SUPPORTIVE SUPERVISION REPORT DISTRICT –

DR. SHIVANGI VATS CONSULTANT NRHM- I

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DISTRICT SATNA, M.P

Executive Summary: NRHM has initiated Action oriented monitoring and provide Supportive Supervision to High Focus Districts of that will reflect in the DHA Plan of a District and to help improve the NRHM indicators of a district and bring about the positive changes so as to achieve the set targets within a committed timeframe. A visit was planned for the same purpose to District Satna, in M.P, identified as High Focus District. The District Satna is situated in mid northern part of Commissioner's Division in Madhya Pradesh state of India. The districts take its name from Satna, the head quarters town, which in its turn takes it from Satna Rewa which flows near the town. In the north, the district boundary marches with that of Banda District of state. Eastern boundary of the district runs with the Teonther, Sirmour and Huzur tehsils of and very small portions of District. The entire western boundary of the district is made by while the southern boundary touches the district in the west and Umaria and on the east. During the field visits, District Hospital (Satna), Civil Hospital (Maiher), 1 Community Health Centre (), 2 Primary Health Centres ( Singhpur & Sohawal), 4 Sub-Centres ( Tighara Kalan, Sitpura, Singhpur & Karahaiya) were visited.

Key Observations & Findings:

 Implementation processes needs to be strengthened from the state level.  Construction of wards should be completed on priority basis and handed over within a set timeline. Proper Monitoring should be done in this regard.  The main areas of concern for ANMs and ASHAs are lack of support from community members. Community education and participation needs to be strengthened in a district. For this a proper Monitoring mechanism and capacity building is needed.  IEC Component should be strengthened further in Satna, messages should be conveyed in a pictorial form than in a textual communication, to make it easy for illiterate communities.  Serious attempts from State to bridge the gaps in HR availability have been made. There is a need to recruit CEmONC trained personnel considering the patient load in the district hospital.  Lakshaya Prapti register for monitoring the Family Planning procedures were missing. Proper Monitoring needs to be strengthened in Satna.  The training sessions should be more frequent for BMOs and BPMs for strengthening of facilities and better functioning.  Selection process for ASHAs needs to be strengthened. Many highly educated ASHAs can be trained for higher level of capacity building. ASHA Monitoring

system should be established in Satna.

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 Nutrition Rehabilitation Centers are established for undernourished children in district. Proper records are maintained of children, Nutritional nurses are well versed with their responsibilities.  There is a lack of basic amenities like safe drinking water in Nutrition Rehabilitation Centre. There is a scarcity of water for the disposal of human waste enhancing the risks of infection. Water Tanks should be established for adequate storage of water.  Better Quality of food should be provided to the mother of children in Nutrition Rehabilitation Centre. Regular Monitoring should be incorporated.  The participation of village health committees is poor, which is reflected by the scanty utilization of funds, deficient understanding of role clarity and responsibilities.  Intensified implementation and monitoring of DOTS Program is needed to decrease the prevalence and incidence rate of TB in Satna. Community participation and education should be strengthened. IEC messages in pictorial form can play a major role in this regard.  District Hospital’s RKS faces resistance from Community for fund raising activities, media influence is high which hype such issues. Community should be educated about the role, responsibility and existence of RKS. Public display of utilization of RKS fund can help in better understanding of RKS by community.  The management committee of Satna’s DH is doing a commendable job in the minimal resources available to them.  The whole caesarian section load is managed by one specialist. She is providing services to the population of 22.5 lakh of Satna and also to the neighboring districts like Panna, Umaria, Banda etc.  The SNCU of Satna is state of the art and can be a model for other districts.  The SEWA SANKALP, a kitchen outsourced by RKS of DH to a group of businessmen for food to patient’s attendants is an innovative model which can be replicable by other districts.

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CONTENTS :

S.NO. CONTENTS PAGE NO. 1. Cover Page 1 2. Executive Summary 2 3. List of Contents 4 4. List of Abbreviations 5 5. Background 8 6. Objectives of the Visit 8 7. Scope of the Study 9 8. Study tools & Data Collection 11 9. District Profile 12 10. Functional Healthcare Facilities of the District 12 11. Mapping of Healthcare Facilities in a District 13 12. Gap Findings in a district 14 12.a. Key findings in regard to New Born Care & FP 14 12.b. Dearth Of Manpower 14 12.c. Training status 16 12.d. RCH Sub Plan 17 12.e. Disease Control Program 19 12.f. RKS Funds 20 12.g. Beneficiaries 21 12.h. VHSC 21 13. Key Findings of Inspected Healthcare Facilities 22 13.a. CHC- Nagod 22 13.b. CH- Maiher 26 13.c. DH- Satna 29 13.d. PHC- Singhpur 33 13.e. PHC- Sohawal 34 13.f. SC- Tighara Kalan 35 13.g. SC- Sitpura 36 13.h. SC- Karahaiya 37 14. Annexure – 1 15. Annexure – 2 16. Annexure - 3

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LIST OF ABBREVIATIONS

AMG Annual Maintenance Grants ASHA Accredited Social Health Activist AWW Anganwadi worker AYUSH Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homeopathy BEmONC Basic Emergency Obstetric & Neonatal Care BHW Basic health worker BPHC Block Primary Health Centre CEmONC Complicated Emergency Obstetric & Neonatal Care CH Civil Hospital CHC Community Health Centre DAM District Accounts Manager DH District Hospital DHA District Health Action Plans DGO Diploma in Gynecology & Obstetrics. DIO District Immunization Officer DPM District program manager DPMU District program management Unit EAG Empowered Action Group FP Family Planning FRU First Referral Unit HSC Health Sub Centre IFA Iron Folic Acid IMNCI Integrated Management of Neonates & Child Illness IMR Infant Mortality Rate IP In Patients IPD Inpatient Department IPHS Indian Public Health Standards JSK Jansankhya Sthirata Kosh JSY Janani Suraksha Yojana LBW Low Birth Weight LHV Lady Health Visitor MMR Maternal Mortality Ratio MMU Mobile Medical Unit MO Medical Officer MoHFW Ministry of Health and Family Welfare MPW Multipurpose Worker MTP Medical Termination of Pregnancy NFHS-3 National Family Health Survey -

3, 2005-06 NRC Nutritional Rehabilitation Centre 5

NRHM National Rural Health Mission Page

DISTRICT SATNA, M.P

NSV Non Scalpel Vasectomy OP Out Patients OPD Out Patient Department ORS Oral Re-hydration Solution OT Operation Theatre PHC Primary Health Centre PWD Public Works Department RCH Reproductive and Child Health RKS Rogi Kalyan Samiti RTI/STI Reproductive Tract Infection/ Sexually Transmitted infection SC Sub Centre SNCU Sick New Born Care Unit UF Untied Funds

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SUPPORTIVE SUPERVISION REPORT DISTRICT SATNA – MADHYA PRADESH

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BACKGROUND

The NRHM was launched in April 2005 with the objective of providing universal access to equitable, affordable and quality health care. The mission seeks to integrate different vertical health programmes, decentralize healthcare service delivery at the village level and improve intersectoral action. The poor in India have always lived in hope; the National Rural Health Mission has become a new hope for them. The mission aims to improve the access of rural people, especially poor women and children, to equitable, affordable, accountable and effective primary healthcare. The NRHM is expected to substantially reduce maternal and infant mortality and communicable diseases within the next five years. It is focused on 18 EAG states that have weak public health indicators, including the seven northeastern states, and 11 states in north and eastern India. Within a span of 5 years we have achieved a lot but still there are miles to go to attain our set targets and commitments. In order to fulfill our commitment to achieve the MDG’s within the set timeframe, 235 districts have been identified as high focus districts out of 642 from various EAG states where intensified monitoring is required to improve the various health deliverables. Ministry of Health & Family Welfare, Govt. of India under the guidance of Secretary H&FW has developed an action oriented monitoring plan and joint teams have been formed to visit the 122 districts for the monitoring in 1st Phase.

For the purpose of action oriented monitoring of these high focus districts , teams of consultants will be monitoring the high focused districts and visit health facilities like Sub-centres, PHCs and Block CHC and various service providers and stakeholders and beneficiaries to track their progress in terms of various parameters which will help to assist States in improving the measurable indicators and deliverables of RCH and NRHM flexipool components in order to bring the positive changes on NRHM indicators. To highlight the best practices and innovations that can be utilized as role models for other states.

A visit of 3 days to District Satna in state of Madhya Pradesh was planned for Action oriented Monitoring, as it is one of the High Focus districts out of 16 identified in Madhya Pradesh state in Phase-1.

OBJECTIVES OF THE VISIT :

Long Term Objective :

Objective of the study is to conduct action oriented monitoring and provide Supportive Supervision to Satna , district of State M.P, identified as High Focus District which will reflect in the DHA Plan of a District and to help improve the NRHM indicators of a district and bring about the positive changes so as to achieve the set targets within a committed timeframe.

Short Term Objectives :

 Assessment of various functional Healthcare Facilities in a District ( DH, CHCs, FRUs, PHCs, BPHCs, APHCs, HSCs )  To assess the Quality of healthcare services provided by these Institutions.

 To assess the standards they are following (as per IPHS Norms).

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 Identifying the Gaps at various levels in the functioning of Healthcare system within the District (matters related to Infrastructure, services, HR, finance, regular monitoring and evaluation etc.)  To assess the transparency and optimum utilization of UF, AMG, and JSY funds.  To assess other services like MMUs and Emergency Response Management services.  To assess the satisfaction level among various stakeholders through interaction with them and collecting the qualitative data.  To assess the functioning of RKS & VHSC.  To identify the best practices and the poor practices in a district.  To suggest innovations to be implemented in a district.

SCOPE OF THE STUDY :

The Study was conducted to do Action oriented Monitoring of identified High Focus Districts and provide Supportive Supervision so as to assist State in improving the NRHM indicators and achieve the targets in District by implementing and including the constructive suggestions provided by the team of consultants in District’s Health Action Plans for the forthcoming PIP and attain the set goals. Special Monitoring formats were developed by MOHFW for this purpose.

Assessment of healthcare facilities (as per the IPHS norms) such as DH, FRUs, CHCs, PHCs, APHCs, BPHCs and HSCs need to be covered along with the various other services namely MMUs and to ensure the transparency and authentic utilization of UF, AMGs & Funds under JSY (provided under Mission Flexipool) records needs to be checked. Proper Functioning of Autonomous bodies like RKS and VHSCs also needed to be inspected under this study. A Qualitative data was collected through interaction with other Stakeholders (like community members, ASHA, ANM, PRI Members, GKS and Beneficiaries) which was the main zest of the study to take the insights of proper functioning of the system within the district and any specific problems faced by them.

The Monitoring formats assess the Healthcare Facilities on various parameters and they were scored against several critical indicators to know the performance level and quality of healthcare provided by the facility. Parameters covered are :

PARAMETERS SCORING INDICATORS 1. Infrastructure  Building condition  Condition of wards  Water supply  Condition of toilets  Patient amenities  Furniture 2. Human Resources/Staff All types of clinical and Para-clinical staff having indicators of staff performance including :  Number of deliveries conducted per SBA ,Number of OP cases per doctor  Bed occupancy rate*  Number of CS per Obstetrician  Number of cataract operations per ophthalmologist  Chest symptomatic sputum population

examination rate

 Minor surgeries per doctor 9  IUD insertions per trained nurse

 MTP services per trained doctor Page

DISTRICT SATNA, M.P

3. Services Available  24 hour doctor available  24 hour nurse available  24 hour delivery services available  24 hour newborn care services available  24 hour caesarean services (if FRU) Tubectomy services available  Safe abortion services available  24 hour blood transfusion services Laboratory Services :  Availability of ECG Facility  X- Ray Facility available  Ultrasound services available  Adolescent sexual & reproductive health services  Functional telephone  Whether fixed day antenatal clinics are conducted 4. Services Outsources  House keeping  Generator  Food  Ambulance

5. Equipments & Supplies  Trolley  Wheelchair  Stretcher  Sterilized gloves  Number of OP Drugs  Life Saving Drugs 6. Equipments in Labor Room  Spot light in labor room  Vacuum extractor  Resuscitation equipment for newborn  Mucous sucker 7. Equipments in OT  Ceiling OT light  Oxygen cylinder  Suction Apparatus  Adequate quantity of linen  Boyles Apparatus 8. Bio-Medical Waste Management  Colour coded buckets  Deep burial pits  Needle cutter  No mix of infection & non-infectious waste  Waste bins not overfilled  Disposable gloves & masks 9. Central Sterilization Unit  Functioning Autoclave  Usage of signalac tape  Usage of biological indicator  Swab test of sterile packs 10. Records & Reports  Delivery register  Referral slips  Recording of major complications during pregnancy 11. Finance  RKS, JSY

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STUDY TOOLS & DATA COLLECTION :

 Monitoring Formats were developed by MOHFW for the purpose of these special visits which assess the Health Facilities on various Parameters and their performance was scored against the several verifiable Indicators. The Formats utilizes the combination of quantitative as well as the qualitative responses (questions were both- open ended & close ended) so as ensure the input on every aspect of the facility.  The data collected was of primary in nature, which was filled through the help of BMOs & MOs, and the scoring for indicators was done by physical assessment of the parameters. Records were checked for financial assessment of UF, AMG, and JSY.  Format (FORM-D) was common for Health Facilities like DH, CHCs , PHCs , APHCs and for assessment of HSC separate format (FORM- E) is used.  The approach to assess the satisfaction among various Stakeholders (Doctors, Staff Nurses, Paramedics, Housekeeping staff, ASHA, ANM, Beneficiaries, VHSC, GKS, and RKS) was based more on qualitative type through interaction and communicating through them to build the rapport so that they can address their areas of concerns and the matters affecting them.

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DISTRICT PROFILE

GEOGRAPHICAL PROFILE OF A DISTRICT :

The District of Satna is situated in mid northern part of Rewa Commissioner's Division in Madhya Pradesh state of India. The districts take its name from Satna, the head quarters town, which in its turn takes it from Satna Rewa which flows near the town. In the north, the district boundary marches with that of Banda District of Uttar Pradesh state. Eastern boundary of the district runs with the Teonther, Sirmour and Huzur tehsils of Rewa district and very small portions of . The entire western boundary of the district is made by Panna district while the southern boundary touches the in the west and Umaria and Shahdol district on the east.

DEMOGRAPHIC PROFILE OF A DISTRICT :

Year 1991 2001 Total Population 1465384 1870104 Percentage of M.P.’s Population 3.02 3.10 Sex Ration 918 925 Population Density 195 249 Total Literacy 44.65% 64.61% Male literacy 60.03 77.14 Female literacy 27.80 51.05 Population Growth rate 27.05 27.62 Sex Ration Among the 0-6 Children - 931 *** SOURCE – Census 1999, 2001.

FUNCTIONAL HEALTHCARE FACILITIES OF A DISTRICT :

INFRASTRUCTURE DETAILS DH CHC’s BPHC’ PHC’s APHC’s/ HSC s NPHC’s BLOCKS POPULATION 1. Nagod 249156 - 1 - 5 - 34 2. 233916 - 1 - 4 - 32 3. Unchehra 199092 - 1 - 3 - 31 4. Majhgawan 297819 - 1 - 9 - 38 5. Rampur Bagh. 290187 - 1 - 6 - 31 6. Kothi 238877 - 1 - 7 - 34 7. Deorajnagar 165968 - 1 - 3 - 24 8. 366465 - 1 - 3 - 34 9. SATNA, Urban 285317 1 - - - - - TOTAL ( in position) 1 9 - 40 - 258 TOTAL (Functional) 1 9 - 40 - 258 TOTAL (Functional providing delivery 1 9 - 15 - 01 services) ****A detailed functional healthcare facilities (block wise) are given in FORM-C attached in Annexure

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MAPPING OF HEALTHCARE FACILITIES IN A DISTRICT :

Apart from the maps available at the JSK site, the DPMU has developed their own detailed map of a district and has allocated all the current health care facilities in a district.

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GAP FINDINGS IN A DISTRICT :

KEY FINDINGS IN REGARD TO NEW BORN CARE AND FP :

Considering the huge population caters and average number of deliveries in a DH (150- 200 per day), a 20 bedded state of art SNCU has already been established in DH but since District has no FRU so there’s a need of establishing more number of SNCU’s. Many PHCs don’t have baby warmer units.

Also, people prefer for sterilization processes during camps and district already has 9 sterilization units, one key finding should be considered that no record of “LAKSHYA PRAPTI REGISTER” was found during visit at any of the HSC to monitor and record the FP successes.

DEARTH OF MANPOWER:

There is a huge gap in the availability of the Human Resource. Human Resource being a critical resource specially in terms of life saving skill like healthcare practices should not be neglected and the gaps should be bridged.

 Availability of mid- wives : There is a huge gap in the number of actually present staff nurses and the required numbers, and DH of Satna is representing this situation quite well.

Though in comparison to staff nurses, the situation is better with ANMs & LHVs.

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 Availability of other technical staff: Other Technical staff like Male Health workers, radiographers, lab technicians and pharmacist are there but there’s still a need to be recruited.

 Availability of medical specialists: Though data shows that there’s a need of only 1 gynecologist to be recruited but considering the patient load in DH at least 2 gynecologists needed there to be present 24*7 on rotatory shift. Pediatrician, Anaesthesist and MO also contribute to the shortfall of specialists in a district.

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TRAINING STATUS:

Updated knowledge and key skills are the main components of HR not only for professional growth but for personal too. Table below provides the details about the training status in district. It shows that only 12 % nurses and 8% ANMs are SBA trained and mostly deployed in HSC where no deliveries are conducted now, so there should be a proper distribution of the trained staff, they should be deployed in CHCs, DH, CH, PHCs where these skilled are required. Only 2 % doctors are trained on LSAS & 3 % on EmONC whereas 11 are trained in NSV.

S.NO. ACTIVITY/MEASURABLE INDICATOR 2009-2010 TARGET FOR 2010- 2011 1. % of ANMs trained as SBAs 8 4 Batch 2. % of Nurses trained as SBAs 12 4 Batch 3. No. of Doctors trained on EmONC 3 - 4. No. of Doctors trained on LSAS 2 - 5. No. of Doctors trained in NSV/ Conventional 11 - Vasectomy 6. No. of Doctors trained in Abdominal Tubectomy 3 - (Minilap) 7. No. of Doctors trained in Laparoscopic Tubectomy 3 - 8. No. of Personnel trained in FIMNCI - -

Graph below shows the status of ASHAs trained last year and to be trained this year for 4th Module.

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INEQUALITY IN HR :

Many ASHAs were overqualified for the post , some are B.Sc and even M.Sc, their skills can be

easily utilized by training them as ANMs.

RCH SUB – PLAN:

LEVEL OF FACILITIES AVAILABLE IN A DISTRICT:

LEVEL – 3 LEVEL – 2 LEVEL – 1 TOTAL (CEmONC) (BEmONC) (Non- BEmONC PHCs, SHCs, GOVT. PVT. GOVT. PVT. Home Based Care/Deliveries NO. OF FACILITIES 1 DH- CHC= 10 OPERATIONALISED AS OF SATNA PHC= 9 NOW FUNCTIONAL BED 400 318 74 792 STRENGTH (10 CHC ( 7 PHCs) (1 DH, 7 CHCs, 11 + 9 PHC) PHCs)

REPORTED 8158 74 26339 1247 1323 37141 INSTITUTIONAL (21.9%) (0.2%) (70.9%) (3.4%) (3.6%), Home (56.9% of DELIVERIES (2009-10) Based Delivery estimated delivery) = 6722 (home delivery : 6722) NORMAL DELIVERIES 7386 65 25136 1247 1323 35156 (94.7% of (21.0%) (0.2%) (71.5%) (3.5%) (3.8%) reported institutional deliveries) CAESAREAN SECTIONS 624 9 - - - 633 (1.7% of (98.6%) (1.4%) reported institutional deliveries) OTHER COMPLICATED 148 0 1203 0 0 1351 ( 3.6% of (11.0%) (89.0%) reported institutional deliveries)

*** Detailed information is given in FORM-A, Sub- Plan for RCH attached in Annexure.

DH is the only available facility at Level -3 with capacity of 400 beds reporting 21.9% institutional

deliveries and 98.6% C-sections , 1 FRU needs to be established in a district considering the patient 17

load in a DH. 19 facilities ( 10 CHC + 9 PHC ) are of level – 2 which are providing BEmONC Page

DISTRICT SATNA, M.P

services across the District. All the facilities if put together shows 56.9% as the reported Institutional Deliveries in 2009-10, data shows that 1.7% C-sections were done and 3.6% complicated pregnancies were handled last year. Considering the percentage of complicated deliveries handled in District, more number of doctors should be trained in CEmONC services as DH alone cannot tackle such a patient load.

 INSTITUTIONAL DELIVERY STATUS :

ACTIVITY/ MEASURABLE INDICATORS 2009-2010 2010-2011 TARGET 1. Total expected deliveries 65840 65296 2. Total reported deliveries 53872 - a. Institutional 47257 48972 b. Home SBA 2944 NA c. Home non- SBA 4679 NA 3. Total Unreported (1-2) 11968 NA 4. Total % of Institutional Deliveries 71.77% To achieve 100% *** Detailed information is given in FORM-A, Sub- Plan for RCH attached in Annexure.

WHY INSTITUTIONAL DELIVERIES:

The graph shows that around 36% of maternal complications during pregnancy are treated under institutional deliveries and around 21 % C- Sections are done under institutional deliveries in case of complications, this can only be done under skilled personnel and well equipped places.

 FAMILY PLANNING STATUS :

Though there are 9 sterilization units in a district but people prefer sterilization during camps only. Last year 50% IUD insertions were done and 45% female sterilization were done as compared to male

sterilization which was only 5%. This highlights a misconception in a community about male 18 Page

DISTRICT SATNA, M.P

sterilization,that it leads to physical weakness and may hamper the day to day activities and more laborious work.

Special focus and extra efforts are needed to achieve the success rates in FP. In HSC, no special efforts were made by ANMs & ASHAs to achieve the set targets, IEC component is weak in this regard to generate more awareness among masses.

DISEASE CONTROL PROGRAMS:

Case detection rate of TB among new sputum positive patients is 39% whereas the treatment success rate among new sputum positive patients initiated on DOTS program is 59% under TB Control Program, though it shows the good results but several cases at community level showcase a different scenario, people’s resistance in continuing the treatment was evident at community level. As far as Malaria Eradication Program is concerned, 2% of ABER rate shows the poor performance of Program in a district where Malaria is still prevalent, these needs to be considered. District shoes the 0% of annual new case detection rate for Leprosy under Leprosy Control Program.

TB AFFECTING THE KOHLS -TRIBAL BELT OF SATNA, LIVES IN A VILLAGE NEAR SITPURA :

TB is a disease taking a toll over the young male adults of this tribe, prevalence and incidence rates are high, the main cause is tobacco abuse. Boys die as young as 20-25yrs in age but still many people refuse to take medicines under DOTS program, despite of every possible efforts

made by ANMs, MPWs & ASHAs. One can find TB affected cases ranging from 16-45 years of age. A serious action needs to be taken in this regard by State.

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RKS FUNDS:

RKS was well oriented towards their duties and responsibilities, grants were well utilized under RKS ( for construction of ramp, purchasing generators, conducting Health camps etc.) in DH. As compared to the patient load handled by DH, funding for RKS is low, special measures should be initiated by State Government to increase the amount of funds under RKS specially for Level- 3 Facility which not only handles the patient load of their district but of its neighboring districts too. High influence of Media hinders in fund raising activities of RKS, eg. To compensate the growing healthcare costs some changes in fee structure were made by RKS which was wrongly quoted and interpreted by Media ( the increment in registration fee was hyped in such a manner that RKS was made to bring down the prices. RKS spends around 1lakh for housekeeping services, 85 sweepers were outsourced keeping in view the patient load. Strong IEC regarding the flow of funds & its utilization through Nationalised & Government channels should be given. Maintenance of transparency should be maintained.

RKS of District Panna, M.P can provide a role basis for various districts, the model of fund raising of RKS in Panna is remarkable, eg. they have built medical stores and are earning rent from these shops.

BENEFICIARIES:

Many Beneficiaries were satisfied with the prompt response of Healthcare Facilities on reaching there, they were accompanied by ASHAs, Hospital releases On time payment of JSY at the time of

discharge, all Vouchers of JSY were maintained, proper transparency was there in JSY funding. 20 Page

DISTRICT SATNA, M.P

VHSC:

The role of VHSC is still not cleared in a district, there’s a lot of ambiguity in the expenditure of Funds. Though in many villages, work of Toilet construction has started. During the conversation with Sarpanch of villages, the main point which comes under consideration is that many families which really deserves to be a BPL Card holder actually never gets the Card. A proper Guidelines need to be issued from State and proper formal training to VHSCs should be given regarding what is expected out of them VHSCs are still don’t have their Role Clarity. Sarpanch blames the increasing dependency of Community members due to funding provided under programs like JSY, people have mindset that the whole sole responsibility is of Government to take care of them, so they ask ASHAs to come to their house for providing immunization to their children as it is the responsibility of Government and ASHAs are accountable to this.

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KEY FINDINGS OF INSPECTED HEALTHCARE FACILITIES :

The inspected healthcare facilities details are given below along with the date of visit. To brief out the report, general facts are given in tabular form along with the positives and negatives of the facility. A Bottom to Top Approach was adopted while visiting the Facilities so as to ensure

Certain remarkable points are noted in a special box to highlight the best practices as well as the bad practices in a district.

DETAILS OF INSPECTED HEALTHCARE FACILITIES :

S.NO. FACILITY VISITED BLOCK DATE OF VISIT 1. CHC + NRC NAGOD 16/6/2010 2. CH MAIHER 16/6/2010 3. HSC – TIGHARA KALAN MAIHER 16/6/2010 4. COMMUNITY MEMBERS OF VILLAGE NAGOD 17/6/2010 - SITPURA 5. SARPANCH- SITPURA NAGOD 17/6/2010 6. HSC- SITPURA NAGOD 17/6/2010 7. HSC- KARAHAIYA NAGOD 17/6/2010 8. HSC- SINGHPUR NAGOD 17/6/2010 9. PHC- SINGHPUR NAGOD 17/6/2010 10. PHC- SOHAWAL SOHAWAL 17/6/2010 11. COMMUNITY MEMBERS OF VILLAGE- SOHAWAL 17/6/2010 SOHAWAL 12. SARPANCH - SOHAWAL SOHAWAL 17/6/2010 13. DH- SATNA + NRC SATNA 18/6/2010

INSPECTED FACILITIES :

CHC – NAGOD :

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ADVANTAGES SCOPE OF IMPROVEMENT PLAN OF ACTION - STRATEGIES CAN BE ADOPTED

- staff was devoted and - CHC has a spacious campus - Keeping in view the patient load a DH caters committed to their duties and but unutilized. (not only of Satna but of its neighbouring doctor stays near the facility. districts like Banda, Umaria, Panna, - It’s a BEmONC facility. Chitrakoot, Katni) &lack of FRU in Satna, CHC may be promoted to FRU by recruiting more specialists & providing FRU facilities.

- A new labour room has been - construction of new labour - Beyond the committed timeline, the constructed in CHC, room started last year and may responsible person should be asked to finish it be expected to finish by within a set deadline. October.

- Campus was neat & clean. - safe drinking water not - water with purifier should be provided in available for IP & OP in CHC. CHC.

- Deep burial pits and - Colour coded baskets were - usage and importance of colour coded baskets incineration pits were present missing. need to be understand in CHC. for bio waste disposal at the back of CHC.

- keeping in view the intensity - OT seems to be non-functional - it should be utilized. of heat in M.P, coolers were and was functional only during placed in wards and NRC. sterilization camps, dog was roaming outside OT.

- stock of vaccines in ILR & - a lot of space was kept - a contract for establishing a kitchen can be drugs were in ample amount unutilized which can be utilized given to NGO under. and were stored appropriately for various means (for kitchen & no expirated drug was to serve food to IP) found. - prompt services were - shortage of staff nurse, ANMs - recruitments should be done as soon as provided to patients on and specialized doctors. possible. reaching CHC. - patients were satisfied with - a 10 bedded SNCU - steps may be taken to approve this proposal as quality of care. construction has been proposed soon as possible and timely construction should by CHC. be ensured.

- CHC has 3 MMUs.

- BMO & BPM & pediatrician were present.

- name based tracking training - sitting arrangements were not - proper arrangements should be made. was going on at point of visit in available for attendants. a meeting room of CHC.

- IEC component was well in - grievance box was not - it should be made available. place but can be improved available in CHC. through more pictorial ads.

- Proper utilization of funds under RKS, UF,AMG and JSY 23

was there, no pending case of Page

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JSY.

- attached toilet was there with -Toilets for IP and OP were not - proper arrangements should be made for a labour room and was clean. clean. maintenance of cleanliness and hygiene.

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POSITIVES NEGATIVES

UNDER CONSTRUCTION PROPOSED 10 BEDED SNCU LABOUR ROOM AT THIS PLACE

CONDITION OF SAFE DRINKING WATER

DEEP BURIAL PITS AT BACK OF CHC

COOLERS IN WARDS CONDITION OF TOILETS FOR ATTENDANTS

MOSQUITO NETS WERE MADE AVAILABLE TO CHLDREN IN NRC

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CIVIL HOSPITAL – MAIHER : Page

DISTRICT SATNA, M.P

ADVANTAGES SCOPE OF IMPROVEMENT PLAN OF ACTION - STRATEGIES CAN BE ADOPTED

- Staff was present but post of - premises inside the wards and - Cleanliness should be pediatrician was vacant. CH was not clean. maintained within and outside the premises of CH. - spacious well equipped OT. - condition of toilets was - proper drainage and sanitation unhygienic and stained, drainage facility should be ensured. system was out of order.

- 24 * 7 doctor availability was - people were lying on floors and - the space wasted in some open there on call. patients beds were laid on area can be utilised for making pathways as no. of Functional wards. beds is more than the sanctioned beds. (i.e Sanctioned Beds = 32, Functional Beds= 60)

- staff nurse & ANM are - labor room was not managed - labor room should be well available for 24*7. appropriately. equipped and well kept.

- oxytocin was available. - ECG machine was available but - it should be functional. not working. - coolers were present in private - Blood transfusion unit was - it should be made operational as wards and NRC and in general present but not functional due to soon as possible with recruitment wards. lack of staff. of staff as it can easily function as FRU of a district to reduce the load on DH.

- Records were well maintained - condition of general ward was - building is old enough and need for utilization of UF, AMG, JSY. worst , the walls of wards were renovation. Mosquito screens or Transparency was there.Vouchers damped and not whitewashed for nets should be provided. 26

were maintained. several years, mosquito screens Page

DISTRICT SATNA, M.P

were present but with huge holes.

- ILR were well maintained and - No deep burial pits and no - provisions to be made for the drugs were stored appropriately. arrangement for BMW proper disposal of BMW management, no colour coded management, or service may be baskets. outsourced in case there’s a lack of space for this purpose.

- name based tracking system - drainage system was clogged. - provisions should be made to training was going on. ensure the unclogged drainage & sanitation system.

- protocols for 3rd stage of labor - no facility of power back-up. - keeping in view the pathetic were displayed. condition of availability of power in Satna , generator should be purchased.

- NRC was well managed. Records - no dustbins were made available - dustbins should be placed at the were well managed, however for public, so the garbage can be pathways of CH. mosquito nets were provided in seen within the premises of CH. NRC.

- Maternal death audit was done - no grievances box. - it should be present. regularly. - sterilization processes are - though IEC component was - Pictorial presentation can conducted but people generally present but not effective. effectively convey the messages to prefer it during camps. illiterate public.

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POSITIVES NEGATIVES Page

DISTRICT SATNA, M.P

WELL EQUIPPED OT DAMPED WALLS OF GENERAL WARD, MOSQUITO SCREENS WITH HOLES, NO ELECTRICITY.

WELL MANAGED

ILL MANAGED LABOR ROOM

NRC BLOOD TRANSFUSION UNIT

POOR DRAINAGE & POOR SANITATION, POOR CONDITION OF TOILETS

DH – SATNA :

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DISTRICT SATNA, M.P

ADVANTAGES SCOPE OF IMPROVEMENT PLAN OF ACTION - STRATEGIES CAN BE ADOPTED

- First and foremost thing – the - High influence of Media hinders - Strong IEC regarding the flow DH of Satna has a state of art in fund raising activities of RKS, of funds & its utilization through SNCU. This can be stated as the eg. To compensate the growing Nationalised & Government role model for other districts too. healthcare costs some changes in channels should be given to However within the same premises fee structure were made by RKS community. one can have extremely varied which was wrongly quoted and - community education and experiences. interpreted by Media participation should be ( the increment in registration fee strengthened on RKS functioning was hyped in such a manner that and its existence. RKS was made to bring down the - Public display of utilization of prices. Fund under RKS can resolve the - RKS spends around 1lakh for issue. housekeeping services, 85 - representative from community sweepers were outsourced keeping can be included during RKS in view the patient load. meetings. - Maintenance of transparency. - 24*7 staff and Doctors remain - daily load of around 150-200 - more DGO trained or CEmONC present both for emergencies as delivery cases managed single trained doctors should be placed well as in SNCU. handedly by Dr.Rekha Tripathi in DH considering the patient who is DGO, not only handles the load. load of satna but of neighboring districts too.

- staff of DH is committed and - toilet attached to labor room was - proper sanitation facility should devoted towards their duties. not in working condition. be ensured attaching the labor room. - Hospital handles not only the - chairs were not available for - sitting arrangements should be load of 23 lakh population of attendants of patient. made available for attendants. Satna but of its neighboring districts too like, Panna, Katni, Umaria, Banda etc.

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- in SNCU the patient load of - pathway was full of patients and - arrangements should be made Page

DISTRICT SATNA, M.P

referral cases from the same attendants lying there due to lack either by constructing more wards districts can be seen. of beds, patient load is huge. to accommodate such a huge (out of 400 sanctioned beds 220 patient load, if FRU is established are functional and 60 are in a District, load may be reduced. functional as MCH beds) -60 MCH beds are also less compared to patient load, women were lying on floor.

- Construction of 20 bedded new - sitting arrangement in waiting - proper arrangements should be ward is near its completion. area is inefficient in handling the made. patient load during the peak hours.

- Medicine storage house was well - deep burial pits were not present - Though for this DH has kept and had ample amount of within the premises of DH. outsourced the responsibility of medicines. disposing off the BMW but still proper arrangements should be ensured for the BMW disposal.

- proper utilization of funds under - huge dearth in manpower, - more staff should be recruited. JSY, UF, AMG, RKS. considering the patient load DH requires more ward boys, ANM and specialized doctors specially CEmONC trained.

- Blood transfusion units - Running water supply was not - provisions should be made to operationalisation was well there, the tanker established last ensure 24 hour water supply. managed. year was insufficient to cater the huge patient load & their attendants.

- generators were in functional - building is old enough. - renovation work should be condition and has 3 generators. started.

- separate wing was made for the - Revenue making of RKS is less - Provisions should be made from diagnostic centre to save DH from and its expenditure is more. the State’s side. being overcrowded.

- Computerised registration was - the wards constructed by PWD - DHS should follow up. there in DH. were started in 2007 but are still not completed.

- ramp was made last year for - toilets were not clean. - cleanliness should be there. ensure easy pathway fro old and movement of stretcher.

- DH has outsourced the kitchen facility to a group of people (generally businessman involved who give 3000 Rs. Per day for functioning of the kitchen named SEWA SANKALP, they provide food to attendants of patient at rs. 5. THIS CAN BE USED AS A

INNOVATIVE MODEL FOR OTHER DISTRICTS TOO.

30 - separate arrangement for

bathing and washing was made Page

DISTRICT SATNA, M.P

outside the premises of DH for the Patient’s attendants.

- colour coded buckets were in place and dustbins are present in pathways of DH, though overfilled.

- proper record were maintained for every service.

- RTI/ STI camps, Sterilization camps are well in place.

POSITIVES NEGATIVES 31 Page

DISTRICT SATNA, M.P

NON-FUNCTIONAL TOILET IN LABOR ROOM.

DR. REKHA TRIPATHI HANDLING THE ALL OG CASES ALONE

UNFINISHED WORK OF 20 BEDED WARD UNDER PWD.

STATE OF ART SNCU AT DH

WAITING AREA OF OPD

SEWA SANKALP, PROVIDING FOOD TO ATTENDANTS

PHC – SINGHPUR : 32 Page

DISTRICT SATNA, M.P

ADVANTAGES SCOPE OF IMPROVEMENT PLAN OF ACTION - STRATEGIES CAN BE ADOPTED

- Doctor is present 24*7, stays - 2 ANMs are posted but only 1 is - SBA training should be given to within the PHC campus. SBA trained. 2nd ANM.

- cleanliness was there. - all the 6 functional beds are used as MCH beds.

- toilets were clean too. - rooms were dumped with - rooms should be used for other condemned articles. purposes like duty room of ANM.

- toilet is attached to labor room. - no FP register is maintained. - records management should be there. - no ambulance is available at - Jannani express should be PHC. provided. - no generator facility. - generators should be supplied on immediate basis. - no infant warmer & vacuum - it should be provided to avoid extractor. unlikely conditions.

- no colour coded buckets were - BMW management should be in used, mix of infectious & non- place. infectious was done, metal sharps are not disposed in puncture proof containers.

- no boundary around PHC - to avoid illegal possession over campus. the PHC campus area, it should be covered by boundary.

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DISTRICT SATNA, M.P

PHC – SOHAWAL :

ADVANTAGES SCOPE OF IMPROVEMENT PLAN OF ACTION - STRATEGIES CAN BE ADOPTED

- Doctor is present 24*7 but on - purified drinking water is not - purified drinking water should call and stays at a distance of 7-8 available for IP and OP. be made available. kms from PHC. - cleanliness was there. - Only 2 functional beds are there - atleast 6 beds should be there. used as MCH beds.

- newly constructed toilets both for - building is very old. - renovation is required. patients and attendants were there. - toilet is attached to labor room. - running water is not available in - water facility should be available labor room. by establishing a tank.

- oxytocin was present. - no ambulance is available at - Jannani express should be PHC. provided.

- ANMs are present 24*7 and - no generator facility. - generators should be supplied on stays beside the PHC on rented immediate basis. place. - 2 ANMs are RCH & SBA - no infant warmer & vacuum - it should be provided to avoid trained out of 3. extractor. unlikely conditions.

- deep burial pit was there behind - no colour coded buckets were - colour coded buckets should be the PHC. used. used.

- all records were maintained. - no separate coloumn was made - separate coloumn should be in delivery register to record major there. complications.

- No protocols for active - proper display should be there. management of 3rd stage labor was

displayed. 34

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DISTRICT SATNA, M.P

- stretcher was not present in - it should be made available. PHC.

SUB- CENTRE – TIGHARA KALAN :

ADVANTAGES SCOPE OF PLAN OF ACTION CONCERNS OF ANM IMPROVEMENT

- ANM stays at SC - Though she is active - she should be motivated - Boundary wall should though deliveries are not but motivational level is by inducing the sense of be made around the SC, conducted at SC as CH is bit low. accountability. as male villagers play just 1 Km away. cards in SC premises that can restrain females to come to SC 7 share their problems. - ANM has knowledge of - no colour coded - it should be used. - Some Contingency all the aspects of NRHM, buckets for disposal of fund should be made committed to her duties, wastes was used. available for expenditure SBA trained , attended during society meetings. last training in 2008- 2009. - has all the material & - no grievances box. - box should be placed. - Running water should equipments with her. be made available, SC has tank, but due to scarcity of water its useless. - maintains all the record books. - funds were utilized properly under UF & AMG. - ANM shares good rapport with MPW & ASHAs & Community members.

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SUB – CENTRE – SITPURA : Page

DISTRICT SATNA, M.P

ADVANTAGES SCOPE OF PLAN OF ACTION CONCERNS OF ANM IMPROVEMENT

- ANM does not stays at - Though she is active - she should be NO SUGGESTIONS & SC though deliveries are but motivational level is motivated by inducing CONCERNS. not conducted at SC as bit low. the sense of CHC is just 4-5 Km accountability. away. - ANM has knowledge of - no colour coded - it should be used. all the aspects of NRHM, buckets for disposal of committed to her duties, wastes was used. SBA trained . - has all the material & - no grievances box. - box should be placed. equipments with her. - maintains all the - No deep burial pits. record books. - funds were utilized properly under UF & AMG. - ANM shares good rapport with MPW & ASHAs & Community members. - 2nd ANM is present.

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DISTRICT SATNA, M.P

SUB – CENTRE – KARAHAIYA :

ADVANTAGES SCOPE OF PLAN OF ACTION CONCERNS OF ANM IMPROVEMENT

- ANM does not stays at - no colour coded buckets - it should be used. - no arrangements of SC though deliveries are for disposal of wastes was electricity supply from not conducted at SC as used. Government side. PHC is just 2 Km away. - ANM has knowledge of - no grievances box. - box should be placed. - availability of water. all the aspects of NRHM, committed to her duties, SBA trained . - has all the material & - No deep burial pits. equipments with her. - maintains all the record books. - funds were utilized properly under UF & AMG. - ANM shares good rapport with MPW & ASHAs & Community members.

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DISTRICT SATNA, M.P

38 Page

DISTRICT SATNA, M.P