Panjab District- Firozpur Evaluation Report of Firozpur District (Punjab

Home , Faridkot district, Firozpur district

Panjab

Evaluation Report of Firozpur District (Punjab) The Regional Evaluation Team, located at Regional Office for Health and Family Welfare (Patna), Ministry of Health and Family Welfare, Government of India carried out sample checks of activities covered under NRHM / RCH in Firozpur District of Punjab State during July, 2011. The findings / observations of the team which are based on the sample checks are detailed below: I. Details of the visited Institutions: As part of evaluation, the team visited Sub District Hospitals (SDH), Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub Centres (SCs) in both Districts of Firojpur and Faridkot as per the details given below:

Districts S.D.H./CHC/PHC Sub Centres Firojpur S.D. Hospital: Fazilka Saraiah, Khuranj, Karma, Chhanga- CHC: Jandwala, Mandot & Guruharsahai khurd, Prabjb & Sohangarh PHC: Jandwala Bhim Shah

II. Major Observations:

1. Human Resources: Shortage is a common phenomenon across all categories of clinical staff. More than 30% Posts of Medical Officers and about 24 % posts of Specialists were lying vacant in the District. The details of posts sanctioned, in position and vacancies are as given below: Post Post sanctioned In position Vacant M.O 159 111 48 Specialists 80 61 19 GNM 266 213 53 Lab Technician 75 41 34

2. Rogi Kalyan Samiti (RKS) and Village Health Sanitation & Nutrition Committee (VHSNC): a) Rogi Kalyan Samitis (RKS) were constituted in all the PHC and above level Health facilities covered in the evaluations study but their meetings were not being conducted regularly. b) Details of funds allocated / available, expenditure incurred during 2010-11 in different institutes are as given below: (in Rs.) Type of Institution 2010-11 Fund Available Expenditure Balance D.H 5,00,000 4,96,481 3,519 S.D.H & Others 3,00,488 2,93,305 7,183 CHCs 8,00,000 7,94,500 5,500 PHCs 54,20,125 52,73,538 1,46,587 c) No funds were released up to July, 2011 to any health facilities during 2011-12. d) It was reported to the team that a total of 1217 Village Health Sanitation & Nutrition Committees were functioning in the district and out of the total budget allocation of Rs. 1,29, 85,544, an amount of Rs. 1, 22, 92,031 was utilized by these VHSNCs during 2010-11. e) The budget allocation for the current year (2011-12) was reported as Rs. 6,93,515 and the utilization up to June, 2011 was only Rs. 1,03,746. 3. Services of Janani Suraksha Yojana (JSY): a) During the field visit, the team observed that necessary information was not recorded in JSY cards and JSY registers were not maintained properly at the facilities covered in the evaluation. b) Mothers of young children (13 Nos.) contacted by the team reported to have received 3 consecutive post natal check-ups after delivery. c) The team was provided details of allocation and utilization funds during evaluation. It was reported that an amount of Rs. 65,60,580 was spent out of the budget allocation of Rs.65,90,480 under JSY. However, during the year 2011-12, funds are not allocated to the district under JSY; an expenditure of Rs.7, 65, 625 has been incurred up to June, 2011. d) It was also reported that the district had spent full amount of Rs.13,69,000 that was provided for Referral Transport for the year 2010-11 under JSY scheme. No allocation for the current year (2011-12) has been made to the district but Rs.2,16,800 spent up to June, 2011. 4. Functioning of ASHA Scheme: a) It was reported to the team that out of a target 1393 ASHAs for the district, 1337 were in position and 1278 were trained in all modules and provided drug kits. b) It was also reported that ASHAs were receiving incentive money on monthly basis. 5 Untied funds: a) It was observed that the untied funds allocated to the SCs were utilised and cash books maintained properly. b) The fund utilization position was quite encouraging during 2010-11 but not so in 2011-12.The details of utilization of untied funds at CHCs, PHCs and SCs level for both the years reveals the position. Type of 2010-11 2011-12 (up to June,2011) Institution Fund Available Expenditure Balance Fund Available Expenditure Balance

CHCs 4,00,573 4,01,227 348 4,00,346 NIL (0%) 4,00,346 (100%) PHCs 8,52,620 8,40,247 12,373 8,62,373 11,000 (1%) 8,62,373 (99%) Sub Centre 25,59,942 22,77,491(89 2,82,451 25,92,451 10,000 (0%) 25,82,451 %)

6. 24 x 7 hours Delivery Care Services: It was reported that there were 16 institutions providing 24 x 7 hours delivery services in the district. 7. Physical Infrastructure and Stock Position: i. CHCs and SDH: a) Blood storage unit was not established at the CHCs at Mandot and Guruharsahai. b) Some of the surgical equipments, Anaesthesia equipment and Inj. Quinine were not available at CHC Mandot. c) Sick New Born Care Unit was not established in CHC Mandot and SDH, Fazilka. ii. PHCs: a) PHC, Jandwala Bhimshah had its own building with Regular water supply, electricity connection and Toilet facility. Maintenance of the hospital building was satisfactory. Telephone facility was also available. b) Most of the essential equipments and supplies were available in the PHC. Stock of OPV, DT. Vit. „A‟ solution etc. was not available on the day of visit. c) There was no residential accommodation at PHC for MO.

iii. HSCs: It was observed that the availability of medicines, clinical consumables, equipment etc. was poor at HSCs visited, the details are: a) Sub Centres at Saraiah and Khuranj were having own government building with regular water supply, electricity connection and toilet facility. b) Labour room, Delivery table, McIntosh sheets, Ambu bag / suction, Delivery Kit and RDT Kit for malaria were not available at both the above visited Sub Centres. c) Steam sterilizer, Nischay pregnancy test kit, Torch and stove were not available at Sarrian Sub Centre. c) EC pills, Co-trimoxazole, Misofrostol, Magsulth and Oxitocine tablet, Ampicillin Capsule and Gentamycine injection were not available at both the Sub Centres. d) Slides for blood test, IFA Tablet/syrup, chloroquine tablets and Metronidazole tablets was not available at Khuranj S/C whereas Kit-A and Kit-B was not available at Sarrian S/C. d) Printed Eligible couple Registers were not available at Khurang Sub Centre. e) SBA training was not given to the ANMs. 8. Community Satisfaction on overall service: i. Services of ANMs: a) Mothers (18) of young children (up to one year of age), who had institutional deliveries, expressed their satisfaction with the services provided by ANMs. b) Though 40% of the contacted mothers were not aware of ARI & ORT, all of them were aware of the benefits of exclusive breast feeding, complementary feeds and the services available at Government Health Facilities. ii. Services of MPW (Male): a) Work of MPW (Male) was assessed at SC Saraich and his service delivery was up to the mark. b) Popularization and distribution of Nirodh by MPW needs further boost. iii. Services of PHC/CHC: a) It was reported that Medical officer of Mandot CHC, Guruharsahai CHC and PHC Jandwala Bhim Shah did not pay regular visits to villages on regular basis. b) Though the community was satisfied with the services provided at CHC/PHC headquarters, some of the contacted mothers were not aware about the ANC, ARI, ORT and AIDS/HIV.

9. Sample Verification of Family Welfare Acceptors: a) Out of 113 acceptors of family planning selected, 63 (55.8%) could be contacted for sample verification in the district. Eleven FP accepters (18.0%) reported that they did not receive any follow-up services. b) Out of 23 selected samples of child immunization, 20 (87%) were contacted in which all beneficiaries confirmed the receipt of immunization doses and expressed their satisfaction. 10. Reconciliation of Reported performance: a) The team observed variations in the performance (Sterilizations) between the figures reported by the District authorities compared with data available at the CHCs for the years 2010-11 and 2011-12 (Table). Sr. Name of centres Sterilization performance reported at No. 2010-11 2011-12 (upto June, 2011) District office Centres District office Centres 1. Guruharsahai CHC 452 450 39 57 2. Jandwala CHC 618 NA 75 NA 3. Fazilka CHC 206 204 57 57 4. Mandot CHC 681 676 73 106 b) While conducting verification of the performance of family planning acceptors, there was no reports and registers available for the year 2010-11 and 2011-12 at CHC Jandwala. It was also observed that CHCs located at Guruharsahai and Mandot did not prepare similar registers for sterilization for the year 2011-12 till visit of the team. c) There were only 192 sterilization cases recorded in the services register at CHC Mandot as against the reported figure of 676 for the year 2010-11. 11. Maintenance of Register & Record: The team observed that: a) Eligible Couple and Child Register were not maintained / not made available at Fazilka CHC, Fazilka and Jandwala CHC. b) Service Registers were not made available at most of the visited centres. c) Stock Register of Cu-T, OP and CC were not maintained properly and not up to date at all visited PHC/CHC and HSC. d) JSY beneficiaries Register was not maintained properly and up to date at all the visited centres. 12. Other Important Observations : a) SBA Training for Staff Nurse & HW(F) and NSV training for MOs was not provided. Also the concerned staff and officers were not trained in MCH tracking. b) The condition of labour room and maternity wards at S.D.Hospital Fazilka was very poor and unhygienic. It was observed that entry restriction for general public / party members was not maintained at the entrance of labour room c) The team observed that the supervision at the centres was totally lacking as a result records and registers found not maintained properly. d) It was observed that the staff working at DPMU and BPMU was not having adequate knowledge about the different programme under NRHM. Re-orientation Training is essential to these units for proper implementation of the programmes.

************

1. District- Faridkot . Evaluation Report of Faridkot District (Punjab) The Regional Evaluation Team, located at Regional Office for Health and Family Welfare (Patna), Ministry of Health and Family Welfare, Government of India carried out sample checks of activities covered under NRHM / RCH in Faridkot District of Punjab State during July, 2011. The findings / observations of the team which are based on the sample checks are detailed below: I. Details of the visited Institutions: As part of evaluation, the team visited Sub District Hospitals (SDH), Community Health Centres (CHCs), Primary Health Centres (PHCs) and Sub Centres (SCs) in both Districts of Firojpur and Faridkot as per the details given below:

Districts S.D.H./CHC/PHC Sub Centres Faridkot CHC: Bajakhana & Jaitu Rumana Ajit Singh, Jaitu & PHC: Golewala Ghughiyana

II. Major Observations:

1. Human Resources: The team observed that large number of vacancies across all categories of clinical staff exist in the district notably the Medical Officers and MPW(M). The details of vacancies are given below:

Post Post sanctioned In position Vacant M.O 41 19 22 Specialists 36 30 6 ANMs 79 67 12 GNM 74 54 20 MPW(M) 69 18 51 Lab 23 20 3 Technician

2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation Committee (VHSC): a) It was observed that Rogi Kalyan Samiti (RKS) was constituted in the district and also at the visited centres but their meetings were not being conducted as per norms. b) Fund utilization position is quite alarming though RKS funds were provided to the institutions viz. DH, SD /CHCs/PHCs in the district during the year 2010-11. The entire amount allocated for the year 2010-11 had been carried forward to 2011-12. Out of the carried forward funds, during 2011-12 (Up to June, 2011)  SDH and other centres utilized only Rs. 18,500 out of Rs. 1, 00,000,  At CHC level, out of Rs. 4,00,000 RKS fund available, Rs. 70,925 had been spent.  At PHC level only Rs.1,22,454 out of RKS fund Rs. 8,96,256 had been utilized  No expenditure was incurred by the district hospital out of RKS funds available (Rs. 5,00,000) during the current year. d) It was reported to the team that 187 Village Health & Sanitation Committees have been constituted in the district and the entire budget allocation of Rs. 18, 70,000 during last year (2010-11) had been fully utilized. However, during 2011-12 (till June, 2011), no fund utilization had been made (Allocation Rs.18, 70,000) by the VHSCs. 3. Service of Janani Suraksha Yojana (JSY): a) The team observed that necessary information was not recorded in JSY cards. JSY registers were also not maintained properly at the visited centres. b) Some of the mothers (out of 9 contacted in the area of visited centres) of young children did not receive three consecutive check-up in time. c) It was observed that the fund utilization position is not encouraging.  During the year 2010-11, funds to the tune of Rs.22,96,675 were spent out of Rs.26,34,175 (Allocation) under JSY head.  During the year 2011-12, out of Rs. 20, 83,288 (Allocation) the utilization was only Rs.5, 34,282 (up to June, 2011).  Under the Referral Transport Head, an amount of Rs. 7, 46,400 out of Rs. 10, 19,175 allocated was spent during 2010-11.  During 2011-12 (Up to June, 2011), out of Rs. 7 73,000 allotted to the district, Rs.2,61,200 had been spent. 4. Functioning of ASHA scheme: a) It was reported that 396 ASHAs were in position as against the targeted of 407 in the district and 360 ASHAs trained in all modules and 396 ASHAs were provided drug kits. b) It was also reported that ASHAs were regularly receiving incentive money per month. 5. Untied funds: a) The total untied fund to the tune of Rs.28,90,000 was received for the year 2010-11 and the whole amount was spent during the year. Out of available fund Rs. 28,90,000 in the year 2011- 12 and Rs. 1,18,705 in the current year up to June, 2011was spent in the district. b) Utilization of untied funds at CHCs, PHCs and SCs level is as follows: Type of 2010-11 2011-12 (up to June, 2011) institutions Fund Available Expenditure Balance Fund Available Expenditure Balance

CHCs 2,00,000 2,00,000 NIL 2,00,000 54,761(27%) 1,45,239 (100%) PHCs 2,00,000 2,00,000 NIL 2,00,000 59,944 1,40,056 (100%) (30%) Sub 6,20,000 6,20,000 NIL 6,20,000 4000 (0.6%) 6,16,000 centre (100%) c) During the visit to SCs, it was found that the untied funds were utilised and the cash books were maintained properly 6. 24 Hours delivery care services:- As reported, there were 5 institutions providing 24 x 7 hours delivery services in the district. 7. Physical infrastructure and stock position: CHCs: a) Most of the equipments, drugs and supplies were available at CHCs Bajakhana and Jaitu. b) X-ray, Anaesthesia equipment and Inj. Quinine were not available at CHC Bajakhana. c) Sick New Born Care Unit was not established in CHC Bajakhana. d) Arteerther & Quinine inj were not available at Jaitu CHC. e) Out of six sanctioned posts, only one specialist was posted at Bajakhana CHC where as not a single specialist was posted at Jaitu CHC. PHC: a) PHC, Golewala had own building with Regular water supply, electricity connection and Toilet facility. Maintenance of the hospital building was satisfactory. Telephone facility was also available there. b) Most of the essential equipments and supplies were available in the PHCs. Stock of DT and. Vit. „A‟ tab. etc. was not available on the day of visit. c) There was no residential accommodation for PHC MO. d) There was no functional Operation Table. HSCs: a) Sub Centre visited at Ghughiyana was having own government building with regular water supply, electricity connection and toilet facility. b) Labour room was available at Ghughiyana SC. Labour room was not available at SC Remuna, but delivieries were not conducted there. c) Ambu bag/suction, Foot Stool, Mcintsh sheets, Delivery Kit and Steam Sterilizer were not available at the Sub Centre Remuna whereas Nischay pregnancy test kit, Torch and stove were available at both the Sub Centres. e) EC pills, Antiseptic solution, Bleaching powder, Metronidazole tablets, Misofrostol tablets was not available at Remuna HSC and DDKs, Kerosene oil, Chloroquine Tab was not available at Ghughiyana SC. f) SBA training was not given to the ANMs. 8. Community Satisfaction on overall service: i. Services of ANMs: a) The team contacted 10 mothers (5 in each SC visited at Remuna and Ghughiyana SCs)) having child up to one year of age and interviewed them to assess their knowledge and opinion of the services rendered by the ANMs. Mothers replied that:  The ANMs stay in HSC villages.  They were satisfied with ANMs‟ services.  Their deliveries were institutional. All mothers were aware of the benefits of exclusive breast feeding and complementary feeding.  Immunisation sessions were conducted on regular basis in their village. b) 3 (40%) of the contacted mothers were not aware about ARI & ORT. c) All mothers were aware of Government Health Facilities where they can get all health facilities. ii. Services of CHCs/PHC: a) The team interviewed some beneficiaries, AWW, ASHAs and village leaders in the area of visited CHCs and PHC. It was found that:  ANC and PNC services were provided in time to the mothers but they did not have knowledge about ARI & ORT.  It was also found that mostly mothers were not aware about AIDS and HIV.  There is a need for popularizing the benefits of institutional deliveries through ASHAs to the expectant mothers regularly. b) The team also observed that mothers of young children should be educated for bringing their children to hospital in right time for Immunization. c) Medical officer of visited CHCs and PHC were not visiting the villages on regular basis.

9. Sample Verification of Family Welfare Acceptors: a) Out of 97 acceptors of family planning selected, 55 (57%) could be contacted for sample verification in the district. 39 (71%) FW acceptors found to have not received follow-up services after accepting the FP methods. b) Out of selected 45 beneficiaries of child immunization, 31 (69%) beneficiaries could be contacted and confirmed the doses. c) Follow up service was not provided to 22 (71%) beneficiaries. 10. Reconciliation of Reported performance: a) It was observed that Sterilization and IUD figures reported at CHC Bajakhana for the year 2010-11 and 2011-12 (up to June, 2011) did not tally with the figures of service registers:  There were 313 Sterilization acceptors and 103 IUD acceptors recorded in the service registers as against the reported figures 937 and 1807 for the year 2010-11.  Similarly, 134 Sterilization and 43 IUD acceptors were recorded in the service registers as against the reported figures of 307 and 466 respectively up to June, 2011 for the current year. b) There were under reporting of sterilization figures at CHC Jaitu :  For the year 2011-12 (up to June, 2011), the actual acceptors of sterilization as per the service register were 129 whereas reported number was 120. 11. Maintenance of Registers & Records: a) Eligible Couple and Child Registers were maintained properly at Bajakhana CHC and Jaitu CHC but the registers were not maintained properly at Golewala PHC. b) Sterilization service register was not maintained properly at Golewala PHC. c) Cu-T service register was maintained properly at Bajakhana & Jaitu CHCs but it was not maintained properly at Golewala PHC. d) ANC Register was maintained properly at Jaitu & Bajakhana CHCs but the same was not maintained properly at Golewala PHC. e) Stock Registers of Cu-T, OP and CC were not maintained properly at all visited CHCs/ PHC/ HSCs. 12. Other Important Observations and Suggestions: a) Training on MCH tracking was given neither to district officials nor to peripheral officials in the district. b) OP & Nirodh distribution under F.W programme was not up to the mark at SC level and also no prescribed Performa was available for maintaining stock and distribution of Cu-T, OP & Nirodh. ANC/PNC registers were also not available. c) It was observed that the staff working in HQ and CHCs/PHC was not having adequate knowledge about the different programmes under implementation under NRHM. Re-orientation Training is essential at these units. d) Out of six sanctioned post, only one post of Specialist was filled in at CHC Bajakhana.

**********

3. District:- Muktsar

Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Muktsar District of Punjab State during the month of May, 2011.

I. Details of the visited Institutions:

District visited SDH/CHCs/PHCs visited HSCs visited A. Muktsar CHCs: Chack Serawalia, Dodai Rupana, Asha Butter, Doda -II, Warring & Lambi. Khera & Killian Wali.

II. Major Observations:

1. Human Resources:- As reported,the status of staff position in the district was as follow:

Particulars of Post Post sanctioned In position Vacant Specialist 72 30 42 MO 12 7 5 Nurse (Grade “A”) 86 32 54 LHV/HS(F) 22 14 8 Lab Technician 34 13 21 ANMs 113 68 45 MPW(M) 91 46 45

In addition to above, 150 posts of 2nd ANM, 3 posts of MPW (M) and 70 posts of Nurses (Gr. “A”) were provided in the different health facilities on contractual basis in the district. This shows that the district was facing acute shortage of Medical Officers, Specialists and supervisory posts which is a hindrance in providing effective health care delivery to the people. 2. Rogi Kalyan Samiti (RKS) & Village Health, Sanitation and Nutrition Committee (VHSNC):- a) 25 Rogi Kalyan Samitis were set up at the DH, 2 SDHs, 5 CHCs and 17 PHCs in the district. Regular meetings of RKS were being conducted quarterly in the visited institutions but proceeding registers were not maintained properly. b) Details of RKS funds available and expenditure incurred at DH, SDH, CHCs and PHCs in the District are given in the following table:

(Amount in Rs.) Type 2010-11 2011-12 (upto August, 2011) of OB Recd. Total Exp. Bal. % of OB Recd. Total Exp. Bal. % of fund Insti- Fund fund Fund utiised tutions utiised DH 0 5,00,000 5,00,000 4,65,699 34,301 93% 34,301 5,00,000 5,34,301 0 5,34,30 0% 1 SDH 0 2,00,000 1,20,780 79,220 60% 79,220 1,00,000 1,79,220 98,45 55% 2,00,00 9 807,61 0 CHCs 0 5,00,000 5,00,000 5,75,801 (-)75,801 115% (-)75,801 6,00,000 52,4,199 15% 80,17 4,44,02 0 9 PHCs 8,81,4 17,00,00 25,81,46 18,75,01 7,06,443 73% 7,06,443 17,00,00 24,06,44 1,94,6 8% 61 0 1 8 0 3 93 22,11,7 50 Total 8,81,4 29,00,00 37,81,46 30,37,29 7,44,161 80% 74,4,161 29,00,00 36,44,16 3,73,3 10% 61 0 1 8 0 1 32 34,70,8 29 OB- Openning Balance c) 264 VHSNCs were functioning in the district. The meetings of VHSNCs were being conducted regularly in the visited institutions. d) As per the details received from the district, Rs. 26,40,000 [@ Rs. 10,000 to each VHSNC] were given as VHSNC to the district each year 2010-11 and 2011-12 without taking account of huge amount of opening balance in the year. Only Rs. 1334458 (56%) in the year 2010-11 and Rs. 35,63,313 (10%) in the year 2011-12 (up to August, 2011) were spent out of available total fund of Rs. 30,15,882 and Rs. 39,74,458 in the respective year. 3. Service of Janani Suraksha Yojana (JSY): a) For the implementation of Janani Suraksha Yojana the district spent Rs. 21,10,200 (121%) against allotted fund out of the available fund of Rs. 17,41,200 during 2010-11. No information about the source of excess expenditure was provided by the District. Rs. 9,73,000 (67%) was spent out of the available fund to the tune of Rs. 15,31,000 in the year 2011-12 (up to August, 2011). b) 17 JSY beneficiaries were interviewed by the team for on the spot verification. All beneficiaries were satisfied with the services and had received MCH cards and three Checks-up during AN and PN period. Most of the deliveries of contacted mothers were institutional and mothers received monetary benefit as per JSY scheme. c) The team observed that JSY amount was utilised properly at SC level but available fund was insufficient as reported by the ANMs. JSY Cards had also not been supplied to the SCs. 4. Functioning of ASHA scheme: 573 ASHAs were working as against the target of 633 in the district. 529 ASHAs were trained up to 5th modules and 573 ASHAs were provided with drug kits in the district. 5. Untied Funds and Annual Maintenance Grant (AMG):- Utilisation of Untied Fund and Annual Maintenance Grant at CHCs, PHCs and Sub Centres in the district was not satisfactory during last two years in the district. The details are as given below: (Amount in Rs.) Type of Fund 2010-11 2011-12 (upto August, 2011) CHCs PHCs Sub Centres CHCs PHCs Sub Centres Untied Fund 2,52,123 4,91,854 11,40,767 3,50,771 5,06,643 11,78,809 Available* 1,51,352 4,10,211 9,81,960 23,705 52,182 86,183 Expenditure 1,00,771 81,613 1,58,807 3,27,066 4,54,461 10,92,626 Balance AMG Fund 501888 1022122 1247733 702063 1282749 1255252 Available* 299825 589373 1012481 20191 92318 119760 Expenditure 202063 432749 235252 681872 1190431 1135492 Balance * Including opening balance. 6. Physical Infrastructure and Stock Position: i. CHCs: a) CHCs visited at Chack Serawali, Dodai and Lambi were functioning in Govt. buildings. Cleanliness in the delivery room was not maintained properly at the CHCs. Water supply and electricity with power back-up were available at all visited CHCs. Condition of beds was found poor in CHC Lambi. b) All surgical equipments for CHC expertise, Ambulance, Oxygen cylinder, Labour room, labour room table & equipment, Operation theatre and OT table were available at visited CHCs, but Blood storage unit, Resuscitation equipments, Neonatal Resuscitation equipments, Sick New born care unit, Quinine injections and Arteether injection were not available in the visited CHCs. c) X-Ray facility was not available at Lambi CHC and Anesthesia equipment was not available at Chack Serawali and Lambi CHC. d) No Specialist doctor was posted at CHC Chack Serawali. ii. HSCs: a) HSCs at Asha Butter and Rupana were functioning in Govt building and HSC Doda-II was functioning in rented building. Drinking water, Electricity and toilet facility were available at Asha Butter and Rupana HSCs. b) ANMs in charge of the visited Sub Centres were staying at their Sub Centre village. Additional ANM was available only at Asha Butter and Rupana HSCs, whereas MPW(M) was not available at all the visited Sub Centres. Labour room was available at Asha Butter and Rupana HSCs, but delivery was not conducted at the visited Sub Centres. c) Water supply, electricity, toilet, labour room and examination table were not available at SC Doda-II there. The post of 2nd ANM and MPW (M) was also not posted there. d) Steam Sterilizer and B.P Apparatus were not available at Doda-II HSC, Delivery kit at Asha Butter HSC and Ambu bag/ suction, steam sterilizer and Heamoglobinometer at the Rupana Sub Centre were not available. e) Condom, Misofrostol, Magsulth and Oxitocine tablets and Ampicillin Capsule and stock of condom was not available at the visited Sub Centre. Besides, Vitamine A solution, IFATable/Syrup, Oral pills, EC Pills, Antiseptic Solution, Clorin Solution, Metronidazol tablets and Gentamycine Injection were not available at Doda-II HSC. f) DDKs, Vitamine A solution, IFATablet/Syrup, Chloroquine tab and Gentamycine injection were not available at Asha Butter HSC and DDKs, Co-trimoxazole tablets, and ECPills were not available at Rupana SC. g) Family planning Service register was not available at Doda-II SC, Formats for monthly reporting and Mother- child Tracking formats/ register were not available at Asha Butter HSC and Stock register was not available at Rupana Sub Centre. h) Buildings of Doda-II and Rupana Sub Centres were not maintained properly for clinic purpose and cleanliness. i) SBA training to ANMs was not given in the district till the visit of the team.

7. Opinion and awareness of the Community on the Health Services: Services of ANMs and MPW (M): a) 70 mothers having child of up to one year of age were interviewed in the visited area of the Sub Centres to assess opinion regarding quality of services of ANMs and HWs (M). The interviewed mothers of the visited HSCs replied that ANMs were available when needed and conducted immunization session in regular basis. They provided IFA and TT to pregnant women. Home deliveries were conducted by trained persons by using DDK. Mothers had no idea about ARI. b) The post of Health Worker (Male) had been lying vacant for more than 3 years at Doda-II and Asha butter SCs. HW(M) of Rupna SC did not stay in SC village and was not available when needed. But he participated in some programme relating to Public health immunization camp and also collected blood smear of the patients. 8. Sample Verification of Family Welfare Acceptors: a) The team selected 132 FW acceptors out of which 81 (61%) could be contacted for sample verification in the district. Discrepancies in the age of spouse in 7 (9%) cases and in the age of youngest child in 12 (15%) cases was found in the recorded details of the acceptors. b) Follow up services were provided to 56 (69%) acceptors and all the contacted sterilisation acceptors received full amount of compensation. c) Out of 45 contacted Cu-T acceptors 4 discontinued the use of Cu T method, 4 for accepting other family welfare methods and 12 acceptors discontinued due to bleeding, backache and pain. e) 19 of the 25 beneficiaries of child immunisation could be contacted for sample verification and 17 beneficiaries confirmed receiving doses. All of them received follow up services by the worker/ASHA. 9. Reconciliation of Reported Performance: a) The consistency between figures reported by District office and reporting centres was not there in respect of performance reported in the year 2010-11 and 2011-12 (up to August, 2011). The details are as below: Name of Centres For the Year 2010-11 For the Year 2011-12 Reported by Reported by Reported by Distt. Reported by Distt. Office Centres Office Centres i) CHC, Chak Sherawala 780 781 289 290 2117 2223 1028 1006 Sterilisation 171576 172376 69696 69637

IUD

Nirodh ii) CHC, Lambi: IUD 1326 1342 729 833 iii) CHC Doda-II: IUD 934 927 454 553 OP 5850 5852 689 845

b) There was also discrepancy in the reported figures at CHCs for Sterilisation and IUD when compared to the figures of service registers at same CHCs for the year 2010-11 and 2011-12 (up to August, 2011). The details are given below: Name of Centres For the Year 2010-11 For the Year 2011-12 Reported by the Recorded in the Reported by Recorded in the centre service register the centre service register i) CHC, Chak Sherawala 781 775 290 133 2223 46 1028 1006 Sterilisation

IUD ii) CHC, Lambi: Sterilisatio 576 511 282 277 n 1342 179 729 833

IUD iii) CHC Doda-II: 927 37 553 32 IUD 10. Maintenance of Registers & Records: a) Eligible Couple and Child Registers were maintained properly and up to date at Chack Sherawali and Dodai CHCs but the same were not maintained properly and updated at Lambi CHC. b) There was Sterilization service cum payment Register maintained at Chack Sherawali CHC but the same was not properly updated. c) Cu-T service register was maintained properly and up to date at Dodai and Lambi CHCs but the same was not maintained properly at Chack Sherawali CHC. d) Oral pills & Nirodh distribution registers were maintained properly and up to date at Lambi CHC but the same were not maintained properly at Chack Sherawali and Dodai CHCs. e) MCH Register was not maintained properly and up to date at all visited CHC. PNC Register was not maintained at Dodai and Lambi CHCs. f) Stock Register of Cu-T, OP and CC were not maintained properly and were not up to date at all visited institution in the district. g) JSY beneficiaries Register was not maintained properly and was not up to date at all the visited centre. 11. IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, BPHC and CHCs. b) MCH tracking formats was available at Sub Centre level. Staff of District Office, BPHCs, PHCs and Sub Centres were sensitized in MCH formats. Data entry was being made at District, BPHC and CHC level. 12. Other Important Observations and Suggestions a) Supervision with necessary guidance at grass root level centres was lacking in the district. It was observed that ANMs were not maintaining the records properly and also were not conducting the field visits according to the community requirement. b) Orientation Training to the staff of District Programme Management Unit and to staff at PHC/CHC may improve their performance. c) In view of the poor performance in respect of OP and Nirodh, staff of the CHCs needed special attention to locate the regular users to improve distribution of OP & Nirodh at SC level. *******

4. District:- Mohali

Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Mohali District of Punjab State during the month of May, 2011.

I. Details of the visited Institutions:

District visited SDH/CHCs/PHCs visited HSCs visited Mohali SDH: Kharar. Paragpur, Mubarakpur & Salempur. CHCs: Derabassi & Kurali PHC: Boothgarh.

II. Major Observations:

1. Human Resources: During visit to the District Office as well as different health facilities, staff position was not made available to the team. However, as reported, 18 of the 79 posts of MPW (M) and 4 of the 89 total sanctioned posts of MO and Specialist doctors were lying vacant in the district. There was no vacancy of the Supervisor (M and F) in the district. 2. Rogi Kalyan Samiti (RKS) & Village Health, Sanitation and Nutrition Committee (VHSNC):- a) 19 Rogi Kalyan Samitis were set up at the DH, SDH, 4 CHCs and 13 PHCs in the district. Regular meetings of RKS were being conducted quarterly in the visited institutions. b) Details of RKS funds available and expenditure incurred at DH, SDH, CHCs and PHCs in the District are given in the following table: (Amount in Rs.) Type 2010-11 2011-12 (upto August, 2011) of OB Recd. Total Exp. Bal. % of OB Recd. Total Exp. Bal. % of fund Insti- Fund fund Fund utiised tutions utiised DH 3,18,0 5,00,000 8,18,057 8,18,057 0 100% 0 5,00,000 3,500 4,96,50 2% 57 5,00,00 0 0 SDH 0 1,00,000 1,00,000 0 100% 0 1,00,000 0 0% 1,00,00 1,00,00 1,00,00 0 0 0 CHCs 2,484 4,00,000 4,02,484 3,95,373 7,111 98% 7,111 3,00,000 34% 3,07,11 42,39 2,64,72 1 1 0 PHCs 4,83,7 12,00,00 16,83,73 10,37,94 6,45,79 62% 6,45,7 12,00,00 3,20,9 17% 39 0 9 8 1 91 0 18,45,7 20 15,24,8 91 71 Total 8,04,2 22,00,00 30,04,28 23,51,37 6,52,90 80% 6,52,9 21,00,00 3,66,8 13% 80 0 0 8 2 02 0 27,52,9 11 23,86,0 02 91

c) 426 VHSNCs were functioning in the district. The team reported that meetings of VHSNCs were being conducted regularly in the visited institutions. d) As per details received from the district, Rs. 36,44,774 out of available fund Rs. 52,00,000 in 2010-11 and Rs. 4,11,145 (10%) out of available fund Rs. 39,74,458 was spent till August, 2011during the year 2011-12 by the VHSNCs. 3. Service of Janani Suraksha Yojana (JSY):- a) In the implementation of Janani Suraksha Yojana though Rs. 31,48,878 during 2010-11was available under the scheme an amount of Rs. 3419852(108%) was spent. No information from the district about source of excess expenditure was made available. Rs. 8,76,300 (130%) were spent against the available fund of Rs. 6,73,026 in the year 2011-12 (up to August, 2011). b) 17 JSY beneficiaries were interviewed by the team. All beneficiaries were satisfied with the services. All beneficiaries were provided MCH cards and also received three Checks-up during ANC and PNC. Most of the deliveries of contacted mothers were institutional and they received monetary benefit as per JSY scheme. 4. Functioning of ASHA Scheme:- Total 532 ASHAs were working in 464 villages in the district and all ASHAs were trained up to 5th modules. Drug Kit was provided to all ASHAs. 5. Untied Funds and Annual Maintenance Grant (AMG): Full utilisation of Untied Fund and Annual Maintenance Grant at CHCs, PHCs and Sub Centres in the district was not fulfilled during last two years. The details are as given below: (Amount in Rs.) Type of Fund 2010-11 2011-12 (upto August, 2011) CHCs PHCs Sub Centres CHCs PHCs Sub Centres Untied Fund 1,50,336 3,90,538 6,81,629 233443 560501 647225 Available* 66,893 1,80,037 7,74,404 66330 84660 112608 Expenditure 83,443 2,10,501 (-) 92 775 167104 475841 534617 Balance AMG Fund 208554 631133 870673 311903 940958 880538 Available* 196651 390175 710135 39281 50154 87641 Expenditure 11903 240958 160538 272622 890804 792897 Balance * Including opening balance. 6. Physical infrastructure and Stock Position: i. CHCs: a) Visited CHCs Derabassi and Kurali and S.D.Hospital Kharar were functioning in govt. buildings. Maintenance of Hospital building was not satisfactory. The OT room is required to be maintained properly and cleanness of delivery room need to be improved. Water supply and electricity with power back-up were available at all visited CHCs. Condition of beds was poor at S.D.Hospital Kharar. b) All CHC level surgical equipment, Ambulance, Oxygen cylinder, Labour room, labour room table & equipment, Resuscitation equipments, Neonatal Resuscitation equipments, Anesthesia equipment, Operation theatre and OT table were available at visited CHC, but Blood storage unit was not available at Derabassi and Kurali CHC, Sick New born care unit not available in all the visited CHCs, Arteether injection was not available at Derabassi and Kurali CHCs and Quinine injections were not available in all the visited CHCs. ii) PHCs: a) Visited PHC Boothgarh was functioning in Govt building with Regular water supply, electricity connection and toilet facility. Telephone facility was also available. b) All equipment & apparatus to PHC expertises, Stock of medicine/drugs, vaccines vials & contraceptives were available. AYUSH medical officer was available and 24x7 service was provided in the PHC. ii. HSCs: a) HSC Paragpur and Salempur were running in Govt building and HSC Mubarakpur was finctioning in private building. Water and electricity were available at all the visited Sub Centres. b) Additional ANM was available only at Mubarakpur HSC, whereas MPW(M) was not available at Mubarakpur Sub Centre. Labour room was not available at Paragpur HSC. Delivery was not conducted at all visited Sub Centres. c) Foot stool, Delivery table, Mcintsh sheets and Nischay pregnancy test kit were not available at Paragpur HSC. Foot stool, Delivery table, Mcintsh sheets, Delivery kit, weighing machine (Infant) and Heamoglobinometer were not available at Salempur HSC. Ambu bag/ suction was not available at all the visited Sub Centres. d) Oral pills cycles and Chlorine solution were not available at Paragpur HSC. Condom, Chlorine solution and Chloroquine tab were not available at Mubarakpur HSC. DDKs, Co-trimoxazole tablets, E.C.Pills, Condom and Metronidazol tab were not available at Salempur HSC. Misofrostol tab, Magsulth tab, Oxitocine tab, Ampicillin Capsule and Gentamycine injection were not available at all visited Sub Centres. e) Eligible couple Register, Formats for monthly reporting, JSY registration card and Mother- Child Tracking Formats/ Register was not available at Mubarakpur and Salempur SCs. Stock register was not available at Paragpur and Salempur Sub Centres and Family planning Service register was not available at Salempur Sub Centre, f) SBA training to ANMs was not organized in the district till visit of the team. There was lack of checking/verification of service register by PHC/District Hospital.

7. Opinion and awareness of the Community on the Health Services: Towards HSCs service: a) 11 mothers having child up to one year age were interviewed to collect opinion of service rendered by ANMs and HWs (M) in the district. The interviewed mothers of all visited HSCs replied that ANM were available when needed and conducted immunization clinic in regular basis. They received IFA and TT and Home deliveries were conducted by trained person with using DDKs. b) Mothers was not sufficiently aware about ARI. c) It was observed that HW(M) of Parargpur SC was not staying at Sub Centre area and also he was not available when locality needed. As informed by the villagers, he was participated in the activities of public health, Immunization camps and collection of blood smear in the villages. He also visited nearby primary school for school health check up activities. d) The post of Heath Worker (Male) was lying vacant for more than 3 years at Mubarakpur SC. 8. Sample Verification of Family Welfare Acceptors: a) Out of 73 selected acceptors, 27 could be contacted, no discrepancy in the demographic data of the acceptors was found during sample check in the district. b) Follow up service was provided to only 11 (40.7%) acceptors. c) Out of 16 selected, only 6 immunization beneficiaries could be contacted for verification and all beneficiaries were found fully immunized. None of the contacted beneficiary faced any complication after availing the services. But they did not receive follow up services by the workers /ASHA. 9. Reconciliation of Reported Performance: a) The performance reported in the year 2010-11 and 2011-12 (up to August, 2011) by the Distt. Office and reporting centres was not consistent. The details are as below:

Name of Centres For the Year 2010-11 For the Year 2011-12 Reported by the Reported by Reported by Reported by centre Centres the centre Centres i)CHC, Derabassi 820 622 67 188 Sterilisation 1004 480 405 405 941 6953 449 5823 IUD 2881 159230 1247 88836

Nirodh

ii) CHC, Kurali: 174 133 18 40 Sterilisation iii) CHC Boothgarh: 1174 223 528 528 IUD 305 773 137 773 OP 1665 119834 861 62040 Sterilisation b) There was also discrepancy in the reported figures at CHCs for Sterilisation and IUD when compared to the figures of service registers at same CHCs for the year 2010-11 and 2011-12 (up to August, 2011). The details are given below: Name of Centres For the Year 2010-11 For the Year 2011-12 Reported by Recorded in the Reported by Recorded in the Distt. Office service register Distt. Office service register i) CHC, Derabassi 622 618 188 177 Sterilisation 480 64 405 58

IUD ii) CHC, Kurali: 133 123 40 38 Sterilisation iii) CHC Boothgarh: 1223 31 528 20 IUD 10. Maintenance of Registers & Records: a) Eligible Couple Register was maintained and updated at Derabassi CHC, but not maintained properly at S.D. Hospital Kharar. EC register was not made available at Kurali CHC and Boothgarh PHC. b) Sterilization service cum payment Register was not maintained properly at CHCs Derabassi and Kurali and Boothgarh PHC. c) Cu-T service register was maintained properly at Derabassi and Kurali CHCs and S.D. Hospital Kharar but the same was not maintained properly and up to date at Boothgarh PHC. d) Oral pills & Nirodh distribution registers were not maintained properly at Derabassi and Kurali CHCs and Boothgarh PHC. e) Stock Register of Cu-T, OP and CC were not maintained properly at Derabassi CHC, S.D. Hospital Kharar and Boothgarh PHC. Some essential information like date of manufacturing & Expiry, Batch No., Model No. etc were not recorded. f) JSY beneficiaries Register was not maintained properly at all the visited centres. 11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, BPHC and CHCs. b) MCH tracking formats was available at Sub Centre level. Staff of District Office, CHCs and, PHC were sensitized in MCH formats. Data entry was being made at District, BPHC and CHC level. 12. Other Observations:- a) The selected CHCs MO and other Paramedical staff were not taking proper attention in respect of distribution of Nirodh under FW programme at SC level. b) Orientation Training to the staff of District Programme Management Unit and to staff at PHC/CHC may improve their performance. d) It was observed that ANMs and MOs were not submitting monthly performance reports in HIMS format in time.