction). One 300 bedded tertiary care hospital was sanctioned in 2011 and currently it is under construction. Quarters for accommodation are existing in all he facilities.

As per 500 secondary care beds per 10 lakh population norm district is having 153 beds per 10 lakh population with total deficit of around 700 secondary care beds.

Facility Strengthening

Services provided by public health facilities are categorized as per the level of institutions. District and District women hospital are providing specialty care services including Surgery, Medicines, obstetrics & gynaecology, cardiology, Emergency, Trauma care, ophthalmology, ENT, family planning services and ancillary services of blood bank, radiology with, pathology etc. CHCs and 24x7 PHCs (18 PHCs) are centric to providing RCH services with focus on minor surgeries, mild inpatient management and 3 specialty care OPDs(Medicine, gynae, CHC-FRUs are not conducting c-section deliveries, complication management is minimal and no blood storage unit.

80% of SCs are providing ANC services, immunization, IUD insertion and OPDs only. 20% of SCs are conducting deliveries in the district. SCs are not conducting Hb tests as well as blood pressure check during ANC. Haemoglobinometer are not available at SC and digital BP apparatus are available at SCs but ANMs are not conducting BP checks (ANM is conducting BP check at tahseenpur SC but not recording and reporting it ).

AYUSH OPDs are not provided at the facility level as AYUSH medicines are not available in the stock.

Equipments for blood storage unit lying idle at CHC Rudauli

Faizabad District – Delivery points Faizabad District – Non-Delivery points CHC PHC APHC SC CHC PHC APHC SC 5 6 10 49 0 0 17 197

Category wise delivery load Total Deliveries Deliveries Deliveries conducted Deliveries deliveries conducted by DH conducted by FRU by 24x7 PHCs conducted by SC (other than DWH) 32129 22.3% 12.3% 39.6% 26.2%

Bed occupancy is 100% in the district hospital and 68% in the health centers. Maximum bed occupancy is accounted from delivery cases in all health facilities.

Bed strength of Faizabad District

Male district Hospital Female district hospital DSW hospital Total (CHC+PHC+APHC+SC) 212 120 85 174 100% 100% 87.66% 63.08%

Bed Occupancy rate in Faizabad district (CHC+PHC+APHC+SC Bed occupancy rate 2010-11 Bed occupancy rate 2011-12 Bed occupancy rate 2012-13

55.10% 58.03% 63.08%

User charges

User charges for utilizing the services are charged for certain services in public health facilities of Faizabad district. User charges for OPD and IPD (OPD registration - Re 1 for 15 days and IPD - Re 1 for admission), X-ray (30rs per x-ray), lab test (4-7 Rs for haemogram and stool test each) are present. In CHC Bikapur, IP admission charges are 13 Rs, ECG – 16 Rs and ambulance is free (however it is displayed that user charges for ambulance – 10rs/Km, major surgery – 400 Rs, minor – 268Rs). In bikapur CHC, 30 Rs is charged for undergoing pregnancy test. User charges are exempted for pregnant women as under JSSK, all the services are free of cost. User charges were not levied for sick neonates and pregnant women coming for ANC due to lack of awareness among user charge collecting personnel. Apart from it, out-of pocket expenditure is mainly for travel from home, diagnostics and drugs that are not available in facility.

Ancillary services

Laboratories at CHC/PHC are providing very basic services like haemogram, stool test, blood smear and sputum test. SCs are not conducting haemoglobin test and even weighing machine is not functional at most of the facilities. Radiography services at CHC/BPHC include x-rays only. Other laboratory and radiography tests like HIV, VDRL, Biochemistry test, USG, mammography etc are present at the district hospital. It has been identified, drugs are available free of cost except those drugs which are not available at the facilities.

Human Resources

Medical Officers and Specialists District has a total of 105 MOs currently in position as against the sanctioned strength of 121 MOs. The availability of General Medical Officers in 24*7 PHCs/CHCs as against IPHS norms is as shown below:

Required MOs (IPHS General Medical Facility name Type of the Facility norms) Officers

DWH DWH-FRU 13 2 Rudauli CHC-FRU 2 3 Bikapur CHC-FRU 2 4 Sohawal CHC-FRU 2 3 Milkipur CHC-Non FRU 2 7 Poorabazar CHC-Non FRU 2 6 Mayabazar 24*7 PHC 2 3

Khandasa 24*7 PHC 2 3 Mawai 24*7 PHC 2 4 Herringtonganj 24*7 PHC 2 2 Tarun 24*7 PHC 2 6 Masaudha 24*7 PHC 2 3

District faces huge dearth of specialists. None of the 5 CHCs (including 3 CHC FRUs) is conducting C- section deliveries because of absence of requisite team of specialists. Some facilities are also hiring specialists on call basis to conduct sterilization operations. The availability of specialists across the facilities (CHC & above) is as follows:

Anesthetists Gynecologists Facility Type of the Pediatricians (Contractual/ (Contractual/ name Facility (Contractual/Regulars) Regulars) Regulars) DWH DWH – FRU 2 1 5 Rudauli CHC-FRU 1 Bikapur CHC-FRU 1 1 Sohawal CHC-FRU 1 1 Milkipur CHC-Non FRU Poorabazar CHC-Non FRU

To fill the service delivery gaps, training of MOs on EmOC, LSAS, BEmOC, Minilap and MTP should be expedited.

Nursing and Paramedical staff Irregular recruitments have led to major vacancies in the category of Staff Nurses, MPWs and X-ray technicians. Shown below is the availability status of Nursing and Paramedical staff in the PHC/CHCs of the district:

Regular Contractual Personnel category Sanctioned Vacant Sanctioned Vacant Staff Nurses 27 18 18 2 ANMs 294 32 91 1

MPWs 102 91 90 0 Pharmacists 49 1 9 1 LTs 21 1 3 0 X-Ray Technicians 9 5 3 0 ASHAs 2056 91

Deployment of AYUSH MOs AYUSH MOs have helped in filling the gaps in service delivery. There are 23 AYUSH MOs working as General Duty Medical Officers (GDMOs) in PHCs where MBBS MOs aren’t present. But there is no TOR determined for AYUSH MOs. There are 11 other AYUSH MOs deployed in School Health Programme also.

Training achievement Training achievement status stands poor in the district. Despite the scarcity of Gynaecologists, there is only 1 CEmOC trained MO in the district. District has its 3 CHC FRUs functioning only with 6 SBA trained Staff Nurses. CHC Rudauli, a 30 bedded facility was found catering to the monthly delivery load of 229 without any SBA trained SN. BPHC Mawai was also functioning without any SBA trained Staff Nurse. In all the facilities visited, none of the NBCC equipments like Radiant warmer, Phototherapy Unit was being utilized because the staff deployed wasn’t trained in NSSK or F-IMNCI.

There is huge requirement of conducting following trainingon: BEmOC, LSAS, IUCD, FBNC, MTP, NSV, Minilap, NSSK and F-IMNCI since the personnel trained in these disciplines are scarcely/not available in the district.

Retention Strategies Provision of giving difficult area incentive of Rs 100 per month has been persistent from quite long time in the state. The amount is not substantial enough anymore to bind the doctors in the peripheral areas.

In addition to revising financial incentives, regulatory strategies & non financial incentives like educational benefits, such as reservation in PG colleges may also be sought to buttress retention of doctors and specialists in the peripheral facilities.

Generation of Human Resources There is a Government ANM training school with capacity of 50 seats in the district but currently the admissions have been suspended due to inadequate faculty.

Remuneration No scaling of remuneration between the MOs and specialists working under NRHM. The only contractual Pediatrician (DCH) placed at SNCU is being given salary equal to that of the general MOs. Salary of Dental MOs under NRHM has been kept at par with that of General MOs.

Huge disparities exist in the salary of regular and contractual Staff Nurses (SN). A contractual SN gets monthly salary of only Rs 16,500 whereas her regular counterpart gets Rs 35,000 as the monthly salary.

School Health Programme School Health Programme is run under the name of ‘Ashirvad Bal Swasthya Garanti Yojna’in the state. Under this programme, teachers have been trained on screening of school children. Round the year, they screen the students, identify and refer the suspected cases to the nearby PHC/CHCs. School Health Teams positioned at BPHCs, and comprising MO/AYUSH MO and SNs/ANMs also visit the schools biannually for screening of students. The staff deployed under the programme is as shown below:

Personnel category Sanctioned posts Working Vacant MBBS/BDS 11 11 0 Physiotherapist 7 7 0 Ophthalmic Assistant 8 8 0 Dental Hygienist 7 7 0 AYUSH for ABSGY 11 11 0 Staff Nurse 11 10 1 ANM 11 11 0

Maternal Health

Institutional Delivery- District reported 32534 institutional and 13806 home deliveries in previous financial year. With this figure around 25% deliveries are unreported out of total 61709 expected deliveries. The unreported deliveries are majorly due to private health facilities not reporting. Institutional delivery coverage comes out to be 52% of total expected deliveries and 70% of all reported deliveries which is higher than 61% institutional delivery coverage of the state. Out of total deliveries in month of MARCH 2013 40% conducted in level 3 facilities , 28% in sub centers and 32% in Level 2 facilities which shows uneven distribution of case load giving major work pressure on 3 CHC and district women hospital. Introduction or emergency transport system 108 even shifted this proportion towards level 3 facilities with lesser deliveries conducted at sub centres. This is reflected in the bed occupancies of level 3 & Level 3 facilities. Even this bed occupancy is when average length of stay is not more than 24 hours. If norm of 48 hours complied at these facilities and other facilities having more than 100

9 deliveries per moth the condition will be more severe. So for providing quality services these facilities may need expansion as distributing delivery load evenly other non performing facilities and operationalization of non FRU CHCs.

S. Facility Bed Strategy No. Occupancy 1. DWH 102 Needs Expansion 2. Sohawal 46 Needs to increase utilization 3. Tarun 57 Needs to increase utilization 4. Masudha 176 Needs Expansion 5. Milkipur 58 Needs to increase utilization 6. Mayabazar 185 Needs Expansion 7. Harrington 154 Needs Expansion Ganj 8. Mawai 94 Optimal 9. Khandasa 246 Needs Expansion 10. Rudauli 42 Needs to increase utilization 11. Poorabazar 38 Needs to increase utilization 12. Bikapur 58 Needs to increase utilization

Antenatal Care –

Antennal check up is provided at all the facilities. Mother and child protection cards are provided and used for this purpose. But The essential component of ANC like measurement of weight and Blood pressure are not done at the PHC s and CHCs visited. At CHC Rudauli no weighing machine and BP apparatus was available at ANC clinic. At PHC Mawai the ANC clinic was closed on the day of visit. There are lot of anemic case coming to these facilities due cannot be treated due to non availability of IFA tablets and iron sucrose. CHC Rudauli gets 25-30 severe anemia cases in a month. Either they are referred to district hospital for BT or patients are made to purchase iron sucrose from outside.

Even ANC records maintained are not much helpful as pregnant women usually do not bring this record the time of delivery. So Care providers have to either rely on clinical judgment or have to prescribe the entire test again if they have enough time before delivery. As ICTC is available at the district hospital only HIV testing cannot be done at lower level of facilities. USG services are available at the district hospital only.

Distribution of 95% 98% 100% Deliveries 79% 76% Unreport 80% ed Institutio Deliverie nal 60% 48% 41% s Deliverie s 40% 25% 53% 20% 0.20% 1.70% 1.10% 0% 2010-11 2011-12 2012-13 Home Deliverie 3ANC s % of women receivedTT2/booster 22% ANC women having severe anaemia treated at institution

Distribution of Deliveries Level wise

L1 28% L3 40%

L2 32%

Intra natal care – District has four designated FRUs namely CHC Sohawal, CHC Rudauli and CHC Bikapur and District women Hospital Faizabad. Out of these only District women hospital Faizabad is the only facility which is providing full packages of services mandated for a FRU. The CHC designated as FRUs are not equipped for providing EMoNC services. The two CHC visited do not have blood storage unit. Facilities are not conducting C-Sections as specialists are not available at the facility. There is lack of coordination in planning of blood storage unit. Equipment has been provided to one facility while training of technician has been provided to another. All complicated cases are referred to the district hospital only resulting in increased case load at there and delay accesses to emergency obstetric care. CHC Sohawal was conducting C-Sectios till previous year, but stopped after surgeon being transferred. Sri ram hospital at Ayodha which has 16 specialist doctors to not provide any maternal health service.

This Hospital has separate maternity wing with dedicated labour room and OT but do noy conduct either normal delivery of C-Sections as there is no specialist doctor. So maternity ward of the hospital is utilized for admitting general patients.

Management of complications varies according level of facility. While APHCs and PHCs are not managing any kind of intrapartum complication and referring all the cases to higher level of facilities, CHCs can manage some complications like Eclampsia and sepsis but has to refer PPH cases to district hospital due non availability of Blood transfusion services. As told by the service providers at district women hospital 80% of their case load are complicated deliveries.

MTP facility is al not fully utilized. While PHC do not conduct MTPs at other level of facilities also it is negligible.

Implementation JSSK & JSY schemes-

The implementation of JSSK program is partial.

User charges like OPD registration, IPD admission and diagnostic services are exempted to pregnant women and mothers. But As many of time due to non availability of drugs and diagnostics patients have to get them from outs side. As there is no provision of reimbursement of such kind of expenditure under JSSK scheme cashless as per JSSK cannot be ensured. Out of pocket expenditure is also occurring in form of informal fees given specifically in labour room in form of ‘inam’ or ‘baksish’ to care providers and group 4 staff. At district women hospital private wards are chargeable for delivery cases also.

Blood transfusion services at district hospital are free of cost for JSSK beneficiaries but blood is issued against the replacement donor only.

Pick up and referral services are provided by 108 and inhouse state ambulance services but there is no separate vehicle for drop back at most of the facilities. Services are provided free of cost to JSSK beneficiaries.

Provision of diet is difficult at small facilities like PHC as contract has been given to agency at district level and they find it not practical and financially feasible to run kitchen for 4-5 patient daily.

The entitlements of JSSK schemes are not prominently displayed at facilities visited.

There is no backlog of JSY payment observed in the facility visited. Entitlement is provided to the mother in form of bearer cheque during the stay at the facility only.

Maternal Deaths –

Faizabad division reports highest maternal mortality rate in country (437) as per recent AHS report. Though this severity is not reflected in the HMIS data as most of the deaths occurring at home and private hospitals and on the wy to reach the hospitals are not getting reported. As community based maternal death review (Verbal Autopsy) are not being conducted so there is no data on causes of these deaths. Some of the facilities have started maternal death reviews of deaths occurring at their facilities.

We analyzed the data of 62 maternal deaths occurred from January 2011 to April 2013. Analysis shows that in 42% of deaths the underlying cause was severe anemia. The next two major causes are APH (17%) and PPH (12%). If we cumulate these causes around 75% of deaths are occurring due to severe anemia compounded by Ante Partum or Post Partum Hemorrhage.

MDR Pareto Analysis for DWH Faizabad

70 100

60 80

50 t

60 n

40 e

C r

30 e 40 P 20 20 10

0 0 C1 a a r k e s i H H i e c c r m P P s h o i e e A P m t h d h n p O S n t A al au O c J re E ve e S C2 30 12 9 5 4 4 3 3 Percent 42.9 17.1 12.9 7.1 5.7 5.7 4.3 4.3 Cum % 42.9 60.0 72.9 80.0 85.7 91.4 95.7 100.0

These deaths can be attributed to the poor availability of preventive and curative services in term of detection of aneamia, treatment of anemia by IFA tablet & Iron sucrose and blood transfusion services. As told by service providers at district women hospital they are getting lot of cases with hemoglobin as low as 2% every months and some time it is difficult to rescue such cases even after best of efforts. As discussed earlier in this report the consumption of IFA tablets is half in the district (36%) compared to state average (66%).

Child health

I Newborn care

1. All facilities providing delivery services have new born care corners and NBSUs; however radiant warmers and other necessary equipments were not functional in most of the facilities (except CHC Sohawal). Radiant warmer is in place in all the CHCs but staff is not using it due non- availability of pediatrician and lack of skills among staff nurses. 2. SNCU is not functional at District Women Hospital even though construction has been completed and equipments staff have been provided since October 2012. After objections from UNICEF on electrification and earthing the facility has been close. Rs 3 lakhs are required for this correction but district and state health administration is are not able to decide from where this money has to be mobilized.

SNCU at District Women Hospital cannot be operationalized due to lack of funds

3. District has highest neonatal mortality rate (72 – AHS 2011) and high percentage of malnourished children; however neonatal health facilities and focus on malnourished children is totally absent. NRC is also not sanctioned in the district by the state. 4. HBNC-HBNC program has been initiated in the district as ASHAs are CCSP trained though training of the ASHAs in Module-Skills That Save Lives is yet to start. It was found that the ASHAs had not been provided HBNC visit forms and they were getting the forms photocopied from the market from their own. There is no provision of either supervision of the forms filling and neither visits of ASHAs nor verification of the filled forms. 5. The State had requested UNICEF to provide printed HBNC visit forms for at least initial 3 months in the selected 37 districts where the HBNC program was launched. However, UNICEF couldn’t provide the required forms which created much confusion in the districts. ASHAs are being paid for making the required home visits and submitting the filled forms. However, the actual visits could not be verified by the monitoring team. 6. ORS and Zinc combo pack provided by micronutrient is available across the district. However IFA syrup is not available at SCs. 7. Training of MOs and staff nurses is a not adequate in the state. 32% of MOs and 0% of Staff nurses are trained in F-IMNCI and 50% of SNs and 40% of MOs are trained in NSSK.

IMNCI (CCSP) F-IMNCI NSSK

Cumula Cumulati Propo Cumula Cumulati Propo Cumula Cumulati Propo

tive ve sed tive ve sed tive ve sed CH Target Achieve numb Target Achieve numb Target Achieve numb Trainings (from ment ers to (from ment ers to (from ment ers to incepti (Since be incepti (Since be incepti (Since be on till inceptio traine on till inceptio traine on till inceptio traine date) n -till d in date) n -till d in date) n -till d in date) 13-14 date) 13-14 date) 13-14 AWW 0 0 ASHA 136295 39781 15000 ANM 22305 5975 2000 2254 1776 600 MPW (M) 0 0 LHV 3744 754 712 Superviso 0 0 r (M) SN 0 0 0 2760 0 384 2210 1307 600 MO 2083 565 576 1642 534 480 2976 1212 300 Physician MO TOT 664 622 48 Others

Immunization

1. Full immunization rate of faizabad district is 62% with minimal dropout cases. SCs are organizing VHND on every Wednesday and Saturday at AWCs and urban health posts are also organizing routine immunization sessions for urban areas. 2. Cold chain management is adequate in the district. ILRs and deep freezers are available at PHCs/CHCs with proper maintenance of temperatures. It has been identified that district has huge shortage electricity supply. On an average, power availability is 4-6 hours in a day but generators and invertors are provided to all the facilities. Provided generators are of low capacity and they are not able to cater the power need of health facility. Cost for fuel is managed from the budgeted head and user charge collected amount. 3. State has established alternate vaccine delivery system, in which 75rs is given for one round of delivery to the delivery person.

BCG DPT3 Measles Vitamin A -1 JE 2011-12 85.93% 83.12% 80.30% 82.5% 67.91% 2012-13 76.29% 76.75% 73.51% 54.19% 58.26%

Family Planning Laparoscopy and NSV operations are generally done at the District hospital and District Women hospital. However, at some facilities like CHC Rudauli, there is a provision of calling in specialists on weekly basis to do NSV and laparoscopic surgeries. In the last year, a total of 1931 Tubectomy operations have been done in the district but achievement of NSV operations have been very low, i.e. only 15.

Shown below is the illustration on usage of Family planning services within the last 2 years:

Usage of Family planning services - District Faizabad

Year 11-12 Year 11-13

21876

17058

3618 2568 1946 2329 370 983

Sterilization IUCD insertion Oral pills Emergency pills

As apparent from the above figures, usage rate of all Family planning services have plummeted in the district. This may be attributed to the lagging training progress and lack of monitoring of the services.

BCC awareness programmes must be taken up in the district to promote NSV operations among men.

Total sterilization 3500 3000 3089 2500 2624 2000 1500 1520 1000 500 0 2010-11 2011-12 2012-13

Quality of Care –

Structure –

1. Availability of essential instrument and delivery kits was not evident at the labour room visited.. PHC Mawai has no instrument except a scissors at labour room.

2. OT in district hospital has no OT lights despite of high load of C- section surgeries. . Procedures are done in 100 watt bulb. The space in OT is also quite cramped. Facility needs additional OT to cater this kind of load.

C-Sections are done under 100 watt bulb at DWH

3. Ramps are not provided at the entrance at PHC Nawai, CHC Rudauli and Sri Ram Hospital Ayodhya.

4. May I help you desk/ Enquiry counters were not available at any of the facility visited.

5. Junks and condemned items were found lying in patient care areas at many place. At OT of DH the sterile supply storage area was filled with junk material. Stray animals were observed at all of the facility.

6. Screens have not been provided between the delivery tables in labour room

7. Fire safety measures like fire extinguisher and fire exit plan was not evident at any of the facility.

Processes-

1. No security system at district hospital. Only two home guard provided these are quite inadequate.

2. Disposal of Bio Medical waste has been outsourced but the agency contracted for the purpose is not collecting the waste regularly from the facilities. Due to objection from district pollution control board the payment to this agency has been withheld. This is leading to dumping of bio medical waste in open within premises. Heaps of un segregated bio medical waste including anatomical waste was observed at district women hospital. Availability of color coded bins and linen were observed at the facilities but segregation of waste according to guidelines was not evident. Similarly needle cutters were available at point use but hardly used. There is no system of reporting needle stick injury and post exposure prophylaxis evident at the facilities.

Biomedical Waste dumped openly at DWH Faizabad

3. Management of Medical records is not poor. Some of the facility visited do not have any standard format for Bed head Ticket and use plain paper. Even at the district hospital there is no standard printed format for consent for surgery. Consent is taken on BHT only.

4 Availability of linen for patient was satisfactory at the facility visited. Through there is no procedure for segregating and disinfecting soiled infectious linen from others. Laundry services are outsourced and linens are washed outside the premises of hospital.

5. Expiry and near expiry register for drugs are not maintained at the facilities and point of use. Expiry drugs were found in the emergency drug tray at Sub center.

6. Cleaning and disinfection of delivery tables and other operating surfaces is not standardized. At many places antiseptics like savlon is used for this purpose.

7. Regular fumigation of Operation theater is not found practiced. District Women Hospital has only one Operation Theater and it hardly get spared for fumigation due to high caseload.

5. Records if autoclaving was not found at any of the facility visited. There is no provision of validation indicators for assuring quality of sterilization process. Delivery instruments at labour room are not

18 autoclaved. They are simply used after boiling. There is practice of forming delivery kits and episiotomy kits. Instruments are used in loose.

6. Pantographs are not being maintained at any of the facility visited. At the CHC and PHC visited ANMs were not aware of any such clinical protocol.

7. Clinical protocols including management of complications, Newborn resuscitation and infection control ere not displayed at any of the facility.

8. Vitals are not noted during the intrapartum care in the labour rooms of PHC s and CHC visited.

9. Bio Medical Waste Management collection is not done by the outsourced agencies.

10. Treatment charts are not maintained at SBNU

Case of Baby of Rekha

Rekha (Name changed) admitted at CHC Rudauli on midnight of 5th may 2013. She delivered a male baby at 6.30 AM next day. As per BHT weight at birth recorded was 2.4 kg . At the time of our visit the mother and baby were already discharged and were preparing for leaving hospital. As per note

written on BHT Mother and Baby were both in good health. Though when we asked the mother she told that the baby is preterm -7 month, By appearance also baby was appearing to be low birth weight. Baby was weighed again in front us it comes out be only 1900 gms. When enquired , nobody has clinically assessed the baby since birth though facility has full time pediatrician. The Mother and baby were discharged by the doctor on duty without even assessing the baby and taking any opinion

from pediatrician. On enquiry it was told that Pediatrician has not done any round in wards in last 24 hours and he was not aware of condition of any of the new born admitted. Facility has SBNU but from its appearance it was evident it is hardly ever used. There was no patient record maintained for the newborns admitted at NBSU. There is no protocol of refereeing the newborns to pediatrician. Mostly they are discharged by duty doctor on his/her own clinical judgment.

Drugs- Availability of drugs was scarce specially at level 1 and level 2 facilities. Even general medicines like Paracetamol , albandazole were not available at PHCs and CHCs. Availability was comparatively better at the district level hospitals. As per information provided by the chief pharmacist at district drug store, drugs are not been either supplied or are supplied in less amount from the rate contracted agencies by state health department. The requisition made in January this year is still pending with the vendors. Vendors usually take a lad time of 2 month to supply drugs which are enormous by any standards for critical commodity like drug. There is no scientific method to calculate the indenting quantity at facility and district level. Drugs are indented by arbitrary method. Facility incharges also complained of dumping unnecessary drugs at their stores by district authority. The same allegation was made by district drug store that state authorities is sending drugs to them those are not indented and required by them. As per status of drug availability provided by district drug store on 8th May only 77 seven type of drugs and consumables were available in their stock.

Referral transport There are a total of 15 BLS ambulances which have catered to 1603 calls made in the last fiscal, among which 669 were the pregnancy related cases. In addition to the NRHM funded ambulances, district also has state owned/funded ambulances but daily fund given for its utilization is quite low, i.e. Rs 500 per day. State ambulances also found to be lacking the basic emergency equipments like Oxygen cylinder, etc. In some facilities like BPHC Mawai, CHC Bikapur and 24*7 PHC Herringtonganj, dropback facilities are not being provided to JSSK beneficiaries.

Complementarity between 108 and state owned ambulances must be sought to address the service gaps and ensure the dropback services for the JSSK beneficiaries.

Advent of 108 ambulances services has strengthen the referral transport system but shifted the patient load towards bigger hospitals

HMIS

State is reporting district level data in the national web-portal. In process to implementing facility wise data reporting, only 4 districts has initiated facility level data entry ( data status is 32%) but faizabad district is reporting district consolidated figures online. In 68 districts, paper based HMIS reporting system exists below district level. It is extremely difficult to identify the non-reporting facilities. Data status of monthly district consolidated report is 94 % i.e. all 68 districts are uploading the district monthly consolidated report on time. Reporting time period is 20-21st of every month and it is uniform across the state.

State is having poorly designed primary registers. Printed register were distributed for the purpose of maternal and child tracking only. However all the parameters of HMIS report related to RCH are not covered in MCH tracking register. And other service delivery registers are manually prepared by the each facility in their own respective way. As HMIS formats are in process of rationalization so state should design uniform registers for each facility type across the state.

In addition to HMIS report, state is compiling many programme specific reports to fulfill the information demand of specific programs. These programme reports has same data elements as in HMIS report. Therefore service providers are submitting multiple reports for same data elements, however consistency among figures are evident. Multiple reports are – family planning reports, MCH report, immunization report, MCTS, monthly progress report, JSY report, training status report, BMGY report,

EMTS report, untied fund report, NBSV, CCSP report, JSSK report, 24x7 report, Accredited SC report, FRU report etc. Block data cum account assistant and MCTS data entry operator is posted at all the 11 blocks and district hospital of faizabad district. Post of data manager and data entry operators at vacant at district head quarter.

HMIS training is not adequate in the state. One day district level training was conducted at the state level and further block teams (BADA & DEO) were trained by the district officials and service provider were trained by the block during review meetings.

Upload mother and child tracking data was initiated in july 2011, however data entry of only 45.7% pregnant women and 27.6% is completed by the state. All the service providers are submitting their registers to data entry operator at block level on monthly basis and collecting it back within 1 week time. Faizabad district has shown considerable improvement in mother and child tracking system, 58% of mothers and 44% of child has been registered as on January 2013. Blocks are not generating work plan from MCTS and therefore main purpose of tracking system is withheld.

Community Process-

ASHA Selection and Training- In the district, against the target of 2056 ASHAs, a total of 2056 ASHAs had been selected and 1924 ASHAs were trained up to Module-5 of ASHA Induction training. The State had conducted ASHAs training up to Module-5 in two versions. Module-1 training was done separately while Modules-2,3 and 4 were combined in a single module. In block Mawai, 152 ASHAs had been targeted to be selected out of which 152 ASHAs were selected and trained up to Module-4. In module-5 training, 147 ASHAS had been trained. In Rudauli block, 210 ASHAs were selected against the same target out of which 204 were trained up to Module-4 and 195 were trained up to module-5. In Sohawal block, 184 ASHAs had been trained up to Module-5.

Regarding the identification and selection of ASHA,it was stipulated that the District Health Mission shall designate a senior level health official who will be responsible for ensuring the full participation of the health department in the district. He will coordinate with other departments and Non-Governmental organisations also in properly implementing the ASHA Scheme in the district. The District Health Mission shall designate a block level nodal officer also, preferably the block medical officer who shall provide full cooperation in the selection, training and implementation of the ASHA Scheme. Initially the Block Nodal Officer shall deploy 10 or more facilitators depending upon the circumstances and the need in the particular block area and each facilitator shall be responsible for 10 villages for undertaking the proper and transparent identification and selection of ASHAs. For the post of facilitators, women shall be given preference who could be the members of local NGO, Mahila Mandal, Mahila Samakhya, AWW, Swasthya Karyakarti or any other social society. In case such a person is unavailable then the local female school teacher shall be designated as the facilitator.

All the selected facilitators shall be called at the district level to participate in a 2 Day orientation workshop in which they will be comprehensively oriented by the district Nodal Officer with the ASHA

Scheme and the process of selection of ASHAs. They shall be apprised with their as well as the Block Nodal Officers’ roles and responsibilities in the selection process of ASHAs.

These facilitators shall conduct Focussed Group Discussions and open meetings in the villages under their jurisdiction during which they shall discuss the ASHA Scheme and shall apprise the community members with the roles, responsibilities and accountabilities of ASHAs so that ultimately she is able to get at least 3 probable candidates for final selection of ASHA in that particular village. From among the 3 names recommended through the above mentioned process, one with the maximum qualification shall be finally selected as ASHA in the Gram Sabha meeting that shall specifically be held for the purpose of selection of ASHA from the concerned village. The minutes of the meeting in which members have unanimously given their agreement over a particular candidate shall be provided to the District Nodal Officer after which the particular Gram Panchayat shall enter into a written contract with the ASHA as had previously been done under the Gram Shiksha Samiti and the Sarva Shiksha Abhiyan programmes for the deployment.

As per the deliberations conducted with the officials as well as ASHAs, it appeared that the Pradhans had not played a major role in the identification and selection of ASHAs, though Pradhan’s clout and power influenced selections in the cases of a number of ASHAs. In most of the cases, it was the ANM who played the role of facilitator, identifier and final approver for selection of ASHAs. The advertisement regarding the ASHA selection was not disseminated widely and generally, it was through word of mouth that information was circulated in the village. However, in the absence of the records of original selection deliberations, it is difficult to agree with the reason given without further corroboration and investigation. (The original records related to the identification and selection of ASHAs are in most of the cases hard to be seen at the various block PHCs/CHCs, the reason generally cited for their unavailability is that the current Medical Officer In charge was posted somewhere else at the time of selection of ASHAs and the related records were never handed over to him by his predecessor.) We have some, though very few, cases where allegations of production of fictitious certificates of 8th class have been reported to satisfy the minimum educational qualification criteria for ASHA selection.

ASHA Drop-out and Replacement selection Status-In the year 2009-2010 very detailed and strict guidelines were framed and sent to districts according to which the issue of drop-out ASHAs was to be tackled. The detailed guidelines stipulated that only those ASHAs shall be deemed to have resigned who give written certifications as per the structured resign letter format devised by the State duly vouched by the concerned ANM and certified by the concerned Medical Officer Incharge.

In the visited blocks, the number of ASHAs who had voluntarily resigned was comparatively very less. Those who had resigned had been selected somewhere. In comparison to other districts, in Faizabad, the number of ASHAs not working was less. Replacement selection had been done in all the blocks except in 1 or 2 cases.

ASHA Facilitators

ASHA facilitators have recently been selected in all the blocks of the district, though their 5 day training is still pending. The district CMO expressed apprehensions with regard to the identification of ASHA

23 facilitators from among the ASHAs themselves. According to him, this had created divisions among the ASHAs. After the completion of the ASHA Facilitators training they are expected to start work.

ASHA Payment-ASHA incentive payment in all the blocks had been done up to March-2013. Payment to ASHAs is made through the single bank advisory and is deposited in the accounts of the ASHAs. All the blocks have been provided ASHA vouchers and Block Master Payment Register except Harrington where neither ASHA vouchers nor Register are available. Payment to ASHAs in Harrington are being made without any authenticated and verified vouchers. Even where ASHA vouchers are being used, they are not submitted by the ASHAs regularly and the block authorities also do not demand the vouchers on regular basis. In Bikapur block, only 5 bank advisories were submitted in the whole fiscal year. Similarly, in Harrington block, only two bank advisories were submitted in the whole fiscal 2012-13 against an ideal number of 12 advisories. It was informed that the blocks initially received the funds under ASHA incentive head for 6 months in August-12 after which requisition was made to the district in October for release of the remaining funds. As an indication of the remuneration being earned by ASHAs on a monthly basis, in one of the blocks, a total of Rs. 245030 was paid to 174 ASHAs forFeb-13 under both JSY and Mission. Also, a sum of Rs. 9207445 was paid to 2056 ASHAs in the district as a whole in the fiscal 2012-13 under Additionalities which means that on an average a sum of Rs. 373 per month was earned by one ASHA in fiscal 12-13 under Additionalities. Similarly, under JSY a sum of Rs. 16280250 was paid to ASHAs in fiscal 12-13 which means on an average, a sum of Rs. 660 was paid per ASHA per month.

ASHA Drug Kit-Funds for ASHA Drug Kit had been transferred to the district in the month of December- 12 @ Rs. 350/ ASHA Drug Kit. However, in Faizabad, like in other districts in the State, Drugs were to be made available through the Rate Contract. The prescribed drugs in the guidelines could not be procured with the sanctioned amount and the districts made a representation in this regard to the State which advised to purchase the most essential drugs worth Rs. 350. The fresh direction issued by the State in this regard is to constitute a committee which will select the most essential drugs worth Rs. 350 after which the list will be presented to the DHS for approval. After the approval from DHS, in case the drugs are in RC, it will be procured through this route, otherwise tender will be floated.

ASHA Monthly Meetings-In all the blocks visited, ASHA monthly meetings are being conducted regularly with the categorization of ASHAs into 3-4 groups as per the guidelines. The quality of the meetings conducted was, of course, not up to mark as the documentation of the minutes didn’t reveal any capacity building sessions or efforts to increase their level of knowledge. Structured formats for categorization of the ASHAs for the purposes of meeting and attendance have been specifically designed and sent to the districts as fresh and modified guidelines for conduction of ASHA monthly meeting. Due to non-adherence to the provided meeting guidelines, the effectiveness and the fulfillment of professed objectives of the meeting have been compromised and this phenomenon is not unique to Faizabad but has been noticed elsewhere also. No structured agenda is prepared before the meeting, neither capacity strengthening topics are decided, nor minuting is done properly. The prescribed monthly review meetings of HEOs are also not regularly conducted at the district level.

CCSP Training and provision of Drugs and Equipment under this program-Though Faizabad is among the first phase CCSP districts in the State, in all the visited blocks, not more than 50% of the targeted ASHAs had been trained under this program. In the district as a whole, out of 2049 ASHAs, a total of 1575 ASHAs were trained in CCSP. No equipments had been provided to ASHAs and drugs, namely, Cotrimoxazole, PCM, ORS and cotton were distributed among the CCSP trained ASHAs one time only.

Performance Monitoring-ASHA Facilitators have been deployed in Faizabad and the selection process for the same has just concluded in the month of March-13. The 6 day induction training of ASHA Facilitators is yet to be done. Issues regarding selection of AFs were reported from one of the visited blocks and the district collector has ordered an investigation into the whole selection process and a report is awaited for the same. Only after the deployment and training of AFs, the structured mechanism of ASHA performance could be initiated.

However, there are incentive payment heads which might provide a broad picture of the performance of the ASHAs. But when looked into its entirety, the ASHA Block Master Payment Register which records details regarding the activities conducted by the ASHAs and payments received by them, cannot be a reliable source of ASHA performance as there are, in fact, a number of institutional and complimentary factors also which influence the performance of ASHAs.

ASHA Activities-The major activities performed by ASHAs are accompanying the delivery cases, participating in the RI sessions, sterilization, epidemic information, acting as DOTS, HBNC. It seems there have not been efforts to motivate the ASHAs to perform other activities. ASHAs informed that though incentivisation of conduction of two community meetings has been discontinued, they were still conducting pregnant women and adolescent girls meeting. The discontinuation of incentive for activities like community meetings, completion and updation of VHIR register, bringing complicated deliveries to facilities has been adversely affecting the motivation and morale of ASHAs.

Caste composition of ASHAs as compared to population they are serving-5 ASHAs out of 7 with whom interactions were done in the Bikapur block didn’t belong to the majority caste of the population they were serving. When ASHAs were from the upper caste, the majority community belonged either to SC or to OBC.

Beneficiaries Perspective-One of the beneficiaries met at the district hospital had been referred from some interior block though she delivered the baby normally without any complications or issues. ASHA had accompanied that lady and was in fact residing with the woman. Majority of the beneficiaries informed that their ANC had been done with the help of the concerned ASHA. When ASHA was asked about the counseling, she told that the mother had been advised to exclusively breastfeed the baby up to 6 months, eat 4 times a day, in case of change of pads for more than 5 times in a day by the mother, referral to facility was required. ASHA told that she will visit the mother and baby for 6-7 times up to 42nd day.

VHSNCs- VHSNCs have been constituted in all the Gram Panchayats of the visited blocks and accounts have also been operationalised in all the VHSNCs. The expenditure pattern is not rationalized and need

25 based. In cases of VHSNCs visited, there had not been any record of conduction of mandatory quarterly meetings of the concerned VHSNC and preparation of village health plan.

The State transferred the VHSNC amount to districts in September-12 but the visited blocks could transfer the funds to the accounts of the VHSNCs only in March-13. The State had given the instruction that the funds to the VHSNCs had to be transferred after adjustment which means that the total funds in the account of any VHSNC should not exceed the limit of Rs. 10,000. The blocks could get the VHSNC wise balance information only in March-13 due to which the transfer of funds to VHSNCs was delayed.

Moreover, due to change in the nomenclature of the VHSNC from VHSC to VHSNC, the banks at some of the places created problems as to the validity of the operationalization of accounts in the name of VHSNC rather than VHSC.

***END of REPORT***

Annex1

Monitoring Team

1. Dr. Nikhil Prakash, - Consultant – Quality Improvement, NHSRC

2. Dr. Sajid Ishtiaque - Consultant – Community Processes, NHSRC-

3. Ms. Itisha Vashisht- Consultant – HMIS, NHSRC

4. Mr. Nishant Sharma- Consultant- Human Resource for Health, NHSRC

Annex 2

Visit Schedule

6th May 2013 to 8th May 2013

Facilities visited by the team DH 3 District Head Quarter Male, District headquarter female, District combined hospital CHC 3 CHC Rudauli, CHC Sohawal, CHC Bikapur PHC 2 PHC Herrington, PHC Mawai SC 2 SC Tahseenpur, SC Devkhali Urban health post 1 Kashmiri Mohalla VHND 1