Rapid Appraisal of National Rural Health Mission

Kotma

Anuppur

Pushprajgarh Jaithari

Population Research Centre Ministry of Health & Family Welfare Department of General & Applied Geography (Government of India) Dr. H. S. Gour Central University Ni rman Bhavan Sagar (M. P.) 470003 New Delhi – 110 108

Draft Report

Contents

Acknowledgement ii List of Tables iii Key Findings vi

Chapter Title Page

Chapter 1: Introduction and State Profile 1

Chapter 2: District Profile 12

Chapter 3: Community Health Centre 20

Chapter 4: Primary Health Centre 38

Chapter 5: Sub Centre 60

Chapter 6: Household Survey 81

Chapter 7: Status and Performance of ASHA 114

Chapter 8: Role, Awareness and Involvement of Gram Panchayat 121

Chapter 9: Quality of Care and Client Satisfaction – IPD Exit Interview 125

Chapter 10: Quality of Care and Client Satisfaction – OPD Exit Interview 140

Appendix-1: District Schedule 153

Appendix-2: Standard of Living Index 173

i Acknowledgements

The PRC study on Rapid Appraisal of NRHM Implementation in Madhya Pradesh and Chhattisgarh could be completed with the immense help from many persons. I take this opportunity to express my gratitude towards them. I am thankful to the Ministry of Health and Family Welfare, Government of India for assigning this study to the PRC, GIPE. We are grateful to the authorities of the MOHFW, particularly to Dr. Ratan Chand (Chief Director, Statistics), Shri Praveen Srivastava (Director, Statistics) and Shri Rajesh Bhatia (Joint Director, Statistics), for their help and input they provided at various stages of the study. I am grateful to Prof. R.S. Agarwal, (the then Vice-Chancellor of our university) and Prof. N. S. Gajbhiye, Vice-Chancellor of our University for their valuable support and encouragement. This exercise could have not been completed without painstaking involvement and zeal of Dr. (Mrs.) Reena Basu (Assistant Director, PRC Sagar) and Mr. Nikhilesh Parchure (Field Investigator, PRC Sagar). Both are the core members of the PRC who have shared all the responsibility of the study. I am thankful to the staff of the PRC, Shri Manoj Namdeo for managing entire office work and coordination of activities at university level. Thanks are also due to Dr. R. Nagarajan, of PRC, Pune for his valuable support in solving problems related to data entry and table generation software as and when needed. I am also thankful to administrative and accounts staff of our university for their help to carry out the study smoothly. I would like to thank specially, Dr. D. K. Kori, Chief Medical and Health Officer (CMHO) and Shri Ravindra Dube, District Programme Manager, NRHM, Anuppur for their excellent help and support to carry out the fieldwork in the district. I also express my gratitude to the officials of the District Hospital, Anuppur and of the selected Community Health Centres and Primary Health Centres and the staff of the Sub Centres for helping us with providing data on health facilities and supporting us to carry out the household survey.

We cannot ignore to acknowledging the sincere efforts of our 22 investigators who carried out the difficult job of taking interviews of respondents. Last but not least, credit goes to those respondents who patiently answered to the long questionnaire without any expectation of any kind.

(Prof. Santosh Shukla) Director PRC, Sagar

ii LIST OF TABLES

Table Title Page 1 The sampling design for the selection of health facilities/households/ 7 respondents for the rapid appraisal of NRHM 2 Schedules canvassed for the study and survey period 8 3 List of selected District Hospital, CHCs, PHCs, SCs and Villages for the survey 9 in Anuppur District as per the sample design C1 Coverage and availability of infrastructure 28 C2 Position of Medical Staff and Paramedical Staff 30 C3 Availability of specific services in CHC 31 C4 Status of specific interventions 31 C5 Status of residential facilities for Doctors and other staff 31 C6 Availability of laboratory facilities 32 C7 Number of Lab tests done in CHC in last 3 calendar months 32 C8 Number of surgeries performed during 2007-2008 33 C9 Reasons for not conducting surgeries 33 C10 Status of performance of Labour Room during 2007-2008 33 C11 Reasons for not conducting deliveries 34 C12 Status of availability of equipments and drugs 34 C13 Availability of specific services 36 C14 Service outcome (based on data for last three months) 37 P1 Coverage and facilities of Primary Health Centre 47 P2 Primary Health Centres by infrastructure 48 P3 Staff position in Primary Health Centre 49 P4 Status of training of personnel at Primary Health Centre 50 P5 Availability of Labour Room in Primary Health Centre 50 P6 Status of performance of Labour Room during 2007-2008 50 P7 Availability of Laboratory Testing in PHC 51 P8 Number of tests done in PHC in last three calendar months 51 P9 Status of specific interventions 52 P10 Availability of selected equipments in PHC 53 P11 Status of availability of drugs 54 P12A Service outcome (based on data for last three months) – PHC, Amiliya 55 P12B Service outcome (based on data for last three months) – PHC, Amarpur 56 P12C Service outcome (based on data for last three months) – PHC, Mada 57 P12D Service outcome (based on data for last three months) – PHC, Khutar 58 P13 Status of record maintenance 59 S1 Sub Centres coverage 68 S2 Sub Centres infrastructure 69 S3 Sub Centres with ANM staying with or away from SC village by distance from 70 Sub Centre and reasons for not staying in Sub Centre S4 Sub Centres with staff in position 70 S5 Availability of Labour Room in Sub Centre 71 S6A Number of deliveries performed during 2007-2008 71 S6B Sub-Centres with arrangement for deliveries between 8 PM to 8 AM 72

iii Table Title Page S7A Sub Centres with availability of equipments 72 S7B Percentage of SCs with functional equipments (among the SCs reported the 73 availability of the equipment) S8 Status of availability of drugs on the date of survey 74 S9 Status of specific skills and procedures 75 S10 Service outcome (based on data for last 3 months) 76 S11 Status of record maintenance 77 S12A Status of awareness of ANM about JSY scheme 78 S12B Status of procedure under JSY scheme 78 S13 Status of performance of ANM under JSY scheme 79 S14 Status of Untied Grants 80 H1 Characteristics of the respondents 95 H2 Characteristics of the household 96 H3 Percent distribution of households by their waste disposal, stagnation of waste 97 water and mosquito breeding around the house and system of medicine preferred by them H4 Percent distribution of household respondents by their information about 98 availability of health worker, health facilities and transport used to take serious patients H5 Percent distribution of household respondents by their knowledge about 99 NRHM, ASHA and her activities, VHND, VHSC and JSY H6 Percent distribution of JSY beneficiaries by their background characteristics 100 H7 Timing, person and place of registration for JSY scheme 101 H8 Receipt of JSY card, role of ASHA in getting JSY card and difficulties 101 faced by the beneficiary in getting the JSY card H9 Role of ASHA during the pregnancy of the beneficiaries 102 H10 Place of delivery and reason for opting institutional delivery 102 H11 Transport of the beneficiaries to reach the health institution 103 H12 Waiting time at the health facility, type of delivery, amount spent at the health 104 facility and satisfaction regarding services available in the health facility. H13 Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives 104 being available under the JSY scheme H14 Cash incentive received by the beneficiary under JSY scheme 105 H15 Utilization of government health facility in last 6 months 106 H16 Characteristics of the respondents who have availed the services in government 106 health facility in last 6 months H17 Type of health facility visited, purpose of visit and client satisfaction regarding 107 behaviour of health worker, privacy and availability of medicines H18 User fees and extra charges 108 H19 Services for the BPL patients 108 H20 Outbreak of selected diseases (Malaria, Measles, Gastroenteritis, Jaundice & 109 Other Diseases) in the respondents’ area in last six months H21 Action to be taken for selected diseases (diarrhoea, high fever, persistent cough, 110 loose motion, persistent cough and breathing problems for a child) H22 Awareness about spacing methods and ideal gap between 1st & 2nd child 111

iv Table Title Page H23 Awareness about modes of getting AIDS, source of information about AIDS 112 and awareness about VCTC H24 Suggestions given by the respondents 113 A1 Status of ASHA 119 A2 Role and Performance of ASHA 119 A3 Distribution of ASHAs by reported types of difficulties faced and kind of 120 support required A4 Distribution of ASHAs by reported awareness on different aspects 120 G1 Status of Gram Panchayats covered 123 G2 Level of awareness and involvement of Gram Panchayats 124 EI-1 Background characteristics of the in-patients 130 EI-2 Purpose of admission in the Health Institution 131 EI-3 Waiting time 131 EI-4 Satisfaction regarding waiting time 132 EI-5 Behaviour of staff 133 EI-6 Unique/innovative measure taken to improve the staff behaviour 134 EI-7 Privacy 134 EI-8 Patient-Doctor/Provider Communication 135 EI-9 Cleanliness of the facility 136 EI-10 Satisfaction of patients regarding cleanliness of the facility 137 EI-11 Crowding in the facility 138 EI-12 Amenities provided by the hospital 139 EI-13 Continuity of treatment 139 EO-1 Background characteristics of the patients 145 EO-2 Purpose of visit to the health institution 145 EO-3 Average waiting time (in minutes) for services by type of facility 146 EO-4 Satisfaction regarding waiting time by type of hospital 147 EO-5 Behaviour of staff 148 EO-6 Privacy 148 EO-7 Patient-Doctor/Provider Communication 149 EO-8 Satisfaction of OPD patients regarding cleanliness of the facility 150 EO-9 Satisfaction of OPD patients regarding crowding in the facility 151 EO-10 Continuity of treatment 152

v Key Findings

In April 2005, the Government of India (GoI) launched the National Rural Health Mission NRHM) with the objectives of meeting the goals set in the Vision 2020, other policy documents and the Millennium Development Goals (MDG). Government of India has undertaken this Rapid Appraisal of the Mission at the state, district and local level through its 18 Population Research Centres (PRC) in 20 states of India. Given the very wide scope of the Mission and diverse nature of its activities, the PRC study on rapid appraisal is restricted to selected core components that directly address the health and family welfare needs of the people. This rapid appraisal has covered following four core components of the NRHM: (1) Utilization of Untied Funds at SC, PHC and CHCs, (2) Implementation of Janani Suraksha Yojana (JSY), (3) Facility up-gradation under the NRHM at different levels and (4) Health and family welfare situation in the district. Rapid Appraisal was carried out in Anuppur district of Madhya Pradesh with the help of 10 interview schedules. Five semi-structured schedules for state, district, CHC, PHC, and SC, were used to collect information about different facilities, manpower, equipments, RKS, untied funds etc at these levels. Gram Panchyat, and ASHA schedule were used to assess the awareness of NRHM and health services availability at the village level. Exit interviews of indoor and outdoor patients were canvassed at the various health facilities to assess the quality and satisfaction with services. Household schedule was canvassed to assess the awareness of NRHM and health programmes and their utilization, particularly the JSY and utilization of government health services.

A. State Profile Madhya Pradesh with a population of 60.3 million in 2001 is the sixth most populous state of India. As per 2001 census, 26.5 percent of the total population of the state was living in urban areas and the remaining is rural. There were 45 districts in the Madhya Pradesh in 2001 and it has since been increased to 50 in the year 2009. The rural population is residing in its 52,117 villages. Twenty percent of Madhya Pradesh’s population belonged to scheduled castes and fifteen percent belonged to schedule tribes as per 2001 census. Health Infrastructure (as on June 30, 2008) in Madhya Pradesh has been

vi poorly networked under the health care services delivery system. The state has a total of 8,659 SCs, 1,155 PHCs, 333 CHCs, 56 Civil Hospitals and 50 district hospitals to implement its public health programme at various levels. NRHM is implemented through these health facilities. Out of the 1,155 PHCs, 267 (23 percent) are designated as 24*7 or BEmOC PHCs.

B. District Profile The total population of the district was 7.27 lakhs and constitutes 1.2 percent of the population of the state. Out of these, 5.3 lakhs (73 percent) were residing in rural areas and 1.95 lakhs (27 percent) were residing in urban areas. Out of the total population of the district, 7.5 percent belong to Scheduled Caste and 44 percent belong to Scheduled Tribe. It may be mentioned that Anuppur district has been reconstituted as a new district in the year 2003, which was earlier a tehsil under Shahdol district. The district has limited public private health facilities for the delivery of services. The district has a total of 174 SCs, 16 PHCs, 8 CHCs, and 1 District Hospital to implement the public health programme at various levels. Out of the 16 PHCs, 5 are functioning as 24*7 PHC. The district hospital is functioning like a BEmOC health facilty due to lack of fully functional blood storage unit and operation facilities. Four health facilities (CHCs) are designated as FRUs but still do not fulfil the criteria of FRUs as per the government norms. New buildings are under construction for 50 SCs and 2 PHCs in the district. The district hospital does not have an AYUSH wing. There is not a single health facility where IPHS upgradation has taken place in Anuppur district either at the SC, PHC, CHC, level. However, the IPHS facility survey has been completed at the district hospital, in all the 4 CHCs and 6 PHCs. The district has no private nursing homes, but has 2 public sector hospitals, Regional Colliery Hospital at Kotma, and Thermal Power Project Hospital at Chacheri (Amarkantak) which have BEmOC facilities. The district has no public private partnership and has not accredited any private health facility for diagnostic or other type of services. However, through 4 MMUs the district is providing health and family welfare services in remote areas. Total number of institutional deliveries reported during 2007-08 in the district was 12018. However, total JSY cases registered and opting for institutional delivery is 11262. It may be mentioned

vii that 6 percent of the total institutional deliveries during 2007-08 took place in the 2 public sector hospitals which do not provide JSY benefits to expectant mothers. The district has merged all the vertical health societies created under different programmes with the District Health Society under NRHM. The district receives the funds through electronic transfer from the state office. The untied grants for the financial year have been provided to 4 CHCs and 16 PHCs. All the 166 Sub Centres in the district have operational joint bank account of ANM and Sarpanch and the Untied Grant was transferred to all these Sub-Centres.

C. District Hospital The DH with bed strength of 33 beds located at a distance of 1 kilometre from the nearest bus stand. Anuppur has received the status of a district in the year 2003. The hospital is located near the residential area the city and the necessary environmental clearance have not been obtained from the Pollution Control Board by the hospital. The hospital building is not disabled friendly as per the provisions of the Disability Act. The DH has a registration counter and waiting space adjacent to each consultation and treatment room, doctor’s duty room, treatment room, isolation room, blood storage unit, pharmacy, and examination and preparation room. However, the ICU, or high dependency wards and critical care area are not functional. The blood storage unit although in place is not fully functional. The hospital has the following services: Except for few services like medical and general stores, ventilation, water coolers, round the clock water supply, overhead water storage tank with pumping and boosting arrangements, services like Central Sterile and Supply Department, provision for fire fighting, and proper drainage and sanitation system are not available in the hospital. The hospital disposes the bio-medical waste by burying in a pit. The bio-medical waste is disposed but there is no facility for segregating into different bins. The hospital has 4 and 8 residential quarters for its medical and paramedical staff respectively. It does not have a separate parking place for vehicles. The hospital does not have a medical records section and disease classification is not being carried out as per protocols. The hospital has telephone and computer facilities, but fax and internet facilities are not available.

viii The hospital does not have a separate ward for female patients. During the last three calendar months 410 OPD patients were attended in the section and 894 deliveries were conducted. The hospital has a separate OT for Obstetrics and gynaecology. The number of surgical OPD and IPD conducted in the section during the last three months prior to the survey was 735 and 1483 respectively. The number of OPD and IPD attended by patients in the Medical Section during the last three months prior to the survey was 12458 and 692 respectively. The section has conducted OPD diagnostics for 194 male patients and 103 female patients during the last three months prior to the survey. The section has the services like x-ray, and ECG but no ultra sonography facilities. The lab has provided 373 laboratory services to the patients during the last three months prior to the survey.

D. Community Health Centres As per the study design, the two CHCs selected for the study are CHC Pushprajgarh located at a distance of 30 kilometres from the district hospital and CHC Kotma is 38 kms (farthest) from the DH. Pushprajgarh is serving for a population of 220,000, whereas Kotma is serving for a population of 242,307. Both Pushprajgarh and Kotma CHCs have been designated as FRU but neither of them is functioning as an FRU due to lack of essential facilities at the two CHCs. Both CHCs Pushprajgarh and Kotma are 30 bedded hospitals although separate beds for males and females have not been allotted in Pushprajgarh CHC. In Pushprajgarh CHC only 19 beds are in use in the wards. It may be mentioned that in Pushprahgarh the new 30 bedded hospital is in place but has not yet been handed over due to administrative reasons. Kotma CHC is functioning from 2 buildings located at a distance of 1.5 kms of each other. In Kotma CHC 21 beds are in use in the 2 buildings (16: in the new CHC building; 5: old CHC building). In the new CHC building in Kotma6 beds are allotted to male and 10 to female patients in the wards, whereas in the old building no separate allocation of beds have been done for male or female patients. Both the CHCs are having regular electricity supply, telephone, and computer and internet facilities. Laboratory facilities are available in both the CHCs but running vehicle/ambulance is available only in Pushprajagrh CHC. Both CHCs have investigative facilities like X-Ray, and OT, labour room, new born care corner and generator facilities.

ix OT for gyanecology is neither being used by Pushprajgarh nor Kotma CHC on regular basis. RKS is registered in both the CHCs and both the hospitals are maintaining the names of JSY beneficiaries in record. Prominent display boards regarding service availability in local language is not seen in either of the two CHCs. IPHS facility survey has been completed in both the CHCs. Both the CHCs receive the grants electronically from the district. Both the CHC have very limited testing facilities in their laboratory. Out of 11 laboratory tests only blood smear examination for malaria parasite, is carried out in the two CHCs. The number of deliveries conducted during 2007-2008 in Pushprajgarh and Kotma is 2639 and 1943 respectively. Whereas Kotma CHC is maintaining the records of 8 pm to 8 am deliveries, Pushprajgarh CHC is not doing so. The BOR for Pushprajgarh CHC is158 and for Kotma CHC the BOR is 34. On Pushprajgarh CHC the patient load is high, Kotma CHc is underutilized.

D. Primary Health Centre Coverage: Under CHC Pushprajgarh, the selected PHCs are Amarkantak and Benibari. Under CHC Kotma, the selected PHCs are Bijori and Kothi. The number of SCs covered by these four PHCs varies from 4 to 7 and the population covered varies from 26,000 to 50,000. Out of the four PHCs, two are having 6 beds, PHC Benibari has 4 beds and Kothi PHC has 5 beds which are in a state of disuse. Three of the PHCs are functioning 24*7 as far as providing delivery services are concerned but Kothi PHC does not provide delivery services. Three PHCs except Kothi are having labour rooms and laboratory facilities are available at Benibari and Bijori PHCs. The PHCs where deliveries are taking place are maintaining the records containing the names of JSY beneficiaries. Three of the 4 PHCs are equipped to provide basic obstetrics services. Labour rooms are available in 3 out of 4 PHCs which are providing 24*7 delivery services.

Infrastructure and Human Resources: Out of four PHCs, 3 are functioning from a designated government building and one of them Bijori PHC is functioning from a donated building. Three PHCs except Kothi are having labour rooms and laboratory facilities are available at Benibari and Bijori PHCs. The PHCs where deliveries are taking place are maintaining the records containing the names of JSY beneficiaries. Only

x Amarkantak PHC has put up a prominent display board regarding service availability in local language. Out of four PHCs, only Benibari has New Born Care Corner. As per our observation, the cleanliness of OPD, compound/premises and rooms/wards is average in the four PHCs but Kothi PHC is more or less non-functional because the M.O. is on leave. OPD/Wards of this PHC are not being used at all. In all the PHCs the sanctioned positions of Medical Officers are filled up. The pharmacist’s post although sanctioned in 3 PHCs is lying vacant and in Bijori PHC there is no sanctioned post of a pharmacist. In 3 PHCs the ANMs are working against the sanctioned post except for Kothi PHC where there is no sanctioned post of ANM. Posts of BHEIO, nurses, and drivers are neither sanctioned nor filled up in any of the 4 PHCs.

Status of Training of Personnel at PHC: In PHC Amarkantak one ANM has undergone training in Pre-Service IMNCI (Integrated management of Neonatal and Child Infections) and New Born Care for 15 days each. One MO has received SBA (3days) and new born care training (4 days).

Availability and Performance of Labour Room: Three out of the 4 PHCs have labour rooms which are in use for providing delivery services except Kothi. The 3 PHCs together conducted 1364 deliveries in the year 2007-08 and 3 10 deliveries carried out between 8 pm to 8 am (In Amarkantak PHC record of 8 pm to 8 am deliveries is being maintained since July 2007. Benibari PHC is not maintaining records of timings). In Kothi PHC it is observed that in the absence of ANM or staff nurse at the PHC the labour room has not yet started functioning.

Status of Specific Interventions: IPHS facility survey has been done in 3 out of four PHCs although none of the medical officers at the 3 PHCs have any knowledge about it. Three PHCs are functioning on 24*7 bases (have 1 MO and 3 or more ANMs/Staff Nurses round the clock). One AYUSH doctor (homeopathy) is providing services in Benibari PHC contractually. The RKS has been formed in all the 4 PHCs but is registered only at Bijori PHC. In the other three PHCs due to some administrative problems the registration process has yet to be completed. There are no display boards showing the composition of

xi the RKS with the names of the members and number of meetings held at Bijori PHC. In all the PHCs RKS is generating resources through user fees which are being used locally.

Service Outcome: The PHC wise performance shows that the PHCs under CHC Pushprajgarh have done better compared to the PHCs under CHC Kotma. PHC wise breakup of OPD cases is reported as follows: Amarkant 1111, Benibari 1221 and Bijori 3084 cases. Kothi PHC has not maintained the data on OPD patients. The number of IPD cases reported is: Amarkantak 104, Benibari 165 and Bijori 173 cases. Kothi PHC is not providing IPD services. The caste wise break-up shows that the ST population mainly uses the PHC facilities more than the ‘Other’ caste groups, Annupur being a tribal dominated district.

Status of Record Maintenance: Amarkantak PHC is maintaining 7 and Benibari 6 out of the 9 registers. In Bijori whereas 4 registers were available in Kothi only 1 register is available. Some of the essential registers are not being maintained by the PHCs because these services are not being directly provided at the PHCs but by the field staff working in their area.

E. Sub-Centre Coverage: The number of villages covered by the SCs varies from 3 to 21 villages and the population covered varies from 721 to 20,600. The average number of villages covered by the SCs is 6 and average population covered is 4913. Twelve SCs are covered for the survey under 4 selected PHCs. The total number of ASHAs working in the 12 SC area is 37 and the average for all the 12 SCs turns out to be 3.9. Availability of infrastructure: Out of the 12 SCs, 9 (75 percent) are running from designated government building, but the Dola SC is functioning from a rented building . The remaining 3 SCs are functioning from the ANMs residence. IPHS facility survey has not been carried out in any of the SCs in the district. Labour room is available only in 25 percent of the SCs. None of the SCs with labour rooms are presently conducting deliveries. More than half of the SCs (58 percent) have quarters for ANM. Out of the 7 SCs with quarters 4 are occupied. Five ANMs are staying in the SC village, whereas 3 are

xii staying outside. The reason cited by the ANM of Bahiatola and Amdari for not staying in SC quarter is security related, and in Rajnagar the ANM’s house is nearby.

Availability of Staff: All the 12 SCs are having at least one health worker (male or female) working in regular position and 5 SCs have both male and female workers in regular position. The staff availability shows that 100 percent of SCs have male and female health workers in regular positions. Three SCs have one contractual ANM in position at the SC.

Availability of Equipments and Drugs: None of the SCs have all the listed 12 equipments available with them. Not single equipment is there which is commonly available at all the SCs. Two SCs (Kothi and Thangaon) have 8-9 equipments out of the 12 listed ones and Amdari has no equipments. Most of the other SCs have 4-6 equipments. Out of 16 drugs, only Lalpur SC showed the availability of 9 drugs followed by Amdari SC reporting availability of 8 drugs. Except for these, two other SCs reported availability of 3-7 drugs.

Specific Skills and Procedures: ANMs in all the 12 SCs reported that they register pregnancy within three months, provide TT, IFA and Immunisation Services. Whereas ninety one percent ANMs reported that they carry out specific examinations like Blood Pressure, Haemoglobin and Urine, and identify high risk pregnancies, two-thirds (67 percent) of the ANMs carryout 3 ANC visits as per the RCH schedule are trained in syndromic treatment of RTI/STI and carrying out IUD insertions. 8 ANMs reported that they carry out IUD insertion only 5 (42 percent) are using IUD A380and have also reported regular supply. Also half of the ANMs reported that they are trained on insertion/removal of IUCD A380.

Service Outcome: The service outcome data for the last three months show that, on an average, each ANM has registered 39 ANCs. Out of the total ANCs, the average number registered by the ANMs in 1st Trimester is 8.7 percent. The average number for the three ANC visits as per RCH schedule is 14.9 in last three months. On an average, each ANM has identified 1.7 high risk cases, conducted zero deliveries and referred 2.6 pregnant women to next higher facility. Neonate infections identified and reported during the last

xiii three months on an average is 0.6. Among the nine SCs where ANM is carrying out IUCD insertion/removal, the average IUCD insertion is 37 during 2007-2008. The service outcome data reveal that the performance of the ANMs varies across the SCs.

Status of Record Maintenance: To know the status of record maintenance, the information was collected for 11 registers from the SCs. Immunisation register is the only register which is maintained by all the 12 SCs. Eligible couple register and cash book is being maintained by 11SCs each (92 percent), antenatal care register and family planning register each are maintained by 10 SCs (83 percent). Household register, post natal care register, birth and death registers and meeting register are being maintained by 8 out of 12 SCs each. JSY register and untied fund register are maintained by 7 and 6 SCs respectively.

Awareness about JSY: Awareness about the JSY and the incentive amounts to be given to the beneficiaries is universal among the ANMs. All 12 ANMs reported that there is an increase in the demand for institutional deliveries after the implementation of the JSY scheme. All of them reported that there is an increase in demand for institutional delivery after implementation of JSY scheme.

Procedure under JSY Scheme: All 12 ANMs reported that the JSY beneficiaries are being paid in cash. All ANMS reported that cheques were the only mode of payment for beneficiaries. Half (50 percent) of the ANMs reported that the JSY beneficiaries are paid within a week and 42 percent said that the beneficiaries are paid after two weeks or later and only 1ANM reported that payment was made in less than one week. Seven out of 12 ANMs reported that the transport support is available under JSY for shifting the pregnant woman from SC to CHC, in case of emergency as Janani Express is used for transporting pregnant women to the health facility. Only 1 ANM said that the register is available with them to record JSY expenditure.

Performance of ANM under JSY Scheme: All the 12 SCs together have registered 126 JSY cases during the last three calendar months and the average number per SC turns out to be 10.5 cases. Three out of 12 SCs have not registered a single JSY case in the last three months. The average number of JSY cases resulted in institutional deliveries during the last

xiv three months is 6.8. No money has been disbursed for JSY cases in last three calendar months by the SCs as payments are made by the PHCs. The performance of SCs/ANMs under JSY varies considerably across the SCs. During the financial year 2007-2008, no money has been disbursed for JSY by the SCs for home deliveries, as home delivery is discouraged in the district. None of the SCs have reported the transport costs under the JSY. None of the SCs have reported payments to ASHA.

Status of Untied Grants: Out of 12 SCs 10 with the exception of Amdari and Bahiatola have received the Untied Grants. All 10 SCs have reported expenditures from untied grants. All the 10 SCs are having joint bank account with the Sarpanch/any other GP functionary. All these 10 SCs maintain written record of transactions being carried out on Untied Funds and 9 SCs reported maintenance of register to record the decisions taken to spend this amount. Two-thirds of the SCs have reported that the Sarpanch/others have reviewed the expenditure records. Two-thirds of the SCs have reported the purchase of drugs, arranging facilities like water purifier for patients (25 percent), paying of telephone bills, and one-third reported buying of ‘other’ items. F. Household Survey Characteristics of the Households : Distribution of the households by social category shows that nearly two-third of the households belong to STs, 21 percent belong to OBC, 6 percent SC, and 9 percent to ‘Other’ castes. Majority households belong to hindus. Only one third of the households have electricity. Only 6 percent of the households are living in pucca houses. Toilet facility is available only in 8 percent of the households. Piped water is used by only 6 percent of the households. Thirty six percent of the households belong to BPL category. The BPL status is also exactly reflected in the households with the low standard of living index (61 percent). The standard of living index is calculated by using the various household items possessed by the households. Among the living children born in these rural households during the last five years, 35 percent of them were born in institutions.

Waste Disposal, Stagnation of Water and Mosquito Breeding and System of Medicine

xv Preferred: Method of waste disposal shows that majority of the rural households (98 percent) throw their waste in the open space. During the survey, in 20 percent of the households, investigators have observed the stagnation of waste water around the household. System of medicine preferred by the rural households reveals that the allopathic medicine is universally preferred (99 percent). In addition to this, one percent of the households prefer Ayurveda treatment.

Information about Health Workers and Health Facilities: About four-fifths respondents (80 percent) have heard about ANM and only 47 percent of them have heard about Male Health Worker. Hardly one-fifth of the respondents reported that the health worker has visited them in last one month. Regarding availability of health facilities the responses reveal the combination of public and private facilities available to them when required. Public health facilities like SC, PHC were mentioned by 15 percent. Majority of the respondents have stated about the availability of ‘other’ (86 percent) facility which for them is a JSR, Jhar-Phoonk wala, barefoot doctor.

NRHM, ASHA and JSY: Hardly, 10 percent the respondents have heard about NRHM. For those who have heard about NRHM, radio/television is the major source of information (40 percent) followed by Panchayat (20 percent) Community Member (16 percent), others (22 percent). Only 2 percent of them have heard about it from ASHA. Overall, nearly two-thirds of the respondents (65 percent) of the respondents have heard about ASHA, and slightly more in the other village (68 percent) than in the SC (62 percent) village. Those who have heard about ASHA were further asked about their awareness/knowledge regarding various activities of ASHA. Half of the respondents are aware that ASHA carries a kit, 55 percent are aware that ASHA provide common medicines free of cost, 24 percent each are aware that ASHA held discussions about hand washing and discussions about safe drinking water and 20 percent are aware that ASHA held discussions about construction of household toilets. The percentage of the respondents aware about different activities of ASHA is slightly higher in SC headquarter villages than in other villages. Nearly half of the respondents (48 percent) have reported that the Village Health and Nutrition Day (VHND) is being organised in the village.

xvi Hardly 7 percent of the respondents reported about the presence of Village Health and Sanitation Committee (VHSC) in the village. Majority (84 percent) of the respondents is aware about JSY scheme. Among those households aware of JSY scheme, 17 percent of them reported that they are beneficiaries of JSY. The percentage of the beneficiary households is more or less in the SC HQ villages (17 percent) than in other villages (18 percent).

JSY Beneficiaries: Social category of the beneficiaries reveals that about three-fifths of them (58 percent) are STs followed by OBCs (26 percent) and Scheduled Caste (9 percent). All the beneficiaries are Hindus. Distribution of beneficiaries by Standard of Living Index (SLI) shows that three-fifths belong to low SLI households, 20 percent belong to medium SLI and another 21 percent to high SLI households. More than one- third (37 percent) of the beneficiaries are from BPL category. In majority of the households (93 percent) place of the last delivery is reported at a health institution. Registration of JSY Beneficiaries: Forty five percent of the beneficiaries heard about the JSY scheme before being pregnant and the rest 55 percent during pregnancy. More than two fifth (45 percent) of the beneficiaries got registered during the first trimester of the pregnancy and the rest (55 percent) during 4th and 5th month of the pregnancy. Two fifths beneficiaries were registered by AWW, 20 percent by ANM and the remaining 18 percent by Doctor/LHV/Others. JSY Card: Only 17 percent of the beneficiaries reported that they received the JSY card (Table H8). Among those who received the JSY card, about half (44 percent) of them were helped by ASHA in getting the JSY card. (It may be mentioned that separate JSY cards have not been provided in the district, ICDS maternal and child health cards or the MCH cards may have been reported as JSY cards by beneficiaries). Ten percent of the beneficiaries reported any difficulty in getting the JSY card. Role of ASHA during the Pregnancy of the Beneficiaries: In spite of presence of ASHA at village level their involvement in the JSY programme is low. In spite of a large presence of ASHA in all the villages only (one-third) 35 percent of the beneficiaries said that the ASHA worker provided specific help during last pregnancy. A little more than one-third of the beneficiaries received advice about diet from ASHA. The percentage of beneficiaries who received advice from ASHA on delivery care, danger signs during

xvii pregnancy, breastfeeding and newborn care is only 14-18 percent. Lesser proportion of beneficiaries received advice about family planning (9 percent).

Place of Delivery and Reason for Opting Institutional Delivery: Among the beneficiaries, 98 percent (171 out of 174) delivered in Institutions and the remaining 1 percent delivered at home. The major reasons cited by the beneficiaries for delivering in institutions are: better care for mother and new born child (32 percent); money available under JSY scheme (30 percent) support services provided by ASHA (29 percent); and better access to institutional delivery (26 percent).

Transport of the Beneficiaries to Reach the Health Institutions: Among the beneficiaries who delivered in health institutions, 34 beneficiaries (20 percent) received a referral slip from ASHA/health personnel to access delivery services (Table H11). Out of the 171 beneficiaries who delivered in institutions, 25 (15 percent) of them faced difficulty in reaching health institution due to late non availability of transport (64 percent), insufficient money (44 percent) and night timing (12 percent). The average distance to the ultimate place of delivery from the beneficiaries’ residence is about 14 kilometres. Majority (89 percent) of the beneficiaries (94 percent) used ‘other’ means of conveyance like public transport or cycle or hired vehicle to reach the ultimate place of delivery, and 5 percent used a private vehicle. For majority of the beneficiaries mainly family members /relatives /husbands had arranged the vehicle, and 11 percent were facilitated by ASHA in arranging the transport.

Reason for Opting Home Delivery: As mentioned earlier, 2 out of 174 beneficiaries (1 percent) opted for the home delivery in spite of cash incentives being available under the JSY scheme. These 3 beneficiaries were asked for the reason for opting home delivery. The major reasons cited by the beneficiaries are home delivery is more convenient and non availability of transport.

Cash Incentive Received by the Beneficiary under JSY Scheme: All the 171 beneficiaries who had an institutional delivery had received the cash incentive under JSY scheme and the average amount received by them is Rs. 1371. Out of those who received

xviii the cash incentive, all received it in one installment. Among those who received the cash incentive, 24 percent received immediately after the delivery, 23 percent received within a week after the delivery and 51 percent received it much later.

Utilisation of Government Health Facility in Last Six Months: Eleven percent of the rural households (126 out of 1200) have availed the health services in government health facility in last six months. The proportion of households availed the services in government health facility is slightly more in households located in SC headquarter villages (12 percent) than in other villages (9 percent). The socio-economic characteristics of the respondents reveal that nearly half (48 percent) of them are illiterates, 57 percent are Schedule Tribes, and 29 percent OBCs and more than two fifths of them (45 percent) belong to BPL households. The percentage of households with low SLI is 66 percent. The characteristics of the respondents clearly reveal that most of them come from poor households.

AIDS and VCTC: Among the respondents, only 29 percent are aware about the HIV/AIDS. The percent of respondents do not know about the modes of getting HIV/AIDS is 71 percent which is considerably high. With regard to knowledge about the modes of transformation of HIV/AIDS, the table reflects that 82 percent of the respondents are aware about unsafe sexual contact, 43 percent sharing of needles/syringes and 31 percent blood transfusion are the very important modes of transformation. Hardly, 5 percent of the respondents are aware that HIV/AIDS transforms from infected mother to child. Only 14 percent of the respondents are aware about the nearby Counselling Centre/VCTC. Among those who are aware about the location of VCTC, most of them (86 percent) reported that that it is located in the government health facility.

G. Status and Performance of ASHA In Madhya Pradesh the concept of ASHA asocial health activist has been accepted by the state government and appointments have taken place in all the districts in a phased manner after 2006. There is a network of 42,777 ASH As spread across the length and breadth of the state in all 45 districts. Each village has at least one ASHA and some villages

xix have 2 ASHAs. Twenty two ASHA’s were interviewed from SC as well as farthest villages covered under the 2 CHCs in Anuppur district. Average population served by ASHAs is 962; i.e for every 962 persons there is one ASHA to provide health related services. All the ASHAs have undergone training (100 percent). Majority of the ASHAs (91 percent) have completed 2 modules of ASHA training. All ASHAs (100 percent) have received a kit. Role and Performance of ASHA: Fifty percent ASHAs are DOTs provider in their villages but only 3.5 JSY cases have been facilitated by them in the last three months. ASHAs on an average have handled 5.1 cases of diarrhoea and given ORS to children in the last three months. ASHAs have accompanied 2.9 institutional delivery cases. On an average an ASHA has distributed 13 Oral Pills, has provided drugs to 15 Malaria patients, and the number of new pregnancies identified is 5.4. Number of group meetings like Mahila mandals arranged by an ASHA is 1.2. Number of Health & Nutrition days arranged is 0.6. Average money incentive received by a ASHA during one month for the different health activities carried out by them is Rs. 211 for JSY Rs. 107 for Sterlisation, Rs. 34 for VHND, and Rs 139 for other activities li ke motivating for immunization. On an average the total amount received by an ASHA is Rs. 493 for different types of services given by her.

Difficulties faced by ASHAs: ASHAs were asked about the types of difficulties faced in implementing programme activities under NRHM. More than half (55 percent) ASHAs stated that funds are not available in time to carry out different activities and 32 percent reported delayed supply of drugs which affected their work. Inadequate facilities for institutional deliveries in the village are reported by more than one-third (36 percent) ASHAs. Adequate training is not provided (14 percent) and behaviour of staff in health facilities is not appropriate (5 percent) is also reported by them.

H. Gram Panchyat Regarding the regular availability of ANM, nearly two thirds (64 percent) of the Gram Panchayats reported that the ANM is regularly available in the village. Out of 17 Gram Panchayats majority (94 percent) have reported the existence of the VHSC in their village but the receipt of Untied Funds for the VHSC is reported by only half of them.

xx Moreover, more than half (56 percent) of the Gram Panchayats reported the regular meetings of the VHSC but only one fourth of the Gram Panchayat (25 percent) have reported the preparation of the Village Health Plan. Less than half (47 percent) of the Gram Panchayats reported conducting of IEC activities during last 6 months on health issues through street play, wall writing, organizing camps, and distributing pamphlets. All the 17 Gram Panchayats (100 percent) have reported the appointment of ASHAs in their respective villages. Awareness about the benefits under the JSY scheme was reported by all 17 Gram Panchayats. A little more than one-third (35 percent) panchyat members reported that the NRHM has brought improvement in their area. Among those Gram Panchayats which have reported improvements due to NRHM stated that there is availability of funds/facilities under JSY (100 percent), funds are available for maintenance of Sub-Centres (50 percent), community support is available as ASHA worker (17 percent) and availability of transport facilities for delivery and better facilities are available for CHCs/PHCs for referred patients (17 percent). Fifteen Gram Panchayats (88 percent) have reported difficulties in implementing programme activities under NRHM. Some of the reported difficulties are funds are not available in time (59 percent) inadequate facilities for institutional deliveries (42 percent), ASHA has not been adequately trained (12 percent) and 47 percent reported ‘other’ difficulties like lack of adequate publicity about NRHM, lack of ambulance, transport facilities and lack of adequate health services and facilities including staff at the village level. The Panchayats were asked about the kind of support required to enable them to implement NRHM more effectively. All seventeen (100 percent) Panchayat members stated that support was required. The kind of support required reported by the Gram Panchayats are: more funds (53 percent), more training for ASHA and community members (53 percent).Gram Panchayats wanted direct control over funds (35 percent), ‘other’ (47percent) support like ambulance facility, transport facility, SC building in the village, increase in t he number of health workers, and management of untied funds should be under the control of district authorities rather than BMO.

I. Quality of care and Client Satisfaction-IPD Exit Interview Waiting Time: The average waiting time for the patients for the Registration is 19 minutes. The average waiting time for Registration in the CHC is relatively higher (28

xxi minutes) than in the DH (8 minutes). After the Registration, the patients had to wait on an average 14 minutes for the Doctor’s call in the hospitals (CHC: 19 minutes; DH: 8). On an average, the doctors have examined the patients for 14 minutes. The examination time of the doctors is higher in DH (16 minutes) than at the CHC (10 minutes). After the examination it takes 7 minutes to get admitted to the ward. Here again, the waiting time to admission to the ward is higher in CHC (10 minutes) than in DH (3 minutes). After admission to the ward, it takes about 14 minutes for the patients to get the services. Patients from DH got the services very quickly (7 minutes) than the patients from CHC (20 minutes). The average time for getting discharged for the patients was 35 minutes at DH and 5 at CHC.

Satisfaction Regarding Waiting Time: Satisfaction of the patients regarding waiting time for different services like the waiting time for registration, doctor’s call, doctor’s examination, admission to ward, and getting services was either short or appropriate for registration, doctor’s call, doctor’s examination, indicating complete satisfaction both at the DH or CHC.

Behaviour of Staff: All the patients said that the doctor greeted them in a friendly manner in the first instance. Regarding the behaviour of doctors, nurses and technical staff, the patients both at the DH and CHC said that their behavior in general is reasonable or good. Regarding the behaviour of ayah, ward boys and counter clerk satisfaction at the DH and CHC appears to be rather high as all the patients said that either they are good or very kind. The patients in general are satisfied with the behaviour of all categories of staff in the health facilities and more so at the DH.

Privacy: On the whole, only 1 out 4 of patients in the CHC said that there was lack of privacy in the place of examination. All the patients in the DH were satisfied with the privacy. This indicates that patients at the district hospital and the CHC are in general satisfied but privacy issue needs more attention at the CHC.

Patient-Doctor/Provider Communication: The response of the patients with respect to their interaction with the doctor shows that the patients have a mixed opinion about the

xxii response received. Regarding listening to the patient’s ailment, 4 patients (DH: 3; CHC: 1) said that the doctor always listened to their ailment patiently, and 3 of them at the CHC said that the doctor listened somewhat. Five patients said that the either the doctor always/somewhat allowed to ask questions or responded to questions (DH: 3; CHC: 2). However, 2 patients one at the DH and one at the CHC said that the doctor did not allow to ask questions. All the patients at the DH and 2 at the CHC said that the doctor responded to their questions somewhat/always, whereas 2 patients at the CHC said that doctor did not respond to their questions. Doctor discussed about the ailment was expressed by all the 3 patients at the DH and 3out of 4 patients at the CHC. Similarly, the doctor talked about recovery was expressed by all the 3 patients at the DH and 3out of 4 patients at the CHC. Two out of 3 patients received ‘other advise’ at the DH and 3 out of 4 at the CHC. The analysis of client-provider communication indicates that clients are more or less satisfied with the doctors’ behavior but patient doctor communication at the CHC needs more attention.

Cleanliness of the Facility: Regarding the frequency of cleaning of the floor, 1 patient at DH and 3 at the CHC reported that the cleaning is done twice in a day, whereas once in day is reported by 2 patients one at the DH and 1 patient at the CHC. Two patients at the DH said that the toilet/bathroom is cleaned once a day but less than once a day of toilet cleaning is reported by 5 patients (DH:1; CHC: 4) . All patients (DH: 3; CHC: 4) said that patient uniform was changed less than once day during their hospitalization. Once a day of bed sheet changes are reported by 3 patients (DH: 2; CHC: 1) and less than once a day of bed sheet change was reported by 4 patients (DH: 1; CHC: 3). Changing beds sheets regularly does not seem to be a regular feature. Overall cleanliness of the facility needs attention both at the district hospital and at the CHCs. Crowding in the Facility: All patients at DH and CHC said that they got the cot not immediately, but on the same day. The cot remained available for the all the 7 patients till the time of discharge. All the patients expressed somewhat satisfaction with the ward arrangements. Regarding the adequacy of space in the ward, all 7 patients said that the space is adequate or somewhat adequate. All the patients reported adequacy of space in IPD as satisfactory.

xxiii

Amenities provided by the Hospital: Out of the 6 amenities, 3 patients know about medical shop, 2 have reported about telephone facilities and all 3 about ambulance facilities at the DH. At the CHC out of 6 amenities only 3 amenities, telephone (3) ambulance (1) and accommodation facility (1) was reported by patients. Satisfaction with medical shop was expressed by only 1 patient at DH and about ambulance facility by the patient at CHC. Thus patient’s satisfaction with the amenities seems to be less than their level of awareness about these amenities.

Continuity of Treatment: None of the patients expressed dissatisfaction with the visit to the health facility. All except one patient at the DH said that they would visit the health facility in case of illness. Similarly, only 1 patient at DH said that he would not recommend the hospital to other. J. Quality of Care and Client Satisfaction-OPD Exit Interview

Average waiting time for services: Overall, to get all the OPD services it takes on an average 57 minutes for the patients in the hospitals. Average time to get the OPD services is highest in PHCs (55 minutes) followed by CHCs (36 minutes) and DH (32 minutes). The waiting for the different OPD services shows that, except dressing (25 minutes), all the other OPD services take less than 10 minutes in the hospitals. The waiting time for the OPD services by type of hospital shows that, to get the services, the patients have to wait for more time in PHCs than in the CHCs and DH.

Satisfaction Regarding Waiting Time: Satisfaction of the patients regarding waiting time for different services is given in. Dissatisfaction with services is not very high as only 1-2 patients in each of the health facilities said that the waiting time is too long for these services, except at the CHCs where the waiting time for getting medicines is reported too long by patients (23 percent) and at the PHCs for receiving injections (17 minutes). One patient at the PHC has complained that waiting time for dressing was too long. In fact, most of the patients (above 90 percent) perceived and reported that the waiting time for these services is appropriate/too short. Patients overall are satisfied by the different

xxiv services provided by the DH, CHCs and PHCs. Though the dissatisfaction levels of OPD services are not very high even the small level of dissatisfaction at the CHCs or PHCs which provide limited services has to be properly addressed. Behaviour of Staff: Two to six percent of the patients said that the doctor did not greet them in a ‘friendly manner’ in the first instance, 40 percent said that the doctor greeted them in ‘somewhat friendly manner’ and 54 percent said that the doctor greeted them in a ‘friendly manner’. Doctor did not greet in a friendly manner was reported by one patient each at the PHCs, CHCs and DH. Doctor’s behavior as rude is reported by 1 patient at the PHC level. Otherwise, majority (94-98 percent) of the patients said that doctor greets in a somewhat/friendly manner and doctors behavior is reasonable, good and kind. Similarly the interaction of patients with nurses shows that 84 percent of patients who interacted said that behavior of nurse’s behavior is reasonable, good and kind. Six patients at the CHC did not interact with the nurses at all. Overall the behavior of nurses and dispenser were seen as reasonable, good and kind by patients of DH and CHC. The figures indicate that, the patients in general, are satisfied with the behaviour of all categories of staff in the health facilities.

Privacy: In the exit interview, all the OPD patients were asked whether there was privacy at the place of examination. On the whole more than three-fourths (78 percent) of patients said that there was privacy in the place of examination. The percentage of patients reporting the presence of privacy is highest at the PHC (95 percent) as compared to DH and CHCs (64 percent). It is clear that the privacy is an issue, particularly in DH and CHCs.

Patient-Doctor/Provider Communication: Regarding listening to the patient’s ailment, 74 percent of the patients said that the doctor ‘always listened’ to their ailment patiently, 22 percent said that the doctor listened somewhat and only 4 percent (CHC: 7 percent; DH: 5) said that doctor did not listen. The percent of patients who said that the doctor did not allow to ask questions is 18 percent, did not respond to questions is 16 percent, did not discuss about the ailment is 8 percent, did not talk about recovery is 32 percent, and did not give ‘other’ advice is 48 percent. Doctor-patient communication by type of hospital shows that more patients from CHC and PHC expressed their unhappiness about it. OPD

xxv patients have expressed their dissatisfaction regarding their communication with the doctors. Doctors did not allow to ask questions (CHC: 36 percent; PHC: 14), did not respond to questions (CHC: 27 percent; PHC: 19 percent), talk to patients about recovery (CHC: 43 percent: PHC: 43) and did not give other advise (CHC: 57 percent; PHC: 62). The results show that the OPD patients at the CHCs and PHCs are not happy with the communication of the doctors.

Cleanliness of the OPD Facility: Overall, all the patients felt that the OPD facilities are clean and almost none of the patients said that the facility is not clean. Compared to IPD patients, less number of OPD patients expressed their dissatisfaction regarding the cleanliness. Only one patient each expressed some dissatisfaction with services in the injection room and laboratory at the DH and one with the services of OPD in PHC. It appears that, cleanliness is an issue for IPD patients rather than for OPD patients. Because IPD patients stay longer in the hospital and expect a cleaner environment whereas, OPD patients visit only for a shorter period and may not be concerned about the cleanliness of the OPD area.

Crowding in the OPD Areas: As in case of cleanliness, very little dissatisfaction exists for crowding/inadequacy of space in the OPD facilities (OPD Room, Examination Room, Dispensary, laboratory, Injection Room and dressing Room) of the hospitals. Hardly, 5 percent patients expressed dissatisfaction for crowding/inadequacy of space in the OPD Room and this dissatisfaction was expressed at the PHC level (5 percent).

Continuity of Treatment: Overall, 30 percent of the patients are ‘satisfied’ with their visit to the facility, 66 percent ‘somewhat satisfied’ and 4 percent is dissatisfied. Two patients (DH: 1; PHC: 1) expressed dissatisfaction with their health facility due to bad experience with the doctor. Satisfaction by type of hospital shows that while all the patients from CHCs are ‘satisfied’ with their visit, at the DH and PHC there is some dissatisfaction with services. Eighty eight percent patients said that they would come again to the facility, in case they fell sick 10 percent were not sure and only 2 percent said they would not visit the facility. Although patients at the CHC were satisfied with services, 21 percent said that they were not sure that they would visit the health facility again. One patient each at the DH and PHC expressed that they were not sure of visiting

xxvi the health facility once again. Overall, surprisingly all the patients said that they would recommend the hospital to others.

xxvii Chapter- 1

Introduction and State Profile

I. Background for the Rapid Appraisal of NRHM The Government of India, with the objective of meeting the basic requirement of Health for all, has launched the National Rural Health Mission (NRHM) in April 2005 to carry out necessary architectural correction in the basic health care delivery system. The Mission aims at provision of comprehensive and integrated primary healthcare to the people, especially to the rural poor, women and children. It adopts a synergic approach by relating Health to determinants of good health viz nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalising Community Health Centres, Primary Health Centres and Sub Centres into functional hospitals meeting Indian Public Health Standards. The Mission lists a set of core strategies to meet its goals like decentralized village and district level health planning and management, appointment of female Accredited Social Health Activists (ASHAs) to facilitate access to health services. The Mission attempts a major shift in the governance of public health by giving leadership to Panchayati Raj Institutions in matters related to health at district and sub-district levels. Another key strategy of the Mission is decentralization of programmes for district level management of health. Under the scheme, all existing societies for health and family welfare programmes, Reproductive and Child Health and National Programmes for TB, Malaria, Blindness, Filaria, Kala Azar, Iodine Deficiency and Integrated Disease Surveillance, shall integrate into a unified District Health Mission. Funding for all these programmes will be eventually funneled into the District Health Mission,which will be empowered to formulate integrated health plan of the district.

1 One of the core strategies of the Mission is to empower local governments to manage, control and be accountable for public health services at various levels. The Village Health and Sanitation Committee, the Standing Committee of the Gram Panchayat, will provide oversight of Mission’s all activities at the village level and be responsible for developing the Village Health Plan with the support of the ANM, ASHA, Anganwadi Worker and Self-Help Groups. Block level Panchayat Samitis will co-ordinate the work of the Gram Panchayats in their jurisdiction and will serve as link to the District Health Mission, which will be led by Zilla Parishad and will control, guide and manage all public health institutions in the district. States will be encouraged to devolve greater powers and funds to Panchayati Raj Institutions.

Rapid Appraisal of NRHM In light of the above background and also the fact as the Mission is now in its fourth year of existence, the Ministry of Health and Family Welfare, Government of India has undertaken this Rapid Appraisal of the Mission at the state, district and local level through its 18 Population Research Centres (PRC) in 20 states of India. Given the very wide scope of the Mission and diverse nature of its activities, the PRC study on rapid appraisal is restricted to selected core components that directly address the health and family welfare needs of the people. It is therefore this rapid appraisal is restricted to the following four core components of the Mission: (A) Utilization of Untied Funds at SC, PHC and CHCs (B) Janani Suraksha Yojana (JSY) (C) Facility up-gradation under the NRHM (D) Assessment of health and family welfare situation at the village level

Objectives of the Rapid Appraisal of NRHM (A) Utilization of Untied Funds NRHM has drawn a plan of action at all levels of healthcare to build up sustainable healthcare delivery system, where all citizens have access to affordable and appropriate quality healthcare. To achieve its goals, NRHM in its strategies, set up a platform for involving the

2 Panchayati Raj Institutions (PRIs) in primary health programmes and infrastructure. The Mission also envisages the following roles for PRIs: (i) States are required to commit for devolution of funds, functionaries and programmes for health to PRIs; (ii) At grassroots level, Village Health and Sanitation Committee (VHSC) has been formed to decentralize the planning and monitoring of various programmes; and (iii) For strengthening the health centres, all the health facilities are provided with Untied Funds. Untied Funds can be used only for the common good and not for the individual needs, except in the case of referral and transport in emergency situations. Each Sub Centre will have an Untied Fund @ Rs.10, 000 per annum. Likewise, each PHC and CHC is provided with Untied Funds of Rs. 25,000 and Rs.50, 000 respectively for local health action. At Sub Centre level, the fund will be deposited in a joint account of the ANM and the woman Sarpanch or the woman member of Panchayat, but the account will be operated by ANM in consultation with Village Health and Sanitation Committee and Multipurpose Health Workers. At the PHC and CHC level, Untied Funds will be kept in the bank account of the concerned Rogi Kalyan Samiti (RKS)/Hospital Management Committee. The funds will be spent and monitored by RKS. This rapid appraisal study attempts to analyze the utilization of Untied Funds at Sub Centre and PHC level. It will also help to know how actively PRIs/RKS are involved with the utilization of Untied Funds in right perspective. The specific objectives of the rapid appraisal under the utilisation of Untied Funds are: 1. To examine the utilization of Untied Funds under different activities at Sub Centre, PHC and CHC level. 2. To highlight the problems faced by CHC and PHC In-charge and ANMs in receiving and utilization of funds. 3. To seek the opinions of CHC and PHC In-charge and ANMs regarding the sufficiency of funds. 4. To study the role of Village Health Committee particularly at Sub Centre level and Rogi Kalyan Samiti in the utilization of funds at CHC and PHC level.

(B) Janani Suraksha Yojana (JSY) Janani Suraksha Yojana (JSY), an integral component for safe motherhood under NRHM, was launched in 2005 with the objective of reducing maternal and neo-natal mortality. The scheme aims to promote institutional deliveries amongst poor pregnant

3 women in all the states and Union Territories (UTs) of the country with special focus on low performing states (LPS). It is a 100 percent centrally sponsored scheme and links cash assistance with delivery and post-delivery care. In availing institutional delivery services, the client is usually escorted, would be requiring transport to reach the institution and in case of complications, referral services would be required. The scheme has considered all these elements and has made provision for transport including referral and escort and at the same time invested in improving public health institutions and services through the Reproductive and Child Health (RCH) Programme interventions. This apart, states have been given flexibility to evolve public-private partnership (PPP) mechanism and accredit private health institutions for providing institutional delivery services. The special dispensation for Low Performing States (LPS) in both rural and urban areas has been made and linked to the ASHA intervention. The LPS are those that have low institutional delivery rates and include Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Orissa, and Jammu and Kashmir. In the remaining states and UTs, categorized as High Performing States (HPS), similar provisions have been made wherein Anganwadi worker or traditional birth attendant or ASHA like activist could be engaged and associated with the JSY scheme. The JSY focuses on: (a) Maternal care through micro-planning of birth, (b) Cash assistance to all eligible mothers for delivery care (c) Cash assistance for referral transport (d) Cash assistance to institutions for hiring specialists for Caesarean Section or for the management of Obstetric complications (e) Cash benefit to ASHA for facilitating institutional delivery The specific objectives of the rapid appraisal under the JSY are: 1. To assess the role of ANM/ASHA in providing services to the beneficiaries of the JSY. 2. To seek the opinions of ANMs/ASHAs regarding the sufficiency of funds and timely disbursement of funds. 3. To study the role of other health officials in the implementation of the scheme at district. 4. To review engagement of private sector including accreditation and compensation. 5. To highlight the problems faced by beneficiaries in receiving the services/funds. 6. Analyze nature and scope of IEC interventions for raising awareness of JSY.

4 (C) Facility Upgradation under NRHM For meeting the health needs of the rural masses, one of the key strategies of the NRHM is to strengthen all the health facilities by upgrading them with necessary infrastructure according to the type of facility (CHC, PHC, SC etc). The main aim is to strengthen hospital care for rural areas, provide specialized care to the community and also to improve the standard of quality of care in order to enhance the level of patient satisfaction. Thus, the rapid appraisal examines as to what extent the SC, PHCs and CHCs have been upgraded under NRHM. The objectives of the study under this component are: 1. To assess the availability and adequacy of infrastructure, furniture, equipment, medicines/drugs and vehicle in the upgraded sub centers, PHCs and CHCs. 2. To examine the availability of manpower - medical and paramedical. 3. To assess the type of services and availability of facilities. 4. To assess the clients perception regarding quality of services through exit interviews.

(D) Assessment of Health and Family Welfare Situation at the Village Level It has been envisaged under NRHM that indicators of health depend as much on drinking water, nutrition, sanitation, female literacy, women’s empowerment as they do on functional health facilities. NRHM seeks to adopt a convergent approach for interventions under the umbrella of the district plan which seeks to integrate all the related initiatives at the village, block and district level. Wherever village committees have been effectively constituted for drinking water, sanitation, ICDS etc., NHRM attempts to move towards one common Village Health Committee covering all these activities. Panchayati Raj Institutions are being fully involved in this convergent approach so that the gains of integrated action can be reflected in district plans. Under NRHM, household surveys through ASHA, AWW will target availability of drinking water, firewood, livelihood, sanitation and other issues in order to allow a framework for effective convergent action in the Village Health Plans. Hence, one of the important objectives of the rapid appraisal is to: 1. Assess the health and family welfare situation in the village in terms of availability of drinking water, sanitation, functional health facilities, quality of services provided, nutritional status, women’s empowerment, maternal and child health, disease prevalence etc.

5 III. Methodology and Study Design The rapid appraisal covers all tiers of the public health care delivery system right from the village level up to the state level. For the sake of objectivity, the rapid appraisal exercise is organised broadly in terms of policy formulation, programming and implementation for each of the four components of the Mission listed above. At the state level, the rapid appraisal exercise focuses primarily on policy formulation with respect to the above listed four components. At the district and community health centre level, the rapid appraisal exercise primarily focuses on programming necessary to translate policy into specific action while at the primary health centre, sub-health centre and village levels, the rapid appraisal exercise concentrates on the implementation aspects. A mix of quantitative and qualitative tools is used for the rapid appraisal. At the village level, a household survey is carried out to assess the health and family welfare situation as well as to assess the use of public health facilities by the community at large. At the institution level, the rapid appraisal is based on review and analysis of the available records of public health institutions and in-depth interviews with the policy makers, programme managers and service providers at different tiers. Each of these Schedules is further divided into a number of separate Blocks capturing information on specific areas of interest. Information for one Schedule has been gathered from a number of different individuals. In every Block, indication about the corresponding respondent / source of information is given.

Health Facilities and the Villages Covered for the Study in Anuppur District District Hospital, Anuppur was covered for the study. Two CHCs, 4 PHCs, 12 Sub Centres and 24 villages were to be covered in the district as per the sampling design mentioned in Table 1. The facilities and the villages covered in the district are given below in Table 3. For household survey, two-three villages were selected from each selected Sub Centre area (because of villages with less number of households). Thus, 29 villages were selected for the household survey. To complete the sample size of 50 households 15 additional villages were covered to fulfil the household selection criteria as per the sampling design. Households were selected from each of the selected village by following the systematic circular random

6 sampling procedure. For selection, the total number of households in a village was divided by 50 to find out the selection interval. Afterwards the first household situated at the north-west corner of the village was randomly selected and subsequently every rth household was selected moving in an ‘anti-clock wise’ direction till 50 ho useholds were selected.

Table 1: The sampling design provided by the Ministry for the selection of health facilities / households / respondents for the rapid appraisal of NRHM Sl. Facility/ Total Selection Criteria Alternate criteria No Household /district 1 District 1 In States where the Male and Female DH SDH or District HQ Hospital are separate, schedule to be filled for both. Hospital One CHC to be the farthest from the In case no CHC is 2 CHC 2 district HQ.If the first CHC selected is an available, the largest FRU then the second CHC could be any Block /Addl. PHC CHC; else the second CHC should preferably be an FRU, if available. 2 PHCs for each CHC.PHC to be 3 PHC 4 vertically under selected CHC.Preferably one 24x7, if available. 3 SCs for each PHC. All to be vertically 4 SC 12 under selected PHC. One SC to be farthest from PHC. 2 villages to be selected from catchment 5 Household 1200 area of SC (if there is one village under the elected Sub Centre, the same will be covered). One village to be where Sub- Centre is located and second village that is farthest from the Sub-Centre. 50 households per village to be randomly selected (total 100 households per SC). All ASHAs in the selected village to be 6 ASHA selected for canvassing ASHA Schedule. Gram Panchayat (GP) Schedule to be 7 Gram canvassed to the member of GP (including Panchayats Sarpanch) representing the selected village. 8 Patients Exit interview be canvassed for 5-10 IPD for Exit and OPD patients at each of the facility Interview including District Hospital, CHC and PHC.

Table 2: Schedules canvassed for the study and survey period in Anuppur district Schedule Survey Period Schedule (S) : State Schedule February 2009 Schedule (D) : District Schedule Part A February 2009 Schedule (D): District Schedule Part B District Hospital February 2009 Schedule (C) : Community Health Centre Schedule February 2009 Schedule (P) : Primary Health Centre Schedule February 2009 Schedule (N) : Sub Centre /ANM Schedule February 2009 Schedule (A) : ASHA Schedule December 2008 February 2009 Schedule (G) : Gram Panchayat Schedule February 2009 Schedule (H) : Household Schedule February 2009 Schedule (EI) : Exit Interview Schedule for IPD Patients February 2009 Schedule (EI) : Exit Interview Schedule for OPD Patients February 2009

Field Work To carry out the study in the district, 22 experienced adhoc investigators (12 female;10 male) were recruited. These selected investigators have earlier worked for the DLHS-3 in M.P. and were familiar with the household survey methods. A 13 day’s training programme was organised for them in Population Research Centre in Sagar. The fieldwork for the household survey was carried out during and January and February 2009. These 22 investigators were divided into 4 teams and each team was supervised by one PRC staff. All the household interviews and exit interviews were carried out by these investigators and the Facility, Gram Panchayat and ASHA questionnaires were administered by the PRC staff. During the entire duration of the fieldwork, PRC staffs were with the field teams and continuously monitored the fieldwork.

8 Table 3: List of selected District Hospital, CHCs, PHCs, SCs and Villages for the survey in Anuppur District as per the sample design

District Hospital Anuppur 2CHCs CHC: Pushparajgarh (1) CHC: Kotma (Farthest) 4PHCS PHC Amarkantak PHC Benibari PHC Bijori PHC Kothi 12 SCs 1 Podki 1 Tulra 1 Bhaiatola 1 Dola (Farthest) 2 Bharni (Farthest) 2 Amdari 2 2 Nandgaon 3 Lalpur 3 Jharha (Farthest) Katkona(Farthest) 3 Thangaon 3 Rajnagar

1 Podki 1 Tulra 1 Bhaiatola 1 Dola 24 villages Bhundakona Laharpur

(includes 7 2 Harratola 2 Beejapuri(Farthest) 2 Dongaria 2 Dola (Farthest) additional (Farthest) (Farthest) villages) Barsod 3 Amdari 3 Nandgaon 3 Bharni 3 Katkona Taali 4 Gediama (Farthest) 4 Parspani (Farthest) 4 Pamra (Farthest) Charkiumar 4 Belichot (Farthest) 5 Jharha 5 Thangaon 5 Lalpur Bhamariya 5 Rajnagar 6 Majholi (Farthest) 6 Belgaon Bacholi 6 Bijori (Farthest) (Farthest) Umarguhan 6 Rajnagar (Farthest)

*Additional villages covered with the farthest village to complete the sample size of 50 households

Chapter Scheme The present chapter provides (a) the background for the rapid appraisal of NRHM, (b) methodology and sampling design for the study. The Chapter two is divided in two parts. The Part-I presents the current status of NRHM interventions (health infrastructure, facilities available for delivery, human resources, RKS, JSY and financial mechanisms) in Anuppur district. The Part-II provides the infrastructural facilities and human resources available in the

9 district hospital. The third and fourth chapters presents the information on: framework and structure related issues; infrastructure status; human resources; availability of services, diagnostic facilities, equipments and drugs; and service outcome statistics for the selected CHCs and PHCs in the district. The fifth chapter presents the findings based on the Sub- Centre/ANM schedule. Specifically it presents the information on population coverage, human resources, infrastructure status, availability of equipments and drugs, skills and practices of ANM, record maintenance, functioning of JSY scheme, and utilization of Untied Grants. The sixth chapter presents the following information about the Gram Panchayat: population, households and villages covered; IEC activities; functioning of VHSC, involvement in ASHA programme and JSY scheme; and awareness about NRHM at Gram Panchayat level. The seventh chapter explains the status of the ASHA scheduled canvassed in the district. Chapter eight presents findings of the household survey. The findings are presented for background characteristics of the household, amenities available to the household, awareness of ASHA programme and JSY Scheme, and feedback from the household about the kind of services availed from a public health facility, quality of care provided and level of satisfaction from the services provided. Chapter 10 presents the findings of the exit interview of the IPD and OPD patients about the quality of services received in the district hospital, CHC and PHC.

6. Status of NRHM interventions at the State Level (based on the State Schedule) This section presents the information based on the State Schedule colleted from the State NRHM Mission Unit. The information is presented for the state level status of health infrastructure, formation of RKS, performance under the JSY, and financial mechanism including transfer of Untied Funds. Madhya Pradesh with a population of 60.3 million in 2001 is the sixth most populous state of India. As per 2001 census, 26.5 percent of the total population of the state was living in urban areas and the remaining is rural. There were 45 districts in the Madhya Pradesh in 2001 and it has since been increased to 50 in the year 2009. The rural population is residing in its 52,117 villages. Twenty percent of Madhya Pradesh’s population belonged to scheduled castes and fifteen percent belonged to schedule tribes as per 2001 census. Health Infrastructure

10 (as on June 30, 2008) in Madhya Pradesh has been poorly networked under the health care services delivery system. The state has a total of 8,659 SCs, 1,155 PHCs, 333 CHCs, 56 Civil Hospitals and 50 district hospitals to implement its public health programme at various levels. NRHM is implemented through these health facilities. Out of the 1,155 PHCs, 267 (23 percent) are designated as 24*7 or BEmOC PHCs. At the state level, information regarding infrastructure, RKS, performance under JSY and financial mechanism are sought and information on these aspect is awaited.

11 Chapter 2

District Profile

I. District Schedule – Part A Population: The total population of the district was 7.27 lakhs and constitutes 1.2 percent of the population of the state. Out of these, 5.3 lakhs (73 percent) were residing in rural areas and 1.95 lakhs (27 percent) were residing in urban areas. Out of the total population of the district, 7.5 percent belong to Scheduled Caste and 44 percent belong to Scheduled Tribe. It may be mentioned that Anuppur district has been reconstituted as a new district in the year 2003, which was earlier a tehsil under Shahdol district. Infrastructure: The district has limited public private health facilities for the delivery of services. The district has a total of 174 SCs, 16 PHCs, 8 CHCs, and 1 District Hospital to implement the public health programme at various levels. Out of the 16 PHCs, 5 are functioning as 24*7 PHC. The district hospital is functioning like a BEmOC health facilty due to lack of fully functional blood storage unit and operation facilities. Four health facilities (CHCs) are designated as FRUs but still do not fulfil the criteria of FRUs as per the government norms. New buildings are under construction for 50 SCs and 2 PHCs in the district. The district hospital does not have an AYUSH wing. There is not a single health facility where IPHS upgradation has taken place in Anuppur district either at the SC, PHC, CHC, level. However, the IPHS facility survey has been completed at the district hospital, in all the 4 CHCs and 6 PHCs. The district has no private nursing homes, but has 2 public sector hospitals, Regional Colliery Hospital at Kotma, and Thermal Power Project Hospital at Chacheri (Amarkantak) which have BEmOC facilities.

Human Resources: When we compare the ‘number of sanctioned posts’ in different categories with ‘total in position’ we can say that the district is not doing well in terms of human resource availability. Among medical officers about three-fourths (74 percent) of the posts are filled including those appointed on contractual position. There are 3 gynaecologists and 3 paediatricians each, working in the two categories against the sanctioned post of 5, and 1

12 anaesthetist working against the sanctioned post of four in the district. It is noteworthy that against the sanctioned post of 7 ‘other specialist’ 1 specialist is in regular position and 6 are working in contractual position in the whole district. Sixty eight percent of the staff nurses and 223 ANMs including75 in contractualposition are working against the sanctioned posts of 175ANMs.

Rogi Kalyan Samitis: The RKS is constituted in the higher level functioning health facilities (DH and CHC) of the district and all of them are registered. Only 1, PHC Bijori out of 16 PHCs (6.2 percent) has a registered RKS in the district. The process of getting approval and registering has yet to be completed for most of the RKS at the PHC level. This indicates that the district authorities have to make efforts towards getting the RKS registered which is being delayed due to some administrative constraints.

PPP initiatives: The Public-Private-Partnership initiative in Annupur is very less due to lack of private health facilities in the district. No private health facilities have been accredited for the implementation of JSY scheme. However, among other initiatives the Mobile Medical Unit (MMU) is providing OPD and family welfare services in all the 4 blocks of the district. Deendayal Mobile Van is providing services in Jaitari, Kotma and Anuppur blocks by an NGO Community Action for Motivation Programme, and another NGO is providing services in the fourth block, Pushprajgarh.

Performance under the JSY: To assess the performance of the JSY by caste and APL/BPL categories in public and private health facilities, the required data was obtained from the District Programme Management Unit (DPMU) as per the District Schedule format given by the Ministry for government facilties. However, data regarding JSY in private accredited health facilities was not available because these health facilities have recently been accredited in the year 2008-09. DPMU provided data for public health facilities the total number of institutional deliveries, number of registered JSY women and number of woman opting for institutional delivery among the women registered for JSY for the year 2007-08. However,

13 data was not available either caste wise or on the basis of socio-economic categories. Total number of institutional deliveries reported during 2007-08 in the district was 12018. However, total JSY cases registered and opting for institutional delivery is 11262. It may be mentioned that 6 percent of the total institutional deliveries during 2007-08 took place in the 2 public sector hospitals which do not provide JSY benefits to expectant mothers. Financial Mechanisms: The district has merged all the vertical health societies created under different programmes with the District Health Society under NRHM. Funds are being transferred to DHS common bank account. The District Health Society is also already registered. The District Health Society maintains a common bank account for all the programmes. For the year 2008-09, the district has prepared the District Action Plan and the same has been approved by the District Health Society. Funds are being allocated to the districts as flexi pool funds and based on Annual Action Plan. The district receives the funds through electronic transfer from the state office. The untied grants for the financial year have been provided to 4 CHCs and 16 PHCs. All the 166 Sub Centres in the district have operational joint bank account of ANM and Sarpanch and the Untied Grant was transferred to all these Sub-Centres.

II. District Schedule – Part B: District Hospital (DH), Anuppur

Location of the Hospital: By using the public transport, the DH, Anuppur District Hospital can be reached in one hour from the farthest CHC. The DH with bed strength of 33 beds located at a distance of 1 kilometre from the nearest bus stand. Anuppur has received the status of a district in the year 2003. The hospital is located near the residential area the city and the necessary environmental clearance have not been obtained from the Pollution Control Board by the hospital. The hospital building is not disabled friendly as per the provisions of the Disability Act.

14 Physical Infrastructure: The DH has a registration counter and waiting space adjacent to each consultation and treatment room, doctors duty room, treatment room, isolation room, blood storage unit pharmacy, and examination and preparation room. However, the ICU, or high dependency wards and critical care area are not functional. The blood storage unit although in place is not fully functional. The hospital has the following services: Except for few services like medical and general stores, ventilation, water coolers, round the clock water supply, overhead water storage tank with pumping and boosting arrangements, services like Central Sterile and Supply Department, provision for fire fighting, and proper drainage and sanitation system are not available in the hospital. The hospital disposes the bio-medical waste by burying in a pit. The bio-medical waste is disposed but there is no facility for segregating into different bins. The hospital has 4 and 8 residential quarters for its medical and paramedical staff respectively. It does not have a separate parking place for vehicles. The hospital does not have a medical records section and disease classification is not being carried out as per protocols. The hospital has telephone and computer facilities, but fax and internet facilities are not available.

Obstetrics and Gynaecology Section: The hospital does not have a separate ward for female patients. During the last three calendar months 410 OPD patients were attended in the section and 894 deliveries were conducted. The hospital has a separate OT for Obstetrics and gynaecology. The section also has limited facilities to provide services related to obstetrics and gynaecology. MTP, assisted/forceps delivery, mid-trimester abortion, are few of the services available at the hospital. The hospital has provided the figures for all these services during the year 2007-2008. Other services like eclampsia, PPH, sterilization, hysterectomy, caesarean section deliveries, suturing cervical tear and infertility treatment are not available.

Surgical Section: The number of surgical OPD and IPD conducted in the section during the last three months prior to the survey was 735 and 1483 respectively. Facilities for emergency surgical services are available in the section. However, the section does not have facilities to

15 conduct pancreas surgery, abdomen surgery, spleen and portal hypertension surgery, breast surgery and leprosy reconstructive surgery.

Medical Section: The number of OPD and IPD attended by patients in the Medical Section during the last three months prior to the survey was 12458 and 692 respectively. The medical section provides only limited services. Most of the services listed in the schedule are not available (dermatology and venerology, pleural biopsy, bronchoscopy, lumbar puncture, pericardial tapping, skin scraping for fungus/AFB, bone marrow biopsy, endoscopic specialised procedures and psychiatric services) in the section except for services under NLEP, RTI/STI.

Paediatric Section: During the year 2007-2008 the number of paediatric OPD attended in the section was 1000. The section does not have any designated beds for newborns. Therefore number of neonates, other infants and children under five years admitted in the section during 2007-08 is not available. The section has the services to manage asphyxia, neo natal sepsis, dehydration and diarrhoea cases and respiratory tract/pneumonia cases and treatment of malnourished children in the newly constructed Nutrition Rehabilitation Centre. The section has the essential equipments like phototherapy unit; laryngoscope, suction machine and thermometer with working condition expect radiant heat warmer. The section has the essential drugs like iron folic acid syrups and paediatric antibiotics, Vitamin A solution, but ORS is not available.

Diagnostic Section: The section has conducted OPD diagnostics for 194 male patients and 103 female patients during the last three months prior to the survey. The section has the services like x-ray, and ECG but no ultra sonography facilities.

Clinical Pathology: The lab has provided 373 laboratory services to the patients during the last three months prior to the survey. Lab has facilities to provide haematology, urine analysis, stool analysis, semen analysis, sputum, and serology. It does not have facilities for

16 many types of test like CSF analysis (cell count), biochemistry, split skin smear examination for leprosy, and aspirated fluids, PAP smear, histopathology, and pulmonary function test.

Human Resources: Out of the 18 sanctioned medical posts in the hospital only 11 are appointed in regular position. The hospital has recruited 1 PGMO in dental section on contractual position among the medical staff. The shortage is visible in the category of General Duty Doctor and out of the 9 sanctioned posts only 6 are appointed. The sanctioned specialist’s positions like surgery specialist, anaesthetist (short term trained M.O.) public health manager, ayush physician, pathologist, psychiatrist, dermatologist, ENT surgeon and orthopaedician are lying vacant in the hospital. Further, among the paramedical staff, the situation is poor with only 50 percent (28 out of 56) of the sanctioned posts filled-in. Among the other category of personnel (technicians and administrative staff), the hospital does not have all the sanctioned posts. Among the posts which are sanctioned 3 out of 11 posts are filled up in the technician category, and only 3 in the administrative category with no manager to take administrative charge of the hospital.

RKS: The hospital has a registered RKS. The hospital exempts SC, ST and BPL patients for the user charges. To avail the exemption, patients have to produce the BPL Ration Card or on certification by the hospital authorities. Through the user fees the RKS generates additional resources other than government grants. The user fees are retained within the hospital for the local use. The hospital has not put up a display board showing number of members, and number of meetings of RKS nor has it any feedback mechanism for grievance redressal. Comments and Observations Remarks by gynaecologist: ‘It is difficult to carry out caesarean deliveries without any facilities. Because of monetary incentives awareness about institutional delivery has increased manifold, but JSY is not sustainable in the longer run. Vital equipments are not available for caesarean operations. The blood storage unit is not fully functional. Thus most of the cases have to be referred to Shahdol district hospital. The pediatrician and senior gynaecologist stay in Shahdol, and are not available 24*7 at the district hospital for providing services.’

17 Remarks by medical officer: ‘Our district is newly constituted and we lack many of the facilities available in other district hospitals. Due to lack of specialist services most of the cases have to be referred outside. There is paucity of staff and equipment. Presently we are functioning in the CHC building and a new building is urgently required.’

Remarks by the Civil Surgeon: ‘Fund flow to the hospital in the form of RKS, flexipool grants has eased out the financial constraints. We have been able to appoint some staff on contingency basis to maintain hygiene and cleanliness in the hospital. I am serving as a CS in charge and cannot take major financial decisions. More decision making power/functional autonomy and administrative control should be given to the hospital authorities to run the hospital administration effectively and implement the NRHM schemes. Owing to lack of proper OT facilities we have not been able to carry out deliveries under caesarean section. The hospital has shortage of manpower for both MOs as well as specialists in medical category and paramedical staff. Record keeping is not being done properly in the different sections as most of the previous records were being maintained at Shahdol. Institutional delivery has improved under JSY but we have limited infrastructure. Infrastructure upgradation is essential. More publicity is needed for the NRHM programmes.

Remarks of CMHO: ‘JSY has increased institutional delivery from 20 percent to 65 percent. However, JSY benefits must be provided upto 3 children, otherwise it will affect the quality of the programme. There is paucity of specialists, orthopedician, gynaecologist, general surgeons and poor manpower effect both the quality of services and implementation of national programmes. Because of low bed capacity we cannot keep the mother for 48 hours in the hospital. More para medical staff is required in the periphery.'

Remarks of DPM: ‘I need my complete team including DAM, BPMs and BAMs to be fully functional. They are in the process of being appointed. The district hospital is a new development and CHCs and PHCs have limited infrastructure development. Ultra Sonography facilities are required at least at the district level to detect obstectric

18 complications. Blood storage facilities need to be set up at the CHC level. ANMS need better orientation on how to spend untied funds. Fund flow has improved under NRHM. But after submitting the action plan we get money in the second or 3rd quarter. If planning is done quarter wise fund flow should be provided quarterly. Due to inconsistency in fund flow JSY incentives get delayed.’

Remarks/suggestions for the improvement of services by the observer: District hospital Anuppur is still functioning from the old CHC building, with poor physical infrastructure. It is located in the city and the patient load is high, but due to lack of facilities most cases are referred to neighbouring Shahdol district hospital. There is no manager to take administrative charge of the hospital although one post is sanctioned at the DH. The CS requires an administrator to assist him in the day to day running of the hospital and monitor the staff attendance, punctuality, hospital load and overall management of the hospital. The records of OPD services being provided under different sections is not being maintained properly. Record maintenance needs immediate attention. For decisions for district hospital purchases from RKS grants there is an internal hospital committee and the expenses made is later verified by the President of RKS (Collector). Thus essential purchases are not hampered due to administrative processes. Centralized purchases from untied funds of ANM and ASHA were observed in the district. The untied funds of ANMs are in the joint names of BMO and ANM in some places. Orientation about the objectives of NRHM is required by all categories of staff at DH, CHC, and PHC involved in programme implementation. Anuppur district needs immediate attention and a new district hospital building with essential infrastructure, manpower, equipments is a prerequisite for being fully functional. Also facility upgradation at all levels is critical to improve the quality of services under NRHM.

19 Chapter 3

Community Health Centres

Coverage As per the study design, the two CHCs selected for the study are CHC Pushprajgarh located at a distance of 30 kilometres from the district hospital and CHC Kotma is 38 kms (farthest) from the DH. Pushprajgarh is serving for a population of 220,000, whereas Kotma is serving for a population of 242,307. For CHC Pushprajgarh the nearest PHC is at a distance of 28 kms and farthest is 65 kms. In case of Kotma CHC the nearest PHC is 12 kms away and the farthest is at a distance of 30 kms. Both Pushprajgarh and Kotma CHCs have been designated as FRU but neither of them is functioning as an FRU due to lack of essential facilities at the two CHCs.

Availability of Infrastructure Both CHCs Pushprajgarh and Kotma are 30 bedded hospitals although separate beds for males and females have not been allotted in Pushprajgarh CHC. In Pushprajgarh CHC only 19 beds are in use in the wards. It may be mentioned that in Pushprahgarh the new 30 bedded hospital is in place but has not yet been handed over due to administrative reasons. The area of the new CHC building is 957.63m 2 and is double storeyed . The CHC is functioning in an old building, with a separate building for office purpose and a third building which is used as a store for medicines. Kotma CHC is functioning from 2 buildings located at a distance of 1.5 kms of each other. In Kotma CHC 21 beds are in use in the 2 buildings (16: in the new CHC building; 5: old CHC building). In the new CHC building 6 beds are allotted to male and 10 to female patients in the wards, whereas in the old building no separate allocation of beds have been done for male or female patients. Both the CHCs are functioning from their own government buildings. It may be mentioned here that Kotma CHC the additional CHC building (old) is a donated building. Both the CHCs are having regular electricity supply, telephone, and computer and internet facilities. Laboratory facilities are available in both the CHCs but running vehicle/ambulance

20 is available only in Pushprajagrh CHC. Both CHCs have investigative facilities like X-Ray, and OT, labour room, new born care corner and generator facilities. OT for gyanecology is neither being used by Pushprajgarh nor Kotma CHC on regular basis. Both the CHCs do not have ECG facilities, and separate areas for septic and aseptic deliveries. Both the CHCs have drug dispensing and drug storage facilities, but separate public utility toilets for males and females is available only in Kotma CHC. In CHC Pushprajgarh the sewerage system is open drain and in Kotma it is a soak pit. Both the CHCs at Pushprajgarh and Kotma are disposing their bio-medical waste by burying in a pit. As per our observation, the cleanliness of OPD, compound/premises and rooms/wards are just average in both the CHCs and maintenance of these needs further improvement. Both the hospitals are maintaining the names of JSY beneficiaries in record. Prominent display boards regarding service availability in local language is not seen in either of the two CHCs. Due to lack of waiting space or shelter for family members accompanying delivery or IPD cases, cooking is being done in the open area outside the CHC building in Pushprajgarh.

Human Resources In Pushprajgarh against the 5 sanctioned posts of medical staff only 2 MO’s are appointed on regular basis. The posts of one medical specialist, as well as the sanctioned posts of PGMO one each in anesthesia and surgery and 1 post of MO dental are lying vacant. Two contractual PGMO’s one each inpaediatrics and gynaecology are presently working in Pushprajgarh. Out of 5 sanctioned posts of medical staff, four of them are working in a regular position at Kotma. This includes one gynaecologist, one paediatrician, and 2 medical officers. Additionally, two medical officers are working on deputation at Kotma CHC. It may be mentioned here that both the paediatrician and the gynaecologist have applied for voluntary retirement and are not reporting for duties. In terms of paramedical and support staff, in CHC Pushprajgarh , out of 18 sanctioned positions 10 are working in regular positions and 3 in contractual position in Pushprajgarh. In Kotma, out of 15 sanctioned positions 11 are working in regular positions and 1 statistical assistant is working on contractual basis. In both the hospitals, the availability of paramedical and support staff is better than in medical staff category.

21 Status of Specific Interventions IPHS facility survey has been completed in both the CHCs. Both the CHCs receive the grants electronically from the district. RKS is registered in both the CHCs but the display boards do not show the composition of the RKS with the names of the members in either of the two CHCs. RKS is generating resources through user fees in both the CHCs. In both the CHCs, there is no feedback mechanism in place for grievances redressal by RKS. All standard treatment guidelines and protocols are not available in the two CHCs. Citizens charter is publicly displayed only in CHC Kotma in the ‘old’ CHC building.

Status of Residential Facilities for Doctors and Other Staff Both CHC Pushprajgarh and Kotma have residential facility for the Doctors and other staff and the residences are occupied by the staff. The MOs quarters are fully occupied in the Pushprajgarh CHC but in Kotma, two quarters of MOs are occupied by persons of other government department. The staff quarters of the supporting staff is fully occupied in the two CHCs. In Pushparajgarh 9 new quarters for MOs are under construction or in the process of being handed over. It may be mentioned that a few staff quarters available along with the old CHC building in dilapidated condition.

Availability of Laboratory Facilities Both the CHC have very limited testing facilities in their laboratory. Out of 11 laboratory tests only blood smear examination for malaria parasite, is carried out in the two CHCs. Tests for haemoglobin, urine RE, rapid test for pregnancy, blood grouping, blood smear, bleeding and clotting time, RTI/STI test is not being carried out in either of the two CHCs.

Number of Laboratory Tests Done in CHC in Last Three Months The CHCs maintain the records related to the number of laboratory tests done during the last three months prior to the survey. Records of blood smear examination for malaria parasite indicate that 334 and 376 cases were handled in the last three calender months. Both hospitals have limited staff and limited laboratory facilities, thus only one type of test is being carried out at the CHCs.

22 Status of Performance of OT during 2007-2008 The performance of the OT shows that both the CHCs of Pushprajgarh and Kotma have very limited OT performance due to lack of surgeons and anaesthetist in the two CHCs. In both the CHCs mainly laproscopic tubectomy (Pushprajgarh: 939; Kotma: 306) and NSV operations (Pushprajgarh: 243; Kotma: 83) have taken place during 2007-08. Two hundred and forty three cataract operations and 51 cases of MTP are reported by Pushprajgarh CHC which was performed during 2007-2008.

Status of Performance of Labour Room during 2007-2008 In both the CHCs the labour rooms are in use and deliveries are being conducted. The number of deliveries conducted during 2007-2008 in Pushprajgarh and Kotma is 2639 and 1943 respectively. In CHC Kotma 580 deliveries were carried out between 8 pm to 8 am but in Pushprajgarh CHC the timings of delivery are not recorded. It may be mentioned that as per the prevailing rules in Madhya Pradesh all pregnant women who came to Pushprajgarh and Kotma CHCs for delivery were considered as JSY beneficiary (M.P. being an EAG state). Round the clock delivery services are provided by both the CHCs.

Status of Availability of Equipments In both the CHCs Pushprajgarh and Kotma, limited numbers of the listed equipments is available and are in working condition. Out of 15 essential equipments only 7 and 6 equipments are available and in working condition in CHC Pushprajgarh and Kotma respectively. Boyles apparatus, ECG machine, oxygen cylinder, horizontal high pressure sterilizer, hydraulic operation table, phototherapy unit, MVA syringe are available at Pushprajgarh CHC and all equipments except hydraulic operation table is reported in working condition. Kotma CHC does not have a Boyles apparatus. Out of 6 equipments, phototherapy unit although available in CHC Kotma is not being used. The ECG machine although in working condition in both CHCs is not being used because there is no technician to handle it in either CHC.

23 Availability of Drugs Out of the 25 listed drugs, CHC Pushprajgarh has received all the drugs (24) except ORS with Zinc adjutant which has never been supplied at the CHC. The drugs supply has been regular in the last 6 months and the drugs have never been out of stock as reported by the CHC. The drugs availability situation is more or less similar in Kotma CHC with only Vitamin A being reported out of stock in the last 6 months and ORS with Zinc adjutant never supplied.Tablet Progestrone has been supplied to CHC Kotma for the first time therefore regularity of supply could not be determined for this particular drug. Thus supply of majority of the essential drugs is more or less regular in both the CHCs.

Availability of Specific Services Out of the 24 specific services listed, CHC Pushprajgarh has reported availability of 15 services and CHC Kotma of 11 services. Some services which are provided by both the CHCs are emergency services (24 hours), leprosy diagnosis management and referral services, DOTs, primary management of wounds, primary management of fractures, and primary management of burns, poisoning, and dog-bites and management of RTI/STI cases. Both CHCs have mobile medical units. Additionally, Pushprajgarh CHC is providing paediatric and gynaecological services and emergency care for sick children. Both CHCs are providing cataract operation facilities, and laproscopic ligation is also done in camp situations.

Service Outcome The service outcome statistics was collected from the CHCs for last three months. Table C14 presents the ‘average monthly figure’ based on the data collected for the last three months. The caste wise figures are maintained in both the CHCs. In almost all the indicators of maternal and child health, the average monthly figures of Kotma are more than that of Pushprajgarh. The Bed Occupancy Rate of the CHCs reveals that Kotma hospital is underutilized and in Pushprajgarh the pressure of IPD patients JSY and emergency cases is high. The BOR of CHC Pushprajgarh is 158 percent and CHC Kotma is 34 percent. Pushprajgarh CHC with high BOR is under great pressure/ strain because of very limited infrastructure, and service related facilities. One of the reasons for the low BOR is that very

24 limited services are available at Kotma CHC. Under utilization of the hospitals reveals the inefficiency in the utilization of the allocated public resources.

Pushprajgarh:

Remarks/suggestions for the improvement of services by the observer: The BMO at Pushprajgarh CHC cited business and was not available for suggestions for improvement in functioning of the CHC. The BMO was reluctant to share information during the appraisal. This created unnecessary delays in collection of essential data and information. The CMHO had to intervene between a number of times to instruct the BMO to cooperate. Inspite of briefing the BMO about the objectives of IPD/OPD there was resistance on his part to allow interaction with patients. Due to this reason, only a few IPD and OPD schedules could be filled up. The untied fund register and pass book of ANMs from the field were submitted at the BMO’s office for audit purposes. These documents were not made available to the research team for observation or verification. The BMO has no drawing and disbursing authority, but under NRHM some expenses related to purchase of stationary, minor repair work from RKS funds, and he maintains an account for JSY cash assistance which he receives on demand depending on the number of expected deliveries. One staff nurse at the CHC was managing and controlling most of the registers and records. Most of the registers were not properly maintained and it was a colossal task collecting data and information at the CHC. The accountant appointed under NRHM does not have access to all the files pertaining to expenditures made under NRHM. There is high inflow of patients and the caseload of IPD is high as BOR indicates. The private practice of MOs adversely affects the timings of OPD services which is reduced by about 2 hours.

25 The CHC has an urgent need of specialists because most of the complicated cases have to be referred outside. Mobile medical unit under PPP is providing services in remote areas under the CHC. The ‘Janani Express’ is providing services to transport pregnant women for delivery at the CHC The CHC must shift into the new building to become fully functional. The BMO needs orientation about how to monitor the processes of implementation of NRHM programme. The paramedical staff also needs proper orientation about the different aspects of NRHM programme which is presently poor.

CHC-Kotma: Remarks and Suggestions

Remarks by BMO: ‘I have been recently given the charge of BMO. There has been improvement in availability and supply of medicines, and furniture due to improvement in fund flow through untied funds under NRHM. CHC although designated as FRU is not functioning as one since there are no blood storage facilities or OT facilities for carrying out operations under the caesarean section’. ‘We have no drawing or disbursing powers, but are meeting out some expenses (between Rs 5000 to 7000 at a time) from RKS funds for repairing the building’s roof, electricity fitting, etc. NRHM accounts with the cash book or opening balance was not submitted by the compounder of the old CHC who was previously handling the accounts. The new accountant (RCH/NRHM) has opened the cashbook on 31st July, 2008 with an amount received through e-banking from the district’. ‘We are functioning from two CHC buildings and testing and laboratory facilities are placed in the other building. Although an MO is working there I find it difficult to monitor all the activities at the other CHC. The second CHC is continuing under political pressure. Patients have to shuttle between two hospitals for services and thus remain dissatisfied’.

26 ‘The CHC lacks basic infrastructure for institutional delivery, labour room and laboratory facilities which are in poor condition. Moreover, an ambulance is needed for providing referral transport services. We have all the responsibilities but cannot take necessary administrative decisions independently’.

Suggestions by BMO: All vacant posts of medical, paramedical and computer operator should be filled up for smooth functioning of CHC. More specialists are required to provide specialist services. The BMOs need more support from the district authorities to carry out their duties systematically. Coordination with block level officers for RKS is a problem as they are not available most of the time. The BMO should have control over the RKS funds. The two CHCs should be merged and start functioning from the present building. We have received funds for a new CHC building but the construction has yet to start.

Remarks/suggestions for the improvement of services by the observer: Record maintenance in different sections of the CHC although manually done is up to the mark. There is paucity of medical staff at the CHC. Hospital is under utilized as the bed occupancy rate is very low. Apart from institutional deliveries the CHC provides regular maternal and child health services like ante-natal checkup, immunization, etc which is carried out by the field staff on the field. With regards to Family Planning services, the records status is satisfactory in CHC. The service outcomes on these aspects were made readily available. A paediatrician and gynaecologist have applied for voluntary retirement which will further deplete the medical staff strength at CHC hampering services. Private practice by medical officers also shortens the OPD time by 2 hours. Monitoring of the day to day activities of two CHCs in different localities is impossible for the BMO which raises questions about the quality of services in implementation of NRHM.

27 Community Health Centres

Table C1: Coverage and Availability of Infrastructure

Coverage and Availability of Infrastructure CHC 1 CHC 2 (Pushprajgarh) (Kotma) Population served by CHC 2,20,000 2,42,307 Distance & Time Taken to travel to CHC in public Distance Time (in Distanc Time (in transport / available mode from (in Kms) Minutes) e (in Minutes) Kms) Nearest PHC in the coverage area 28 60 12 20 Farthest PHC in the coverage area 65 120 30 45 District Hospital 30 45 38 60 No. of Beds available Male 0 6 Female 0 10 Availability of Infrastructure (Yes:1; No: 0) CHC 1 CHC 2 (Kotma) (Pushprajgarh) Status of Building Own government Building 1 1 Rented premises - - Other Rent-free Building - - Electricity in all parts: No regular electricity supply 0 0 Regular electricity supply in all parts 1 1 30 or more beds 0 0 Generator 1 1 Telephone 1 1 Computer 1 1 Internet 1 1 Running Vehicle/Ambulance 1 0 Laboratory 1 1 Investigative facilities ECG 0 0 X-Ray 1 1 Ultrasound 0 0 OT (Operation Theatre) 1 1 OT used for Gynaecology 0 0 Labour Room 1 1 Separate areas for septic and aseptic deliveries 0 0 New Born Care Corner 1 1 Names of JSY beneficiaries maintained in record? 1 1 Pharmacy for drug dispensing and drug storage 1 1 Counter near entrance of CHC to obtain 1 1 contraceptives, ORS packets, Vitamin A and medicines Separate public utilities (toilets) for males and 0 1 females Suggestion / complaint box 0 0

OPD rooms / cubicles 1 1 Waiting room for patients 1 1 Does the waiting room have adequate sitting place 0 0 Is drinking water available in the waiting area? 0 0 Emergency Room / Casualty 0 1 Separate wards for males and females 0 1 Coverage and Availability of Infrastructure Type of sewerage system Soak pit 0 1 Open drain 1 0 Connected to Municipal Sewerage 0 0 Other 0 0 Waste disposal Buried in a pit 1 1 Collected by an agency 0 0 Incernation 0 0 Thrown in open 0 0 Status of Cleanliness of OPD reported good or fair 1 1 Status of Cleanliness of Compound / Premises 0 0 reported good or fair Status of Cleanliness of Room/Wards reported good 1 1 or fair Prominent display boards regarding service 0 0 availability in local language Names of JSY beneficiaries maintained in record? 1 1 Pharmacy for drug dispensing and drug storage 1 1 Counter near entrance of CHC to obtain 0 1 contraceptives, ORS packets, Vitamin A and medicines

Table C 2: Position of Medical Staff and Paramedical Staff Type of Staff CHC 1 (Pushprajgarh) CHC 2 (Kotma) Position of Medical Staff (clinical) Numbers Numbers in position Numbers Numbers in position Sanctioned Regular Contractual Total Sanctioned Regular Contractual Total General Surgeon 0 - - - 0 - - - Physician 1 0 0 0 0 0 0 0 Obstetrician / Gynaecologist 1 0 0 0 1 1 0 1 Medical Officer trained with short term 0 - - - 0 - - - obstetrics course) Paediatrician 0 - - - 1 1 1 1 Anaesthetist 0 - - - 0 - - - Medical Officer trained with short term 0 - - - 0 - - - Anesthesia course) General Duty Medical Officer 3 2 0 2 3 2 0 2 Eye Surgeon 0 - - - 0 - - - Public Health Nurse Position of Paramedical and Support Staff Lady Health Visitor (LHV) 2 2 0 2 1 1 0 1 Block Extension Educator (BEE) 1 1 0 1 0 0 0 0 ANM 3 1 1 2 0 0 0 0 Staff Nurse 4 1 0 1 6 3 0 3 Dresser 2 2 0 2 1 2 0 2 Pharmacist / Compounder 2 1 0 1 2 1 0 1 Lab. Technician 2 1 1 2 2 2 0 2 Radiographer 1 1 0 1 1 1 0 1 Ophthalmic Assistant 0 - - - 1 1 0 1 Statistical Assistant / Data entry operator 1 0 1 1 1 0 1 1 OT attendant 0 0 0 0 0 0 0 0 Ambulance Driver 0 0 0 0 0 0 0 0 Registration Clerk 0 0 0 0 0 0 0 0

Table C3: Availability of Specific Services in CHC Availability of Specific Services(Yes: 1; No: 0) CHC 1 CHC 2 (Pushprajgarh) (Kotma) Functioning on 24x7 1 1 Functioning as FRU 0 0

Table C4: Status of Specific Interventions CHC 1 CHC 2 Status of Specific Interventions (Yes: 1; No: 0) (Pushprajgarh) (Kotma) IPHS Facility Survey done 1 1 Funds being electronically transferred from District 1 1 Registered Rogi Kalyan Samiti 1 1 RKS generating resources through user fees 1 1 Money generated by RKS being used 1 1 Display board showing no. of meetings & members of 1 1 RKS Feedback mechanism in place for grievances redressed by 0 0 RKS Citizens Charter publically displayed 0 1 All Standard Treatment Guidelines and Protocols 0 0 available

Table C5: Status of Residential Facilities for Doctors and Other Staff Residential Facilities (Yes: 1; No: 0) CHC 1 CHC 2 (Pushprajgarh) (Kotma) For Doctors Residential Facility for Doctors 1 1 Non-Occupied Residential Quarters 0 0 Reason for non-occupancy being poor condition / - - insecurity / lack of electricity and water supply For Other Staff Residential Facility for Staff 1 1 Non-Occupied Residential Quarters 0 0 Reason for non-occupancy being poor condition / - - insecurity / Lack of electricity and water supply

Table C6: Availability of Laboratory Facilities CHC 1 CHC 2 Laboratory Testing (Yes: 1; No: 0) (Pushprajgarh) (Kotma) Type of Laboratory Testing Haemoglobin 1 1 Urine RE 0 0 Blood sugar 0 0 Blood grouping 0 0 Blood Smear 0 0 Bleeding time, clotting time 0 0 Diagnosis of RTI/ STIs with wet mounting, grams stain 0 0 etc. Blood smear examination for malaria parasite 1 1 Rapid test for Pregnancy 0 0 RPR test for Syphilis 0 0 Rapid test for HIV 0 0

Table C 7: Number of Laboratory tests done in CHC in last 3 calendar months Type of tests done CHC 1 (Pushprajgarh) CHC 2 (Kotma) Haemoglobin 0 0 Urine RE 0 0 Blood sugar 0 0 Blood grouping 0 0 Blood Smear 0 0 Bleeding time, clotting time 0 0 Diagnosis of RTI/ STIs with wet 0 0 mounting, grams stain etc. Blood smear examination for 334 376 malaria parasite Rapid test for Pregnancy 0 0 RPR test for Syphilis 0 0 Rapid test for HIV 0 0

Status of performance of OT

Table C8: Number of surgeries performed during 2007-2008 Number of surgeries performed Type of surgeries during 2007-2008 CHC 1 CHC 2 (Pushprajgarh) (Kotma) Caesarean Sections 0 0 No. of C-section deliveries for JSY Card holders 0 0 Surgical cases 0 0 Cataract 249 0 Tubectomy 999 0 Laproscopic Sterlisation 939 306 NSV 243 83 Conventional Vasectomy 0 0 MTP 0 0 Laprotomy 0 0

Table C9: Reasons for not conducting surgeries (If OT available, but surgeries not conducted) Reasons for not conducting deliveries(Yes: 1; No: 0) CHC 1 CHC 2 (Pushprajgarh) (Kotma) Non availability of doctor/anaesthetist/staff 1 1 Lack of equipment/poor physical state of the 1 0 operation theatre No power supply in the OT 0 0 Other 0 0

Status of performance of Labour Room

Table C 10: Status of performance of Labour Room during 2007-2008 Number of deliveries performed Number of deliveries during 2007-2008 CHC 1 CHC 2 (Kotma) (Pushprajgarh) Total Institutional Deliveries 2639 1943 Deliveries carried out from 8 pm to 8 am NA 580 Institutional deliveries for JSY card holders 2639 1943 Number of neonates resuscitated 0 0

Table C11: Reasons for not conducting deliveries (If Labour room available but deliveries not conducted) Reasons for not conducting deliveries(Yes: 1; No: CHC 1 CHC 2 0) (Pushprajgarh) (Kotma) Non availability of doctors/staff - - Poor condition of the labour room - - No power supply in the labour room - -

Table C12: Status of availability of Equipments and drugs

Status of availability of equipments Equipments available / working CHC 1 (Pushprajgarh) CHC 2 (Kotma) (Yes:1; No: 0) Available Working Available Working Boyles Apparatus 1 1 0 - ECG Machine 1 1 1 1 Cardiac Monitor for OT 0 - 0 - Defibrillator for OT 0 - 0 - Ventilator for OT 0 - 0 - Horizontal High Pressure Sterilizer 1 1 0 0 Vertical High Pressure Sterilizer 2/3 0 0 1 1 drum capacity OT Care Fumigation Apparatus 0 - 0 - Gloves & Dusting Machines 0 - 0 - Oxygen Cylinder 1 1 1 1 Hydraulic Operation Table 1 0 1 1 Resuscitation trolley 0 - 0 - Phototherapy unit 1 1 1 0 MVA syringe 1 1 1 1 Baby incubator 0 - 0 -

Status of availability of drugs

CHC reporting stock out or irregular supply of specific Type of Drugs drugs in last 6 months (Yes: 1; No: 0) CHC 1 (Pushprajgarh) CHC 2 (Kotma) Stock Out Irregular Stock Out Irregular Supply Supply Iron Folic Acid (IFA) 0 0 0 0 Oral Pills (OPs) 0 0 0 0 IUD 380 0 0 0 0 ORS (Oral Rehydration Salts) 0 0 0 0 ORS with Zinc adjutant as per - - 0 0 policy Vitamin A 0 0 1 0 Tab. Fluconazole 0 0 0 0 Tab. Metronidazole 0 0 0 0 Tab. Co-trimoxazole (Kid) 0 0 0 0 Tab. Nefidipine 0 0 0 0 Inj. Oxytocin 0 0 0 0 Inj. Gentamycin 0 0 0 0 Inj. Magnesium Sulphate 0 0 0 0 Tab. Misoprostal 0 0 0 0 Tab. Progestrone 0 0 0 0 Inj. Lignocaine Hydrochloride 0 0 0 0 Inj. Pentazocine Lactate 0 0 0 0 Inj. Adrenaline 0 0 0 0 Cap. Doxycycline 0 0 0 0 Silver Sulphadiazine oint. 0 0 0 0 IV Fluids 0 0 0 0 Inj. Prociane Penicillin 0 0 0 0 Inj. Atropine 0 0 0 0 Syp Amoxycyclin 0 0 0 0 IFA Syrup 0 0 0 0 *-drugs never supplied to CHC

Table C13. Availability of Specific Services (Yes: 1; No: 0) Type of Service CHC 1 CHC 2 (Pushprajgarh) (Kotma) Medicine 0 0 Surgery 0 0 Obstetric & Gynae 1 0 Pediatrics 1 0 DOTS 1 1 Cataract Surgery 0 0 Leprosy diagnosis management and referral services 1 1 Emergency Services (24 Hrs) 1 1 mobile medical unit 1 1 separate neo-natal care unit 0 0 emergency care for sick children 1 0 Full Range of Family Planning Services including 0 0 Laproscopic ligation safe abortion services 1 0 Treatment of STI/RTI 1 0 Blood Storage facility 0 0 Counseling Facility on HIV/AIDS/STD etc 0 0 Voluntary Counselling and Testing Centre (VCTC) 0 0 AYUSH facility 0 0 Primary management of wounds 1 1 Primary management fracture 1 1 Primary management of cases of poisoning/snake, insect 1 1 or scorpion bite Primary management of dog bite 1 1 Primary management of burns 1 1 Management of RTI/STI 1 1

Table C14: Service Outcome (based on data for last three months) Average monthly figure reported in CHC based on last three Indicator months CHC 1 (Pushprajgarh) CHC 2 (Kotma) SC ST Others Total SC ST Others Total Total ANC Registration 18 65 32 115 38 47 90 175 Total JSY cases registered 18 65 32 115 38 47 90 17 5 Ist Trimester Registration 6 36 15 57 13 18 36 67 ANC given 3 Checkups as per RCH 4 12 8 24 28 32 82 142 Schedule Out of above, the no. of JSY beneficiaries 4 12 8 24 28 32 82 142 ANC given TT (2nd dose+Booster) 7 16 17 40 41 52 92 185 Out of above, the no. of JSY beneficiaries 7 16 17 40 41 52 92 185 ANC completed IFA Prophylaxis - - - - 37 45 86 168 Out of above, the no. of JSY beneficiaries - - - - 37 45 86 168 Number of pregnant women identified - - - - 2 2 4 8 and attended with obstetric complications Out of these, how many have been referred - - - - 1 1 3 5 from PHC/SHC Total Institutional Deliveries 89 339 76 504 99 112 239 447 No. of JSY cases (out of total institutional 89 339 76 504 99 112 239 447 deliveries) No. of infants given BCG 18 51 24 93 42 51 86 179 No. of infants given DPT3 3 12 12 27 27 30 69 126 No. of infants given Measles 4 11 14 29 22 29 64 115 No. of infants given Vit. A-first dose 0 0 0 0 21 2 8 67 116 Children given IFA Syp. (6-60 Months) ------IUD Inserted - - - - 12 17 25 54 Total Indoor Patients - - - - 118 137 253 508 No. of cases referred beyond CHC - - - - 0 1 2 3 No. of Leprosy cases currently under 1 7 2 9 2 12 27 41 treatment No. of new TB cases enrolled for DOTS - - - 25 15 1 5 60 90 No. of cases given Blood Transfusion in 0 0 last 3 months Bed occupancy rate in the last 12 months? 158 34 (As on March 31, 2008) Average Daily OPD Attendance (Total) 80 49 Average Daily OPD Attendance Average Daily OPD Attendance Male 25 35 Average Daily OPD Attendance Female 31 12 Average Daily OPD Attendance Children 24 2 Out of the total OPD attendance, specify 0 0 the referred cases from PHC/ SHC

Chapter 4

Primary Health Centres

As per the study design, two PHCs are selected under the each selected CHC. The selected PHCs are vertically under the CHCs. Under CHC Pushprajgarh, the selected PHCs are Amarkantak and Benibari. Under CHC Kotma, the selected PHCs are Bijori and Kothi. Three of the PHCs are functioning 24*7 as far as providing delivery services are concerned but Kothi PHC does not provide delivery services. This chapter presents the information collected from these four PHCs.

Coverage and Facility The number of SCs covered by these four PHCs varies from 4 to 7 and the population covered varies from 26,000 to 50,000. The distance from the nearest SC in the coverage areas to these PHCs varies between 5 to 16 kilometres and distance from the farthest SC varies from 14 to 35 kilometres. Time taken to reach the PHCs from the nearest SCs varies from 15 to 30 minutes and from the farthest SCs it varies from 45 to 90 minutes. Out of the four PHCs, two are having 6 beds,PHC Benibari has 4 beds and Kothi PHC has 5 beds which are in a state of disuse. Three of the PHCs are functioning on 24*7 basis and these PHCs are equipped to provide basic obstetrics services.

Infrastructure Out of four PHCs 3 are functioning from a designated government building and one of them Bijori PHC is functioning from a donated building. Three PHCs except Kothi are having labour rooms and laboratory facilities are available at Benibari and Bijori PHCs. The PHCs where deliveries are taking place are maintaining the records containing the names of JSY beneficiaries. Only Amarkantak PHC has put up a prominent display board regarding service availability in local language. Pharmacy for drug dispensing and drug storage is available in all four PHCs. OPD rooms/cubicles, are available in all the PHCs, regular electricity supply is available in 3 PHCs except Kothi which has got a temporary connection

38 from outside. Generator/inverter facilities for power backup is available in 3 of the four PHCs except Kothi but separate toilets for males and females are available in none of the 4 PHCs. Although Kothi PHC has a number of toilets they have not been separately designated as male or female. In none of these PHCs suggestion/complaint box is kept. Piped water supply is available in none of the PHCs. Telephone is available in the 3 PHCs except Kothi, all have a computer and none of them have internet facility. Type of sewerage in these PHCs is either a soak pit or open drain. The PHCs dispose their bio-medical waste by burying in a pit, burning or throwing in open. Out of four PHCs, only Benibari has a New Born Care Corner. As per our observation, the cleanliness of OPD, compound/premises and rooms/wards is average in the four PHCs but Kothi PHC is more or less non-functional because the M.O. is on leave. OPD/Wards of this PHC are not being used at all.

Staff Position In all the PHCs the sanctioned positions of Medical Officers are filled up. Out of the 5 MOs two are working on contractual basis. The pharmacist’s post although sanctioned in 3 PHCs is lying vacant and in Bijori PHC there is no sanctioned post of a pharmacist. In 3 PHCs the ANMs are working against the sanctioned post except for Kothi PHC where there is no sanctioned post of ANM. Out of 2 sanctioned posts of lab technicians only one is working on regular position in Kothi CHC. Only one MO Ayush is working contractually against the sanctioned post at Benbari CHC. Staff nurses sanctioned and in position are visible in 3 PHCs except Kothi where there is no sanctioned post of a staff nurse. LHV’s post is only sanctioned at Amarkantak PHC and is filled up. Two lab assistants are working contractually against the sanctioned posts in Bijori PHC. Posts of BHEIO, nurses, and drivers are neither sanctioned nor filled up in any of the 4PHCs. Statistical assistant’s post is sanctioned and filled up in Amarkantak PHC only. Although the staff position in none of the PHCs is fully satisfactory, it is extremely poor in Kothi CHC.Sweepers have been appointed on contingency basis from RKS in three PHCs, Amarkantak, Bijori and Benibari.

39 Status of Training of Personnel at PHC In PHC Amarkantak one ANM has undergone training in Pre-Service IMNCI (Integrated management of Neonatal and Child Infections) and New Born Care for 15 days each. One MO has received SBA (3days) and new born care training (4 days).

Availability and Performance of Labour Room Three out of the 4 PHCs have labour rooms which are in use for providing delivery services except Kothi. The 3 PHCs together conducted 1364 deliveries in the year 2007-08 and 310 deliveries carried out between 8 pm to 8 am (In Amarkantak PHC record of 8 pm to 8am deliveries, is being maintained since July 2007. Benibari PHC is not maintaining records of timings). In Kothi PHC it is observed that due to the absence/ irregular attendance of staff at the PHC the labour room has not yet started functioning.

Availability of Laboratory Testing in PHC Out of the four PHCs 2 PHCs, Bijori and Kothi have laboratory facilities. Amarkantak PHC does not have any laboratory facilities whereas in Benibari PHC although lab facilities for RNTPC and chemicals etc. are available, but due to the non availability of lab technician laboratory services are not being provided by the PHC. The two PHCs of Bijori and Kothi have just carried out blood smear examination for malaria parasite in the last one year. The tests for Haemoglobin, Urine RE, Blood Smear, and Rapid Test for Pregnancy, Blood Sugar, Diagnosis for RTI/STI and Rapid Test for HIV are not available in any of the 2 PHCs. These PHCs also do not have the testing facility for Blood Grouping, Bleeding and Clotting Time, and RPR Test for Syphilis.

Number of Tests Done in PHCs The number of blood smear examination for malaria parasite tests done in the last three months is 97 and 145 respectively in Bijori and Kothi PHCs during the last three calendar months.

40 Status of Specific Interventions IPHS facility survey has been done in 3 out of four PHCs although none of the medical officers at the 3 PHCs have any knowledge about it. This information was obtained from the District Progamme Manager. Three PHCs are functioning on 24*7 bases (have 1 MO and 3 or more ANMs/Staff Nurses round the clock). One AYUSH doctor (homeopathy) is providing services in Benibari PHC contractually. The RKS has been formed in all the 4 PHCs but is registered only at Bijori PHC. In the other three PHCs due to some administrative problems the registration process has yet to be completed. There are no display boards showing the composition of the RKS with the names of the members and number of meetings held at Bijori PHC. In all the PHCs RKS is generating resources through user fees which are being used locally. In none of the PHCs feedback mechanism is in place for grievances redressed by RKS. Standard treatment guidelines and protocols are not available with the PHCs. Citizens charter is not publicly displayed in any of the PHCs.

Availability of Specific Services All the four PHCs have the specific services for primary management of wounds and facility for minor surgeries is available in all 4 PHCs. Burn cases are handled in 2 PHCs Amarkantak and Bijori. Primary management of fracture is done by Amarkantak PHC. Treatment of poisoning/snake/insect/scorpion bite, dog bite and is available in 4 PHCs and management of RTI/STI is available in 3 PHCs. AYUSH services are available only in Kothi PHC. Care of malnourished children, management of neonatal asphyxia, MTP is not available in any of the CHCs.

Availability of Selected Equipments in PHC Out of 23 equipments for which the information was collected from the PHCs, Amarkantak PHC has 13 equipments out of which 11 are in working order with the exception of suction apparatus and oxygen mask. Benibari has 14 equipments out of which all except sterilization equipment are in working order, Bijori PHC has 12 equipments, of which three, sterilization and resuscitation equipment, and thermometer, is not working. Kothi PHC has 13 equipments out of which 10 are in working condition. Auto analyzer, Bag and

41 mask, radiant warmer, cradle and laryngoscope are equipments not available at any of the 4 PHCs. The equipments which are available at Kothi PHC although in working condition are hardly being used because the PHC is not functioning in full capacity and is hardly providing any services. The equipments have been reported by PHC staff but not physically verified because the store was locked and the keys were not available at the time of survey.

Status of Availability of Drugs Out of the 25 drugs Amarkant and Benibari PHCs have complete stock of 20 (80 percent) drugs with regular supply. Out of the 25 drugs 11 drugs (48 percent) drugs like Vitamin A, measles vaccine, oral pills, IUDs, MVA syringe, Partograph, tablet Fluconazole, AYUSH drugs, DOTS drugs, MDT drugs, blister packs, Injection Oxytocin and Haemoccele have never been supplied to Kothi PHC. Similiarly, Bijori PHC has never been supplied with 8 drugs (25 percent) drugs. The drugs/vaccines like oral pills, measles vaccines, IUDs essential for maternal and child health as well as family planning services, have either not been supplied or are out of stock. The reasons given by the concerned staff is that the field staff under the PHC are providing these services and the PHC staff are not directly involved in providing vaccination programme or family planning services. Thus availability of drugs is better in PHCs under Pushprajgarh CHC, than those under Kotma CHC.

Service Outcome The service outcome statistics was collected from the PHCs for last three months prior to the survey. Table P12 presents the ‘average monthly figure’ based on the data collected for the last three months. The caste wise break-up is maintained by the PHCs for some of the indicators. The average number of institutional delivery is 350 as reported by 3 PHCs (In Kothi PHC no institutional deliveries are taking place). Out of four PHCs, 3 have reported registering on an average 102 cases of JSY. Since M. P. is an EAG state all women who come for institutional deliveries are provided cash assistance under JSY. The PHC wise performance shows that the PHCs under CHC Pushprajgarh have done better compared to the PHCs under CHC Kotma. PHC wise breakup of OPD cases is reported as follows: Amarkant 1111,

42 Benibari 1221 and Bijori 3084 cases. (Kothi PHC has not maintained the data on OPD patients). The number of IPD cases reported is: Amarkant 104, Benibari 165 and Bijori 173 cases (Kothi PHC is not providing IPD services).

The caste wise break-up shows that the ST population mainly uses the PHC facilities more than the ‘Other’ caste groups, Annupur being a tribal dominated district.

Status of Record Maintenance Amarkantak PHC is maintaining 7 and Benibari 6 out of the 9 registers. In Bijori whereas 4 registers were available in Kothi only 1 register is available. Some of the essential registers are not being maintained by the PHCs because these services are not being directly provided at the PHCs but by the field staff working in their area.

Remarks and Suggestions: PHCs under CHC Pushprajgarh

Remarks by MO In-Charge (Amarkantak): ‘Fund flow has improved (especially untied funds) after 2006. Renovations have been done, and purchase of necessary equipments has been made. All categories of staff should be available in the PHC for implementation of NRHM and for providing a range of maternal and child health services. The lab technician is required for conducting diagnostic tests, and permanent ward boy for providing IPD services. At least two MOs are required for running the PHC 24*7. There must be residential quarters for the paramedical and supporting staff to provide 24*7 services. Referral transport services are essential for remote villages which get cut off during the rainy seasons.’

Remarks/suggestions for the improvement of services by the observer: Amarkantak PHC is providing institutional delivery services round the clock. The concerned medical officer has maintained the health facility well. The cleanliness of OPD/rooms/wards is commendable. The RKS has been formed but not yet registered due to some administrative problems. Some furniture like chair table, computers, fridge etc. have been centrally purchased at the district and then sent to the PHCs. The amount was deducted from RCH funds. Boundary wall has

43 also been constructed from these funds. The original pass book and untied fund register was submitted to the BMO Pushprajgarh for audit purposes and could not be verified. BeMOC services are being provided by the PHC. Family planning services are being provided by the PHC staff. The records of institutional delivery services and JSY beneficiaries are properly documented and maintained. The beneficiaries are receiving Rs.1400 for institutional delivery whereas ASHA’s are being paid Rs. 600 in a single installment for promoting institutional delivery. The MO does not have any knowledge about the IPHS survey conducted for the PHC.

Remarks by MO (Benibari): ‘This PHC is working with a single MO and my appointment is contractual. My PHC is functioning without the necessary infrastructure and staff. We urgently need a lab technician and compounder to provide proper OPD services. We have problems regarding regular electricity and water supply. We urgently need referral transport services because of distances from remote villages. My priority is getting a boundary wall constructed.’

Remarks/suggestions for the improvement of services by the observer Benibari PHC: The Benibari PHC is functioning from a newly constructed building but due to lack of staff and services only skeletal OPD services were observed. However, BEmOC services are being provided by the PHC. An MO under AYUSH is providing homeopathy services and treatment. The records of institutional delivery services and JSY beneficiaries are properly documented and maintained. But timings of delivery (8AM to 8 PM) are not recorded by the PHC staff. They were advised to record the timings of birth in future. The beneficiaries are receiving Rs.1400 for institutional delivery whereas ASHAs are being paid Rs.600 in a single installment for promoting institutional delivery. The MO does not have any knowledge about the IPHS survey conducted for the PHC. The original pass book and untied fund register was submitted to the BMO Pushprajgarh for audit purposes and could not be verified. The PHC is catering to remote and outreach villages and therefore referral transport services are needed urgently to provide transport services for institutional delivery and other emergencies in the area.

44 Remarks and Suggestions: PHCs under CHC Kotma

Remarks by MO (PHC Bijori): ‘We are providing BEmOC services with 2 staff nurses 1ANM with round the clock delivery services. However, both the MO’s are contractual here therefore decision making on various financial and administrative issues related to the functioning of the PHC is difficult. I do not have any drawing and disbursing power because I have been appointed on contractual basis. There should be availability of staff quarters so that the staff can stay at the PHC head quarters. We are running this PHC in an old building. A boundary wall is required to provide privacy. The building needs expansion and PHC needs upgradation. An ambulance is urgently required for referral transport services for institutional delivery and other emergencies in the area.’

Remarks/suggestions for the improvement of services by the observer: At Bijori PHC brisk OPD services are being provided. The record keeping of OPD/ IPD services is poor. The PHC records/ registers were not produced for verification. The MO’s were being dominated in their decisions by a compounder who has been serving at the PHC for more than 20 years. There was hesitation in showing records and providing necessary information. Like other PHCs, Bijori also has purchased computer, chairs, almirah, telephone, table, BP instrument from RKS funds. These purchases have been made by the district authorities for them. The untied funds are being used by the PHC for meeting the expenses of telephone bills. Two sweepers have been appointed on contingency basis since 2006 and their payments are being made from the untied funds.ANC/ PNC and immunization registers should be maintained at the PHC because a field ANM attached to this PHC provides services twice week. The MO should have proper administrative control over his supporting staff.

Remarks/suggestions for the improvement of services Kothi PHC: Kothi PHC has a newly constructed building but no staff was available on the day of survey. The MO was on study leave and the PHC was closed. It was reported by the PHC staff that the MO visits the PHC from time to time and not regularly ever since he has joined services in the year 2000. OPD services are irregular because of the absence of the doctor who was also reported to run

45 his private nursing home at Bijori. After persistent efforts made to collection necessary data and information, the field staff of Kothi PHC provided some information about the PHC. Only skeletal OPD services are being provided by the ward boy. It is a grossly underutilized PHC and needs immediate attention from the district authorities because the PHC has been newly constructed and needs to be made fully functional.

46 Primary Health Centres

Table P1: Coverage and facilities of Primary Health Centre CHC 1 Pushprajgarh CHC 2 Kotma Coverage and facilities PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Number of Sub- Centres covered by 10 17 3 7 PHC Population covered 26,000 34,000 50,000 35,000 PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Distance & Time Distance Time (in Distance Time (in Distance Time (in Distance Time (in Taken to travel in (in Kms) Minutes) (in Kms) Minutes) (in Kms) Minutes) (in Kms) Minutes) public transport / available mode from Nearest Sub Centre in the coverage area 16 30 7 20 9 15 5 15

Farthest Sub Centre in the coverage area 35 90 30 75 14 45 21 60

Nearest CHC 40 90 30 75 23 60 35 90 No. of Beds available Male 0 0 0 0 Female 0 0 0 0 Total 6 4 6 5 PHC functioning on 24x7 basis (Yes:1; No: 1 1 1 0 0) PHC equipped to provide basis obstetric 1 1 1 0 services (Yes:1; No: 0) PHC with 4-6 beds (Yes:1; No: 0) 1 1 1 0

Table P2: Primary Health Centres by Infrastructure CHC 1 Pushprajgarh CHC 2 Kotma PHC 1 PHC 2 PHC 1 PHC 2 Infrastructure (Amarkantak) (Benibari) (Bijori) (Kothi) PHC functioning in designated govt. Building . (Yes:1; No: 0) 1 1 0 1 Labour Room (Yes:1; No: 0) 1 1 1 0 Laboratory(Yes:1; No: 0) 0 1 1 0 Prominent display boards regarding service availability in local language (Yes:1; No: 0) 1 0 0 0 Names of JSY beneficiaries maintained in record(Yes:1; No: 0) 1 1 1 0 Pharmacy for drug dispensing and drug storage 1 1 1 1 (Yes:1; No: 0) Separate public utilities (toilets) for males and 0 0 0 0 females (Yes:1; No: 0) Suggestion / complaint box (Yes:1; No: 0) 0 0 0 0 OPD rooms / cubicles (Yes:1; No: 0) 1 1 1 1 Piped Water Supply (Yes:1; No: 0) 1 0 1 0 Electricity Supply No regular electricity supply(Yes:1; No: 0) - - - 1 Regular electricity supply in all parts(Yes:1; 1 1 1 - No: 0) Telephone (Yes:1; No: 0) 1 1 1 0 Computer (Yes:1; No: 0) 1 1 1 1 Internet (Yes:1; No: 0) 0 0 0 0 Type of sewerage system(Yes:1; No: 0) Soak pit 1 - 1 1 Connected to municipal sewerage - - - - Open drain - 1 - - Other - - - - Waste disposal(Yes:1; No: 0) Buried in a pit 1 - - - Collected by an agency - - - - Incernation/burning - 1 1 - Thrown in open - - - 1 Standby facility (generator etc.) available in working condition(Yes:1; No: 0) 1 1 1 0 Separate areas for septic and aseptic deliveries available? (Yes:1; No: 0) 0 0 0 0 New Born Care Corner available? (Yes:1; No: 0) 0 1 0 0 Status of Cleanliness of OPD reported good or fair 1 1 1 0 Status of Cleanliness of Compound / Premises reported good or fair 1 1 1 0 Status of Cleanliness of Room/Wards reported good or fair 1 1 1 0

Table P3: Staff Position of in Primary Health Centre CHC 1 Pushprajgarh CHC 2 Kotma

Type of Staff PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Numbers in Position Numbers in Position Numbers in Position Numbers in Position S R C T S R C T S R C T S R C T

Medical Officer 1 1 0 1 1 0 1 1 2 0 2 2 1 1 0 1 Pharmacist 1 0 0 0 1 0 0 0 0 0 0 0 1 - - - Nurses 0 - - - - 0 0 0 0 0 0 1 0 - - - ANM 2 1 1 2 2 1 1 2 1 0 1 1 0 - - - Lab Technician 0 - - - 1 0 0 0 0 - - - 1 1 0 1 Driver 0 - - - - 0 0 0 0 - - - 0 - - - Medical Officer 0 - - - - 0 1 1 0 - - - 0 - - - AYUSH Staff Nurse 1 0 1 1 1 1 0 1 2 0 2 2 0 - - - Lady Health Visitor 1 1 0 0 0 - - - 0 0 0 0 0 - - - Lab Assistant 0 - - - 0 - - - 2 0 2 2 0 - - - Block Health Education 0 - - - 0 - - - 0 - - - 0 - - - and Information Officer (BHEIO) Statistical Assistant 1 0 1 1 0 - - - 0 - - - 0 - - -

S: Sanctioned; R: Regular; C: Contractual; T: Total

Table P4: Status of training of personnel at Primary Health Centre PHC having personnel trained in specific category of training during 2007 (Yes:1; No: 0) Training CHC 1 Pushprajgarh CHC 2 Kotma PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Pre Service IMNCI 1 0 0 0 Safe Abortion Methods 0 0 0 0 Skill Birth Attendant 0 0 1 0 Training0 New Born Care 1 0 1 0

Table P5: Availability of Labour Room in Primary Health Centre CHC 1 Pushprajgarh CHC 2:Kotma

Labour Room (Yes:1; No: 0) PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Availability of Labour Room 1 1 1 0 Labour Room Currently in Use 1 1 1 - Reasons for not using Labour Room Non availability of - - - - doctors/staff Poor condition of the labour - - - - room No power supply in the labour - - - - room Other - - - -

Table P6: Status of performance of Labour Room during 2007-2008 Number of deliveries performed in PHC during 2007-2008 CHC 1 Pushprajgarh CHC 2 Kotma Number of deliveries PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Total Institutional Deliveries 260 494 610 - Deliveries carried out from 8 126 0 184 - pm to 8 am Institutional deliveries for 260 494 610 - JSY card holders Number of neonates 0 0 0 0 resuscitated

Table 7: Availability of laboratory testing in PHC Availability Laboratory CHC 1 Pushprajgarh CHC 2 Kotma Testing (Yes:1; No: 0)

PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Haemoglobin - - 0 0 Urine RE - - 0 0 Blood sugar - - 0 0 Blood grouping - - 0 0 Blood Smear - - 0 0 Bleeding time clotting - - 0 0 time Diagnosis of RTI STIs - - with wet mounting grams 0 0 stain etc. Blood smear examination - - 1 1 for malaria parasite Rapid test for Pregnancy - - 0 0 RPR test for Syphilis - - 0 0 Rapid test for HIV - - 0 0

Table P8: Number of tests done in PHC in last three calendar months Number of tests done in last 3 calendar months CHC 1 Pushprajgarh CHC 2 Kotma Type of Test PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) Haemoglobin - - 0 0 Urine RE - - 0 0 Blood sugar - - 0 0 Blood grouping - - 0 0 Blood Smear - - 0 0 Bleeding time clotting - - 0 0 time Diagnosis of RTI STIs - - with wet mounting grams 0 0 stain etc. Blood smear examination - - 97 145 for malaria parasite Rapid test for Pregnancy - - 0 0 RPR test for Syphilis - - 0 0 Rapid test for HIV - - 0 0

Table P9: Status of Specific Interventions Status of Specific Interventions CHC 1 Pushprajgarh CHC 2 Kotma (Yes:1; No: 0) PHC 1 PHC 2 PHC 1 PHC 2 (Amarkantak) (Benibari) (Bijori) (Kothi) IPHS Facility Survey done 1 1 1 0 PHC functioning on 24 x 7 basis (have 1 MO and 3 or more ANMs / Staff Nurses 1 1 1 0 round the clock)? AYUSH doctor providing services 0 1 0 0 Registered Rogi Kalyan Samiti 0 0 1 0 RKS generating resources through 1 1 1 1 user fees Money generated by RKS being used 1 1 1 1 Display board showing no. of 0 0 0 0 meetings & members of RKS Feedback mechanism in place for 0 0 0 0 grievances redressed by RKS Citizens Charter publically displayed 0 0 0 0 All Standard Treatment Guidelines 0 0 0 0 and Protocols available Availability of Specific Services Primary management of wounds 1 1 1 1 Primary management fracture 1 0 0 0 Management of Neonatal asphyxia, 0 0 0 0 sepsis Management of malnourished children 0 0 0 0 Minor surgeries like draining of 1 1 1 1 abscess etc Primary management of cases of 1 1 1 1 poisoning/snake, insect or scorpion bite Primary management of dog bite cases 1 1 1 0 Primary management of burns 1 0 1 0 Facility for MTP available 0 0 1 0 0 Management of RTI/STI 0 1 1 1 AYUSH services 0 1 0 0

Table P 10: Availability of selected equipments in PHC Equipments CHC 1 Pushprajgarh CHC 2 Kotma available / working PHC 1 PHC 2 PHC 1 PHC 2 (Yes:1; No: 0) (Amarkantak) (Benibari) (Bijori) (Kothi) Avai- Working Avail- Work- Avail Workin Avail- Workin able able ing -able g able g Patient Trolley 1 1 1 1 1 1 1 1 Examination table 1 1 1 1 1 1 1 1 Delivery table 1 1 1 1 1 1 1 1 Wheel chair 0 - 1 1 0 0 1 0 Stretcher/ trolley 1 1 1 1 1 1 1 1 Oxygen Cylinder 1 1 1 1 1 1 1 1 Suction Apparatus 1 0 1 1 1 1 1 1 Infant warmer 1 1 0 0 0 0 0 0 Radiant Warmer 0 0 0 0 0 0 0 0 Cradle 0 0 0 0 0 0 0 0 Autoclave 1 1 1 1 0 0 1 0 Sterlisation 1 1 1 0 1 0 1 0 equipment Bag & Mask 0 0 0 0 0 0 0 0 Laryngoscope 0 0 0 0 0 0 0 0 Oxygen Mask 1 0 0 0 0 0 0 0 Thermometer 0 0 1 1 1 0 0 0 Suction Machine 1 1 1 1 1 1 1 1 Water Purifier 1 1 1 1 1 1 0 0 Microscope 0 0 1 1 1 1 1 1 Haemoglobinometer 0 0 0 0 0 0 1 1 Auto Analyser 0 0 0 0 0 0 0 0 Autoclave 1 1 1 1 0 0 1 1 Resuscitation 0 0 0 0 1 0 0 0 equipment

Table P 11: Status of Availability of Drugs PHC reporting stock out or irregular supply of specific drugs in last 6 months (Yes:1; No: 0) Type of Drugs CHC 1 Pushprajgarh CHC 2:Kotma PHC 1 PHC 2 PHC 1 (Bijori) PHC 2 (Kothi) (Amarkantak) (Benibari) Stock Irregula Stock Irregula Stock Irregula Stock Irregular Out r Out r Out r Out Supply Supply Supply Supply IFA tablets 0 0 0 0 0 0 0 0 Iron Syrup 0 0 0 0 1 1 1 1 Oral Pills 1 1 1 1 - - - - Vitamin A 0 0 1 1 - - - - Measles Vaccine 0 0 0 0 0 0 - - ORS 0 0 0 0 0 0 0 0 Tab. Methergin 0 0 0 0 0 0 0 0 Tab. Albendazole/ 0 0 0 0 0 0 0 0 Mabendazole IUDs 0 0 0 0 0 0 - - Inj oxytocin 0 0 0 0 0 0 - - Magnesium sulphate 0 0 0 0 0 0 0 0 Tab. Fluconazole 0 0 0 0 1 1 - - Partograph 0 0 0 0 0 0 - - MVA syringe 0 0 0 0 0 0 - - Tab Ciprofloxacin 0 0 0 0 0 1 0 0 Syp Cotrimoxazole 0 0 0 0 0 1 0 0 Syp Paracetamol 0 0 1 1 1 1 0 0 Ringer’s Lactate 0 0 0 0 - - - - Haemoccele 1 1 0 0 0 0 0 0 AD syringes 0 0 1 0 1 1 0 0 Disposable Gloves 0 0 0 0 0 1 0 0 Bandages 0 0 0 0 0 0 0 0 AYUSH drugs - - 0 0 - - - - DOTS drugs - - 0 0 0 0 0 0 MDT drugs, blister ------packs -Drugs never supplied to PHC

Table P12 A: Service Outcome (based on data for last three months) CHC 1 Pushprajgarh Average monthly number reported Indicator in PHC 1 (Amarkantak) SC ST Others Total Total ANC Registration 3 16 6 25 Total JSY cases registered 3 16 6 25 Ist Trimester Registration 0 0 0 0 ANC given 3 Checkups 0 10 7 17 ANC given TT1 1 8 2 11 ANC given TT2+Booster 3 19 6 28 ANC completed IFA Prophylaxis 0 0 0 0 Total Institutional Deliveries 0 0 0 72 No. of JSY cases (out of total institutional 3 16 6 72 deliveries) No. of infants given BCG 0 0 0 22 No. of infants given DPT3 0 0 0 6 No. of infants given Measles 0 0 0 6 No. of infants given Vit. A-first dose 0 0 0 6 Children given IFA Syp. 0 0 0 0 IUD Inserted 0 0 0 1 Male sterilisation carried out 0 0 0 29 Female sterilisation carried out 0 0 0 0 Total indoor patients 0 0 0 104 Total outdoor patients 45 944 122 1111 RTI/STI cases treated 0 0 0 0 Number of maternal deaths in 2007-2008 0 0 0 0 No. of cases of obstetric complications 0 0 0 0 referred beyond PHC No. of cataract surgeries carried out 0 0 0 0 No. of new TB cases enrolled for DOTS 0 0 0 0 No. of new leprosy cases registered for 0 0 0 0 MDT No. of leprosy cases completed treatment 0 0 0 0 for leprosy

Table P12 B: Service Outcome (based on data for last three months) CHC 1 Pushprajgarh Average monthly number reported Indicator in PHC 2 (Benibari) SC ST Others Total Total ANC Registration 0 67 0 67 Total JSY cases registered 0 67 0 67 Ist Trimester Registration 2 15 0 17 ANC given 3 Checkups 0 67 0 67 ANC given TT1 2 15 0 17 ANC given TT2+Booster 6 54 0 60 ANC completed IFA Prophylaxis 6 54 0 60 Total Institutional Deliveries 1 124 0 125 No. of JSY cases (out of total 0 67 0 125 institutional deliveries) No. of infants given BCG 0 0 0 0 No. of infants given DPT3 0 0 0 0 No. of infants given Measles 0 0 0 0 No. of infants given Vit. A-first dose 0 0 0 0 Children given IFA Syp. 0 0 0 0 IUD Inserted 0 0 0 0 Male sterilisation carried out 0 0 0 52 Female sterilisation carried out 0 0 0 355 Total indoor patients 0 165 0 165 Total outdoor patients 291 800 130 1221 RTI/STI cases treated 0 0 0 0 Number of maternal deaths in 2007-2008 0 0 0 0 No. of cases of obstetric complications 0 0 0 1 referred beyond PHC No. of cataract surgeries carried out 0 0 0 0 No. of new TB cases enrolled for DOTS 0 1 0 1 No. of new leprosy cases registered for 0 0 0 0 MDT No. of leprosy cases completed treatment 0 0 0 0 for leprosy

Table P12 C: Service Outcome (based on data for last three months) CHC 2 Kotma Average monthly number reported Indicator in PHC 1 (Bijori) SC ST Others Total Total ANC Registration 0 0 0 0 Total JSY cases registered 0 0 0 0 Ist Trimester Registration 0 0 0 0 ANC given 3 Checkups 0 0 0 0 ANC given TT1 0 0 0 0 ANC given TT2+Booster 0 0 0 0 ANC completed IFA Prophylaxis 0 0 0 0 Total Institutional Deliveries 25 50 78 153 No. of JSY cases (out of total 0 0 0 153 institutional deliveries) No. of infants given BCG 0 0 0 0 No. of infants given DPT3 0 0 0 0 No. of infants given Measles 0 0 0 0 No. of infants given Vit. A-first dose 0 0 0 0 Children given IFA Syp. 0 0 0 0 IUD Inserted 0 0 0 31 Male sterilisation carried out 4 5 11 20 Female sterilisation carried out 87 111 173 371 Total indoor patients 0 0 0 173 Total outdoor patients 0 0 0 3084 RTI/STI cases treated 0 0 0 32 Number of maternal deaths in 2007-2008 0 0 0 0 No. of cases of obstetric complications referred beyond PHC 0 0 0 6 No. of cataract surgeries carried out 0 0 0 0 No. of new TB cases enrolled for DOTS 0 0 0 13 No. of new leprosy cases registered for 0 0 0 0 MDT No. of leprosy cases completed treatment 0 0 0 0 for leprosy

Table P12 D: Service Outcome (based on data for last three months) CHC 2 Kotma Average monthly number reported Indicator in PHC 2 (Kothi) SC ST Others Total Total ANC Registration 2 3 5 10 Total JSY cases registered 2 2 5 10 Ist Trimester Registration 0 0 0 0 ANC given 3 Checkups 1 1 5 7 ANC given TT1 2 3 5 10 ANC given TT2+Booster 1 3 3 7 ANC completed IFA Prophylaxis 2 3 5 10 Total Institutional Deliveries 0 0 0 0 No. of JSY cases (out of total 2 2 5 0 institutional deliveries) No. of infants given BCG 1 4 10 15 No. of infants given DPT3 2 2 6 10 No. of infants given Measles 1 0 7 8 No. of infants given Vit. A-first dose 1 0 7 8 Children given IFA Syp. 0 0 0 0 IUD Inserted 0 3 3 6 Male sterilisation carried out 0 0 0 0 Female sterilisation carried out 0 0 0 0 Total indoor patients 0 0 0 0 Total outdoor patients 0 0 0 0 RTI/STI cases treated 0 0 0 0 Number of maternal deaths in 2007- 0 0 0 0 2008 No. of cases of obstetric complications 0 0 0 0 referred beyond PHC No. of cataract surgeries carried out 0 0 0 0 No. of new TB cases enrolled for 1 2 9 12 DOTS No. of new leprosy cases registered for 0 0 0 0 MDT No. of leprosy cases completed 0 0 0 0 treatment for leprosy

Table P13: Status of record maintenance Status (Yes: 1; No: 0) CHC 1 CHC 2:Kotma PHC 1 PHC 2 PHC 1 PHC 2 Type of Records (Amarkantak) (Benibari) (Bijori) (Kothi) Ante Natal Register 1 1 0 0 Eligible Couple Register 0 0 0 0 Post Natal Care Register 1 1 1 1 Family Planning Register 1 0 0 0 Birth & Death Register 1 1 1 0 Immunisation Register 1 0 0 0 Meeting Register 0 1 0 0 JSY Register 1 1 1 0 Untied Funds Register 1 1 1 0

Chapter 5

Sub Centre

As per the study design, three SCs are to be covered for the survey under each selected PHCs and one of the three SCs should be farthest from the PHC. Accordingly, we have covered 12 SCs under four PHCs, SC information is available for 12 centres. The list of selected SCs as per the study design is given in Table 2 of the introductory chapter.

Coverage by Sub-Centres Table S1 shows that the number of villages covered by the SCs varies from 3 to 21 villages and the population covered varies from 721 to 20,600. The average number of villages covered by the SCs is 6 and average population covered is 4913. The average distance between the PHC and SC is 13.5 kilometres and the actual distance varies between 4 to 24 kilometres. The average time taken to travel in public/available mode of transport from furthest village to SC is 49 minutes, from SC to PHC is 43 minutes and SC to CHC is 88 minutes. ASHA’s are providing services in all the 12 SCs. The total number of ASHAs working in the 12 SC area is 37 and the average for all the 12 SCs turns out to be 3.9.

Availability of infrastructure Out of the 12 SCs, 9 (75 percent) are running from designated government building, but the Dola SC is functioning from a rented building . The remaining SCs are functioning from the ‘ANMs own house’ (3 SCs). IPHS facility survey has not been carried out in any of the SCs in the district. Labour room is available only in 25 percent of the SCs i.e., 3 out of 12. Piped water supply is available in 2 SCs and regular electricity is available only 1 SC in Rajnagar. Telephone facility is available in 5 (42 percent) of the SCs although connectivity is poor in the area. Majority of the SCs (58 percent) release their sewerage through an open drain, only Amdari SC has a soakpit. Twenty five percent of the SCs dispose their bio-medical waste by burying in a pit, 1 SC by burning and 42 percent throw it in open.

60 Residential Status of ANM More than half (58 percent) of the SCs have quarters for ANM. Out of the 7 SCs with quarters 4 are occupied. Five ANMs are staying in the SC village, whereas 3 are staying outside. The reason cited by the ANM of Bahiatola and Amdari for not staying in SC quarter is security related, and in Rajnagar the ANM’s house is nearby.

Availability of Staff All the 12 SCs are having at least one health worker (male or female) working in regular position and 5 SCs have both male and female workers in regular position. The staff availability shows that 100 percent of SCs have male and female health workers in regular positions. Three SCs have one contractual ANM in position at the SC.

Availability of Labour Room and Number of Deliveries Conducted As mentioned above, only 3 out of 12 SCs (25 percent) have labour rooms. None of the SCs with labour rooms are presently conducting deliveries. As reported by the ANMs the deliveries are conducted at the PHCs or CHCs where delivery facilities are available. Thus no deliveries were conducted at any of the SCs under Amarkantak, Benibari, Bijori and Kothi PHCs during the year 2007-2008. Reasons provided for not conducting deliveries inspite of a labour room are: ‘do not stay in the same village’, ‘no instruments for conducting delivery’, ‘doctor does not stay here, institutional deliveries are conducted by a doctor’.(Reported by ANMs of Amdari, Bahitola,and Thangaon SCs respectively).

Availability of Equipments None of the SCs have all the listed 12 equipments available with them. Not a single equipment is there which is commonly available at all the SCs. A common equipment like weighing machine is available at 11 subcentres. Amdari subcentre does not possess one. Suction machine is available at none of the 12 SCs. BP apparatus is available in 10 SCs (83 percent). Cucos Speculum is present in two-thirds (67 percent) SCs and fetoscope and thermometer in about three-fifths (58 percent). Height measuring scale is available in one-

61 third SCs (33 percent). Whereas Mucos extractor is available in only 3 SCs, three equipments sterilizer, haemoglobinometer, and bag and mask are available in only one SC each. Surprisingly Regent Strips for Urine Test used for testing pregnancy is available in only 1 SC. Two SCs (Kothi and Thangaon) have 8-9 equipments out of the 12 listed ones and Amdari has no equipments. Most of the other SCs have 4-6 equipments. Thus all the essential equipments required for providing services are not fully available at any of the SCs. Except few cases, most of the equipments available with the SCs are by and large in working condition. BP machine is available in 10 SCs of which 2 are not found in working condition.

Availability of Drugs Availability of drugs on the date of survey was collected from the SCs. The information was obtained for 16 drugs. The availability of drugs shows a mixed picture. Out of 16 drugs, only Lalpur SC showed the availability of 9 drugs followed by Amdari SC reporting availability of 8 drugs. Except for these, two other SCs reported availability of 3-7 drugs. Jharha SC has reported availability of only1 drug i.e. iron folic acid. The availability of drugs in the SCs under Pushprajgarh CHC is comparatively better than those functioning under Kotma CHC. Iron/ Folic Acid were available in all the12 SCs on the date of survey. ORS (75 percent) condom and oral pills (50 percent each), were the other most commonly available drugs. Whereas pregnancy test kit was available in 2 SCs, DDK and tablet misoprostal was available in 1 SC each. Availability of most of the drugs is not satisfactory in the SCs.

Specific Skills and Procedures ANMs in all the 12 SCs reported that they register pregnancy within three months, provide TT, IFA and Immunisation Services. Whereas ninety one percent ANMs reported that they carry out specific examinations like Blood Pressure, Haemoglobin and Urine, and identify high risk pregnancies, two-thirds (67 percent) of the ANMs carryout 3 ANC visits as per the RCH schedule are trained in syndromic treatment of RTI/STI and carrying out IUD insertions. Out of the 8 ANMs who reported that they carry out IUD insertion only 5 (42

62 percent) are using IUD A380and have also reported regular supply. Also half of the ANMs reported that they are trained on insertion/removal of IUCD A380.

Service Outcome The service outcome data for the last three months show that, on an average, each ANM has registered 39 ANCs. Out of the total ANCs, the average number registered by the ANMs in 1st Trimester is 8.7 percent. The average number for the three ANC visits as per RCH schedule is 14.9 in last three months. On an average, each ANM has identified 1.7 high risk cases, conducted zero deliveries and referred 2.6 pregnant women to next higher facility. Neonate infections identified and reported during the last three months on an average is 0.6. Among the nine SCs where ANM is carrying out IUCD insertion/removal, the average IUCD insertion is 37 during 2007-2008. The service outcome data reveal that the performance of the ANMs varies across the SCs.

Status of Record Maintenance To know the status of record maintenance, the information was collected for 11 registers from the SCs. Immunisation register is the only register which is maintained by all the 12 SCs. Eligible couple register and cash book is being maintained by 11SCs each (92 percent), antenatal care register and family planning register each are maintained by 10 SCs (83 percent). Household register, post natal care register, birth and death registers and meeting register are being maintained by 8 out of 12 SCs each. JSY register and untied fund register are maintained by 7 and 6 SCs respectively.

Awareness about JSY Awareness about the JSY and the incentive amounts to be given to the beneficiaries are universal among the ANMs. All 12 ANMs reported that there is an increase in the demand for institutional deliveries after the implementation of the JSY scheme. All of them reported that there is an increase in demand for institutional delivery after implementation of JSY scheme.

Procedure under JSY Scheme All 12 ANMs reported that the JSY beneficiaries are being paid in cash. All ANMS reported that cheques were the only mode of payment for beneficiaries. Half (50 percent) of the ANMs reported that the JSY beneficiaries are paid within a week and 42 percent said that the beneficiaries are paid after two weeks or later and only 1ANM reported that payment was made in less than one week. Seven out of 12 ANMs reported that the transport support is available under JSY for shifting the pregnant woman from SC to CHC, in case of emergency as Janani Express is used for transporting pregnant women to the health facility. Only 1 ANM said that the register is available with them to record JSY expenditure.

Performance of ANM under JSY Scheme All the 12 SCs together have registered 126 JSY cases during the last three calendar months and the average number per SC turns out to be 10.5 cases. Three out of 12 SCs have not registered a single JSY case in the last three months. The average number of JSY cases resulted in institutional deliveries during the last three months is 6.8. No money has been disbursed for JSY cases in last three calendar months by the SCs as payments are made by the PHCs . The performance of SCs/ANMs under JSY varies considerably across the SCs. During the financial year 2007-2008, no money has been disbursed for JSY by the SCs for home deliveries, as home delivery is discouraged in the district. None of the SCs have reported the transport costs under the JSY. None of the SCs have reported payments to ASHA.

Status of Untied Grants Out of 12 SCs 10 with the exception of Amdari and Bahiatola have received the Untied Grants. All 10 SCs have reported expenditures from untied grants. All the 10 SCs are having joint bank account with the Sarpanch/any other GP functionary. All these 10 SCs maintain written record of transactions being carried out on Untied Funds and 9 SCs reported maintenance of register to record the decisions taken to spend this amount. Two-thirds of the

64 SCs have reported that the Sarpanch/others have reviewed the expenditure records. Two- thirds of the SCs have reported the purchase of drugs, arranging facilities like water purifier for patients (25 percent), paying of telephone bills, and one-third reported buying of ‘other’ items.

Remarks by Sub-Centres The remarks given by some of the ANMs regarding the programmes are given below in their own words (the name of the SC is given brackets): 1. ‘There should be a boundary wall around the SC building and drainage facility for disposal of waste water. There should be facility for piped water in the SC (SC Podki).’

2. ‘We have to spend the untied funds jointly with the BMO.I have no freedom to use the untied fund to improve this SC (SC Bharni).’

3. ‘There is no separate SC building. We are functioning from an old Panchyat building where we are not able to keep our drugs, equipments, safely. We are also facing problems of joint account of untied funds with BMO and purchases of equipments for us by the district authorities. Some of the equipments like BP machine purchased recently are not in working condition and we were already having a water filter and a new one was purchased once again (SC Lalpur).’

4. ‘We are facing problems regarding the SC building. Two ANMS have been asked to share the SC building for residential purposes. Neither can we reside properly nor are we able to provide essential services due to inadequate space (SC Tulra).’

5. ‘We need necessary equipments to carry out institutional deliveries (SC Amdari).’

6. A new building is our primary need. In this remote area if we have a proper SC with residential facility we can function more effectively (SCJarha).

7. SC building is essential for proper functioning. Regular supply of medicines, transport facilities is also essential (Bahiatola/Nandgaon).

8. Written instructions and guidelines for use of NRHM untied funds must be clearly provided. The untied fund should not be kept in a joint account with the Sarpanch because they ask for money (Dola).

65 Suggestions by the observer for the improvement of services 1. Three SCs immediately need buildings need buildings which are fully equipped to make the functioning of the SC more efficient. The ANMs require residential quarters so that they are able to stay in the SC village and provide active services.

2. Two SCs are functioning from old panchayat buildings which have no proper facilities for providing essential health services. Most of the other SC buildings are not properly maintained and display of services under NRHM was not seen in any of the SCs.

3. Electricity supply is available in one SC and piped water connection in only two SCs. These are basic facilities which are prerequisite for providing basic services.

4. Three SCs have labour rooms, yet none of them are being used either due to poor electricity supply, or lack of water facilities or the ANM stays in another village due to security reasons.

5. There is paucity of essential drugs required for maternal and child health services. Except for Iron folic acid and ORS all essential drugs were not available at the SCs at the time of survey. Medicine supply needs to be restored and continuity maintained on priority basis.

6. ANMs can provide limited services with many of the essential equipments not being available at the SCs. This also needs to be given top priority.

7. The ANMs are motivating pregnant women of their areas for institutional delivery and very few home deliveries were reported in their respective areas. However, delivery services are not being provided at the SC level, due to lack of essential facilities.

8. Jarha SC with a single male health worker is not providing ANC, NC or PNC services. The SC needs additional female staff to take up these services.

9. All the ANMs know about the importance of institutional delivery but preparation of micro-plan with the help of ASHA of their respective area is not being done. Most of the ANMs are recording ANC checkups on the MCH cards.

10. The district has outreach areas and referrals transport ‘Janani Express’ which is only available at the CHCs. It is difficult for the ANMs to arrange for transport to reach the PHCs which are providing institutional delivery services. Referral transport linkages need to be strengthened in the district.

11. Most of the ANMs have been provided equipments and instruments, some of which are not in working order or are not needed by the SC. These have been purchased at

66 the district level and the bills have been adjusted against the untied funds provided to them.

12. The ANMs have reported of having joint account with the BMO for untied funds (under the directives from state government).This is a cause of discontent because the utilization of untied funds is not based on local need assessment at SC level, but decided centrally by the district level authorities. On the other hand where joint accounts are with GP, ANMs are under pressure to pay money to jointly operate these accounts.

13. The pass books and cash registers of untied funds of ANMs under Pushparjgarh CHC were deposited with the BMO for audit purposes and were not made available to the visiting team for observation or verification.

14. ANMs need training and orientation regarding JSY to effectively implement the programme and to create awareness about importance of institutional delivery.

15. Careful monitoring of the implementation of NRHM programme at SC level by Medical Officers of the PHCs of SCs under their area is essential to give it an impetus.

16. IPHS survey has not been conducted in any of the SCs. None of the ANMs are aware about it. More effective communication strategies are required for vertical flow of information which is presently absent.

67 Sub Centre Table S1: Sub Centres Coverage Coverage of Sub- Sub Centre Average per Sub Centre CHC 1 (Pushprajgarh) CHC 2 (Kotma) Centre PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkhona Rajnagar Dola Nandgaon Thangaon Number of villages 5 4 4 5 8 5 4 4 21 3 3 6 6.0 covered by Sub Centre Population coverage 2300 2484 721 4084 3400 4301 36 68 4393 20,600 5642 3013 4348 4912.8 Distance between PHC 16 24 19 7 20 24 10 12 10 9 4 7 13.5 and Sub Centre Time Taken (In minutes) to travel in public transport / available mode from Farthest village to 50 75 120 50 75 120 15 20 15 15 20 15 49.2 Sub Centre Sub Centre to PHC 30 75 75 30 75 75 30 25 22 3 0 25 22 42.9 Sub Centre to CHC 90 150 135 90 150 135 45 52. 5 55 45 52.5 55 87.9 No. of ASHAs working 5 3 4 5 7 5 4 4 1 1 2 6 3.9 in the Sub Centre area

68 Table S2: Sub Centres Infrastructure Sub Centre % of Sub Availability of CHC 1 (Pushprajgarh) CHC 2 (Kotma) Centres Infrastructure in Sub having PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Centres (Yes:1; No: 0) respective Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola* Nandgaon Thangaon facility Functioning in 1 0 1 1 1 1 0 0 1 1 1 0 75.0 designated government building IPHS Facility Survey 0 0 0 0 0 0 0 0 0 0 0 0 0.0 Done Labour Room 0 0 0 0 1 0 1 0 0 0 0 1 25.0 Piped water supply 0 0 0 0 0 0 0 0 1 1 0 0 16.6 Regular electricity 0 0 0 0 0 0 0 0 1 0 0 0 8.3 supply Telephone 1 1 1 0 0 1 0 0 1 0 0 0 41.6 Type of sewerage system 0 - 0 0 1 0 - 0 0 0 0 - 8.3 Soak pit Connected to any 0 - 0 0 0 0 - 0 0 0 0 - 0.0 Sewerage line 1 - 1 1 0 1 - 0 1 1 1 58.3 Open Drain - Waste disposal Buried in a pit 0 - 0 1 1 0 - - 0 0 0 1 25.0 Collected by an 0 - 0 0 0 0 - - 0 0 0 0 0.0 agency 1 - 0 0 0 0 - - 0 0 0 0 8.3 Incernation/burning 0 - 1 0 0 1 - - 1 1 1 0 41.6 Thrown in open *The SC is located in a rented shop

69 Table S3: Sub Centres with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre quarter Sub Centre % of Residential status of CHC1 (Pushprajgarh) CHC 2 (Kotma) Sub ANM (Yes:1; No: 0) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Centres Podki Bharni Lalpur Tulra Amdari Jharha* Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon Sub Centre with ANM 1 0 0 1 1 1 1 0 1 0 0 1 58.3 quarter Sub Centre with ANM staying in SC’s quarters 1 0 0 1 0 1 0 0 0 0 0 1 3 3.3 staying within SC’s 0 1 0 0 1 0 1 0 1 1 0 0 41.6 village staying outside SC’s 0 0 1 0 0 0 0 1 0 0 1 0 25.0 village Reason for ANM not staying on SC quarter: Quality of quarter - - - - 0 - 0 - 0 - 0 0 0 .0 Family related reason - - - - 0 - 0 - 1 - 0 0 8.3 Security reason - - - - 1 - 1 - 0 - 0 0 16.6 *Jharha SC is functioning in an old panchayat building with residential facilities

Table S4: Sub Centres with Staff in Position Sub Centre % of Sub Availability of Staff CHC1 (Pushprajgarh) CHC 2 (Kotma) Centres with (Yes: 1; No: 0) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) specific staff Podki Bharni Lalpur Tulra Amdari Jharha Bahitola Katkona Rajnagar Dola Nandgaon Thangaon available Health Worker Male 1 0 0 1 1 1 1 0 1 1 0 1 66.6 Health Worker 2 1 1 1 0 0 1 1 1 1 1 1 75.0 Female Addl. ANM 0 0 1 1 1 0 0 0 0 0 0 0 33.3 contractual

70 Table S5: Availability of Labour Room in Sub Centre Sub Centre % of Sub Labour Room CHC1 (Pushprajgarh) CHC 2 (Kotma) Centres (Yes: 1; No: 0) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Podk Bharn Lalpu Tulra Amdari Jharha Bahiatol Katkona Rajnaga Dola Nandgao Thangao i i r a r n n Labour Room 0 0 0 0 0 0 0 0 0 0 0 0 0.0 currently in use Reasons for not using Labour Room ANM not staying - - - - 0 - 1 - - - - 0 8.3 Poor - - - - 0 - 0 - - - - 0 0.0 condition/no power/electric 1 - 0 0 8.3 supply Other - - - - 1 - 0 - - - - 1 16.6

Table S6 A: Number of deliveries performed during 2007-2008 Sub Centre Average deliveries Deliveries CHC1 (Pushprajgarh) CHC 2 (Kotma) conducted Performed PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) per Sub Podki Bharni Lalpur Tulra Amdari Jharha Bahitola Katkona Rajnagar Dola Nandgaon Thangaon Centre Total deliveries conducted 0 0 0 0 0 0 0 0 0 0 0 0 0

71 Table S6 B: Sub-Centres with arrangement for deliveries Sub Centre % of Sub Centres Arrangement for Deliveries CHC1 (Pushprajgarh) CHC 2 (Kotma) (Yes: 1; No:0) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon Deliveries conducted at Sub 0 0 0 0 0 0 0 0 0 0 0 0 0 Centre itself and if required referred to higher facility Deliveries not conducted at Sub 0 0 0 0 0 0 0 0 0 0 0 0 0 Centre but referred to higher facility Referred to Private/NGO facility 0 0 0 0 0 0 0 0 0 0 0 0 0

Table S7 A: Sub Centres with availability of equipments Sub Centre Availability of the CHC1 (Pushprajgarh) CHC 2 (Kotma) % of Sub equipments (Yes: 1; No: 0) PHC 1 (Amarkantak) PHC 2( Benibari) PHC 1(Bijori) PHC 2 ( Kothi) Centres with Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkon Rajnaga Dola Nandgaon Thangaon equipment a r available Sterliser 0 0 0 0 0 0 0 0 1 1 0 0 16.7 Haemoglobinometer 1 0 0 0 0 0 0 0 0 0 0 1 16.7 Bag & Mask 0 1 0 0 0 0 0 0 0 0 0 1 16.7 Suction Machine 0 0 0 0 0 0 0 0 0 0 0 0 0.0 Thermometer 1 0 1 1 0 1 0 0 1 1 0 1 58.3 BP Apparatus 1 0 1 1 0 1 1 1 1 1 1 1 83.3 Weighing Machine 1 1 1 1 0 1 1 1 1 1 1 1 91.7 Height Measuring Scale 0 1 0 0 0 1 0 0 0 1 0 1 33.3 Reagent Strips for Urine Test 0 0 0 0 0 0 0 0 0 1 0 0 8.3 Cuscos Speculum 1 1 1 0 0 1 0 1 1 1 0 1 66.7 Mucus Extractor 0 0 0 0 0 0 0 1 0 1 0 1 25.0 Fetoscope 1 1 1 1 0 1 0 0 1 1 0 0 58.3

72 Table S7B: Percentage of SCs with functional equipments Sub Centre % of Sub Functional Centres with equipments (Yes: 1; CHC1 (Pushprajgarh) CHC 2 (Kotma) functional No: 0) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1( Bijori) PHC 2( Kothi) equipment Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon Sterliser 0 0 0 0 0 0 0 0 1 1 0 0 16.6 Haemoglobinometer 1 0 0 0 0 0 0 0 0 0 0 1 16.6 Bag & Mask 0 0 0 0 0 0 0 0 0 0 0 1 8.3 Suction Machine 0 0 0 0 0 0 0 0 0 0 0 0 0.0 Thermometer 0 0 1 1 0 1 0 0 1 1 0 1 50.0 BP Apparatus 0 0 1 1 0 1 0 1 1 1 1 1 66.6 Weighing Machine 0 1 1 1 0 1 1 1 1 1 1 1 83.3 Height Measuring 0 1 0 0 0 1 0 0 0 1 0 1 33.3 Scale Reagent Strips for 0 0 0 0 0 0 0 0 0 1 0 0 8.3 Urine Test Cuscos Speculum 1 1 1 0 0 0 0 1 1 1 0 1 58.3 Mucus Extractor 0 0 0 0 0 0 0 1 0 1 0 1 25.0 Fetoscope 1 0 1 1 0 0 0 0 1 1 0 0 41.6

73 Table S 8: Status of availability of drugs Sub Centre % of Sub CHC1 (Pushprajgarh) CHC 2 (Kotma) Centres Type of Drugs PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) reporting Available (Yes: 1; Po Bharn Lalpu Tulra Amdari Jharh Bahiatol Katkona Rajnaga Dola Nandgao Thangao availability No: 0) dki i r a a r n n of drug on date of survey Iron/ Folic acid 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Disposable Delivery 0 0 0 1 0 0 0 0 0 0 0 0 8.3 Kit Oral Pills 1 0 1 1 1 0 1 0 0 0 0 1 50.0 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 0.0 contraceptive pills Condoms 1 0 0 1 1 0 0 0 1 0 1 1 50.0 IUD 1 0 1 1 0 0 0 0 0 0 1 0 33.3 ORS 1 1 1 0 1 0 1 1 1 1 1 0 75.0 Tab. flucanazole 0 0 1 1 1 0 0 0 0 0 0 0 25.0 Vaginal Tab. Misoprostal 0 0 0 0 1 0 0 0 0 0 0 0 8.3 Partograph 0 0 0 0 0 0 0 0 0 0 0 0 0.0 Pregnancy test kit 1 0 0 0 0 0 0 0 0 1 0 0 16.7 Syp. Cotrimoxazole 0 0 1 1 1 0 1 0 0 1 0 0 33.3 Syp. Paracetamol 0 0 1 0 0 0 1 0 0 1 0 0 25.0 Vi. A 0 0 1 0 0 0 1 0 0 0 0 0 16.7 Tab. Ciprofloxacin 0 1 0 0 1 0 1 0 0 0 0 0 25..0 Disposable Gloves 1 0 1 0 0 0 0 1 0 1 0 0 33.3

74 Table S9: Status of Specific Skills and Procedures Sub Centre % of Sub CHC1 (Pushprajgarh) CHC 2 (Kotma) Centres Type of Skill / Procedure PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) reporting (Yes: 1; No: 0) availability of Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon specific skill / procedure Register pregnancy within 100.0 1 1 1 1 1 1 1 1 1 1 1 1 three months Carry out 3 ANC visits as 66.7 per the RCH schedule (1st : nd th 0 0 1 1 0 0 1 1 1 1 1 1 6 month, 2 : 7 Month, 3rd: 9th Month) Carry out specific 91.7 examinations like Blood 1 0 1 1 1 1 1 1 1 1 1 1 Pressure, Haemoglobin, and Urine Provision of TT, IFA etc. 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Identification of High Risk 91.7 1 1 1 1 1 1 0 1 1 1 1 1 Pregnancies Is the ANM carrying out 66.7 IUCD Insertion/ Removal 1 1 1 0 0 0 0 1 1 1 1 1 Is IUCD insertion being 41.6 carried out using IUD 1 1 1 0 0 0 0 0 0 0 1 1 A380 Is the supply of IUD A380 41.6 1 1 1 0 0 0 0 0 0 0 1 1 regularly available Has the ANM been trained 50.0 on the insertion/ Removal 1 0 1 1 1 0 0 0 0 0 1 1 of IUD A380 Is the ANM trained in 66.7 syndromic treatment of 0 0 1 1 1 1 0 0 1 1 1 1 RTI/STI? Immunisation services 1 1 1 1 1 1 1 1 1 1 1 1 100.0

7 Table S 10: Service Outcome (based on Data for last 3 months) Sub Centre Average CHC1 (Pushprajgarh) CHC 2 (Kotma) per Sub Indicator PHC 1 (Amarkantak) PHC 2: Benibari PHC 1: Bijori PHC 2: Kothi Centre Podki Bharni Lalpur Tulra Amdari Jharha Bahitola Katkona Rajnagar Dola Nandgaon Thangaon Total ANC registered 13.0 13.0 46.0 34.0 31.0 35.0 34.0 50.0 48.0 33.0 3 0.0 29.0 33.0 Out of total ANC, No. 8.0 4.0 15.0 8.0 5.0 0 0 20.0 15.0 13.0 7.0 9.0 8.7 Registered in 1st Trimester No. given 3 ANC 8.0 9.0 15.0 34.0 0 22.0 8.0 0 45.0 19.0 3.0 16.0 14.9 visits as per the RCH schedule No. of High Risk Cases 0 0 0 1.0 6.0 0 4.0 1.0 3.0 1.0 1.0 3.0 1.7 identified Deliveries conducted 0 0 0 0 0 0 0 0 0 0 0 0 0.0 by ANM at Sub Centre Pregnancies referred 0 8.0 0 1.0 6.0 3.0 4.0 1.0 3.0 2.0 0 3.0 2.6 and attended by the next higher facility No. of neonate 0 1.0 0 0 0 0 0 0 3.0 2.0 0 1.0 0.6 infections identified and referred No. of IUCD 22.0 29.0 24.0 0 0 0 0 33.0 60.0 91.0 21.0 15.0 36.9 insertions in 2007-2008

76 Table S11: Status of Record Maintenance Type of Sub Centre % of SCs Records CHC1 (Pushprajgarh) CHC 2 (Kotma) reporting maintained PHC 1 (Amarkantak) PHC 2( Benibari) PHC 1 (Bijori) PHC 2 (Kothi) maintenance (Yes: 1; No: Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon of record 0) Household 1 1 0 1 1 1 0 1 0 1 0 1 66.7 Survey Register Ante Natal 1 1 1 1 1 0 0 1 1 1 1 1 83.3 Register Eligible 1 1 1 1 1 1 0 1 1 1 1 1 91.7 Couple register Post Natal 1 1 0 1 1 0 0 1 1 1 0 1 66.7 care Register Family 1 1 1 1 1 1 0 1 0 1 1 1 83.3 Planning Register Birth & Death 0 1 0 1 1 1 0 1 1 1 0 1 66.7 register Immunisation 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Register Meeting 1 1 0 1 1 0 0 1 0 1 1 1 66.7 Register JSY register 1 1 1 1 0 1 0 0 0 1 1 0 58.3 Untied Funds 0 1 0 1 0 0 0 1 0 1 1 1 50.0 register Cash Book 2 1 1 1 0 1 2 2 2 1 1 1 83.3

Table S12 A: Status of Awareness of ANM about JSY Scheme ANM’s awareness about JSY Number of ANMs Interviewed Reporting Awareness Aware about JSY 12 100.0 Aware about amounts to be given to beneficiaries 12 100.0 ANM reporting increase in demand for Institutional 12 100.0 delivery after implementation of JSY Scheme

Table S12 B: Status of procedure under JSY Scheme ANM’s awareness about JSY % of ANMs according to response Funds being paid to beneficiaries by Cash 0.0 Cheque 100.0 Vouchers 0.0 Average time taken after birth for JSY payment to beneficiary Less than 1 week………1 8.3 1- 2 weeks………………2 50.0 More than 2 weeks…….3 41.7 Transport support for shifting of cases available from Sub 58.3 Centre to PHC/CHC Register available for recording of JSY Expenditure 8.3 Total no. of ANMs interviewed 12

Table S13: Status of performance of ANM under JSY Scheme Performance of ANM CHC1 (Pushprajgarh) CHC 2 (Kotma) Average under JSY Scheme PHC 1 PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) per Sub (Amarkantak) Centre Podki Bha Lalpu Tulr Amdar Jharh Bahiatol Katkon Rajnaga Dol Nandgao Thangao rni r a i a a a r a n n Total cases of JSY 5.0 13.0 15.0 8.0 15.0 35.0 10.0 0 0 10.0 15.0 0 10 .5 registered in last 3 calendar months Total JSY cases 7.0 8.0 15.0 8.0 5.0 3.0 10.0 0 0 10.0 15.0 0 6.8 resulted in Institutional deliveries in last three months? Total cash disbursed in 0 0 0 0 0 0 0 0 0 0 0 0 0.0 last 3 calendar months for JSY cases? (Rs.) Out of total amount disbursed, the amount disbursed on the following Home Deliveries 0 0 0 0 0 0 0 0 0 0 0 0 0.0 (Rs.) Institutional 0 0 0 0 0 0 0 0 0 0 0 0 0.0 deliveries: (Rs.) Transport Costs 0 0 0 0 0 0 0 0 0 0 0 0 0.0 (Rs.) Amount given to 0 0 0 0 0 0 0 0 0 0 0 0 0.0 ASHA (Rs.)

79 Table S 14: Status of Untied Grants Status of Untied Grants (Yes: Sub Centre % of Sub Centres 1; No: 0) CHC1 (Pushprajgarh) CHC 2 (Kotma) PHC 1 (Amarkantak) PHC 2 (Benibari) PHC 1 (Bijori) PHC 2 (Kothi) Podki Bharni Lalpur Tulra Amdari Jharha Bahiatola Katkona Rajnagar Dola Nandgaon Thangaon Sub Centre received Untied 1 1 1 1 0 1 0 1 1 1 1 1 83.3 Grant Sub Centre reported 1 1 1 1 0 1 0 1 1 1 1 1 83.3 expenditure from Untied Grant ANM having a joint account 1 1 1 1 0 1 0 1 1 1 1 1 83.3 with the Sarpanch/any other GP functionary Sub Centre reporting 1 1 1 0 0 1 0 1 1 1 1 1 75.0 maintenance of register to record the decisions taken to spend this amount Sub Centre reporting written 1 1 1 1 0 1 0 1 1 1 1 1 83.3 record of transactions being carried out on Untied Funds Sub Centre reporting that 0 0 1 1 0 1 0 1 1 1 1 1 66.6 Sarpanch/others ever reviewed the expenditure records Sub Centre reporting expenditure from Untied Grant on the following: Spent on Purchase of Drugs 0 1 0 1 0 1 0 1 1 1 1 1 66.6 Arranging Transport 0 0 0 0 0 0 0 0 0 0 0 0 0 .0 Paying of Power/ Telephone 0 0 0 0 0 0 0 0 1 0 0 0 8.3 bills Arranging facilities like Water 0 0 0 1 0 0 0 0 0 1 1 0 25.0 Cooler etc. for patients Other (like white wash, 1 1 1 0 0 0 0 0 0 0 0 1 33.3 maintenance etc.)

80 Chapter 6

Household Survey

This chapter presents the findings of the household survey on NRHM. For the survey, two-three villages were selected from each selected Sub Centre area. To complete the sample size of 50 households 15 additional villages were covered to fulfil the household selection criteria as per the sampling design. Households were selected from each of the selected village by following the systematic circular random sampling procedure. Thus, 29 villages were selected for the household survey. For selecting the households, the total number of households in a village was divided by 50 to find out the selection interval. After that, the first household situated at the north-west corner of the village was randomly selected and subsequently every rth household was selected moving in an ‘anti-clock wise’ direction till 50 households were selected. In the district, from the selected i villages, we have covered about 2-3 percent more than the stipulated 1200 households (2-3 percent). Households from which incomplete information was received were finally dropped. In all 1200 households are considered for data analysis, the coverage rate being 100 percent.

Characteristics of the Respondents Table H1 presents the background characteristics of the respondents (head/senior member of the household). Roughly, about two-thirds of the respondents are relatively young below 40 years of age and approximately one-third above 40 years. Fifty five percent of the respondents are males and 45 percent are females. Forty five percent of the respondents are illiterates. Majority of respondents are currently married (89 percent) and the rest are either unmarried (6 percent), or divorced/separated (4 percent) or widowed (1 percent).

Characteristics of the Households

81 Table H2 presents the percentage distribution of the rural households by selected background characteristics. Distribution of the households by social category shows that nearly two-third of the households belong to STs, 21 percent belong to OBC, 6 percent SC, and 9 percent to ‘Other’ castes. Distribution of households by religion shows that 99 percent of the households are Hindus. Only one third of the households have electricity. Only 6 percent of the households are living in pucca houses. Toilet facility is available only in 8 percent of the households. Piped water is used by only 6 percent of the households. Hardly 7 percent of households use LPG/Biogas for cooking. A little less than three-fifths (57 percent) of the households own/cultivate agricultural land. None of the households own a colour/B&W television. One-fifth of the households (20 percent) have a mobile phone. Thirty six percent of the households belong to BPL category. The BPL status is also exactly reflected in the households with the low standard of living index (61 percent). The standard of living index is calculated by using the various household items possessed by the households (Appendix-). Among the living children born in these rural households during the last five years, 35 percent of them were born in institutions.

Waste Disposal, Stagnation of Water and Mosquito Breeding and System of Medicine Preferred Method of waste disposal shows that majority of the rural households (98 percent) throw their waste in the open space and the remaining bury it in a pit or burn it (Table H3). Percentage of households that throw the waste in the open space is same in the households located in other villages (97 percent) as those households located in SC headquarter village (98 percent). During the survey, in 20 percent of the households, investigators have observed the stagnation of waste water around the household. Among the households where the stagnation of waste water was observed, the investigators have further observed the mosquito breeding in the stagnant water in almost all these households (96 percent). There is little difference in the stagnation of waste water and the instances of mosquito breeding between the households located in the SC headquarter village (95 percent) and households located in other villages (97 percent).

82 System of medicine preferred by the rural households reveals that the allopathic medicine is universally preferred (99 percent). In addition to this, one percent of the households prefer Ayurveda treatment.

Information about Health Workers and Health Facilities Four-fifths respondents (80 percent) have heard about ANM and only 47 percent of them have heard about Male Health Worker (Table H 4). Hardly one-fifth of the respondents reported that the health worker has visited them in last one month. There is a little difference in these aspects between the households located in the SC headquarter village (23 percent) and households located in other villages (16 percent). About two fifths (37 percent) of the respondents further reported that the health workers are available to them when needed. Higher proportion of respondents (42 percent) living in SC headquarter village reported that the health workers are available to them when needed than the respondents living in other villages (34 percent). Respondents were asked about the availability of the health facilities to the households when required. The responses reveal the combination of public and private facilities available to them when required. RMP was reported by hardly one percent of the respondents and private clinic/NGO was reported by 5 percent respondents. Public health facilities like SC, PHC were mentioned by 15 percent. Only those respondents living in SC headquarter village (29 percent) reported that the SC is available to them when required. None of the respondents living in other villages have reported about availability of this facility. Majority of the respondents have stated about the availability of ‘other’(86 percent) facility which for them is a JSR, Jhar-Phoonk wala, barefoot doctor, or the ANM/MPW(shown privately) of the area, the presence of which is more prominently reported in the other village (96 percent). Respondents were further asked about the health facility for which the serious patients are taken. Majority of the respondents (56 percent) mentioned that they take the serious patients to the NGO hospital/ clinic. PHC, CHC and District Hospital were mentioned by 38 percent, 23 percent and 13 percent of the respondents respectively. It is observed that respondents of headquarter village having access to government health institutions (PHC,

83 CHC or DH) have availed of NGO hospital/clinic services in less proportion than respondents of remote villages who have poor access to government health facilities. Mode of transport used to take serious patients when required was asked from the respondents. Majority of the respondents mentioned ‘other’ means of transport (71 percent) like hired vehicle, cycle, or walking on foot to carry serious patients. Bus/public transport is used by 44 percent respondents to take the serious patients, when required. Hardly 8 percent respondents have reported of having access to private vehicles and 3 percent have availed of the ambulance.

NRHM, ASHA and JSY Table H5 presents the distribution of respondents by their knowledge about NRHM, ASHA and her activities, VHND, VHSC and JSY. Hardly, 10 percent the respondents have heard about NRHM and there is no difference in this between households located in SC HQ villages (11 percent) and other villages (10 percent). For those who have heard about NRHM, radio/television is the major source of information (40 percent) followed by Panchayat (20 percent) Community Member (16 percent), others (22 percent). Only 2 percent of them have heard about it from ASHA. Overall, nearly two-thirds of the respondents (65 percent) of the respondents have heard about ASHA, and slightly more in the other village (68 percent) than in the SC (62 percent) village. Those who have heard about ASHA were further asked about their awareness/knowledge regarding various activities of ASHA. Half of the respondents are aware that ASHA carries a kit, 55 percent are aware that ASHA provide common medicines free of cost, 24 percent each are aware that ASHA held discussions about hand washing and discussions about safe drinking water and 20 percent are aware that ASHA held discussions about construction of household toilets. The percentage of the respondents aware about different activities of ASHA is slightly higher in SC headquarter villages than in other villages. Nearly half of the respondents (48 percent) have reported that the Village Health and Nutrition Day (VHND) is being organised in the village. Hardly 7 percent of the respondents reported about the presence of Village Health and Sanitation Committee (VHSC) in the

84 village. Nearly three fifths of the respondents (64 percent) reported that VHND is being organised once in a month in the village. The percentage of the respondents reporting the frequency of the VHND as quarterly and annually is 13 percent and 18 percent respectively. All the respondents were asked about their awareness regarding JSY scheme. It shows that majority (84 percent) of the respondents is aware about JSY scheme and there is very little difference in the awareness between respondents from SC HQ villages (85 percent) and other villages (83 percent). Those who are aware about the JSY scheme were further asked about their source of information about the JSY. It shows that the major sources of information about JSY are ASHA worker (32 percent) followed by Radio/television (25 percent). Those who said that they are aware about the JSY scheme were further asked whether anyone in the household is a beneficiary of JSY scheme. Among those who are aware about the JSY scheme, seventeen percent of them reported that the household is a beneficiary of the JSY scheme. The percentage of the beneficiary households is more or less in the SC HQ villages (17 percent) than in other villages (18 percent). Among the total surveyed households, 15 percent (174 out of 1200) are beneficiaries of the JSY scheme.

JSY Beneficiaries Selected characteristics of the beneficiaries are presented in Table H6. Age distribution of the beneficiaries shows that, about half of them are in the age 20-24 years (48 percent). More than one- fifth (28 percent) of the beneficiaries are aged 25-29 years and 8 percent are less than 20 years. Parity of the beneficiaries shows that nearly 53 percent are second parity women and 47 percent are third parity women. In M.P. cent percent households are eligible for JSY benefits irrespective of the social category these represent. Social category of the beneficiaries reveals that about three-fifths of them (58 percent) are STs followed by OBCs (26 percent) and Scheduled Caste (9 percent). All the beneficiaries are Hindus. Distribution of beneficiaries by Standard of Living Index (SLI) shows that three-fifths belong to low SLI households, 20 percent belong to medium SLI and another 21 percent to high SLI households.

85 More than one- third (37 percent) of the beneficiaries are from BPL category. In majority of the households (93 percent) place of the last delivery is reported at a health institution.

Registration of JSY Beneficiaries JSY first starts with the registration of the pregnant woman for receiving the benefits. Forty five percent of the beneficiaries heard about the JSY scheme before being pregnant and the rest 55 percent during pregnancy. Stage of pregnancy when beneficiary got registered for JSY scheme reveals that more than two fifth (45 percent) of the beneficiaries got registered during the first trimester of the pregnancy and the rest (55 percent) during 4th and 5th month of the pregnancy. Two fifths beneficiaries were registered by AWW, 20 percent by ANM and the remaining 18 percent by Doctor/LHV/Others. Place of registration of beneficiaries’ shows that 37 percent of them were registered in the Anganwadi Centre. The percent of beneficiaries registered in PHC is 20 percent; CHC is 12 percent and at home is 22 percent (Table H7).

JSY Card Only 17 percent of the beneficiaries reported that they received the JSY card (Table H8). Among those who received the JSY card, about half (44 percent) of them were helped by ASHA in getting the JSY card. (It may be mentioned that separate JSY cards have not been provided in the district, ICDS maternal and child health cards or the MCH cards may have been reported as JSY cards by beneficiaries). Ten percent of the beneficiaries reported any difficulty in getting the JSY card. They either reported that cards were not available or formalities for making cards were cumbersome.

Role of ASHA during the Pregnancy of the Beneficiaries In Anuppur district, among the villages surveyed, ASHAs are appointed in all the villages of the two blocks selected for the study. In spite of presence of ASHA at village level their involvement in the JSY programme is low. Table H 9 presents the role of ASHAs during the pregnancy of the beneficiaries. In spite of a large presence of ASHA in all the villages

86 only(one-third) 35 percent of the beneficiaries said that the ASHA worker provided specific help during last pregnancy. A little more than one-third of the beneficiaries received advice about diet from ASHA. The percentage of beneficiaries who received advice from ASHA on delivery care, danger signs during pregnancy, breastfeeding and newborn care is only 14-18 percent. Lesser proportion of beneficiaries received advise about family planning (9 percent). Beneficiaries were further asked about the type of information received during the antenatal period (micro birth planning) from Doctor/ANM/ASHA. It shows that the percent of beneficiaries who received the information regarding date of next check up is 37 percent, place of next check up is 31 percent, expected date of delivery is 28 percent and place of delivery is 45 percent. Only 18 percent beneficiaries were told about the referral place, if complications arise.

Place of Delivery and Reason for Opting Institutional Delivery Among the beneficiaries, 98 percent (171out of 174) delivered in Institutions and the remaining 1 percent delivered at home (Table H10). The major reasons cited by the beneficiaries for delivering in institutions are: better care for mother and new born child (32 percent); money available under JSY scheme (30 percent) support services provided by ASHA (29 percent); and better access to institutional delivery (26 percent).

Transport of the Beneficiaries to Reach the Health Institutions Among the beneficiaries who delivered in health institutions, 34 beneficiaries (20 percent) received a referral slip from ASHA/health personnel to access delivery services (Table H11). Out of the 171 beneficiaries who delivered in institutions, 25(15 percent) of them faced difficulty in reaching health institution due to late non availability of transport (64 percent), insufficient money (44 percent) and night timing (12 percent). The average distance to the ultimate place of delivery from the beneficiaries’ residence is about 14 kilometres. Majority (89 percent) of the beneficiaries (94 percent) used ‘other’ means of conveyance like public transport or cycle or hired vehicle to reach the ultimate place of delivery, and 5 percent used a private vehicle. For majority of the beneficiaries mainly family members /relatives

87 /husbands had arranged the vehicle, and 11 percent were facilitated by ASHA in arranging the transport. Two-thirds of the beneficiaries (67 percent) had the money to pay for the transport services. Three beneficiaries had no money to pay for their transport. The average amount spent by these beneficiaries on transport is Rs 1031. Average amount received by beneficiaries is Rs.24 only. None of the beneficiaries had received transport assistance under JSY scheme and 164 beneficiaries spent more on transport than what they received. For 70 percent of the beneficiaries, relatives accompanied them to the health institution. Among ‘others’ are neighbours and friends who accompanied the woman for delivery.

Waiting Time, Type of Delivery and Satisfaction Regarding Services The average waiting time at the facility until someone attended the beneficiary is 10 minutes. Out of 171 beneficiaries 155 (91 percent) had the normal delivery and the remaining 9 percent of them had delivery assisted by forceps or caesarean. The average number of days spent in the health facility till discharge is 1.5 days. Nearly three-fifths (57 percent) of the beneficiaries had to pay at the health centre and the average amount turns out to be Rs. 496/- for them. Among the 171 beneficiaries, 144 (84 percent) were satisfied with the services available in the health centre, 10 percent were somewhat satisfied and 5 percent were not satisfied. The reason for the non satisfaction given by them was rudeness of staff, non cleanliness of the facility, and poor quality of services at the health facility.

Reason for Opting Home Delivery As mentioned earlier, 2 out of 174 beneficiaries (1 percent) opted for the home delivery in spite of cash incentives being available under the JSY scheme. These 3 beneficiaries were asked for the reason for opting home delivery. The major reasons cited by the beneficiaries are home delivery is more convenient and non availability of transport.

Cash Incentive Received by the Beneficiary under JSY Scheme

88 All the 171 beneficiaries who had an institutional delivery had received the cash incentive under JSY scheme and the average amount received by them is Rs. 1371. Out of those who received the cash incentive, all received it in one installment. Among those who received the cash incentive, 24 percent received immediately after the delivery, 23 percent received within a week after the delivery and 51 percent received it much later. More than three-fourths (79 percent) beneficiaries received cash incentive from the doctor, ANM/LHV delivered the cash incentive to 11 percent beneficiaries, for 3 percent Angawadi Worker delivered it and for the rest 7 percent ‘other’ like male health worker delivered it. Place of delivery of cash incentive shows that the beneficiaries have mainly received the cash incentive at the following places: PHC (65 percent), CHC (33 percent) and DH (2 percent).Eight beneficiaries reported that they had faced difficulty in getting the incentive. Nine (15 percent beneficiaries) reported that they faced difficulty in getting their incentive. Eight of them reported of facing difficulties like having to pay bribes (2), payment through cheque (2) and had to visit twice to get the incentive money (4).

Utilisation of Government Health Facility in Last Six Months This section addresses some of the issues related to the quality of care in government health facilities. First, to understand the extent of utilisation of the government health facilities in last six months, all the surveyed households were asked whether anyone from the household availed the services in any government health facility in last six months. It shows that 11 percent of the rural households (126 out of 1200) have availed the health services in government health facility in last six months. (In case the household availed the services for the children below 16 years of age, the adult household member accompanied the child was interviewed). The proportion of households availed the services in government health facility is slightly more in households located in SC headquarter villages (12 percent) than in other villages (9 percent). The selected characteristics of the patients/respondents who have availed the health services in government health facilities are presented in Table H 16. The age distribution of the respondents shows that 52 percent are age below 30 years and 8 percent are age 60 years

89 and above. Sex of the respondents show that 54 percent are females and 46 percent are males. The socio-economic characteristics of the respondents reveal that nearly half (48 percent) of them are illiterates, 57 percent are Schedule Tribes, and 29 percent OBCs and more than two fifths of them (45 percent) belong to BPL households. The percentage of households with low SLI is 66 percent. The characteristics of the respondents clearly reveal that most of them come from poor households.

Client Satisfaction Table H 17 presents the type of health facility visited, purpose of visit; and satisfaction regarding behaviour of health worker, privacy and availability of medicine at the facility. The type of health facility visited by the respondent’s shows that 48 percent visited PHC, 29 percent visited the CHC, 17 percent visited District Hospital and 6 percent visited the SC. The major reason reported by the respondents for the visit shows that more than half (90 percent) visited for the treatment of minor ailment and other services the remaining 10 percent visited for ANC care, child care, and immunization. Regarding the behaviour of the staff at the health facility, 87 percent of the respondents said that the staffs were courteous. However, 13 percent respondents reported that the behaviour of the staff were casual/ indifferent/insulting/derogatory. Eighty eight percent of the respondents said that the doctor/staff at the health facility listened to their complaints, 7 percent said that they have somewhat listened and 5 percent said that they did not listen. It appears that, except few, the respondents are generally satisfied with the behaviour of staff at the health facility. One of the problems often cited for the government health facilities is the lack of privacy for the woman patients. The problem can be easily addressed with either a simple partition of the examination room or with a cloth curtain. To know about this, the respondents were asked whether women patients treated with privacy and dignity. Seventy percent of the respondents reported that women patients are treated with privacy and dignity and 20 percent said that they are not treated with privacy and dignity.

90 Regarding the availability of medicines, 35 percent of the respondents said that patients with chronic illnesses (like joint pains, heart disease, blood pressure, diabetes etc.) get medicines regularly from the government health facility. However, 19 percent of the respondents said that they don’t get medicines and more than half (51 percent) said they don’t know. Respondents were further asked whether doctor from government health facility do private practice during or after the duty hours. For this question, 36 percent said ‘yes’, 36 percent said ‘no’, and 29 percent said ‘don’t know’. Satisfaction of the respondents regarding the overall services of the government health facility reveals that 72 percent are satisfied, 19 percent are somewhat satisfied and 8 percent are not satisfied. Satisfaction of the respondents regarding the behaviour of staff at the government health facility also shows a similar level of higher satisfaction with 77 percent satisfied, 16 percent somewhat satisfied and 9 percent are not satisfied. Though the level of satisfaction appears to be higher, even a smaller level of dissatisfaction regarding services and behaviour of staff has to be looked into.

User Fees and Extra Charges In Anuppur, user fees are charged for various services in the government health facilities with some categories of patients exempted for the charges. In the survey, among the respondents who have availed the services in government health facility in last six months, 61 percent (i.e., 77 out of 126) said that they were charged user fees by the health facility (Table H18). Among those who paid the user fees, 91 percent paid for registration, 14 percent for laboratory services, 7 percent for X-ray, 3 percent for ultrasound and 10 percent for ‘other’ services like purchase of IV set and injection. Among those who have paid the user fees, more than three fourths (79 percent) said that they have received the receipt for the same but the remaining 21 percent clients said that receipts was not given. Among those who paid the user fees, 30 percent said that extra money was charged from them for the services provided.

Services for the BPL Patients

91 BPL respondents were asked whether BPL patients are provided free/subsidized services (Table H 19). For this question, 54 percent of the respondents said that they are provided free/subsidized services, 24 percent said that they are not provided free/subsidized services and 22 percent said that they don’t know. More than half of the BPL respondents (54 percent) said that they don’t face difficulty in getting free/subsidized services whereas; 24 percent of them said that BPL patients face difficulty in getting free/subsidized services. Only 24 percent BPL respondents said that RKS facilitates the paper work for BPL patients.

Outbreak of Diseases All the respondents were asked whether there was any outbreak of malaria, measles, gastroenteritis, jaundice and other diseases in their area in the last six months (Table H20). The percentage of respondents reporting the outbreak of the above diseases in their area in the last six month is 42 percent, 25 percent, 32 percent, 25 percent and 8 percent respectively. These figures should be noted with caution as these are orally reported outbreaks by the respondents. However, it indirectly indicates that mosquito breeding is a major issue in the villages as outbreak of malaria is reported by 42 percent of the respondents and incidence of gastroenteritis is also high.

Action to be taken for Selected Diseases All the respondents were asked about the following: steps for prevention of diarrhoea; actions to be taken if a family member has a high fever, persistent cough for more than two weeks and loose motions lasting for more than 24 hours; and action to be taken if a child in the family has persistent cough and breathing problems (Table H21). For the prevention of diarrhoea, the proportion of respondents mentioned the hand washing, use of safe food and water, and use of covered containers is 22 percent, 42 percent and 9 percent respectively. The proportion of respondents who do not know any simple steps for the prevention of diarrhoea is 53 percent which is considerably high. Actions to be taken for high fever, persistent cough and loose motions for a family member and persistent cough and breathing problems for the child in the family shows that percentage of respondents who will take the family

92 member/child to the ‘jhola chaap’ or quack doctor visiting the village is 89-93 percent followed by 23-26 percent to the nearest government health facility. Taking the family member/child to the ‘jhola chaap’doctor who frequent the village and to the nearest government health facility are the two prominent actions reported by respondents. It indicates that there is lack of the availability of government health facility nearer to the people at the times of need and therefore the ‘other’ option becomes prominent. The proportion reported that they will try with home remedies vary between 28 to 42 percent for diarrhea and persistent coughing respectively. However, for the loose motions, only 14 percent of the respondents said that they will start giving ORS indicating low level of awareness.

Awareness about Spacing Methods and Ideal Gap between Children The ideal spacing between 1st and 2nd child mentioned by the respondents reveals that majority of them (69 percent) prefer the ideal spacing to be 3 and more years (Table H22). Twenty nine percent of respondents said that the ideal spacing should be 2 years. Only a few respondents mentioned the ideal spacing as one year. The ideal spacing of 3+ years reported by majority of the respondents clearly indicates the need for spacing methods in our family planning programme. Knowledge regarding the spacing methods reveals that Oral Pills is known to 89 percent of the respondents followed by Condom (40 percent) and IUD is known only to 10 percent respondents. More than one third (37 percent) of the respondents said that they don’t know the family planning methods available for spacing.

AIDS and VCTC The awareness, modes of getting and source of information for HIV/AIDS are presented in Table H 23. Among the respondents, only 29 percent are aware about the HIV/AIDS. The percent of respondents do not know about the modes of getting HIV/AIDS is 71 percent which is considerably high. With regard to knowledge about the modes of transformation of HIV/AIDS, the table reflects that 82 percent of the respondents are aware that unsafe sexual contact, 43 percent sharing of needles/syringes and 31 percent blood transfusion are the very important modes of transformation. Among those who are aware of

93 modes of transformation, hardly, 5 percent of the respondents are aware that HIV/AIDS transforms from infected mother to child. However, no respondent reported the misconceptions like shaking hands, sneezing and insect bite as the modes of getting HIV/AIDS. Source of information for the HIV/AIDS reveals that TV is the most prominent source of information (41 percent) for the respondents followed by radio ( 26 percent). About 20 percent respondents have got information from friends/relatives/neighbours/community etc. Those who were aware about HIV/AIDS were further asked about their awareness regarding the HIV/AIDS Counselling Centre/Voluntary Counselling and Testing Centre (VCTC) nearby. The response shows that, only 14 percent of the respondents are aware about the nearby Counselling Centre/VCTC. Those who are aware about the nearby Counselling Centre/VCTC were further asked about the location of Counselling Centre/VCTC. The percent of respondents who said that the Counselling Centre/VCTC is located in PHC is 18 percent, CHC 40 percent, District Hospital 26 percent and Sub District Hospital 2 percent. Among those who are aware about the location of VCTC, most of them (86 percent) reported that that it is located in the government health facility.

Suggestions given by the respondents The suggestions given by the respondents for the improvement of services in the villages are given in Table H24. It shows that respondents generally expect toilet facility, health facility, health workers, cleanliness, sanitation, safe drinking water, pucca road and transport facility for their villages. The suggestions given by them reveal the genuine expectations of the villagers for the improvement of the health and sanitation in their villages.

94 Household Characteristics

Characteristics of the respondents Table H1. Percent distribution of respondents by background characteristics Characteristics of the respondents Percent Age < 30 years 35.4 30-39 years 29.6 40-49 years 20.7 50-59 years 11.3 60 years or more 3.0 Sex Male 55.4 Female 44.6 Years of Schooling Illiterate 45.3 1-5 years 22.0 5-9 years 21.6 10 years or more 11.2 Marital Status Unmarried 5.8 Currently Married 89.3 Widowed/Divorced 0.9 Separated 3.9 Total number of respondents 1200

95 Table H 2. Percent distribution of households by their background characteristics Characteristics of the household Percent Social Category SC 5.5 ST 64.3 OBC 21.4 Others 8.8 Religion Hindu 99.4 Muslim 0.5 Christian 0.1 Sikh 0.0 Others 0.0 Households having BPL status 35.9 Households living in pucca house 6.3 Households with electricity 32.7 Households with toilet facility 7.8 Households with piped water supply 5.8 Households using LPG/Biogas for cooking 6.6 Household having own agricultural land /cultivating any 56.6 agricultural land 0.0 Household own a colour/B&W television 19.6 Household have a mobile phone 61.4 Households with low Standard of Living Index 35.0 % of children born in Health Institutions during last 5 years Total number of households 1200

96 Table H 3. Percent distribution of households by their waste disposal, stagnation of waste water and mosquito breeding around the house and system of medicine preferred by them. Waste disposal, stagnation of Households All Households water and mosquito breeding and located in Sub located in system of medicine preferred Centre HQ other village Village Method of waste disposal by the household Thrown in the open 98.0 97.0 Buried in a pit 1.2 2.0 97.5 Burnt 0.8 1.0 1.6 Other methods 0.0 0 0.9 0 Stagnation of waste water around the household (stagnation of waste 20.3 19.2 19.8 water observed by the interviewer) Instance of mosquito breeding in the stagnant water 95.1 97.4 96.2 (among the households where stagnation of water is observed) System of medicine preferred (multiple answer) Allopathic 99.5 99.3 99.4 Ayurveda 0.7 0.3 0.5 Yoga and Naturopathy 0.0 0.3 0.2 Unani 0.0 0.2 0.1 Siddha 0.0 0 0 Homeopathy 0.0 0.2 0.1 Traditional Healing 0.2 0 0.1 Any other 0.0 0.2 0.1 None 0.0 0 0 Total number of households 600 600 1200

97 Table H 4. Percent distribution of household respondents by their information about availability of health worker, health facilities and transport used to take serious patients Information about health workers Households Households All and health facilities located in Sub located in Centre HQ other village Village

Availability of health workers Heard about ANM 82.2 78.5 80.3 Heard about Male Health Worker 44.0 49.2 46.6 Visited by a Health Worker in last 23.3 16.3 19.8 one month Health Workers are available when 41.7 33.8 37.8 needed Availability of health facilities to the households, when required (multiple responses) 1.5 0.3 0.9 RMP 5.7 5.0 5.3 Private Clinic/NGO 29.2 0.5 Sub Centre 0.0 0.0 14.8 PHC 0.0 0.0 0.0 CHC 0.0 0.0 0.0 Others 77.2 95.7 0.0

86.4 Facility for which serious patients are taken, when required (multiple responses) RMP/private Clinic 3.8 1.0 2.4 NGO Hospital Clinic 52.2 60.5 56.3 PHC 39.3 36.0 37.7 CHC 26.0 20.8 23.4 District/Sub Divisional Hospital 12.8 12.3 12.6 Others 7.0 6.7 6.8 Mode of transport used to take serious patients, when required (multiple responses) Bullock Cart 0.3 0.2 0.3 Bus 42.3 45.7 44.0 Private Vehicle 8.3 7.2 7.8 Ambulance 3.8 2.0 2.9 Others 69.3 72.3 70.8

Total number of household 600 600 1200 respondents

98 Table H 5. Percent distribution of household respondents by their knowledge about NRHM, ASHA and her activities, VHND, VHSC and JSY Households NRHM, ASHA and JSY Households located in All located in Sub Centre other village HQ Village Heard of NRHM 10.8 9.8 10.3 (65) 59 (154) If heard of NRHM, source of information about NRHM (multiple responses) ASHA 1.5 1.7 1.6 Radio/television 40.0 39.0 39.5 Newspaper 3.1 1.7 2.4 Panchayat 20.0 20.3 20.2 Community Member 15.4 16.9 16.1 Other 20.0 23.7 21.8 Heard of ASHA 61.8 68.0 64.9 (371) (408) (779) ASHA and her activities, VHND and VHSC ASHA carry a kit 50.6 48.5 49.5 ASHA provide a common medicines free of cost 50.6 58.2 54.6 ASHA held discussions about hand washing 26.0 22.3 24.0 ASHA held discussions about construction of 22.5 18.2 20.2 household toilets ASHA held discussions about safe drinking 25.7 22.8 24.2 Water Village Health and Nutrition Day being 46.5 50.3 48.4 organized in the village Presence of Village Health and Sanitation 6.8 6.2 6.5 Committee in the village Frequency of Village Health and Nutrition Day Weekly Monthly 3.6 6.4 5.1 Quarterly 65.6 61.7 63.6 Annual 14.5 12.4 13.4 16.3 19.5 17.9 Aware about the JSY scheme 85.2 83.0 84.1 (511) (498) (1009) If aware about JSY, source of information about the JSY (multiple options) Radio/Television 5.3 5.4 5.4 Pamphlets 1.6 0 0.8 Hoardings at SC/PHC etc. 3.9 5.8 4.9 ASHA Worker 16.8 20.9 18.8 Anganwadi Centre/Worker 16.0 21.3 18.6 ANM 12.7 4.8 8.8 Doctor 6.1 4.4 5.3 Gram Panchayat 4.5 5.4 5.0 NGOs/SHGs 0.2 0.2 0.2 Other 54.2 53.8 54.0 Household beneficiary of JSY Scheme 16.8 17.7 17.2 (86) 88) (174) Total number of household respondents 600 600 1200

99 Table H 6. Percent distribution of JSY beneficiaries by their background characteristics Characteristics of the JSY beneficiaries Percent Age < 20 years 8.0 20-24 years 47.7 25-29 years 28.2 30-34 years 8.6 35-39 years 5.2 40-44 years 2.3 45-49 years - Parity 0 - 1 0.6 2 52.9 3 & 3+ 46.6

Social category SC 9.2 ST 58.0 OBC 25.9 Others 6.9 Religion of the household Hindu 100.0 Muslim - Christian - Sikh - Others - SLI of the household Low 59.8 Medium 19.5 High 20.7 BPL household 36.8 Place of last delivery (delivery previous to this delivery) Household 6.9 Health Institution 93.1 Total number of JSY beneficiaries interviewed 174

100

Table H 7. Timing, person and place of registration for JSY scheme Timing, place of registration for JSY scheme and JSY card Percent Timing of hearing about JSY scheme Before being pregnant 45.4 During pregnancy 54.6 Stage of pregnancy when beneficiary got registered for JSY scheme 1st month 6.4 2nd month 8.5 3rd month 30.5 4th month 10.6 5th month or later 44.0 Person who registered the beneficiary for JSY scheme Doctor 10.3 LHV - ANM/FHW 19.5 Anganwadi worker 39.7 ASHA worker 27.0 Others 3.4 Place where the beneficiary was registered for JSY scheme District/Sub-district Hospital 1.1 Community Health Centre 11.5 PHC 20.1 Sub-Centre 4.6 Anganwadi Centre 37.4 Private hospital accredited by the government - At home 22.4 Other places 2.9 Total number of JSY beneficiaries 174

Table H 8. Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the beneficiary in getting the JSY card JSY Card Percent JSY card received by the beneficiary 16.7 ASHA worker helped the beneficiary in getting JSY card 44.4 Beneficiary faced difficulty in procuring JSY card 10.3 If faced difficulty, type of difficulties faced by beneficiary (multiple options) Cards were not available 33.3 Formalities for making cards were too cumbersome 33.3 Was asked to pay money for the card - Other difficulties 33.3 Total number of JSY beneficiaries 174

101 Table H 9. Role of ASHA during the pregnancy of the beneficiaries Role of ASHA during the pregnancy of the beneficiaries Percent ASHA worker provided specific help during last pregnancy 34.5

Beneficiary received advice from ASHA during pregnancy for the following (multiple options) Diet 33.9 Danger signs 13.8 Delivery care 17.8 Breastfeeding 15.5 Newborn care 14.4 Family planning 8.6 Not applicable (ASHA not appointed in the village) 1.7 Information given to the beneficiary (Micro Birth Planning) during antenatal period by Doctor/ANM/ASHA (multiple options) 36.8 Date of next check-up 30.5 Place of next check-up 28.2 Date of expected delivery 45.4 Place of delivery 18.4 Place of referral, if complications arise Total number of JSY beneficiaries 174

Table H 10. Place of delivery and reason for opting institutional delivery Place of delivery and reason for opting institutional delivery Percent Place of delivery District/Sub-district Hospital 0.6 Community Health Centre 32.4 PHC 65.9 Sub-Centre - Trust/NGO Hospital - Private hospital - Private hospital accredited by the government - At home 1.1 Reasons for opting Institutional Delivery (multiple reasons) Money available under JSY scheme 29.8 Better access to institutional delivery 25.7 Better care for mother and new born child 32.2 Services in the area - Support provided by ASHA 29.2 Availability of transport assistance 0.6 Previous child was born in an institutions 2.9 Other 25.1

Total number of JSY beneficiaries 172

102 Table H 11. Transport of the beneficiaries to reach the Health Institution Process of Transport Percent Received referral slip from ASHA/health personnel to access 19.9 delivery services Faced difficulty in reaching Health Institution 14.6 If faced difficulty, type of difficulties faced in reaching the Health Institution by the beneficiaries (multiple options) It was late in the night 12.0 Did not have sufficient money 44.0 Transport was not immediately available 64.0 Male members in the household were not present 8.0 ASHA was not readily available 4.0 Others 4.0 Average distance to the ultimate place of delivery from the 13.9 beneficiary’s residence (in kms) Mode of transport used by the beneficiary to reach the ultimate place of delivery Government Ambulance 1.2 Private vehicle 4.7 Vehicle arranged by Local Health Committee - Other 94.2 Persons facilitated in arranging the transport ASHA 10.5 ANM/Health Worker 0.6 Village Health Committee - Family members/relatives - Others - Beneficiary had money to pay for the transport services 66.7 Average amount spent on transport (in Rs.) 1031.0 Average amount of transport assistance received under JSY 24.0 scheme by the beneficiary (in Rs.) Cases where amount spent on transport is more than the 164 amount received Persons accompanied the beneficiary to the Health Institution ASHA 29.8 Relatives 49.7 Mother/Mother-in-law - Husband - ANM/health Worker - Others 20.5 Total number of JSY beneficiaries 172

103 Table H 12. Waiting time at the health facility, type of delivery, amount spent at the health facility and satisfaction regarding services available in the facility Waiting time, type of delivery and satisfaction regarding services Percent Average waiting time at the facility until someone attended the 9.8 beneficiary (in minutes) Type of delivery (Percent) Normal 90.6 Assisted (Forceps, Vacuum) 5.3 Caesarean 4.1 Average number of days spent in the facility till discharge 1.5 Percent beneficiary who have to pay at the health centre 57.3

Average amount paid to the health centre (Rs.) 496.0 Satisfaction regarding the services available in the health centre (Percent) Satisfied 84.2 Somewhat satisfied 10.5 Not satisfied 5.3 Reasons for not satisfied with the services in the health centre (Percent) Staff was rude 44.4 Facility was not clean 11.1 Poor quality of services 11.1 Other 33.3 Total number of JSY beneficiaries 174

Table H 13. Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives being available under the JSY Scheme Reason for the beneficiary to opt home delivery Percent Reasons for home delivery (multiple options) Home delivery is more convenient 50.0 Fear of stitches/caesarean - Indifferent behaviour of Medical/paramedical staff - Cultural/social reasons - Transport not being available 50.0 Can’t afford - Others - Total number of JSY beneficiaries under Home Delivery 2

104 Table H 14. Cash incentive received by the beneficiary under JSY scheme Cash incentive Percent Beneficiary received cash incentive under JSY scheme (Percent) 100.0 Average amount received by beneficiary as cash incentive (in Rs.) 1370.8 Received the cash incentive: In one go 100.0 In 2 instalments - In 3 instalments - Timing of the receipt of the cash incentive by beneficiary At the time of registration - At the time of antenatal checkups - Much before the delivery - Within a week before the EDD - Immediately after the delivery 25.2 Within a week after the delivery 22.6 Much later 51.2 Not received yet - Do not know/husband knows 1.2 Other - The person who delivered the cash incentive to the beneficiary Doctor 78.6 LHV 2.4 ANM/FHW 8.9 Anganwadi worker 0.6 ASHA worker 2.4 Others 7.1 Place where the cash incentive received by the beneficiary District/Sub-district Hospital 1.8 Community Health Centre 32.7 PHC 64.9 Sub-Centre 0.6 Anganwadi Centre - Private hospital accredited by the government - At home - Other place - Faced difficulty in getting incentive money 4.8 (8) If faced difficulty, type of difficulty faced by the beneficiary Was asked to pay the bribe 25.0 When paid by cheque/draft 25.0 Other difficulty 50.0 Total number of JSY beneficiaries 172

105 Table H 15. Utilization of government health facility in last 6 months Utilization of government health facility Households located in Households All Sub Centre HQ located in Village other village Percent of household who availed health services in 12.0 9.0 10.5 government health facility in last 6 months 72 (54) 126 Total number of households 600 600 1200

Table H 16. Characteristics of the respondents who have availed the services in government health facility in last 6 months Characteristics of the respondent Percent Age <16 years 17.5 16-19 years 6.3 20-29 years 27.8 30-39 years 16.7 40-49 years 16.7 50-59 years 7.1 60 years or more 7.9 Sex Male 46.0 Female 54.0 Years of schooling completed Illiterate 48.0 1-5 years 20.0 6-9 years 24.0 10+ years 8.0 Marital status Unmarried 19.0 Currently Married 77.8 Divorced/Separated 0.8 Widowed 2.4 Social category of the household SC 4.8 ST 57.1 OBC 28.6 Others 9.5 Religion of the household Hindu 99.2 Muslim 0.8 Christian - Sikh - Others - BPL Household 45.2 Standard of Living Index of the household Low SLI 65.9 Medium SLI 16.7 High SLI 17.5 Total respondents 126

106 Client Satisfaction Table H 17. Type of health facility visited, purpose of visit and client satisfaction regarding behaviour of health worker, privacy and availability medicines Type of health facility visited, purpose of visit and client satisfaction Percent Type of health institution where service availed District/Sub District Hospital 16.7 CHC 29.4 PHC 47.6 Sub Centre 6.3 AYUSH - Purpose of visit to the health facility Treatment of minor ailment 90.5 ANC care 3.2 Child care 6.3 Immunization - Other - Behaviour of the staff at the health facility Courteous 87.3 Casual/Indifferent 10.3 Insulting/Derogatory 2.4 Listening of complaints by Doctor/staff Listened to complaints 88.1 Somewhat listened 7.1 Not listened 4.8 Can’t say - Women patients treated with privacy and dignity Yes 69.8 No 19.8 Don’t know 10.3 Patients with chronic illnesses (like joint pains, heart disease, blood pressure, diabetes etc.) get medicines regularly from health facility Yes 34.9 No 14.3 Don’t know 50.8 Private practice of the doctors during and after the duty hours Yes 35.7 No 35.7 Don’t know 28.6 Satisfaction with the overall services of the govt health facility Satisfied 69.8 Somewhat satisfied 21.4 Not satisfied 8.7 Satisfaction with behaviour of staff at the govt health facility Satisfied 72.2 Somewhat satisfied 19.0 Not satisfied 8.7 Total respondents 126

107 Table H 18. User fees and extra charges User fees and extra charges for the services provided Percent User fees charged from the users Yes 61.1 No 38.9 If user fees charged, type of user fees Registration 90.9 X-ray 6.5 Ultrasound 2.6 Lab test 14.3 Other 10.4

Receipt given for the user fees Given 79.2 Not given 20.8 Extra money charged for the services provided Yes 29.9 No 63.6 Don’t know 6.5 Total respondents who have availed the services in 77 government health facility in last 6 months

Table H 19. Services for the BPL patients BPL Patients Percent BPL patients provided free/subsidized services Yes 54.1 No 24.3 Don’t know 21.6 BPL patients face difficulty in getting free/subsidized services Yes 24.3 No 54.1 Don’t know 21.6 RKS facilitates the paperwork for BPL patients Yes 24.3 No 48.6 Don’t know 27.0 Total BPL respondents who have availed the services in 37 government health facility in last 6 months

108 Table H 20. Outbreak of selected diseases (Malaria, Measles, Gastroenteritis, Jaundice and Other Diseases) in the respondents’ area in the last six months Outbreak of diseases Percent Outbreak of Malaria in the last six months Yes 42.2 No 43.9 Don’t know 13.9 Outbreak of Measles in the last six months Yes 25.3 No 57.0 Don’t know 17.8 Outbreak of Gastroenteritis in the last six months Yes 32.3 No 51.6 Don’t know 16.1 Outbreak of Jaundice in the last six months Yes 24.5 No 57.4 Don’t know 18.1 Outbreak of Any Other Diseases in the last six months Yes 7.8 No 66.2 Don’t know 26.0 Total number of household respondents 1200

109 Table H 21. Action to be taken for selected diseases (diarrhoea, high fever, persistent cough, loose motion, persistent cough and breathing problems for a child) Action to be taken for selected diseases (Multiple responses) Percent Prevention of diarrhoea Hand washing 21.8 Use of safe food and water 41.7 Use of covered containers 9.4 Proper disposal of garbage 5.7 Other 6.9 Don’t know 52.9 Action to be taken if a family member has a high fever Get the blood tested for malaria 3.2 Taken to the RMP 3.3 Take to the nearest govt. health facility 25.8 Consult ASHA 0.8 Try home remedies 14.2 Other 93.2 Don’t know - Action to be taken if a family member has a persistent cough for more than two weeks Taken for sputum testing 1.8 Taken to the RMP 2.9 Take to the nearest govt. health facility 25.8 Consult ASHA 1.3 Try home remedies 39.8 Other 92.5 Don’t know - Action to be taken if a family member has loose motions lasting for more than 24 hours Stop giving Oral Fluids/Food etc 1.2 Start giving ORS 13.6 Taken to the RMP 2.9 Take to the nearest govt. health facility 23.2 Consult ASHA 2.0 Try home remedies 27.8 Other 91.6 Don’t know 0.1 Action to be taken if a child in the family has persistent cough and breathing problems Try home remedies 41.8 Taken to the RMP 2.6 Take to the nearest govt. health facility 23.5 Consult ASHA 0.9 Other 89.3 Don’t know 0.8 Total number of household respondents 1200

110 Table H 22. Awareness about spacing methods and ideal gap between 1st and 2nd child Awareness about spacing methods and ideal gap Percent between children Aware about the family planning methods 62.5

Ideal gap between 1st and 2nd child 1 year 1.9 2 year 29.2 3 and more years 68.9 Methods available for spacing IUD 9.9 Oral Pills 88.9 Nirodh/Condom 40.4 Any other 4.8 Don’t know 6.4 Total number of household respondents 1200

111 Table H 23. Awareness about modes of getting AIDS, source of information about AIDS and awareness about VCTC AIDS and VCTC Percent Heard of HIV/AIDS 28.7 Awareness about modes of getting HIV/AIDS (out of respondents who have heard of AIDS) Unsafe sexual contact 82.3 Blood transfusion 31.4 Sharing needles/syringes 43.3 From mother to child 5.2 Shaking hands 1.5 Sneezing - Insect bite - Kissing - Others 11.0

Source of information for HIV/AIDS (out of respondents who have heard of AIDS) Radio 26.2 TV 41.0 Health workers 6.4 Posters 4.1 Newspapers 3.2 Others 20.3 Aware about HIV/AIDS counselling centre/VCTC nearby(out of respondents who have heard of AIDS) 14.5

Respondents by reported location of HIV/AIDS counselling centre/VCTC(out of respondents who are aware about HIV/AIDS counselling centre/VCTC nearby) PHC 18.0 CHC 40.0 District Hospital 26.0 Sub-District Hospital 2.0 Private Hospital 4.0 Other 10.0 Total number of household respondents 50

112 Table H 24: Suggestions given by the respondents

• Govt. Hospital/PHC/SC needed in the village • Doctor/ANM/ health worker should stay in the village • Doctor/ANM needed in the village • Facility for delivery should be available within the village • Treatment should be available for all types of diseases • Medicines should be available regularly • Treatment should be free of cost • Drinking Water, Toilets Electricity facility needed in the village • Transport facility for patients is needed • Cleanliness needed in the village • Pucca roads needed/roads should be repaired • Information/publicity about health schemes needed • ASHA should provide information about health schemes • No suggestions/can’t say/ 62 (5.2 percent)

113 Chapter 7

Status and Performance of ASHA

In Madhya Pradesh the concept of ASHA asocial health activist has been accepted by the state government and appointments have taken place in all the districts in a phased manner after 2006. There is a network of 42,777 ASHAs spread across the length and breadth of the state in all 45 districts. Each village has atleast one ASHA and some villages have 2 ASHAs. Twenty two ASHA’s were interviewed from SC as well as farthest villages covered under the 2 CHCs in Anuppur district. Presented below is the status and performance of ASHA, role and performance of ASHA and their awareness about different programmes.

Status of ASHA Average population served by ASHAs is 962, i.e for every 962 persons there is one ASHA to provide health related services. Average number of village/habitations served by ASHA is 3.1. Regarding their selection process more than half (AWW: 55 percent; ANM: 54) have been selected on the recommendation of AWW and ANM, 23 percent on recommendation of Gram Pradhan and another 5 percent on the recommendation of Village Health Committee. Thus AWW and ANMs have played a major role in identifying and selecting the ASHA of their areas. All the ASHAs have undergone training (100 percent). Majority of the ASHAs (91 percent) have completed 2 modules of ASHA training. All ASHAs (100 percent) have received a kit.

Role and Performance of ASHA Fifty percent ASHAs are DOTs provider in their villages but only 3.5 JSY cases have been facilitated by them in the last three months. ASHAs on an average have handled 5.1 cases of diarrhoea and given ORS to children in the last three months. ASHAs have accompanied 2.9 institutional delivery cases. On an average an ASHA has distributed 13 Oral Pills, has provided drugs to 15 Malaria patients, and the number of new pregnancies identified is 5.4. Number of group meetings like Mahila mandals arranged by an ASHA is 1.2. Number of Health & Nutrition days arranged is 0.6. Average money incentive received by a ASHA

114 during one month for the different health activities carried out by them is Rs. 211 for JSY Rs. 107 for Sterlisation, Rs. 34 for VHND, and Rs 139 for other activities like motivating for immunization. On an average the total amount received by an ASHA is Rs. 493 for different types of services given by her.

Difficulties faced by ASHAs ASHAs were asked about the types of difficulties faced in implementing programme activities under NRHM. More than half (55 percent) ASHAs stated that funds are not available in time to carry out different activities and 32 percent reported delayed supply of drugs which affected their work. Inadequate facilities for institutional deliveries in the village are reported by more than one-third (36 percent) ASHAs. Adequate training is not provided (14 percent) and behaviour of staff in health facilities is not appropriate (5 percent) is also reported by them.

Support required by ASHA ASHAs were asked about the type of support they required for effective functioning and implement the programme in their area. Two issues which were stated by majority of them are related to monetary remuneration. ASHAs opined that they should be ‘paid a fixed remuneration’ (59 percent). ‘payments should be made timely’ (50 percent). Some ASHA’s expressed the necessity of ‘more training to be arranged for ASHA and community members’ (18 percent) while some of them also raised ‘other’ issues (41 percent) like provision of travelling allowance and transport facilities for JSY cases, more medicines should be available on time and a health facility should be available in the village.

Awareness Level of ASHAs The Awareness level of the ASHAs on different health aspects is high. Majority (96 percent) of them know about one or more steps about the prevention of diarrhoea. Breast feeding should be started soon after birth is known to all the 22 ASHAs. Correct age of child till when he/she should be exclusively breastfed is also known to majority (96 percent) the

115 ASHAs. Amount of cash incentive given under JSY is also known to all the ASHAs. However, majority know that amount of cash incentive of Rs.1400 is given under JSY to the beneficiary.

Remarks of ASHAs The remarks given by some of the ASHAs regarding the programmes are given below in their own words (the name of the village is mentioned in the brackets): 1. ‘Facilties for delivery should be available in the village and transport facilities to transport pregnant women to the health facility must be available’ (Parspani/ Dola).

2. ‘Transport facilities like ‘Janani Express’ for pregnant women should be available to ensure safe journey from remote distant villages’ (Pamra/Amdari).

3. ‘We must receive our payments on time because there is a lot of delay in our payments’ (Tulra).

4. ‘We should receive untied funds independently. More funds should be given for VHSC and we should get more training to function more effectively’ (Tulra/Majholi/).

5. ‘We should be paid affixed monthly remuneration’ (Dola/Podki/Beejapuri).

6. ‘Facilities for delivery should be available at the SC so that people do not have to travel outside’ (Harratola).

7. ‘We must receive our drugs like ORS; oral pills etc regularly so that continuity is maintained in providing these to the local people. If we stop distributing medicines people lose faith in us’ (Katkona/Lalpur).

8. ‘ASHA should have telephone/mobile facilities for contacting for institutional delivery’ (Jarha/Lalpur)

9. ‘We should receive a fixed monthly remuneration to provide regular services and it should be paid on time’ (Rajnagar/Beliachot).

10. ‘ANM/AWWW/ASHA have many regarding sharing of work and incentives. Proper guidelines must be provided by the authorities and our work progress must be monitored’ (Pamra).

116 11. ‘Clear instructions regarding how to spend untied funds have not been provided to us.’ (Harra tola).

Suggestions by the observer for the improvement of services 1. Majority ASHAs have received training covering the 2 modules and some upto 3 modules the district level with the assistance of DPMU. They are providing JSY, immunization and family planning services. ASHA’s have been provided identity cards and drug kits in the whole district.

2. Behaviour Communication Change (BCC) to be effective, there is an urgent need of transformation in the perception/attitude of those who have been selected to ensure community mobilization and participation. Most ASHA’s are shy and inhibited and need more orientation to overcome communication barriers. Special emphasis should be given during training to encourage effective communication.

3. ASHAs of majority of the villages covered in the district have limited knowledge about ongoing health programmes, are not very well informed and have organized few VHND. As a result they have not made a mark in the local community, which has yet to accept them as a community mobilizer.

4. ASHAs have knowledge about cash incentives (Rs.1400) for beneficiaries for institutional deliveries under JSY. However, they lack clarity about the package including amount provided for transport and their own incentives. Most ASHAs are receiving Rs.600 at the PHC or CHC on accompanying expectant mothers to the health facility and no separate accounts are maintained for referral transport.

5. JSY guidelines are still not clear to health providers leading to delays in release of incentives to ASHA and resulting in dissatisfaction among them.

6. Although ASHA’s are documenting the number of antenatal care and immunization cases in registers, most of these are incomplete and not verified by the ANM. They need more orientation by the ANM, on proper maintenance of records for a breakup of cases serviced by them.

7. Separate register/diary is essential to maintain the records of incentives ASHA’s receive every month and may be verified by the concerned ANM of the area.

8. Drug kits are not continuously filled as most ASHA’s have complained about lack of medicines in their kits. They also lack awareness about the drugs expiry dates etc. The provision for drug replenishment must be continuous and not periodic or adhoc.

9. The expenditure patterns from untied funds are uniform (Rs.484 left in the passbooks) in Pushprajgarh CHC in the district. Some purchases like dari, table, chair, cups and glasses

117 etc. have been made at the district level and then distributed to ASHAs, who have been thereafter provided the bills. This amount has been deducted from their untied funds as observed during field visit. Most of these purchased items are of extremely poor quality.

10. Cash registers maintained also indicated uncanny similarity in expenses made by ASHAs under Pushprajgarh CHC.

11. At most villages ASHA/GP could not provide any evidence of reported construction or cleaning of areas around tube wells in their respective villages for which they have shown expenditures. Before providing the next installment of untied funds this aspect needs to be thoroughly investigated.

12. Although the VHSC have been formed in most of the villages where ASHAs and GP have joint accounts for receiving untied funds it is more of a formality. Very few ASHAs/GP reported preparation of village health plans.

13. No wall writings of NRHM or JSY seen in the villages, indicating poor publicity and IEC of activities being undertaken under NRHM.

14. Villages being scattered it is difficult for one ASHA to cover a vast area.

15. Strengthening of linkages between ASHA/ANM/AWW and GP is essential for more effective implementation of VHND, VHSC, JSY and other components of NRHM.

118 Status and Performance of ASHA

Table A1: Status of ASHA A. Number of ASHA interviewed in the district 22 B. Average population served by ASHAs interviewed 961.6 C. Average number of village / habitations served by 3.09 AHSAs covered D. Percentage of ASHAs by method of selection Selected on recommendation of ANM 53.8 Selected on recommendation of Gram Pradhan 22.7 Selected on recommendation of Anganwadi Worker 54.5 Selected by Village Health Committee 4.5 Previously working as Dai 4.5 Other 0.0 E. Percentage of ASHAs undergone training 100.0 F. Percentage of ASHAs undergone training by modules Module 1 90.9 Module 2 90.9 Module 3 50.0 Module 4 18.2 G. Percentage of ASHAs issued ASHA Kit 100.0

Table A2: Role and Performance of ASHA

A. Percentage of ASHAs who are DOTS provider 50.0 B. Average monthly no. of JSY cases facilitated in last 3 3.5 months by ASHA C. Average no. of cases handled in last three months Children with diarrhoea given ORS 5.1 Accompanied Institutional deliveries cases 2.9 Number of Oral Pills distributed 12.9 Number of Malaria Patients given drugs 14.6 Number of new pregnancies identified 5.4 Number of group meetings like Mahila mandals arranged 1.2 Number of Health & Nutrition days arranged 0.6 D. Average money incentive received by an ASHA on an average during one month JSY 211.4 Sterlisation 106.8 VHND 34.1 Other 138.6 Total 493.2

119

Table A3: Distribution of ASHAs by reported types of difficulties faced and kind of support required A. Percentage of ASHAs by types of difficulties faced in implementing programme activities under NRHM Funds not available in time 54.5 Adequate training is not provided 13.6 Delayed supply of drugs 31.8 Behaviour of staff in health facilities is not appropriate 4.5 Inadequate facilities for institutional deliveries 36.4 B. Reported kind of support require ASHA to enable her to implement the programme more effectively More training is to be arranged for ASHA & Community 18.2 members ASHA should be paid a fixed remuneration 59.1 Payments should be made timely 50.0 Other 40.9

Table A4: Distribution of ASHAs by reported awareness on different aspects A. Percentage of ASHAs reporting

Awareness about important steps for prevention of diarrhea 95.5 Time of initiating Breast Feeding 95.5 Age of child till when he/she should be exclusive breastfed 86.4 Amount of cash incentive given under JSY 100.0

120 Chapter 8

Gram Panchayat

Gram Panchayat schedule was canvassed to the member of GP/Sarpanch representing the selected village. It covered the basic information about the Gram Panchayat (population and households covered), IEC activities carried out, functioning of the VHSC, implementation of Mitanin and JSY, and awareness about the ASHA at the Gram Panchayat level. Out of 29 villages covered for the survey, interview of 17 Gram Panchayats Members/Sarpanches was done from 22 Panchayat villages. The average population of the 17 villages is 3699 with an average SC population of 731 (19.8 percent) and ST population of 1270 (34.3 percent). The average number of households per village is 1082 with an average of 248 SC and 380 ST households. The average number of BPL families per village is 265 with an average of 40 SC and 170 ST households.

Awareness and Involvement of Gram Panchayats in NRHM Regarding the regular availability of ANM, nearly two thirds (64 percent) of the Gram Panchayats reported that the ANM is regularly available in the village. A little more than one third Gram Panchayats (35 percent) reported that they know the tour plan of the ANM and more than half (53 percent) reported that the Sub Centre is providing timely services to the patients in the village. A little more than half (53 percent) of the Gram Panchayats reported that it had a role in conducting/finalising IEC programme in the village. Out of 17 Gram Panchayats majority (94 percent) have reported the existence of the VHSC in their village but the receipt of Untied Funds for the VHSC is reported by only 50 percent of them. Moreover, more than half (56 percent) of the Gram Panchayats reported the regular meetings of the VHSC but only one fourth of the Gram Panchayat (25 percent) have reported the preparation of the Village Health Plan. Less than half (47 percent) of the Gram Panchayats reported conducting of IEC activities during last 6 months on health issues through street play, wall writing, organizing camps, and distributing pamphlets.

121 All the 17 Gram Panchayats (100 percent) have reported the appointment of ASHAs in their respective villages. Awareness about the benefits under the JSY scheme was reported by all 17 Gram Panchayats. A little more than one-third (35 percent) panchyat members reported that the NRHM has brought improvement in their area. Among those Gram Panchayats which have reported improvements due to NRHM stated that there is availability of funds/facilities under JSY (100 percent), funds are available for maintenance of Sub-Centres (50 percent), community support is available as ASHA worker (17 percent) and availability of transport facilities for delivery and better facilities are available for CHCs/PHCs for referred patients (17 percent). Fifteen Gram Panchayats (88 percent) have reported difficulties in implementing programme activities under NRHM. Some of the reported difficulties are funds are not available in time (59 percent) inadequate facilities for institutional deliveries (42 percent), ASHA has not been adequately trained (12 percent) and 47 percent reported ‘other’ difficulties like lack of adequate publicity about NRHM, lack of ambulance, transport facilities and lack of adequate health services and and facilities including staff at the village level. The Panchayats were asked about the kind of support required to enable them to implement NRHM more effectively. All seventeen (100 percent) Panchayat members stated that support was required. The kind of support required reported by the Gram Panchayats are: more funds (53 percent), more training for ASHA and community members (53 percent).Gram Panchayats wanted direct control over funds (35 percent), ‘other’ (47percent) support like ambulance facility, transport facility, SC building in the village, increase in the number of health workers, and management of untied funds should be under the control of district authorities rather than BMO.

Suggestions by GP members Majority of the GP members suggested that buildings, health staff/doctors, medicines should be freely available to make the NRHM programme successful. Residential staff quarters for health workers were also proposed so as to motivate the health staff to reside in the villages. Facilities of referral transport services were also suggested by them due to remoteness of many of the villages in the area.

122 Role, Awareness and Involvement of Gram Panchayats

Table A1: Status of Gram Panchayats Covered

A.Number of Gram Panchayats covered in the district 17 B. Average population of the Gram Panchayat covered Scheduled Caste 731.2 Scheduled Tribe 1269.9 Total 3698.9 C. Average number of Households in the Gram Panchayats covered Scheduled Caste 247.6 Scheduled Tribe 380.3 Total 1082.1 D. Average number of BPL families in the Gram Panchayats covered Scheduled Caste 39.9 Scheduled Tribe 169.5 Total 265.4

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Table A2: Level of awareness and involvement of Gram Panchayats

A1. Percentage of Gram Panchayat reporting regular availability of ANM 64.7 A2. Percentage of Gram Panchayat reporting awareness about ANM Tour Plan 35.3

B. Percentage of Gram Panchayat reporting timely services provided by Sub Centre to 52.9 the patients C. Percentage of Gram Panchayat reporting role of Gram Panchayat in 52.9 conducting/finalizing IEC programme in Gram Panchayat D. Percentage of Gram Panchayat reporting existence of VHSC in their Gram 94.1 Panchayat E. Percentage of Gram Panchayat reporting regular meetings of VHSC 56.3 F. Percentage of Gram Panchayat reporting Village health Plan been prepared by 25.0 VHSC G. Percentage of Gram Panchayat reporting that VHSC has received any Untied Fund 50.0 H. Percentage of Gram Panchayat reporting ASHA workers in position 100.0 I. Percentage of Gram Panchayat reporting awareness of the benefits under JSY 100.0 scheme J. Percentage of Gram Panchayat reporting that NRHM brought about any 35.3 improvement in their area K. Percentage of Gram Panchayat reporting conduct of IEC activities during last 6 52.9 months L. Distribution of Gram Panchayats covered by type improvement reported due to NRHM Funds available for maintenance of Sub Centres 50.0 Community support is available as ASHA worker 16.7 Funds/facilities are available under JSY 100.0 Better facilities are available for CHCs/PHCs for referred patients 16.7 Transport facilities are available 16.7 Other 0.0 M. Distribution of Gram Panchayats by type of difficulties faced in implementing programme activities under NRHM Funds not available in time 58.8 Decision making with the community leaders is difficult 0.0 ASHA has not been adequately trained 11.8 Adequate facilities for institutional deliveries not available 41.2 Any other 47.1 M. Distribution of Gram Panchayats by kind of support required to enable them in implementing the programme more effectively More funds are required for maintenance/ effective functioning 52.9 Gram Panchayat should be given direct control over funds 35.3 More training is to be arranged for ASHA and Community Members 52.9 Any other 47.1

124 Chapter 9 Quality of Care and Client Satisfaction (Based on IPD Exit Interview)

Introduction As per the study design, 5-10 IPD patients have to be interviewed at each of the health facility (1 District Hospital, 2 CHCs and 4 PHCs) at the time of discharge. Hence, the expected number of exit interview in the district varies between minimum of 35 and maximum of 70. However, in Anuppur district the inpatient services are virtually non-existent at the PHC and limited at the CHC level. The district hospital is also providing very limited IPD services. Thus only 4 IPD interview could be conducted at the CHC level and 3 at district level inspite of consistent efforts. In Pushprajgarh CHC the BMO expressed reservations, therefore exit interviews were discontinued. As the number of patients interviewed is small (3 for DH, 4 for CHCs and none for PHCs), a caution is necessary while interpreting the figures. The age distribution of the IPD patients shows that 6 patients are in the age group of 20- 29 years and the remaining 1 is in the age group of 30-39 years. Among IPD patients interviewed all are females, 6 of them are currently married and 6 patients are from rural areas. Purpose of admission to the health facility shows that 1 of the patients was admitted for minor illness and 6 women for delivery purposes. (Table E I2).

Waiting Time The average waiting time for the patients for the Registration is 19 minutes (Table EI- 3). The average waiting time for Registration in the CHC is relatively higher (28 minutes) than in the DH (8 minutes). After the Registration, the patients had to wait on an average 14 minutes for the Doctor’s call in the hospitals (CHC: 19 minutes; DH: 8). On an average, the doctors have examined the patients for 14 minutes. The examination time of the doctors is higher in DH (16 minutes) than at the CHC (10 minutes). After the examination it takes 7 minutes to get admitted to the ward. Here again, the waiting time to admission to the ward is higher in CHC (10 minutes) than in DH (3 minutes).

125 After admission to the ward, it takes about 14 minutes for the patients to get the services. Patients from DH got the services very quickly (7 minutes) than the patients from CHC (20 minutes). The average time for getting discharged for the patients was 35 minutes at DH and 5 at CHC.

Satisfaction regarding Waiting Time Satisfaction of the patients regarding waiting time for different services is given in Table EI-4. The satisfaction with the waiting time for registration, doctor’s call, doctor’s examination, admission to ward, and getting services and to get discharged is assessed with four categories: too long, appropriate, too short and can’t say. All the patients felt that the waiting time was either short or appropriate for registration, doctor’s call, doctor’s examination, indicating complete satisfaction both at the DH or CHC. For one patient at CHC waiting time for registration, doctor’s call and getting services took a long time. For two patients at the CHC doctor took a long time in examination. Two patients at the DH expressed that getting discharged took a long time. Otherwise majority patients at the DH and CHC said that waiting time was appropriate or too short which expressed their satisfaction.

Behaviour of Staff Behaviour of each category of staff (doctor, nurse, and technical staff) is assessed with a four point scale - rude, reasonable, good and very kind (Table EI-5). All the patients said that the doctor greeted them in a friendly manner in the first instance. Regarding the behaviour of doctors, nurses and technical staff, the patients both at the DH and CHC said that their behavior in general is reasonable or good. However, one patient from the CHC reported that the behaviour of the nurse was rude. The behavior of ayah, ward boy and counter clerk is also assessed on 4 point scale-negligent, arrogant, indifferent and good. Regarding the behaviour of ayah, ward boys and counter clerk satisfaction at the DH and CHC appears to be rather high as all the patients said that either they are good or very kind. The figures indicate that the patients in general are satisfied with the behaviour of all categories of staff in the health facilities and more so at the DH.

126 The patients were asked whether the hospital authorities have taken some unique/innovative measure to improve the staff behaviour in the hospital (Table EI7). In all 3 patients (1: DH and 2 CHC) reported that any unique/innovative measure was taken to improve the behaviour of the staff.

Privacy One of the criticisms for the services in public health facilities in India is lack of privacy during the examination, particularly for female patients. This can be addressed easily by making partitioning of the room or by keeping a curtain in the examination room. In the exit interview all the patients were asked whether there was privacy at the place of examination. On the whole, only 1 out 4 of patients in the CHC said that there was lack of privacy in the place of examination. All the patients in the DH were satisfied with the privacy. This indicates that patients at the district hospital and the CHC are in general satisfied but privacy issue needs more attention at the CHC.

Patient-Doctor/Provider Communication Client-provider communication is one of the important dimensions of the quality of care. The doctor-patient communication was assessed from the patients in the following issues: doctor listened to the description of the ailment; doctor allowed to ask questions; doctor responded to questions; doctor discussed about ailment; doctor talked about recovery; and doctor gave other advice (Table EI-8). The response of the patients with respect to their interaction with the doctor shows that the patients have a mixed opinion about the response received. Regarding listening to the patient’s ailment, 4 patients (DH: 3; CHC: 1) said that the doctor always listened to their ailment patiently, and 3 of them at the CHC said that the doctor listened somewhat. Five patients said that the either the doctor always/somewhat allowed to ask questions or responded to questions (DH: 3; CHC: 2).However, 2 patients one at the DH and one at the CHC said that the doctor did not allow to ask questions. All the patients at the DH and 2 at the CHC said that the doctor responded to their questions somewhat/always, whereas 2 patients at the CHC said that doctor did not respond to their questions. Doctor discussed about the ailment was expressed by all the 3 patients at the DH and 3out of 4 patients at the CHC. Similarly, the doctor talked about recovery was expressed by

127 all the 3 patients at the DH and 3out of 4 patients at the CHC. Two out of 3 patients received ‘other advise’ at the DH and 3 out of 4 at the CHC. The analysis of client-provider communication indicates that clients are more or less satisfied with the doctors’ behavior but patient doctor communication at the CHC needs more attention.

Cleanliness of the Facility Cleanliness of health facilities is assessed through the frequency of cleaning of floor and toilet/bathroom, changing patient’s uniform and changing bed-sheets. Regarding the frequency of cleaning of the floor, the percentage 1 patient at DH and 3 at the CHC reported that the cleaning is done twice in a day, whereas once in day is reported by 2 patients one at the DH and 1 patient at the CHC. Two patients at the DH said that the toilet/bathroom is cleaned once a day but less than once a day of toilet cleaning is reported by 5 patients (DH:1; CHC: 4) . All patients (DH:3; CHC:4) said that patient uniform was changed less than once day during their hospitalization. Once a day of bed sheet changes are reported by 3 patients (DH: 2; CHC: 1) and less than once a day of bed sheet change was reported by 4 patients (DH:1; CHC: 3). Changing beds sheets regularly does not seem to be a regular feature. Overall cleanliness of the facility needs attention both at the district hospital and at the CHCs.

Satisfaction Regarding the Cleanliness of the Facility The satisfaction regarding cleanliness of the facility is assessed through three categories of satisfaction – satisfied, somewhat satisfied and not satisfied (Table EI 10). It shows that 5 patients are satisfied or somewhat satisfied with cleaning of floor (DH: 3; CHC: 2) and 2 patients at the DH are somewhat satisfied with the cleaning of toilet/bathroom. However, all the patients at the CHC are not at all satisfied with the cleaning of toilet/bathroom and two patients expressed dissatisfaction about the cleaning of the floor. Regarding the changing of patients’ uniform none of the 7 patients either at the DH or at the CHC are satisfied with the services. Except for 3 patients (DH: 2; CHC: 1) who are somewhat satisfied with the changing of bed sheets rest of the 4 patients (DH: 1; CHC: 3) have expressed dissatisfaction for not cleaning of bed sheets. The data on frequency of the cleanliness and satisfaction regarding the same clearly shows that although the number of inpatients interviewed are few in number lack of cleanliness is a major issue in the health facilities and warrant immediate attention.

128 Crowding in the Facility Crowding in the facility is assessed through availability of cot for the patients, adequacy of the space in the ward, satisfaction with the arrangement of ward and adequacy of space in IPD (Table EI-11). All patients at DH and CHC said that they got the cot not immediately but on the same day. The cot remained available for the all the 7 patients till the time of discharge. All the patients expressed somewhat satisfaction with the ward arrangements. Regarding the adequacy of space in the ward, all 7 patients said that the space is adequate or somewhat adequate. All the patients reported adequacy of space in IPD as satisfactory.

Amenities Provided by the Hospital The availability of amenities in health facilities as reported by the patients are given in Table EI-12. It shows that out of the 6 amenities, 3 patients know about medical shop, 2 have reported about telephone facilities and all 3 about ambulance facilities at the DH. At the CHC out of 6 amenities only 3 amenities, telephone (3) ambulance (1) and accommodation facility (1) was reported by patients. Satisfaction with medical shop was expressed by only 1 patient at DH and about ambulance facility by the patient at CHC. Thus patient’s satisfaction with the amenities seems to be less than their level of awareness about these amenities.

Continuity of Treatment Patients satisfied with the services will continue to visit the facility. However, dissatisfied patients may cause harm to the public health programmes/facilities by discouraging others to go the government facility. Hence, any dissatisfaction may lead to underutilization of the facilities and wastage of precious public resources. To understand this, the patients were asked about their overall satisfaction with the visit to the health facility, their willingness to visit again and their willingness to recommend the facility to others. Table EI- 13 shows that, overall, all 3 patients at the DH expressed ‘somewhat satisfied’ and 4 patients at the CHC have reported the same. Thus none of the patients expressed dissatisfaction with the visit to the health facility. All except one patient at the DH said that they would visit the health facility in case of illness. Similarly, only 1 patient at DH said that he would not recommend the hospital to other.

129 Quality of care and Client Satisfaction

IPD Facilities

Table EI 1: Background characteristics of the in-patients Background Characteristics of the In-Patients Percent Age < 20 years - 20-29 years 85.7 30-39 years 14.3 40-49 years - 50-59 years - 60 years or more - Sex Male - Female 100.0 Marital Status Unmarried - Currently Married 85.7 Divorced/Separated - Widowed 14.3 Residence Rural 85.7 Urban 14.3 Type of Health Facility District Hospital 42.9 CHC 57.1 PHC - Total In-patients interviewed 7

130 Table EI 2: Purpose of admission in the Health Institution Type of Health Facility (Percent) Purpose of admission in the Health Institution District CHC PHC All Hospital Minor illness 33.3 - - 14.3 Family planning surgery - - - - Delivery 66.7 100.0 - 85.7 Cataract surgery - - - - Child admitted - - - - Other - - - - ¤ Total In-patients interviewed 3 4 - 7

Table EI 3: Waiting time Type of Health Facility (Average waiting time in minutes) Average waiting time for: District CHC PHC All Hospital Registration 8.3 27.5 - 19.3 Doctor’s call 8.3 18.8 - 14.3 Doctor’s examination 10.0 16.3 - 13.6 Admission to ward 3.3 10.0 - 7.1 Getting services 6.7 20.0 - 14.3 To get discharged 35.0 5.0 - 17.9 Total In-patients interviewed 3 4 - 7

131 Table EI 4: Satisfaction regarding waiting time Waiting time for / Type of Health Facility (Percent) Satisfaction. District CHC PHC All Hospital Registration Too Long - 25.0 - 14.3 Appropriate 100.0 75.0 - 85.7 Too Short - - - - Can’t Say - - - - Doctor’s call Too Long - 25.0 - 14.3 Appropriate 66.7 50.0 - 57.1 Too Short 33.3 25.0 - 28.6 Can’t Say - - - -

Doctor’s examination - Too Long - 50.0 - 28.6 Appropriate 33.3 25.0 - 28.6 Too Short 66.7 25.0 - 42.9 Can’t Say - - - Admission to ward - Too Long - - - - Appropriate 100.0 75.0 - 85.7 Too Short - 25.0 - 14.3 Can’t Say - - - Getting services - Too Long - 25.0 - 14.3 Appropriate 66.7 50.0 - 57.1 Too Short 33.3 25.0 - 28.6 Can’t Say - - - To get discharged - Too Long 66.7 - - 28.6 Appropriate - 100.0 - 57.1 Too Short 33.3 - - 14.3 Can’t Say - - - Total In-patients interviewed 3 4 - 7

132

Table EI 5: Behaviour of Staff Type of Health Facility (Percent) Staff Behaviour District CHC PHC All Hospital Doctor greet in a friendly manner Yes 33.3 100.0 - 71.4 Somewhat 66.7 - - 28.6 No - - - - Behaviour of Doctor Rude - - - - Reasonable 66.7 50.0 - 57.1 Good 33.3 50.0 - 42.9 Very kind - - - -

Behaviour of Nurse Rude - 25.0 - 14.3 Reasonable 66.7 - - 28.6 Good 33.3 75.0 - 57.1 Very kind - - - - Behaviour of Technical Staff Rude - - - - Reasonable - - - - Good 100.0 100.0 - 100.0 Very kind - - - - Behaviour of Ayah Rude - - - - Reasonable - - - - Good - - - - Very kind 100.0 100.0 - 100.0

Behaviour of Ward Boys Rude - - - - Reasonable - - - - Good - - - - Very kind 100.0 100.0 - 100.0 Behaviour of Counter Clerk Negligent - - - - Arrogant - - - - Indifferent - - - - Good 100.0 100.0 - 100.0 Total In-patients interviewed 3 4 - 7

133 Table EI 6: Unique/innovative measure taken to improve the staff behaviour Type of Health Facility (Percent)

Staff Behaviour Staff District CHC PHC All Hospital Unique/innovative measure taken to improve the staff behaviour 33.3 50.0 - 42.9 Yes 66.7 50.0 - 57.1 No - - - - Don’t know Total In-patients interviewed 3 4 - 7

Table EI 7: Privacy Type of Health Facility (Percent) Privacy District CHC PHC All Hospital Patients reporting Presence of privacy at the place of examination 100.0 75.0 - 85.7

Total In-patients interviewed 3 4 0 7

134 Table EI 8: Patient-Doctor/Provider Communication Type of Health Facility (Percent) Patient-Doctor Communication District CHC PHC All Hospital Doctor listened to description of ailment patiently Yes, somewhat 100.0 25.0 - 57.1 Yes, always - 75.0 - 42.9 No - - - - Doctor allowed to ask questions Yes, somewhat 66.7 50.0 - 57.1 Yes, always - 25.0 - 14.3 No 33.3 25.0 - 28.6

Doctor responded to questions Yes, somewhat 100.0 25.0 - 57.1 Yes, always - 25.0 - 14.3 No - 50.0 - 28.6

Doctor discussed about the ailment 100.0 75.0 - 85.7

Doctor talked about the recovery 100.0 75.0 - 85.7

Doctor gave ‘other advice’ 66.7 75.0 - 71.4

Total In-patients interviewed 3 4 - 7

135 Table EI 9: Cleanliness of the facility Type of Health Facility (Percent)

Frequency of cleaning District CHC PHC All Hospital Floor Thrice a day - - - - Twice a day 33.3 75.0 - 57.1 Once a day 66.7 25.0 - 42.9 Less than once a day - - - - Not applicable - - - - Toilet/Bathroom cleaning Thrice a day - - - - Twice a day - - - - Once a day 66.7 - - 28.6 Less than once a day 33.3 100.0 - 71.4 Not applicable - - - - Changing Patient’s Uniform Thrice a day - - - - Twice a day - - - - Once a day - - - - Less than once a day 100.0 100.0 - 100.0 Not applicable - - - - Changing Bed Sheets Thrice a day - - - - Twice a day - - - - Once a day 66.7 25.0 - 42.9 Less than once a day 33.3 75.0 - 57.1 Not applicable - - - - Total no.of In-patients 3 4 - 7 interviewed

136 Table EI 10: Satisfaction of patients regarding cleanliness of the facility Type of Health Facility ( percent) Satisfaction District CHC PHC All Hospital Floor cleaning Satisfied 33.3 50.0 - 42.9 Somewhat satisfied 66.7 - - 28.6 Not satisfied - 50.0 - 28.6 Toilet/Bathroom cleaning Satisfied - - - - Somewhat satisfied 66.7 - - 28.6 Not satisfied 33.3 100.0 - 71.4 Changing Patient’s Uniform Satisfied - - - - Somewhat satisfied - - - - Not satisfied 100.0 100.0 - 100.0 Changing Bed Sheets Satisfied - - - - Somewhat satisfied 66.7 25.0 - 42.9 Not satisfied 33.3 75.0 - 57.1 Total no.of In-patients 3 4 - 7 interviewed

137 Table EI 11: Crowding in the facility Type of Health Facility (Percent) Crowding in the facility District CHC PHC All Hospital Availability of cot Immediately - - - - Not immediately but same day 100.0 100.0 - 100.0 Next day - - - - After more than a day - - - - Availability of cot/bed till the time of discharge Yes 100.0 100.0 - 100.0 No - - - -

Adequacy of space in the ward Not adequate - - - - Somewhat adequate 66.7 75.0 - 71.4 Adequate 33.3 25.0 - 28.6

Satisfaction with the ward arrangement Not satisfied - - - - Somewhat satisfied 100.0 100.0 - 100.0 Satisfied - - - - Adequacy of space in IPD Not adequate - - - - Somewhat adequate 66.7 100.0 - 85.7 Adequate 33.3 - - 14.3 Total number of in-patients interviewed 3 4 0 7

138 Table EI 12: Amenities provided by the hospital Percentage of in patients Type of Health Facility (Percent) reporting availability/% Percent District Percent CHC Percent PHC Percent All reporting satisfaction Hospital Availability of amenities Television ------Canteen ------Medical shop 100.0 3 - - - - 42.9 3 Telephone 66.7 2 75.0 3 - - 71.4 5 Accommodation for relatives - - 25.0 1 - - 14.3 1 Ambulance 100.0 3 25.0 1 - - 57.1 4 Satisfaction among those who said the amenity is avilable. Television ------Canteen ------Medical shop 33.3 1 - - - - 33.3 1 Telephone ------1 Accommodation for relatives ------1 Ambulance - - 100.0 1 - - 25.0 1

Table EI 13: Continuity of treatment Type of Health Facility (Percent)

Continuity of treatment District CHC PHC All Hospital Satisfaction with the visit to the health facility - - - - Dissatisfied 100.0 100.0 - 100.0 Somewhat satisfied - - - - Satisfied Reason for dissatisfaction (if dissatisfied) Lack of facilities - - - - Bad experience with the Doctor - - - - Poor quality of services - - - - Charges are exorbitant - - - - Other - - - - Visit again to the facility (if fell sick) Yes 66.7 100.0 - 85.7 No 33.3 - - 14.3 May come/unsure - - - - Recommend this hospital to others Yes 66.7 100.0 - 85.7 No 33.3 - - 14.3 Total number of in-patients interviewed 3 4 - 7

139 Chapter 10 Quality of Care and Client Satisfaction

(Based on OPD Exit Interview)

As per the study design we have to interview 5-10 OPD patients at each of the selected health facility (1District Hospital, 2 CHCs and 4 PHCs) at the time of their exit from the hospital. Hence, the expected number of OPD exit interview in the district varies between minimum of 35 and maximum of 70 interviews. We have conducted total 50 OPDs in Anuppur district out of which, 15 OPD interviews are from DH, 14 from the two selected CHCs and 21 from the three selected PHCs. At Kothi PHC (Kotma CHC) no OPD services were being provided when the team visited the centre. As the number of patients interviewed is small (15 for DH, 14 for CHCs and 21 for PHCs), a caution is necessary while interpreting the figures. Characteristics of the patients interviewed for the OPD exit-interview are presented in Table EO-1. The age distribution of the OPD patients shows that 50 percent of the patients are aged less than 30 years of age, 26 percent between 30-49 years of age, and the remaining 24 percent are above 50 years of age. The proportion of female OPD patients (54 percent) is more than male patients (46 percent), 78 percent are currently married and 68 percent are from rural areas. Purpose of visit to the health facility shows that about two thirds of them (64 percent) visited the facility for availing treatment for minor illness, 16 percent for child illness and 10 percent for ANC/PNC care, 4 percent for MDT- DOTs and 4 percent for ‘other’ illnesses (Table EO-2). Purpose of OPD visit by type of facility shows that minor and child illnesses are the two major reasons for the visit to the health facility.

Average Waiting Time for Services Overall, to get all the OPD services it takes on an average 57 minutes for the patients in the hospitals (Table EO-3). Average time to get the OPD services is highest in PHCs (55 minutes) followed by CHCs (36 minutes) and DH (32 minutes). The waiting for the different OPD services by type of health facility shows that, except dressing (25 minutes), all the other

140 OPD services take less than 10 minutes in the hospitals. The average waiting time for the Registration is 6 minutes. The average waiting time for registration in DH is higher (8 minutes) than in CHCs (7 minutes) and PHCs (4 minutes). After the Registration, the patients have to wait on an average 9 minutes for the examination of the doctor. The average waiting time for Doctor’s examination is higher in PHCs (11 minutes) than CHCs or DH (8 minutes). For getting injection and medicines, patients have to wait on an average 7 minutes in the hospitals. Getting medicines on an average takes 7 minutes in the hospitals. Time taken for getting medicines is maximum in CHCs (10 minutes) and minimum at the PHCs and DH (5 minutes). The waiting time for the OPD services shows that, to get the services, the patients have to wait for more time in PHCs than in the CHCs and DH.

Satisfaction Regarding Waiting Time Satisfaction of the patients regarding waiting time for different services is given in Table EO-4. The satisfaction with the waiting time for registration, doctor’s examination, injection, dressing, getting medicines, and paying bill is assessed with four categories (too long, appropriate, too short and can’t say). It shows that, dissatisfaction with services is not very high as only 1-2 patients in each of the health facilities said that the waiting time is too long for these services, except at the CHCs where the waiting time for getting medicines is reported too long by patients (23 percent) and at the PHCs for receiving injections (17 minutes). One patient at the PHC has complained that waiting time for dressing was too long. In fact, most of the patients (above 90 percent) perceived and reported that the waiting time for these services is appropriate/too short. Patients overall are satisfied by the different services provided by the DH, CHCs and PHCs. Though the dissatisfaction levels of OPD services are not very high even the small level of dissatisfaction at the CHCs or PHCs which provide limited services has to be properly addressed.

Behaviour of Staff Behaviour of each category of staff (doctor, nurse, technical staff, ayah, ward boy and counter clerk) is assessed with a four point scale - rude, reasonable, good and very kind (Table

141 EO-5). Two to six percent of the patients said that the doctor did not greet them in a ‘friendly manner’ in the first instance, 40 percent said that the doctor greeted them in ‘somewhat friendly manner’ and 54 percent said that the doctor greeted them in a ‘friendly manner’. Doctor did not greet in a friendly manner was reported by one patient each at the PHCs, CHCs and DH. Doctor’s behavior as rude is reported by 1 patient at the PHC level. Otherwise, majority (94-98 percent) of the patients said that doctor greets in a somewhat/friendly manner and doctors behavior is reasonable, good and kind. Similarly the interaction of patients with nurses shows that 84 percent of patients who interacted said that behavior of nurse’s behavior is reasonable, good and kind. Six patients at the CHC did not interact with the nurses at all. Overall the behavior of nurses and dispenser were seen as reasonable, good and kind by patients of DH and CHC. The figures indicate that, the patients in general, are satisfied with the behaviour of all categories of staff in the health facilities.

Privacy In the exit interview, all the OPD patients were asked whether there was privacy at the place of examination. On the whole more than three-fourths (78 percent) of patients said that there was privacy in the place of examination. The percentage of patients reporting the presence of privacy is highest at the PHC (95 percent) as compared to DH and CHCs (64 percent). It is clear that the privacy is an issue, particularly in DH and CHCs.

Patient-Doctor/Provider Communication The response of the OPD patients with respect to their interaction with the doctor shows that the patients have lot of concern about this. Regarding listening to the patient’s ailment, 74 percent of the patients said that the doctor ‘always listened’ to their ailment patiently, 22 percent said that the doctor listened somewhat and only 4 percent (CHC: 7 percent; DH: 5) said that doctor did not listen. The percent of patients who said that the doctor did not allow to ask questions is 18 percent, did not respond to questions is 16 percent, did not discuss about the ailment is 8 percent, did not talk about recovery is 32 percent, and did not give ‘other’ advice is 48 percent. Doctor-patient communication by type of hospital

142 shows that more patients from CHC and PHC expressed their unhappiness about it. OPD patients have expressed their dissatisfaction regarding their communication with the doctors. Doctors did not allow to ask questions (CHC: 36 percent; PHC: 14), did not respond to questions (CHC: 27 percent; PHC: 19 percent), talk to patients about recovery (CHC: 43 percent: PHC: 43) and did not give other advise (CHC: 57 percent; PHC: 62). The results show that the OPD patients at the CHCs and PHCs are not happy with the communication of the doctors.

Cleanliness of the OPD Facility Satisfaction of the patients regarding the cleanliness of the OPD facilities (OPD room, examination room, dispensary, laboratory, injection room and dressing room) is presented in Table EO-8. It shows that, overall, all the patients felt that the OPD facilities are clean and almost none of the patients said that the facility is not clean. Compared to IPD patients, less number of OPD patients expressed their dissatisfaction regarding the cleanliness. Only one patient each expressed some dissatisfaction with services in the injection room and laboratory at the DH and one with the services of OPD in PHC. It appears that, cleanliness is an issue for IPD patients rather than for OPD patients. Because IPD patients stay longer in the hospital and expect a cleaner environment whereas, OPD patients visit only for a shorter period and may not be concerned about the cleanliness of the OPD area.

Crowding in the OPD Areas As in case of cleanliness, very little dissatisfaction exists for crowding/inadequacy of space in the OPD facilities (OPD Room, Examination Room, Dispensary, laboratory, Injection Room and dressing Room) of the hospitals. Hardly, 5 percent patients expressed dissatisfaction for crowding/inadequacy of space in the OPD Room and this dissatisfaction was expressed at the PHC level (5 percent).

143 Continuity of Treatment Table EO-10 shows that, overall, 30 percent of the patients are ‘satisfied’ with their visit to the facility, 66 percent ‘somewhat satisfied’ and 4 percent is dissatisfied. Two patients (DH: 1; PHC: 1) expressed dissatisfaction with their health facility due to bad experience with the doctor. Satisfaction by type of hospital shows that while all the patients from CHCs are ‘satisfied’ with their visit, at the DH and PHC there is some dissatisfaction with services. Eighty eight percent patients said that they would come again to the facility, in case they fell sick 10 percent were not sure and only 2 percent said they would not visit the facility. Although patients at the CHC were satisfied with services, 21 percent said that they were not sure that they would visit the health facility again. One patient each at the DH and PHC expressed that they were not sure of visiting the health facility once again. Overall, surprisingly all the patients said that they would recommend the hospital to others.

Observations/remarks of the Observer: • No OPD services were being provided at PHC Kothi in the presence of the study team therefore no OPD exit interviews were conducted at this PHC.

• During OPD timings Kothi PHC was found closed.

• In PHC Benibari OPD timings are reduced by two hours because of the MO’s private practice.

144 OPD Facilities

Table EO1: Background characteristics of the patients Background Characteristics of the Out-Patients Percent Age < 20 years 18.0 20-29 years 32.0 30-39 years 16.0 40-49 years 10.0 50-59 years 14.0 60 years or more 10.0 Sex Male 46.0 Female 54.0 Marital Status Unmarried 18.0 Currently Married 78.0 Divorced/Separated 0 Widowed 4.0 Residence Rural 68.0 Urban 32.0 Type of Health Facility District Hospital 30.0 CHC 28.0 PHC 42.0 Total out-patients interviewed 50

Table EO 2: Purpose of visit to the Health Institution Purpose of visit in the Health Type of Health Facility (Percent) Institution DH CHC PHC All Minor Illness 86.7 35.7 66.7 64.0 FP Services - - - - Antenatal Care 6.7 7.1 - 4.0 PNC - 7.1 9.5 6.0 Eye Check-up MDT-DOTs - 7.1 - 2.0 Child Illness - 7.1 4.8 4.0 Other - 28.6 19.0 16.0 6.7 7.1 - 4.0 Total out-patients interviewed 15 14 21 50

145 Table EO 3: Waiting time (in minutes) for services by type of facility No. of patients Average waiting Average waiting time for availed the service time (in minutes) A. District Hospital Registration 15 8.3 Doctor’s examination 15 8.2 Injection 07 5.7 Getting medicines 15 5.1 Dressing 0 0 Paying bill 13 4.6 Total time taken for OPD services * 31.9 B. CHC Registration 14 6.5 Doctor’s examination 14 8.1 Injection 7 8.1 Getting medicines 13 10.4 Dressing 0 0 Paying bill 10 2.4 Total time taken for OPD services * 35.5 C PHC Registration 21 3.9 Doctor’s examination 21 10.8 Injection 12 7.9 Getting medicines 20 5.4 Dressing 2 25.0 Paying bill 20 2.4 Total time taken for OPD services * 55.4 D. ALL Registration 50 5.9 Doctor’s examination 50 9.3 Injection 26 7.4 Getting medicines 48 6.6 Dressing 2 25.0 Paying bill 43 3.0 Total time taken for OPD services * 57.5

146 Table EO 4: Satisfaction regarding waiting time No. of Satisfaction (% of patients) patients Too Long Appropriate Too Short Can’t Waiting time for availed the Say service A- District Registration 15 - 86.7 13.3 - Doctor’s 15 - 80.0 20.0 - examination Injection 7 - 85.7 - 14.3 Getting medicines 15 - 86.7 13.3 - Dressing 0 - - - 100.0 Paying bill 7 - 76.9 15.4 7.7 B -CHC Registration 14 7.1 78.6 14.3 - Doctor’s 14 7.1 85.7 7.1 - examination Injection 7 14.3 71.4 - 14.3 Getting medicines 13 23.1 53.8 23.1 - Dressing 0 - - - - Paying bill 13 - 100.0 - - C-PHC Registration 21 - 81.0 19.0 - Doctor’s 21 10.0 70.0 20.0 - examination Injection 12 16.7 58.3 16.7 8.3 Getting medicines 20 - 71.4 28.6 - Dressing 2 50.0 50.0 - Paying bill 20 - 100.0 14.3 - D-ALL Registration 50 2.0 82.0 16.0 - Doctor’s 50 6.1 77.6 16.3 - examination Injection 26 11.5 69.2 7.7 11.5 Getting medicines 48 6.1 77.6 16.3 - Dressing 2 50.0 50.0 - - Paying bill 43 - 93.0 4.7 2.3

147 Table EO 5: Behaviour of Staff Type of Health Facility (Percent) Staff Behaviour DH CHC PHC All Doctor greet in a friendly manner Not friendly 6.7 7.1 4.8 6.0 Yes, somewhat 33.3 59.1 33.3 40.0 Yes 60.0 35.7 61.9 54.0 Did not interact / Not applicable - - - - Behaviour of Doctor Rude - - 4.8 2.0 Reasonable - 28.6 - 18.0 Good 93.3 71.4 - 76.0 Very kind 6.7 - 4.0 Did not interact / Not applicable - - - - Behaviour of Nursing Staff Rude - - - - Reasonable 20.0 15.4 28.6 22.4 Good 66.7 30.8 66.7 57.1 Very kind 6.7 7.7 - 4.1 Did not interact / Not applicable 6.7 46.2 4.8 16.3 Behaviour of Dispenser Rude - - - - Reasonable 26.7 28.5 23.8 26.5 Good 66.7 71.5 61.5 65.3 Very kind 6.7 - 14.3 8.2 Did not interact / Not applicable - - - - Behaviour of Technician Rude - - - - Reasonable 7.1 - 4.8 5.3 Good 21.4 7.2 14.3 15.8 Very kind 7.1 - 9.5 5.3 Did not interact / Not applicable 64.3 92.8 71.4 73.7 Total out-patients interviewed 15 14 21 50

Table EO 6: Privacy

Type of Health Facility (Percent) Privacy DH CHC PHC All Patients reporting presence of privacy at 64.3 64.3 95.2 77.6 the place of examination

Total out-patients interviewed 15 14 21 50

148 Table EO 7: Patient-Doctor/Provider Communication Type of Health Facility (Percent) Patient-Doctor Communication DH CHC PHC All Doctor listened to description of ailment patiently Yes, somewhat 6.7 21.4 33.3 22.0 Yes, always 93.3 71.4 61.9 74.0 No - 7.1 4.8 4.0 Doctor allowed to ask questions Yes, somewhat 6.7 14.3 28.6 18.0 Yes, always 86.7 50.0 57.1 64.0 No 6.7 35.7 14.3 18.0 Doctor responded to questions Yes, somewhat 33.3 21.4 19.0 24.0 Yes, always 66.7 50.0 61.9 60.0 No - 28.6 19.0 16.0 Doctor discussed about the ailment Yes 100.0 85.7 90.5 92.0 No - 14.3 9.5 8.0 Doctor talked about the recovery Yes 93.3 57.1 57.1 68.0 No 6.7 42.9 42.9 32.0 Doctor gave ‘other advice’ Yes 80.0 42.9 38.1 52.0 No 20.0 57.1 61.9 48.0 Total out-patients interviewed 15 14 21 50

149 Table EO 8: Satisfaction of OPD patients regarding cleanliness of the facility No. of Satisfaction regarding patients Partially Not Clean Clean availed the Clean service A. District Hospital OPD Room 15 - 33.3 66.7 Examination Room 15 - 33.3 66.7 Dispensary 15 - 33.3 66.7 Laboratory 1 - 100.0 - Injection Room 5 - 20.0 80.0 Dressing Room 0 - - - B.CHC OPD Room 14 57.1 42.9 Examination Room 14 - 14.3 85.7 Dispensary 14 - 64.3 35.7 Laboratory 1 - - 100.0 Injection Room 6 - 66.7 33.3 Dressing Room 2 - - 100.0

C. PHC OPD Room 21 - 23.8 76.2 Examination Room 21 - 15.0 81.0 Dispensary 21 - 33.3 66.7 Laboratory 2 - 100.0 - Injection Room 15 - 13.3 86.7 Dressing Room 6 - 33.3 66.7 D. All OPD Room 50 - 36.0 64.0 Examination Room 50 - 22.0 78.0 Dispensary 50 - 42.0 58.0 Laboratory 4 - 75.0 25.0 Injection Room 36 - 44.4 55.5 Dressing Room 8 - 25.0 75.0

150 Table EO 9: Satisfaction of OPD patients regarding crowding in the facility No. of Crowding (% of patients) patients Satisfaction regarding Not Somewhat availed the Adequate Adequate Adequate service A. District Hospital OPD Room 15 - 13.3 86.7 Examination Room 15 - 33.3 66.7 Dispensary 15 - 26.7 73.3 Laboratory 1 - - 100.0 Injection Room 5 - 40.0 60.0 Dressing Room 0 - - - B. CHC OPD Room 14 - 57.1 42.9 Examination Room 14 - 7.1 92.9 Dispensary 14 - 64.3 35.7 Laboratory 1 - - 100.0 Injection Room 6 - 50.0 50.0 Dressing Room 2 - - 100.0 C. PHC OPD Room 21 4.8 28.6 66.7 Examination Room 21 - 9.5 90.5 Dispensary 21 - 42.9 57.1 Laboratory 2 - - 100.0 Injection Room 15 - 20.0 80.0 Dressing Room 6 - - 100.0 D. All OPD Room 50 - 32.0 68.0 Examination Room 50 16.0 84.0 Dispensary 50 - 44.0 66.0 Laboratory 4 - - 100.0 Injection Room 26 - 30.8 69.2 Dressing Room 8 - - 100.0

151 Table EO10: Continuity of treatment Type of Health Facility (Percent) Continuity of treatment DH CHC PHC All Satisfaction with the visit to the health facility Dissatisfied 6.7 - 4.8 4.0 Somewhat satisfied 46.7 85.7 66.7 66.0 Satisfied 46.7 14.3 28.6 30.0 Reason for dissatisfaction, if dissatisfied Lack of facilities - - - - Bad experience with the Doctor 100.0 - 100.0 100.0 Poor quality of services - - - - Charges are exorbitant - - - - Other - - - -

Visit again to the facility (if fell sick) Yes 93.3 78.6 90.5 88.0 No - - 4.8 2.0 May come/unsure 6.7 21.4 4.8 10.0 Recommend this hospital to others Yes 100.0 100.0 100.0 100.0 No - - - - Total out-patients interviewed 15 14 21 50

152 SCHEDULE (D): DISTRICT SCHEDULE The interviewer is expected to interact with District NRHM society (Part A) member for collection of district level information and follow this up with a visit to the district hospital (Part B)

Part A

Block A. Identification Details (Information to be collected from District NRHM Society) Q. No. Questions D101. Name of the District Anuppur D102. Total Number of Blocks in the District 4 D103. Total Number of Census Villages (2001 census) in 561 the District D104. Name of the Respondent Dr. D. K. Kori D105. Designation of the Respondent Chief Medical and Health Officer

Block B. Population of the District (As on 2001 as per Population Census) (I) Rural Urban Total Q. No. Category Male Female Male Female Male Female D106. Scheduled Caste 14736 20934 10033 9172 24769 30106 D107. Scheduled Tribe 136469 147641 18386 17633 154855 165274

D108. Others 86828 124859 74472 65656 161300 190515 D109. Total 238033 293434 102891 92461 340924 385895

Block B. Population of the District (As on March, 2008) (Information to be collected from State Health (II) Department) Rural Urban Total Source Code (Population Projection – 1; Q. No. Category Male Female Male Female Male Female State Estimate – 2; Not Available- 3) D110. Scheduled Caste ------3 D111. Scheduled Tribe ------3 D112. Others ------3 D113. Total ------3 NA=not available

153 Block Infrastructure [Information to be collected from Chief Medical Officer (CMO) Office] C. Q. No. D114. Name of the Respondent Ravindra Dubey D115. Designation of the Respondent District Programme Manager Public Health Total New Total No. of Infrastructure Existing Buildings Number facilities (In Nos.) (As Under where IPHS where IPHS on 30.6.2008) Construction facility Upgradation (In Nos.) (As survey completed on 30.6.2008) completed (As on 30.6.2008) (As on 30.6.2008) D116. Sub Centre 174 50 0 0 D117. PHC 16 02 06 0 D118. 24x7 PHCs 05 0 05 0 D119. CHC 04 0 04 0 D120. First Referral Units 04* 2 04 0 (FRUs) (only designated) D121. Mobile medical units 04 D122. Sub Divisional Hospitals 0 0 0 0 D123. District Hospitals 1 0 1 0 D124. AYUSH 1 0 0 0 Private Health Infrastructure Total Existing (In Nos.) (As on 30.6.2008) D125. Hospitals (More than 30 bedded) 0 D126. Nursing Homes (Less than 30 bedded) 0 Facilities available in the district for delivery Facility Number of Facilities Total Operational Providing Providing With New Born existing in 24x7 BeMOC CeMOC Care Unit the District (Having Blood (As on Storage, 30.6.2008) Anesthetist and Gynecologist) D127. District Hospital 1 1 1 1* 0 D128. Sub Divisional - - - - - Hospital D129. CHC 4 4 4 0 0 D130. PHC 16 5 0 0 0 D131. Public Maternity 0 0 0 0 0 Homes

154 D132. Others Public 02 02 02 0 0 (ESI, Railways etc.) D133. Others Private ------D134. Private 0 0 0 0 0 accredited for JSY *Blood storage facilities is not fully functional

Block Human Resources Available in the District (Information to be collected from Chief Medical D. Officer (CMO) Office) Q. No. Category No. Regular in Contractual Total in Position sanctioned Position Recruits D135. Medical Officer 46 29 05 34 D136. Gynaecologist 05 02 01 03 D137. Anaesthetist 04 01 01 01 D138. Paediatrician 05 02 01 03 D139. Other Specialists 07 01 06 07 D140. Staff Nurses 57 34 05 39 D141. ANM 175 150 73 223

Block E. Rogi Kalyan Samities (RKS) Information to be collected from District Programme Management Unit (DPMU) Q. No. D142. Name of the Mr. Ravindra Dubey Respondent D143. Designation of the District Programme Manager Respondent Number of facilities having Rogi Kalyan Samities (RKS) Registered? Total functioning No. with Registered RKS D144. District Hospital 1 1 D145. Sub Divisional Hospital -- -- D146. CHC 4 4 D147. PHC 16 1

155 Block E. Rogi Kalyan Samities (RKS) Information to be collected from District Programme Management Unit (DPMU) Q. No. Block F. Janani Suraksha Yojana(JSY) (Information to be collected from District Programme Management Unit (DPMU)) Q. No. Response Category Skip D148. Whether any PPP Yes………………….1 initiative being No………………….2 > Q D151 undertaken in the district for the implementation of JSY Scheme? D149. If yes, number of private health facilities accredited for JSY scheme D150. Which of the following Lab services…………….…A areas are covered under Diagnostics like Ultrasound & PPP initiatives (Encircle X-Rays………………….…..B all applicable options) Bio Medical waste Disposal..C

Sanitation……………..……D Security……………………..E Hiring of specialist services….F Procurement of Drugs/ Equipment…………………...G Providing transportation facility for delivery & referral cases....H Other...... I Q. No. Total Total number of Out of total Institutional Registered JSY number of Deliveries Women during Registered JSY Reported 2007-08 Women, number of during 2007- women opting for 08 Institutional Delivery during 2007-08 At Govt. Facilities D151. Scheduled Caste -- -- NA

156 Block E. Rogi Kalyan Samities (RKS) Information to be collected from District Programme Management Unit (DPMU) Q. No. D152. Scheduled Tribe -- -- NA D153. General -- -- NA D154. APL -- -- NA D155. BPL -- -- NA D156. Total 12018 11262 11262 At Private Total Total number of Out of total number Facilities Institutional Registered JSY of Registered JSY (Wherever Deliveries Women during Women, number of accredited for Reported 2007-08 women opting for services) during 2007- Institutional 08 Delivery during 2007-08 D157. Scheduled Caste NA* NA NA D158. Scheduled Tribe NA NA NA D159. General NA NA NA D160. APL NA NA NA D161. BPL NA NA NA D162. Total NA NA NA NA=not available as the private health facilities are non existent and not accredited

Block G. Financial Mechanisms (Information to be collected from Finance Manager in District Programme Management Unit (DPMU)) Q. No. D163. Name of the Respondent Ravindra Dubey D164. Designation of the Respondent DPM Response Category Skip D165. Have all the vertical health Yes………………….1 societies created under different No………………….2 >Q programmes merged in to a District D168 Health Society? D166. Whether the merged district health Yes………………….1 society is registered? No…………………..2

157 D167. Is there a common bank account for Yes………………….1 all programmes in District Health No………………….2 Society D168. Whether the district has prepared Yes………………….1 District Action Plan for the current No………………….2 >Q year? D170 D169. If yes, has the plan been approved Yes………………….1 by the district society? No………………….2 D170. How are the funds being received Activity wise…….……………A from the State in the district As flexi pool funds……..……..B (Encircle all applicable options) Based on a set formula like size of district etc…………….………C Based on previous year’s expenditure …………………....D Based on Annual Action Plan ...E Others (pl Specify) ……………F Not aware...... G D171. Are the funds received were Yes………………….1 transferred electronically by the No………………….2 State D172. How many Sub Centres have Operational Joint Bank Account of 166 ANM and Sarpanch? No. of centres for which Untied Grant for the current year 166 transferred? D173. CHC 04 D174. PHC 16 D175. Sub Centre 166

158

Part B District Hospital The infrastructure details to be supported by digital photographs of the facility and other areas like operation Theater, wards, pharmacy, lab etc

Block A. Identification Details (Information to be collected from the Office Of Medical Superintendent of the Hospital) Q. No. Questions (for both Male/Female) D176. Name of District Hospital District Hospital Anuppur D177. Name of the Respondent Dr. D178. Designation of the Respondent Civil Surgeon Distance & Time Taken to travel to District Hospital in Distance (in Time (in public transport from Kms.) Hrs.) D179. Nearest CHC in the coverage area 00 00 D180. Farthest CHC in the coverage area 39 1.00 D181. Distance of District Hospital from the nearest bus stop (in < 0.5 Km.………….1 Kms.) 0.5 – 1 Km…………2 >1 Km...... 3 D182. Has the IPHS facility survey been carried out in the District Yes………………1 Hospital No………………….2

Block B. Physical Infrastructure (Information to be collected from the Office Of Medical Superintendant of the Hospital and supplemented by observation)

Q. No. Questions Response Category D183. Area of the Hospital (in Sq. mtrs.) 8369 Sq mtrs D184. Number of indoor beds available 33 beds Yes……………….1 D185. Is the hospital located near residential area? No……………….2 D186. Is necessary environmental clearance obtained from Yes……………….1 Pollution Control Board by the Hospital? No……………….2 D187. Whether hospital building is disable friendly as per Yes……………….1 provisions of Disability Act? (Ramp, Lift, wheel chair No……………….2 movement etc.)

159 Administrative/ Main Block (Availability of following)

D188. Waiting Space adjacent to each consultation and Yes- in all ……….1 treatment room No……………….2 Yes – in some……3 Yes……………….1 D189. Registration Counter No……………….2 Yes……………….1 D190. Blood Bank/ Blood storage Unit No……………….2 Yes……………….1 D191. Doctors' Duty Room No……………….2 Yes……………….1 D192. Isolation Room No……………….2 Yes……………….1 D193. Treatment Room No……………….2 Yes……………….1 D194. Pharmacy (Dispensary) No……………….2 Yes……………….1 D195. Intensive Care Unit (ICU) No……………….2 Yes……………….1 D196. High Dependency Wards No……………….2 D197. Yes……………….1 Critical Care Area (Emergency Services) No……………….2

Yes……………….1 D198. Examination and Preparation Room No……………….2

Hospital Services Yes……………….1 D199. Hospital Kitchen (Dietary Service) No……………….2

Yes……………….1 D200. Central Sterile and Supply Department (CSSD) No……………….2

Yes……………….1 D201. Hospital Laundry No……………….2 Yes……………….1 D202. Medical and General Stores No……………….2 Yes……………….1 D203. Engineering Services Backup No……………….2 Ventilation (Natural or mechanical exhaust) in the Yes……………….1 Wards No………………..2 D204.

160 Water coolers / Refrigerators Yes……………….1 D205. No………………..2 Yes……………….1 D206. Round the clock water supply No……………….2 Overhead water storage tank with Pumping and Yes……………….1 D207. boosting arrangements No……………….2

Yes……………….1 D208. Provision for fire fighting No……………….2 Proper drainage and sanitation system for waste Yes……………….1 D209. water, surface water, sub soil water and sewerage No……………….2 Buried……….…….A Incernation………….B How is the Bio Medical Waste disposed? (Encircle D210. Outsourced to agency all applicable options) ……………………C Thrown in open…….D Is Bio Medical Waste segregated in three different Yes……………….1 D211. bins? No……………….2

Number of Residential Quarters available for all No. No.

medical and Para medical staff Available Occupied D212. Medical Staff 4 3 D213. Para medical staff 8 4 Yes……………….1 D214. Parking place No……………….2

Yes……………….1 D215. Medical Records Section No……………….2

Yes……………….1 Is the disease classification being carried out as per D216. No……………….2 protocols

Yes……………….1 D217. Availability of telephone No……………….2 Yes……………….1 D218. Availability of Fax equipment No……………….2 Yes……………….1 D219. Availability of Computers No……………….2 Yes……………….1 D220. Availability of Internet services No……………….2

161

Obstetrics & Gynae Section (Information to be collected from the Sister In charge of Gynae ward & supplemented by Observation from records) D221. Name of the Respondent Smt. Marlynn Thomas D222. Designation of the Respondent Staff Nurse Response Category Skip D223. Is there a separate Ward for Female Yes………………….1 Patients? No………………….2 >Q D226 D224. If Yes, the number of beds D225. Bed Occupancy Rate in the last 12 months (As on March 31, 2008) D226. Total OPD in last 3 calendar months 410 D227. Total deliveries in last 3 calendar 894 months D228. Is there a separate OT available for Yes…………………..1 Gynaecology & Obstetrics No…………………..2 Procedures Carried Out Particulars Availability of Services If Yes, Numbers in 2007-2008 2906 D229. Total deliveries conducted Yes………………….1 D230. Caesarean section deliveries No…………………..2 If yes, no. done in

2007-08 Yes………………….1 0 D231. Caesarean section for JSY No…………………..2 Yes………………….1 3 D232. Assisted Delivery No…………………..2 Yes………………….1 2 D233. Forceps delivery No…………………..2 Yes………………….1 7 D234. MTP No…………………..2 Yes………………….1 D235. Mid trimester Abortion No…………………..2 55 Yes………………….1 D236. Ectopic Pregnancy No…………………..2 Yes………………….1 D237. Retained Placenta No…………………..2

162 Yes………………….1 D238. Eclampsia No…………………..2 Yes………………….1 D239. PPH No…………………..2 Yes………………….1 D240. Sterlisation No…………………..2 Yes………………….1 D241. Suturing Cervical Tear No…………………..2 Yes………………….1 D242. Hysterectomy No…………………..2 Yes………………….1 D243. Infertility Treatment No…………………..2

Surgical Section (Information to be collected from the Sister In charge of Surgical ward & supplemented by Observation)

D244. Name of the Respondent D245. Designation of the Respondent No. of Surgical OPD in last three months 735

D246. Female 297 D247. Male 438 No. of Surgical IPD in last three months 1483 D248. Female 1416 D249. Male 67

Availability of Services Response Category If Yes, Numbers in last 3 months D 250 Emergency (Accident & other emergency) Yes………………….1 1620 (Casualty) No…………………..2 D250. Yes………………….1 Pancreas Surgery No…………………..2 D251. Yes………………….1 Spleen and Portal Hypertension Surgery No…………………..2 D252. Yes………………….1 Abdomen Surgery No…………………..2 D253. Yes………………….1 Breast Surgery No…………………..2 D254. Yes………………….1 Leprosy Reconstructive surgery No…………………..2

163

Medical Section (Information to be collected from the Sister In charge of Medical ward & supplemented by Observation) D255. Name of the Respondent Smt Seema Samuel D256. Designation of the Respondent Staff Nurse Medical OPD in last three months 12458 D257. Female 6096 D258. Male 6362 Medical IPD in last three months 692 D259. Female 258 D260. Male 434 Availability of Services Response Category If Yes, Numbers in last 3 months Dermatology and Venerology (Skin & Yes………………….1 330 D261. VD) RTI / STI No…………………..2 D262. Yes………………….1 272 Services under NLEP No…………………..2 D263. Yes………………….1 5 Pleural Aspiration No…………………..2 D264. Yes………………….1 Pleural Biopsy No…………………..2 D265. Yes………………….1 Bronchoscopy No…………………..2 D266. Yes………………….1 Nos. NA Lumbar Puncture No…………………..2 D267. Yes………………….1 Pericardial tapping No…………………..2 D268. Yes………………….1 Skin scraping for fungus / AFB No…………………..2 D269. Yes………………….1 Bone Marrow Biopsy No…………………..2 D270. Yes………………….1 Endoscopic Specialised Procedures No…………………..2 D271. Yes………………….1 Psychiatry Services No…………………..2

164

Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) D272. Name of the Respondent Dr. Sonvani D273. Designation of the Respondent Pediatrician Pediatric OPD in 2007-2008 Numbers D274. Female 467 D275. Male 533 D276. Designated/identified Beds for Yes ------1

newborns available? No ------2 >Q D279 D277. If yes, no. of beds Pediatric Patients admitted in Numbers 2007-2008

D278. Total Admitted NA D279. Neonates admitted NA D280. Other Infants (0-1 years) NA admitted

D281. Children under 5 yrs admitted NA Services Available

D282. Asphyxia Management Yes………………….1 No…………………..2 D283. Management of severe Yes………………….1 malnourished children No…………………..2 D284. Yes………………….1 Management of Neo Natal Sepsis No…………………..2 D285. Management of Dehydration and Yes………………….1 Diarrhoeal Cases No…………………..2 D286. Yes………………….1 Management of Respiratory Tract No…………………..2 / Pnuemonia Cases

165 Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation) Available? If available, whether Equipment Available working? D287. Yes………………….1 Yes………………….1 Cradle No…………………..2 No…………………..2 D288. Yes………………….1 Yes………………….1 Incubator No…………………..2 No…………………..2 D289. Yes………………….1 Yes………………….1 Radiant Heat Warmer No…………………..2 No…………………..2 D290. Yes………………….1 Yes………………….1 Phototherapy Unit No…………………..2 No…………………..2 D291. Yes………………….1 Bag with Mask No…………………..2 D292. Yes………………….1 Yes………………….1 Laryngoscope No…………………..2 No…………………..2 D293. Yes………………….1 Oxygen Mask No…………………..2 D294. Yes………………….1 Yes………………….1 Suction Machine No…………………..2 No…………………..2 D295. Yes………………….1 Yes………………….1 Thermometer No…………………..2 No…………………..2 Availability of drugs D296. Yes………………….1 ORS (WHO new formula) No…………………..2 D297. Yes………………….1 Vitamin A Solution No…………………..2 D298. Yes………………….1 Iron folic Acid Syrup No…………………..2 D299. Yes………………….1 Paediatric Antibiotics No…………………..2

166 Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation) D300. Name of the Respondent H.H. Kushwaha D301. Designation of the Respondent Radiographer Diagnostic OPD in last 3 months 297 D302. Female 103 D303. Male 194 Availability of services Response Category If Yes, Number carried out in last 3 months D304. X-Ray Yes………………….1 400 No…………………..2 D305. Yes………………….1 Ultrasound No…………………..2 D306. Yes………………….1 Ultrasound guided Biopsy No…………………..2 D307. Yes………………….1 6 ECG No…………………..2

Lab Services (Information to be collected from the Lab Technician & supplemented by Observation) D308. Name of the Respondent Kamlesh Kr. Patel D309. Designation of the Respondent Laboratory Technician Number attended in last 3 months 373 D310. Female 209 D311. Male 164 Availability of services Response Category If Yes, Number carried out in last 3 months CLINICAL PATHOLOGY D312. Yes………………….1 98 Haematology No…………………..2 D313. Yes………………….1 69 Urine Analysis No…………………..2

167 Lab Services (Information to be collected from the Lab Technician & supplemented by Observation) D314. Yes………………….1 0 Stool Analysis No…………………..2 D315. Semen Analysis (morphology, Yes………………….1 2 count) No…………………..2 D316. CSF Analysis (Cell count, culture Yes………………….1 sensitivity etc., gram staining) No…………………..2 D317. Aspirated fluids (cell count Yes………………….1 cytology) No…………………..2 PATHOLOGY D318. Yes………………….1 PAP smear No…………………..2 D319. Split Skin Smear Examination for Yes………………….1 leprosy No…………………..2 D320. Yes………………….1 141 Sputum No…………………..2 D321. Yes………………….1 Histopathology No…………………..2 D322. Microbiology Yes………………….1 No…………………..2 D323. Yes………………….1 10 Serology No…………………..2 D324. Biochemistry Yes………………….1 53 No…………………..2 D325. Physiology (Pulmonary function Yes………………….1 test) No…………………..2

Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D326. Name of the Respondent D327. Designation of the Respondent Category of Personnel Sanctioned Regular Contractual Total In Position In Position D328. Hospital Superintendent 1 0 0 0

168 Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D329. Medical Specialist 1 1 0 1 D330. Surgery Specialist 1 0 0 0 D331. Gynaecologist 1 1 0 1 D332. Gynaecologist (short term trained 1 1 0 1 MO) D333. Pediatrician 1 1 0 1 D334. Anesthetist 1 1 0 1 D335. Anesthetist (short term trained 0 0 0 0 MO) D336. Radiologist 1 0 0 0 D337. General Duty Doctor 9 6 0 6 D338. Public Health Manager 0 0 0 0 D339. AYUSH Physician 0 0 0 0 D340. Pathologists 1 0 0 0 D341. Psychiatrist 0 0 0 0 D342. Dermatologist / Venereologist 0 0 0 0 D343. ENT Surgeon 0 0 0 0 D344. Ophthalmologist 1 1 0 1 D345. Orthopaedician 1 0 0 0 D346. Microbiologist 0 0 0 0 D347. Dental Surgeon* 1 0 1 1 Para-Medicals D348. Staff Nurse 20 15 0 15 D349. Hospital worker (OP/ward +OT+ 1 0 0 0 blood bank) D350. Sanitary Worker 18 5 0 5 Category of Personnel Sanctioned Regular Contractual Total In Position In Position D351. Ophthalmic Assistant / 1 1 0 1 Refractionist D352. Social Worker / Counselor 2 0 2 2 D353. ECG Technician 0 0 0 0 D354. Audiometrician 0 0 0 0

169 Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical Superintendent of the Hospital) D355. Laboratory Technician ( Lab + 3 2 0 2 Blood Bank) D356. Laboratory Attendant (Hospital 2 0 0 0 Worker) D357. Dietician 1 0 1 1 D358. ANM 0 0 0 0 D359. LHV 0 0 0 0 D360. PHN 1 0 0 0 D361. Radiographer 1 1 0 1 D362. Pharmacist 4 1 0 1 D363. Matron 1 0 0 0 D364. Physiotherapist 1 0 0 0 D365. Medical Records Officer / 0 0 0 0 Technician Administrative Staff

D366. Manager (Administration) 1 0 0 0 D367. Junior Administrative Officer 0 0 0 0 D368. Office Superintendent 0 0 0 0 D369. Accounts Manager 0 0 0 0 D370. Driver 1 1 0 1 D371. Peon 2 2 0 2

Block D. Other Framework and Structure Related Issues (Information to be collected from the Office of Medical Superintendent of the Hospital) Response Category Skip D372. Whether the Rogi Kalyan Samiti Yes………………….1 established for the Hospital No…………………..2 >Q D382 D373. If Yes, whether Rogi Kalyan Yes………………….1 Samiti Registered for the No…………………..2 Hospital? D374. Are there any official charges for Yes………………….1 consultation/ procedures? No…………………..2 >Q D378 D375. If yes, are people belonging to BPL/ Yes………………….1 SC/ ST exempted/ subsidized? No…………………..2 >Q D378

170 Block D. Other Framework and Structure Related Issues (Information to be collected from the Office of Medical Superintendent of the Hospital) D376. If yes, what is the procedure for Based on BPL Ration granting exemption (Encircle all Card……………………A applicable options) Based on Certification by hospital authorities/ Govt.…………………...B Based on recommendation of RKS…………………C Based on Financial compensation by RKS……………….……D Others (please specify)……………….… E D377. How do RKS generate additional Donation…………….……A resources other than govt. grants? User (Encircle all applicable options) fees…………..……..B Other innovative means (through arrangements like PPP, outsourcing of services etc.)………………………C D378. How is the money generated used? Retained within the facility (Encircle all applicable options) for local use……..……..…A Retained but not used….....B Transferred to district Accounts………….…….C Other …………….……..D D379. Is display board put up in Hospital Yes………………….1 showing number of members, number of meetings of RKS etc? No…………………..2 D380. How feedback is taken for grievance Social Audit………..……..1 Public Scrutiny of action redressal by RKS? taken ……………..………..2 No feedback mechanism .....3 Others (please specify)…....4

D381. Any Other Special Ward/ Procedures not covered above

Observations presented at the end of chapter-2 ______

171 ______D382. Any other remarks by MS of the hospital/ Other members which have not been captured in the questions above but are relevant

Observations presented at the end of chapter-2 ______D383. Any other remarks or suggestions for improvement of services by Observer which have not been captured in the questions above but are relevant

Observations presented at the end of chapter-2 ______If the patient has availed service either in (OPD or IPD) the observer to go to Exit Interview Schedule D D M M Y Y 2 5 0 2 0 9 Dr. Reena Basu

172

Appendix - 2 Scores given for the computation of Standard of Living Index Variables Categories Categories Scores Type of house Pucca 4 Semi Pucca 2 Kachcha 0 Ownership of house Yes 2 No 0 Separate Kitchen Yes 1 No 0 Toilet facility Separate toilet Yes 2 No 0 Fuel for cooking LPG/Biogas for cooking Yes 2 No 0 Source of drinking water Water supply - piped Yes 2 No 0 Ownership of items Mattresses Yes 1 Pressure cooker Yes 1 Chair Yes 1 Cot/Bed Yes 1 Table Yes 1 Clock/ Watch Yes 1 Electricity Yes 2 Sofa set Yes 2 Fan Yes 2 Radio/Transistor Yes 2 Television (Black & White) Yes 2 Sewing Machine Yes 2 Telephone (Other than Yes 2 mobile) Bicycle Yes 2 An Animal Drawn Cart Yes 2 Water pump Yes 2 Thresher Yes 2 Television (Colour) Yes 3 Telephone (mobile) Yes 3 Computer Yes 3 Motor Cycle/Scooter Yes 3 Refrigerator Yes 3 Washing Machine Yes 3 Car/Van/Jeep Yes 4 Tractor Yes 4 Ownership of agricultural land 5 acres or more 4 2 - 4.9 acres 3 < 2 acres/Not known 2 No agricultural land 0 Ownership of irrigated land At least some irrigated 2 land No irrigated land 0 Total (Maximum) 78

SLI (Standard of Living Index) Score Low 0 – 14 Medium 15 – 24 High 25 - 78

173