Program Monitoring Report of Chattisgarh District Narayanpur First Quarter 2013-14 (April – June 2013) By National Health Systems Resource Center

Executive Summary

The report is based on monitoring visit to Narayanpur district of Chhattisgarh in June 2013.

A) Introduction: The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district. Narayanpur is one of the least developed district of India and of Chattisgarh. The district borders Chattisgarh and Maharashtra. In the past, Narayanpur was part of the larger Bastar district of erstwhile Madhya Pradesh and later Chattisgarh. Almost 5 / 6 th of the district is the Abujhmarh, which is an extremely densely forested, hilly area. It remain the only unsurveyed area of India. Currently, Abujhmarh is the stronghold of the Left Wing Extremist groups. Narayanpur is tribal dominated, with Gond, Madia and Bada Madia being the scheduled and primitive tribe. Abujhmarh is almost a sanctuary of the Madia tribe without any access to roads, schools and health services. Parts of Abujhmarh are accessible by roads, but invariably after a certain point roads disappear. The only way of commuting is on foot, or vehicle like Tractor. It is crucial to note that Narayanpur being one of the most heavily affected districts due to LWE. Health, ICDS and school education are probably the only 3 programs signifying the existence of Government in the district, especially, in the affected area (which is the majority of the district).

B) Analysis of overall indicators of Narayanpur: 1) Availability of data: Lack of reliable data in general, and especially from the Abujhmarh part of the district is a key problem. Any data needs to be evaluated in this context, with significant underreporting possibly the norm. This may be a reason why Narayanpur could not figure in the list of 183 High Priority Districts. Interestingly (and as a pointer to the significant underreporting), the NMR, IMR and CMR of the district are lower than the State as a whole.

2) High Priority district: The exclusion of Narayanpur from the list of High Priority District should be reconsidered as 5/6 th part of Narayanpur is Abujhmarh, which is probably the most backward and inaccessible part of India. The planning of health system and priority should be local with flexibility. Narayanpur should be included in the list of districts for the ‘Annual Health Survey’. This is crucial to get the baseline data for the district.

C) Status of Facilities: Narayanpur has total 68 public health facilities out of these 30 are designated delivery points. Private health care providers are few and public health care providers are the only source of modern health care. The public health centers and personnel are concentrated in mostly the north – east corner of the district. The area which is the primary Abujhmarh, has negligible residential and functional health facility.

D) Human Resources: 1) Overall HR: The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant.

2) Rural Medical Assistant (RMA): The RMA cadre was the backbone of health services in Narayanpur. Considering the remoteness, the difficulty in mobility and the conflict nature of the district, it is crucial that this cadre is encouraged and strengthened.

3) MPW: Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant as there was only 1 MPW training institute in the entire division, which is in the adjoining district of Kanker (Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate considering the total requirement of MPW (44 vacancies in only 1 district). A combination of MPW and ANM is an optimum combination in areas like Narayanpur, where instead of 2 nd ANM, a MPW can be considered. The MPW can provide the necessary support to the ANM including mobility and security in difficult areas during difficult times, provide curative services and work for National Disease Control Programs.

4) AYUSH: The involvement of AYUSH doctors in disease control programs as well as other NRHM activities is minimal.

5) ANM: The ANM are involved in several other works other than primary health work, for example preparing ration cards, which affected immunization coverage in the recent past and several immunization sessions did not happen.

6) HR Supervisory cadre and Supervision: The nodal officers for various programs in Narayanpur are appointed without any specific criteria with existing staff being given additional charges. For example, the BMO of Orcha block is also the District Malaria Officer. For nursing staff, there are only 2 LHV in the district. The reasons for significantly less number of LHV is due to absence of promotions of ANM to LHV, which was not happening due to the inability of the interested ANM to receive the 2 year training to become LHV as as there is not a single training institution for LHV in Chhattisgarh.

7) Specialist training: The selection of HR to be trained and the subsequent utilization of the training by appropriate posting was severely lacking in the district.

E) Institutional Delivery The district could report 84% of the expected deliveries, of which majority (52%) were home deliveries.

1) C - Section and Complicated Deliveries: The C-Section rate is 2.3%, which is very low, and would mean that several needy women are unable to reach emergency obstetric care center of not receiving after reaching. This would also mean higher maternal mortality. Similarly, the proportion of complicated pregnancies attended is also extremely low. This could be improved by better training of ANM, RMA and PHC MO.

2) Stay in facility after delivery: Majority of the women were leaving the facility within 48 hours after delivery.

3) Management of Obstetric complications: The identification and management of obstetric complications such as Eclampsia was negligible (0%) in Narayanpur. The detection of maternal anemia is severely lacking. For ANC care there is lack of standard protocols and urine testing for Albumin, nitrite, leukocyte esterase and blood was lacking, which would miss cases of pre Eclampsia and UTI. The use of obstetric interventions as antibiotics, oxytocics was also severely lacking in Narayanpur.

F) Janani Shishu Suraksha Karyakram (JSSK): 1) OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum women and newborns in all the facilities visited.

2) Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to pregnant women if the medicines are available. The system is centralized purchasing but the supply was not regular and timely for several medicines. System of maintaining inventory including regular watch of expiry date and timely replenishment is lacking. ANM and Supervisors were not replenishing the drugs or proactively getting demands from the ASHA. EDL was absent in the facilities visited and the records and stock were not computerized.

3) Diagnostics: Free Lab/diagnostics services were available at CHCs and DH. Exemptions for diagnostic services are available for PW and Sick new born. What is missing is the overall plan of maintenance including AMC, calibration of equipments, provisioning of diagnostics reagents and regular laboratory technician.

4) Diet: Free diet was provided to pregnant and postpartum women. The food was generally according to standard menu.

5) Referral transport: 4 Government and 3 Private Vehicles are available for JSSK transport. If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or using their own vehicle when the regular ambulances are not available on call or it is not possible to connect with the facility due to lack of cellular connectivity. Drop back facility was available in all the facilities visited though limited due to distances, limited number of Ambulances with respect to the size of the district and extremely difficult terrain. The referral transport mechanism was especially poor in case of newborns and (as per the data provided by the district authorities) not a single newborn had received any referral transport in the entire month of May.

6) Display of entitlement and awareness of community JSSK Entitlements were displayed in only 1 of the all facilities visited (PHC Chotedongar). Boards in Local language (Gondi) would be needed in the facilities in the tribal areas of the district.

7) Grievance Redressal / Nodal officer: No specific mechanism for redressal of grievances exists in facilities visited. The district does not have a separate JSSK nodal officer for solving grievances. There was lack of clarity on who is the specific point person for such is. There is no specific accountability or responsibility for following up on complaints received has been instituted.

8) Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the ASHA expressed the inability, finally the mother was delivered in the DH itself.

9) Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free referral transport but the cellular connectivity is almost absent especially in the Orchha block of the district. This creates a major bottleneck in the optimum implementation of JSSK in the district.

10) Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to pregnant anemic women is very few. The blood bank has most of the infrastructure and is waiting to get the License for operationalization.

G) JSY: The implementation of JSY in Narayanpur is significantly below mark, especially in the case of home deliveries where only 15.56 % had received the payment. The key bottlenecks are lack of banking network and unwillingness of Bankers to open ‘0’ balance account. Considering the overall literacy and awareness level, there are also instances of cheque lying with tribal for long time.

H) Neonatal and Child Health: 1) Vital rates: The current SBR is high, signifying high burden of birth asphyxia and lack of emergency obstetric care, including LSCS. The high SBR could also be due to mis-classification or reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth Asphyxia. This creates an erroneous picture of less IMR preventing the possibility of corrective measures, and hence must be audited. The Post neonatal mortality is also high, signifying lack of even ARI and diarrhoea management services.

2) Timing of Childhood Mortality: The high Post Neonatal and Toddler Mortality is extremely worrisome. It is indicative that Narayanpur is lagging far behind India as a whole where now NMR is the key component of Childhood mortality. In Narayanpur, ARI and Diarrhea managmenet programs are also possibly dysfunctional, with lack of training and supplies to frontline workers, leading to high childhood mortality in these age groups.

3) Causes of Childhood Mortality: Causes of childhood mortality show great preponderance of Pneumonia. This needs to be urgently addressed with training of ASHA and ANM in Childhood ARI management and ensuring supplies.

4) Anganwadi Centers: In Narayanpur, Anganwadi Centers are in functional in several remote villages and are the only residential, functional facilities with several run by RK Mission. These Anganwadi offer unique opportunity with an almost captive population of children for any intensive nutritional and health intervention and are manned by educated and committed workers trained by RK Mission. The children in these Anganwadi have several health problems, especially nutritional, dermatological, ophthalmic and of ENT. Hence strengthening the Anganwadi with better drug supplies, training and health interventions has possibility of rich dividends for child health.

I) SNCU: There was no SNCU at district hospital. Only a NBSU with average 31 admissions / month. There were no outbound admission in NBSU in the entire year reflecting lack of referral linkage or refusal to accept admission. Proportion of Still Births was 8.18% and very high. This reflects lack of facility and training of asphyxia management and lack of timely emergency obstetric intervention. Similarly, the proportion of newborn delivered in the hospital and being admitted into the NBSU was 34% and very high. This reflects lack of proper labour room management, and must be rectified.

J) Nutritional Rehabilitation Center: There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It was heartening to see patients in the NRC.

Areas of Concern: • Keeping the mothers with the children for the required number of days is a major problem despite the remunerative incentives to stay. This was due to family considerations. • Follow up was poor and keeping up with follow up was a major problem. • The weight gain was unsatisfactory. 15% weight gain was observed in < 50% cases. • There were no remunerative incentives if the children were admitted again or for follow up. The remunerative incentives for the first admission were only for a stay of 15 days, and not more (even if the family wishes to stay for longer duration and the weight gain is unsatisfactory). In places like Narayanpur, with high overall disease burden, poor outreach services, recurrent communicable diseases and overall poor literacy and financial levels, it is very much likely that a child who has once recovered from undernutrition would again fall back due to the above mentioned reasons. It is also highly likely that the duration required for a Madia / Gond child in Narayanpur for catch up weight gain would be significantly higher, and a cut-off of 15 days would be inadequate. • Hence all the financial remunerative incentives to the mother as well we the Mitanin must be continued for follow up as well as subsequent admission. There should be no cap of 15 days stay in the facility if the mother wishes to stay for more days with the child and there should be commensurate remunerative incentive for this.

K) Outreach Services: The key finding emerging from the district is that overall ANC registration and post partum visits are significantly less. There was lack of availability of MCH registers. MCH Clinics are not functional in Narayanpur, and as per the district health personnel, is not assigned to the district as well.

L) Immunization: 1) Immunization coverage: The immunization rate for individual vaccines as well as the overall full immunization coverage at 1 year is around 90%, and this is significant achievement. The Cold Chain was difficult to maintain considering the lack of electricity.

2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA including difficult terrain and inability to pass on information should be considered. If the delivery is not institutional, the child is not given any dose of Hepatitis B vaccine.

3) Immunization system: • There were only 8 BCG vials in the District Hospital. The rule of supply of the vials as per the expected population of children and 1 vial per 4 children and to be used immediately after opening is creating difficulties in Narayanpur. It is observed that the villages in Narayanpur are very small (to the extent of 304 houses only) which means effectively the number of children to be immunized would be quite less, in several cases, less than 4. At the same time, the distances being large and terrain being difficult, generally visit to 1 or 2 such hamlets would only take the entire day. Overall, this was resulting into wastage of vials where 1 vial was being used for less than 4 children and then discarded. And finally less supply (based on the norm of 1 vial for 4 children) compared to actual feasibility of use in Narayanpur. • Hence the norm may be reconsidered in Narayanpur with more supply.

M) ASHA, VHSNC and NGO Partners: 1) The key problems identified were: Lack of HBNC kits, regular drug kits and system of drug refilling, lack of adequate training d skill set of Mentor Facilitator and lack of Travel Allowance for the Mitanin.

2) Conflict Situation and its effects: There are several instances of the Left Wing Extremists asking for medicines to the health staff as well as the Mitanins. At the same time, the security forces also question the Mitanin regarding the stock and supplies they carry from the block of district HQ meeting to their villages with the doubt the medicines they carry would be for the Maoists. Overall, in places like Narayanpur where the formal health system is weak, it is extremely crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system, which is feasible locally, extend their training, provide them the necessary supplies and expand the roles. They are the last connection with the people of the health system, especially in districts like Narayanpur where the regular other health system is limited due to several reasons.

3) VHSNC: Gram Panchayat are not fully functional in Narayanpur as due to the opposition by the Maoists to elections, Sarpanch and Gram Sevak hardly resides in villages. The method of release of their payment through Panchayat is non functional and the concern was with the implementation of the system of payment through Panchayat; the minimal incentives the Mitanin were getting so far will also get stopped, reducing their involvement further. Considering the unavailability of the Sarpanch and Gram Sevak, Bearer Cheque may be considered.

4) IEC: The orientation camps undertaken in the past with rigorous group discussions was a better and more personalized model to communicate with tribal considering the culture and literacy level in this area. The current method where the contents, IEC material are directly sent from Raipur and are not in the local language (Gondi nor Madia) was not working.

5) NGO: Ramakrishna Mission is functional in Narayanpur district in the most interior parts, providing extremely useful services. More convergence and involvement of the RK Mission with health services will be useful.

N) Program Management: 1) Key issues emerging were: Induction training for NRHM staff and the DPM and establishing block program management structure was desired in Narayanpur. The criteria of recruiting only from the district was probably acting as a bottleneck in filling the vacancies as there is lack of the trained HR for the respective positions in the district. Hence, can this rule be relaxed, probably on a case basis, and / or allowing recruitment from adjoining districts such as Kanker, Dantewada, Bijapur, Sukma, Kondagaon and Bastar?

2) PIP Planning and setting priorities: The process of setting priorities for Narayanpur should consider local morbidity pattern. For example, it was observed that the BMO of Orcha (the only MBBS doctors in the entire block), who is holding additional charge of District Malaria Officer, had to go to Raipur to attend a meeting on ‘YAWS’, leading to his absence from the facility and the block for 3 days, depriving the people of crucial health services. Is YAWS is a priority in general and specifically for Narayanpur?

O) Quality of Services and supportive services: 1) Solar: The regular functionality of the solar back-up system is heartening and to maintain this, there should be an integrated plan for regular maintenance and troubleshooting.

2) Mobility facilities: Roads are in poor condition and completely blocked in monsoon. No regular 4-wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel but only Tractor (or similar vehicles) or a Jeep with 4 Wheel gear system and motorcycle. Ambulances cannot travel due to poor roads and less ground clearance of the vehicle severely affecting the availability of emergency medical transport system preventing the health system of performing its crucial task and eliminates the possibility of the representation of the State in a human form at the most crucial and required hour. Lack of funds for the repair of vehicles including tires and battery in Narayanpur where the life cycle of vehicles gets reduced from 10 to 5 years is concern.

3) Mobile and Internet connectivity: Lack of connectivity, which is already limited within a radius of few kilometers of the district HQ, and further jammed when the security forces go for patrolling to avoid information being spread about the whereabouts of the security personnel and avoid an ambush. Internet connectivity is only in the district HQ, even where reliable network is generally limited to the offices of Collector and CEO.

4) Infrastructure creation, maintenance and public works department: • The work of the PWD was poor and maintenance was unsatisfactory in several of the facilities visited. Uniformly water seepage, lack of staff quarters and delayed construction were problems. The Maoists due to the possibility of the structures being used by security forces to establish their bases oppose any structure with solid walls and flat roof. • The district administration has proposed a novel structure of Bamboo, which is treated to be fireproof, waterproof and anti termite with reasonable strength to last for up to 30 years. These structures are being constructed in Bijapur and so far are unopposed by the Maoists.

5) HMIS / MCTS: • It is extremely difficult to establish and operationalize internet-based systems such as MCTS which assume reasonable speed and penetration of internet facilities in places like Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur may be affecting the regular functioning of the system. • Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to only the district HQ (not even block HQ) for such entry, as district HQ is the only place with overall internet facility. For such, she would require to travel and spend 3 days considering the lack of transport facilities in the district. At the same time, there is no assurance that the internet would be functioning on that particular day when the ANM has reached the district HQ. • There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero dose in the manual format but its inclusion in the software. Additionally there is the persistence problem of villages of a certain PHC / block shown under different PHC / Block resulting in more problems in reporting. Offline entry was not possible in MCTS.

P) Other health priorities / programs: 1) Mobile Medical Unit: 1 MMU is operational with average daily OPD of 52 patients and average 14 lab tests. The average number of villages covered each month was 20 with 20 functional days per month. It will be useful to explore how to improve the diverse functionality of the MMU, including services for NCD. A key problem was the large size and poor ground clearance of the MMU which would lead to the vehicle getting stuck several times on the roads.

2) Surgical morbidities and tertiary care: The tribal from interior village were willing to receive medical care for their morbidities, but unable to, due to lack of surgical care at the district HQ, funds and support. Hence surgical care through camps and a special fund at the district level to provide free advanced referral care to tribal including transport, a trained medical social worker as accompanying person and the entire medical care would be useful.

Q) Disease Control Programs: 1) IDSP: The DPMU had recruited a person after significant efforts as IDSP I / c who was functioning. Nevertheless, due to the recent change in the HR criteria, which makes it mandatory to have 3 years of experience to be eligible for the post, the current IDSP manager would be terminated. In places like Narayanpur, it may not be feasible to insist on 3 years of prior experience and may effectively mean that the post would remain vacant. Instead, on job training may be an alternative, if the candidate is committed and willing to learn and work.

2) Malaria: Narayanpur is endemic for malaria, especially falciparum. Though the commitment of the outreach staff who are willing to work in a mission mode in cases of malaria epidemics is remarkable, the key concerns are lack of integrated malaria prevention and management plan, absent schedule of IRS and lack of supplies of LLIN or ACT and other antimalarials.

3) RNTCP: Considering that the burden of TB would be quite high in tribal district like Narayanpur (as is the experience from other tribal districts), the suspected cases examined are less, with a proportion of only 140 / 1,00,000. Screening and case detection can be increasing through TB screening through the MMU, mass-selective screening of patients of cough through ANM and ASHA, increasing the access to sputum collection through ANM and ASHA and considering establishing advanced diagnostic method like DNA / PCR.

Detail Report

A) Introduction: The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district, which is one of the least developed district of India and of Chattisgarh, bordering Chattisgarh and Maharashtra. In the past, Narayanpur was part of the larger Bastar district of erstwhile Madhya Pradesh and later Chattisgarh.

Almost 5 / 6 th of the district is the Abujhmarh, which is an extremely densely forested, hilly area. It is also the only unsurveyed area of India and currently the stronghold of the Left Wing Extremist groups. Primarily Narayanpur is tribal dominated, with Gond, Madia and Bada Madia being the scheduled and primitive tribe inhabiting Narayanpur. Abujhmarh is almost a sanctuary of the Madia tribe without any access to roads, schools and health services.

It is crucial to note that Narayanpur being one of the most heavily affected districts due to LWE. Health, ICDS and school education are probably the only 3 programs signifying the existence of Government in the district, especially, in the affected area (which is the majority of the district).

Parts of Abujhmarh are accessible by roads, but invariably after a certain point beyond the district HQ, roads become non-existent, leading to only forest. The only way of travel is on foot, or vehicle like Tractor.

Table 1: Visit Schedule of first quarter visit was as follows Dates Facility Facility/places visited Personnel Type 22 nd , District Meeting with District Collector 23 rd and Meeting with District CEO 24 th District Hospital, June Civil Surgeon’s Office, CHMO office, DPMU CHC Orchha PHC Dhanora PHC Chotedongar RMA Sonpur Mitanin Kurushnar Trainer Mitanin Ader ICDS Rohtad B) Analysis of overall indicators of Narayanpur: 1) Key observations: • Lack of reliable data in general, and especially from Abujhmarh is a key problem. Any data needs to be evaluated in this context, with significant underreporting probably the norm. The same underreporting may be a reason why Narayanpur could not figure in the list of 183 High Priority Districts. Interestingly (and as a pointer to the significant underreporting), the NMR, IMR and CMR of the district are lower than the State as a whole! • The MMR of Chhattisgarh as a State is 263; MMR of Narayanpur is 283. This could be due to lesser availability of emergency obstetric facilities, inability to seek timely referral due to unavailability of cellular network remote and being tribal and extremist-affected district. • The district has 2 blocks, Narayanpur and Orcha (comprising the entire Abujhmarh area). There were 60 Gram Panchayat for 413 villages (and even more hamlets, which are placed at quite a distance), the average number of villages per VHSNC would be 6. Considering the terrain and distance in Narayanpur, effectively this would mean non-functional VHSNC.

2) High Priority district: • The exclusion of Narayanpur from the list of High Priority District should be reconsidered urgently. In fact, a separate category may be considered of ‘Extremely High Priority Districts’ for Narayanpur as almost 5/6 th part of Narayanpur is Abujhmarh, probably the most backward and inaccessible part of India. • The planning of health system and priority should be localized and there should be significant flexibility. Additionally, Narayanpur district should be included in the list of districts for the ‘Annual Health Survey’. This is crucial to get the baseline data for the district and was voiced as a key demand by the district authorities.

Statistics Chattisgarh Narayanpur Person 2,55,40,196 1,39,820 Population - Census – 2011 Male 1,28,27,915 70,104 Female 1,27,12,281 69,716 Sex Ratio ( No. of Females per1000 Census - 2011 991 995 males) Sex Ratio 0 - 6 years Census - 2011 964 946 MMR ( per 100,000 live births) 263 (HMIS) 281(HMIS) CBR ( per 1000 population) 21.5 21.5 CDR ( per 1000 population) 7.9 7.9 SRS - 2012 IMR 48 (RHS 2012 ) 42 (HMIS) Neo- natal Mortality Rate 35 (HMIS) 22.16 (HMIS) Under Five Mortality Rate 66 (HMIS) 51 (HMIS) Literacy Rate - Census – 2011 Person 71.04 40.49 Male 81.45 47.71 Female 60.59 33.23 % Decadal Growth Rate 22.59 28.74 Population Density per Sq.K.m 189 20 Blocks 02 Villages 413 Gram Panchayat 69

C) Status of Facilities: • Narayanpur has total 68 public health facilities out of these 30 are designated delivery points, the number and distribution as well as designated delivery points are as follows. • In Narayanpur private health care provider are few and public health care providers are the only source of modern health care. Crucially though, the public health centers and personnel are concentrated in mostly the north – east corner of the district. The area in the west, and bordering Maharashtra, which is the primary Abujhmarh, has negligible residential and functional health facility. This situation is complicated further by overall the lack of roads, and especially problematic conditions in Monsoon.

Total Designated Delivery number points (%) Level I facility 1 SHC 59 23 (39 %) Level II facility 2 PHC 7 5 (71.4 %) 3 CHC 1 1 (100 %) Level III facility . 4 DH 1 1 (100 %) Total 68 30 (44.11%) No. of licensed blood banks (include pvt) 0 No. of licensed blood storage units/centers 0

D) Human Resources:

1) Overall HR: • The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant. In District Hospital, of the sanctioned 26 Class 1 posts, only 1was filled. Of the sanctioned 22 Class II posts, only 7 are filled. • It was desired by the contractual staff that considering the overall conflict situation of Narayanpur, at least Life Insurance Policy should be considered for the staff. In fact considering that the health staff is the only other state staff apart from education and ICDS to venture in interior and provide services, the distinction between contractual and permanent may be reduced to possible extent. • There is need of specific HR policy including clarification on promotions and regularization and payment rules in an integrated manner, not fragmented. Similarly there is need of retaining the staff to have institutional memory (the lack of which was sighted by the district authorities as a major problem).

2) Rural Medical Assistant (RMA): • The RMA cadre was the backbone of health services in Narayanpur. Considering the remoteness, the difficulty in mobility and the conflict nature of the district, it is crucial that this cadre is encouraged and strengthened. It is important to understand that the work of a medical personnel in the conflict zone in districts like Narayanpur is not only providing services but several others such as establishing access, communicating with people and doing unexpected tasks as even rescuing a vehicle stuck in mud. • Hence, increasing the number of RMA and their skill set by continuous training in CMC Vellore should be increased. Additionally, new training should be planned as per the desired skill set for RMA.

3) MPW: • Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant. There was only 1 MPW training institute in the entire division, which is in the adjoining district of Kanker (Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate considering the total requirement of MPW (44 vacancies in only 1 district). • Considering this, ideally, an MPW training institute should be established for 2 districts and all the posts should be filled at the earliest. • It is important to note that a combination of MPW and ANM is the optimum combination in areas like Narayanpur, where instead of 2 nd ANM, a MPW can be considered. The MPW can provide the necessary support to the ANM including mobility and security in difficult areas during difficult times, provide curative services and work for National Disease Control Programs.

4) AYUSH: • There was no integration of the regular NRHM activities with AYUSH with a parallel structure not involving the regular CMHO. The involvement of AYUSH doctors in disease control programs as well as other NRHM activities is minimal and should be increased to optimally utilize them. An Ayurvedagram was observed in Orcha. It was reported that the doctors remains present in the facility for 3-4 days in the week with OPD of 3-4 per day. Generally, the cases are of URI and fever. • Overall, the functionality, utilization and usefulness of AYUSH services and Ayurvedagram were limited and can be reorganized catering to the immediate priorities of the people.

5) ANM: • The ANM are involved in several other works other than health work, as preparing ration cards. This affected immunization coverage in the recent past and several immunization sessions did not happen. Overall, this was pointed as trend overloading the ANM. • Recently a Government ANMTC was established in the district. A private ANMTC is functioning since 2 years.

6) HR Supervisory cadre and Supervision: • Overall supervision is extremely difficult in Narayanpur due to several reasons including lack of HR, difficult terrains and lack of connectivity. • The nodal officers for various programs in Narayanpur are appointed without any specific criteria with existing staff being given additional charges. This adversely affects the supervision. Example, the BMO of Orcha block is also the District Malaria Officer. Orcha BMO being from an interior facility level, his additional charge requires him to stay at the district HQ, affecting the regular work of providing medical services in the facility and in the block. Finally, there is no overall comprehensive plan of supervision for doctors. • Though there is plan for supervising ANM, only 2 LHV were present, affecting actual supervision. The reasons for significantly less number of LHV is due to absence of promotions of ANM to LHV, which was not happening due to the inability of the interested ANM to receive the 2 year training to become LHV. The training could not be provided, as there is not a single training institution for LHV in Chhattisgarh. The only one is in Jabalpur, in Madhya Pradesh. This is leading to a situation where the ANM are retiring as ANM only without any prospects of receiving additional training and promotion. There were examples of staff in the service for 32 years (Orcha acting Sector Supervisor) without formal promotion and the benefits. • Hence a separate plan of supervision if required in such areas and establish a training institution in Chhattisgarh at the earliest to provide the necessary cadre.

7) Specialist training: Overall, the selection of HR to be trained and the subsequent utilization of the training by appropriate posting was severely lacking in the district. This is of great concern considering that severe lack of trained HR in the district and unwillingness of HR to join in.

F) Deliveries: Overall

The district could report 84% of the expected deliveries, of which majority (52%) were home deliveries. In addition to cultural reasons, the lack of transport and mobile services as well as the absence of expedited channels of payments was key reasons for lack of institutional deliveries. Narayanpur Deliveries - Apr'12 to Mar'13 Total Population 1,39,820 Expected Deliveries 3,511 Total Deliveries Home SBA Home Non SBA Institutional (Pub & Pvt) Reported 530 1,315 1088 2,933 Total Deliveries Home SBA % Home Non SBA% Institutional % Reported % 15% 37% 31% 84%

G) Institutional Delivery

1) C - Section and Complicated Deliveries: The C-Section rate is 2.3%, which is very low, and would mean that several needy women are unable to reach emergency obstetric care center o r not receiving after reaching. This would also mean higher maternal mortality. The proportion of compli cated pregnancies attended is also extremely low. This could be improved by better training of ANM, RMA and PHC MO.

C sections & Complicated Deliveries 12 - 13 Institutional Institutional Total Institutional

Deliveries (Public) Deliveries (Pvt) deliveries Total Deliveries 1088 NA 1088 C Section (%) 25 (2.3%) NA 25 (2.3%) Complicated Pregnancies 26 (2.4%) NA 26 (2.4%) attended (%)

2) Stay in facility after delivery : Majority of the women were leaving the facility within 48 hours after delivery.

Chattisgarh-Naryanpur- Stay duration as percentage of Reported Institutional Deliveries - Apr'12 to Mar'13 Stay for more than 48 hrs after delivery 8%

Stay for less than 48 hrs after delivery 92%

3) Management of Obstetric complications : The identification and management of obstetric complications as Eclampsia was negligible (0%). The detection of maternal anemia was also lacking. For ANC care there is lack of standard protocols. Similarly, urine testing for Albumin, nitrite, leukocyte esterase and blood was absent missing cases of pre Eclampsia and UTI. The use of obstetric interventions as antibiotics, oxytocics was also severely lacking in Narayanpur. Overall, there is significant need for strengthening obstetric services and emergency care.

Management of Complications 12 - 13 % against reported Reported ANC Registration Hypertensive cases detected at institution 301 9.4% Eclampsia cases managed during delivery 0 0% ANC women having Hb level<11 377 11.7% ANC women having severe anemia (Hb<7) 46 1.4% treated at institution Obstetric Interventions Cases C - Section 25 PP Maternal Complications 1 Abortions 82 Still Births 90 Severe anemia cases treated 46 Blood Transfusion 2 IV antihypertensive / Magsulph injection 10 IV Oxytocin 23 IV Antibiotics 22

I) Janani Shishu Suraksha Karyakram (JSSK):

1. OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum women and newborns in all the facilities visited. The awareness of the new rule of extending the benefit to 1 year may be focused upon.Nevertheless, there were informal reports from Mitanin that Doctors in the District Hospital demand money (in the specific case recounted, 5000 INR) for services.

2. Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to pregnant women if the medicines are available. The system is centralized purchasing and probably in the process of being established as the supply was not regular and timely for several medicines. The system of maintaining inventory including regular watch of expiry date and timely replenishment is lacking. Several drugs were expired. ANM and Supervisors were not proactively replenishing the drugs. EDL was absent in the facilities visited and the records and stock were not computerized.

3. Diagnostics: • Free Lab/diagnostics services were available at CHCs and DH. Exemptions for diagnostic services are available for PW and Sick new born. What is missing is the overall plan of maintenance including AMC and calibration. In both the CHC as well as the PHC the facilities were poor with lack of regular provisioning of diagnostics and regular laboratory technician. In such situation, the antenatal check up is devoid of any significant benefits. Even basic laboratory reagents and kits were also lacking. • In view of this, and in view of the significant investment in provision of modern and high end equipments being provided and sanctioned in the budget, the provision of such a maintenance plan, agency and personnel should be made integral part of the PIP. A separate wing like IDW can be considered for the same. The full functionality of equipments is necessary for optimum services and are as crucial as other civil infrastructure. Similarly, Point of Care Tests should be considered to improve diagnostic facilities.

4. Diet: Free diet was provided to pregnant and postpartum women. The food was generally according to standard menu.

5. Display of entitlement and awareness of community: JSSK Entitlements were displayed in only 1 of the all facilities visited, which is the PHC Chotedongar. Nevertheless, similar boards in Local language (Gondi) would be needed in the facilities in the tribal areas of the district.

6. Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the ASHA expressed the inability, finally the mother delivered in the DH itself.

7. Referral transport • Overall in the district, 4 Government and 3 Private Vehicles are available for JSSK transport. If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or using their own vehicle when the regular ambulances are not available on call or it is not possible to connect with the facility due to lack of cellular connectivity • Drop back facility was available in all the facilities visited though limited due to distances, limited number of Ambulances with respect to the size of the district and extremely difficult terrain. • The referral transport mechanism was especially poor in case of newborns with as per the data provided by the district authorities, not a single newborn receiving any kind of referral transport in the entire month of May.

8. Grievance Redressal / Nodal officer • No specific mechanism for redressal of grievances exists in facilities visited. The district does not have a separate JSSK nodal officer for solving grievances. There was lack of clarity on who is the specific point person for such is. There is no specific accountability or responsibility for following up on complaints received has been instituted. No records of registration of complaints, follow up actions, and post-resolution feedback related to JSSK have been maintained with the primary reasons mostly being the lack of complaints. • Hence, a grievance redressal mechanism needs to be put in place urgently at all levels of health facilities, and records of the same maintained. Meaningful analysis can be done after 2-3 months of operationalizing the grievance redressal process and determining the commonest complaints, actions taken and the response time. Considering the significant tribal population of the district, for voicing any grievance in the district, a special mechanism versed in the local language may be needed.

9. Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to pregnant anemic women is very few. The blood bank has most of the infrastructure and is waiting to get the License for operationalization. This must be expedited urgently considering the immense need of blood transfusion.

10. Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free referral transport but the cellular connectivity is almost absent especially in the Orchha block of the district. This creates a major bottleneck in the optimum implementation of JSSK in the district.

JSSK Referral Transport Service Report of Narayanpur:- MAY 2013

NAME OF No. of No. of No. of Pregnant & Lactating no. of No. of Neonate Provided free INSTITUTE vehicles deliveries Mothers provided free sick transport transport neonate Home Institute Drop admitted Home Institute Drop to to back to to back Institute Institute Home Institute Institute Home monthly monthly monthly monthly monthly monthly monthly monthly DISTRICT 4+3 96 76 6 86 30 0 0 0 NARAYANPUR DH 3+1 70 60 4 62 30 0 0 0 NARAYANPUR CHC ORCHHA 1+1 8 5 2 8 3 0 0 0

JSSK Referral Transport Service Report of Narayanpur: 2012 - 13

NAME OF No. of no. of No. of Pregnant & Lactating no. of No. of Neonate Provided free INSTITUTE vehicles deliveries Mothers provided free sick transport transport neonate admitted Home Institute Drop Home Institute Drop back to to back to to Home Institute Institute Home Institute Institute

District 4 771 81 43 662 377 - - - Hospital Benoor PHC 0 33 3 0 27 0 4 - -

Chhotedongar 1 123 10 2 63 0 8 - 1 PHC Orchha CHC 1 33 5 0 15 0 - - -

J) JSY:

• The implementation of JSY in Narayanpur is significantly below mark, especially in the case of home deliveries where only 15.56 % had received the payment. One of the key bottlenecks in payment is the lack of banking network and women find it extremely difficult to open bank accounts. Considering the overall literacy and awareness level, there are instances of cheque lying with tribal for long time. Unwillingness of Bankers to open ‘0’ balance account despite clear instructions is a recurring problem. With accountant payee cheque in the absence of bank accounts, the concern was raised that this may lead to further reduction of JSY payments. • It can be discussed as to why there is need of separate accounts for each scheme and why the payment of JSY cannot be done through existing account such as of MGNREGA. Similarly, the payment of JSY should be also allowed through BC, DCC and Urban Cooperative banks as per the feasibility of the patients.

Naryanpur: JSY Paid to Mothers as % of reported deliveries 12 - 13 JSY Paid % JSY paid against reported Deliveries to mothers deliveries Home 1,845 287 15.56% Institutional (Public) 1,088 1,060 97.43% Total 2933 1347 45.93 %

K) Family planning:

1) Achievement: It was heartening that the utilization of spacing methods was 89%. Overall, the priority of family planning in Narayanpur should be considered in view of the small size of the Madia Community.

Narayanpur FP Methods 12 - 13 % of All Reported Reported FP Methods Total Reported FP Method (All types) Users 4,127 - Sterilizations 453 11% IUD 220 5% Condom Users 1,939 47% OCP Users 1,515 37% Limiting Methods 453 11% Spacing Methods 3,674 89%

2) Type of sterilization: Of the total procedures, majority were female sterilization and mostly Laparoscopic. The district needs to undertake steps to increase NSV by especially by training PHC MO in NSV and conducting more camps at PHC and CHC level.

Narayanpur Sterilizations 12 - 13

Reported % of Reported Sterilization Total Sterilization 453 NSV 123 27% Laparoscopic 328 72% MiniLap 2 0% Post Partum - 0% Male Sterilization 123 27% Female Sterilization 330 73%

3) Unmet need of family planning: The total unmet need is 26.4% in the district, which is understandable considering the overall picture of the district.

Naryanpur- Unmet need ( DLHSIII) met by reported FP Methods - Apr'12 to Mar'13

Unmet need met Estimated total Eligible Couples for Total reported by Reported Eligible Couples 24,329.89 unmet need FP Users Family Planning (17% of population) Methods Unmet Needs 26.4 6,423 4,127 64% Total Limiting 10.9 2,652 453 7% Spacing 15.5 3,771 3,674 57%

L) Neonatal and Child Health: Overall:

1) Vital rates: • There is lack of district specific data from SRS or AHS. There is also significant possibility of underreporting. For example, the NMR is almost equivalent to Maharashtra! To rule out this, an independent audit would be advisable, and the district should be included in AHS. • The current SBR is high, signifying high burden of birth asphyxia and lack of emergency obstetric care, including LSCS. The high SBR could also be due to mis-classification or reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth Asphyxia. This creates an erroneous picture of less IMR preventing the possibility of corrective measures, and hence must be audited. • The Post neonatal mortality is also high, signifying lack of even ARI and diarrhoea management services.

Narayanpur: Deaths 12 - 13 Early Neonatal Live Births - Reported Live Births estimated Still Births deaths 2,843 3,420 90 60 Under 5 Late Neonatal Deaths Infant Death Maternal Deaths Deaths 3 118 145 8 Narayanpur Vital rates Against Reported Live Against Estimated Live Births

Births (1000) (1000) Reported Still Birth 31.66 26.31 Reported Perinatal Mortality 52.76 44 Reported Neonatal Mortality 22.16 18.42 Reported Infant Mortality 41.51 34.50 Reported Under 5 Child Deaths 51.0 42.39

2) Timing of Childhood Mortality: • Early Neonatal, Post Neonatal and Toddler Mortality are significantly high in Narayanpur. The provision of home based newborn care, timely referral, provisions of standard and quality intensive care can prevent a significant proportion of these deaths. Hence it is crucial to identify delays in identifying critical newborns, whether facility admissions are as per the protocol and whether there has been adequate and quality roll out of HBNC. • A postpartum visit by both the ANM and ASHA in case of home deliveries as well as in case of institutional deliveries where the mother gets discharged early is hence crucial. There is significant possibility of this not happening and hence the there is need of supervision of the work of ANM. • The high Post Neonatal and Toddler Mortality is extremely worrisome. It is indicative that Narayanpur is lagging far behind India as a whole where now NMR is the key component of Childhood mortality. In Narayanpur, ARI and Diarrhea management programs are also possibly dysfunctional, with lack of training and supplies to frontline workers, leading to high childhood mortality in these age groups.

3) Causes of Childhood Mortality : The causes of childhood mortality show great preponderance of Pneumonia as overall cause of childhood deaths. This needs to be urgently addressed (and can be easily done) with training of ASHA and ANM in Childhood ARI management and ensuring supplies.

4) Anganwadi Centers: In Narayanpur, Anganwadi Centers are in functional in several remote villages. In fact, they are the only residential, functional facilities. Several of these Anganwadi are run by RK Mission. These Anganwadi centers offer unique opportunity in that they have an almost captive population of children for any intensive nutritional and health intervention and are manned by educated and committed workers trained by RK Mission. On the other hand, the children in these Anganwadi have several health problems, especially nutritional, dematological, ophthalmic and of ENT.

Hence strengthening the Anganwadi with better drug supplies, training and health interventions has possibility of rich dividends for child health.

M) SNCU: There was no SNCU at district hospital. Only a NBSU is present with average 31 admissions per month.

Areas of concern: • No outbound admission was in NBSU in the entire year. This reflects severe lack of referral linkage or refusal to accept admission, and must be explored and rectified. • The proportion of Still Births was 8.18% and very high. This reflects lack of facility and training of asphyxia management as well as lack of timely emergency obstetric intervention. • The proportion of newborn delivered in the hospital and being admitted into the NBSU was 34% and very high. This reflects lack of proper labour room management, and must be rectified. • Overall, the maintenance of data was poor and need attention.

Name of District Narayanpur : 1 APRIL 2012 - 31 MARCH 2013 Total Admissions to Still > < 150 < Cure LAM Referre Deat % Deliver NBSU Birt 2500 2000 0 - 150 d & A d h Deat y h gm - 200 0 D / c h Inbor Out Tot 2500 0 gm n bor al gm gm n 1099 377 0 377 90 Data not available

N) Nutritional Rehabilitation Center: There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It was heartening to see patients in the NRC. Areas of Concern: • Keeping the mothers with the children for the required number of days is a major problem despite the remunerative incentives to stay. This was due to family considerations. • Poor Follow up and difficulty in community based follow up. • The weight gain was unsatisfactory. 15% weight gain was in less than 50% cases. • Lack of remunerative incentives if the children are admitted again or for follow up. The remunerative incentives for the first admission were only for a stay of 15 days, and not more (even if the family wishes to stay for longer duration and the weight gain is unsatisfactory). • In places like Narayanpur, with high overall disease burden, poor outreach services, recurrent communicable diseases and overall poor literacy and financial levels, it is very much likely that a child who has once recovered from undernutrition would again fall back due to the above mentioned reasons. It is also highly likely that the duration required for a Madia / Gond child in Narayanpur for catch up weight gain would be significantly higher, and a cut- off of 15 days would be inadequate. • Hence all the financial remunerative incentives to the mother as well we the Mitanin must be continued for follow up as well as subsequent admission. There should be no cap of 15 days stay in the facility if the mother wishes to stay for more days with the child and there should be commensurate remunerative incentive for this.

NRC: April 2012 - March 2013 Total Bed Achieved Discharge LAMA / Non Death Still in admissions Occupancy target weight from NRC Defaulte Respond Ward Rate (15% weight r ers gain) 149 75.9 11.35% 128 14 2 1 0

NRC: April 2012 - March 2013 Children Children Defaulter for Non Death Relapse No. of Achieve due for followed follow up responder during Children d follow up up after 4th follow completed MUAC follow up up 4th follow >11.5 period up cm & wet>2sd 142 67 71 2 0 2 4 22>91

O) Outreach Services:

Overall ANC registration and post partum visits are significantly less. There was lack of availability of MCH registers. Despite repeated demands to the State HQ, there has been no provision since 5 to 6 months. Ultimately, the district printed the MCH registers using the untied funds. MCH Clinics are not functional in Narayanpur, and were not assigned to the district.

Performance Indicators of ANM Apr'12 to Mar'13 % ANC Registration in First Trimester % PNC visits within 48 hours and 24% 42% against Reported ANC registration 14 days against total deliveries % Three ANC checkups against estimated % Severe anemia (Hb<7) treated 69% 1.4% pregnancies. against reported ANC registration ANC ANC Check-up in first trimester 758 3 or more ANC Check-up 2,578 At least 1 TT received 2,091 100 IFA Tablets 3,311

P) Immunization:

1) Immunization coverage: The immunization rate for individual vaccines as well as the overall full immunization coverage at 1 year is around 90%, and this is significant achievement. The Cold Chain was difficult tp maintain considering the lack of electricity. Also, the staff had to walk for several kilometers to ensure vaccination in the hamlets and villages.

2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA including difficult terrain and inability to pass on information should be considered.

Child Immunisation (0 to 11 months) Measles given against Expected Live 82% Births

Measles given against Reported Live Births 98%

Fully Immunised Children against 95% Reported Live Births Fully Immunised Children against 79% Expected Live Births Required numbers of VHNDs per 1,7 thousand population in 12 months 17

3) Hepatitis B Vaccination: If the delivery is not institutional, the child is not given any dose of Hepatitis B vaccine. It was pointed out to the district officials that it is better to vaccinate late than never. Considering the situation of Narayanpur where institutional delivery is difficult, the opportunity to vaccinate a child for Hepatitis B should be utilized any time when possible including when the ANM visits the village and encounters the child for the first time.

4) Alternate Vaccine Delivery System: The district health system officials pointed that instead of sending the vaccines through another person, sending the vaccines through ANM with additional incentive to the ANM would improve the efficiency of vaccine delivery pointed it.

5) Immunization system: • There were only 8 BCG vials in the District Hospital. • The rule of supply of the vials as per the expected population of children and 1 vial per 4 children and to be used immediately after opening is creating difficulties in Narayanpur. It is observed that the villages in Narayanpur are very small (to the extent of 304 houses only) which means effectively the number of children to be immunized would be quite less, in several cases, less than 4. At the same time, the distances being large and terrain being difficult, generally visit to 1 or 2 such hamlets would only take the entire day. Overall, this was resulting into wastage of vials where 1 vial was being used for less than 4 children and then discarded. And finally less supply (based on the norm of 1 vial for 4 children) compared to actual feasibility of use in Narayanpur. • Hence the norm should be reconsidered in Narayanpur and more supply should be provided with more liberal norm.

Q) ASHA, VHSNC and NGO Partners:

1) Selection: • In Narayanpur, of the approved 525ASHA, 508 were in place. Similarly the positions of 2 Block Community Mobilizers have been filled.

2) ASHA training: No. of ASHAs trained in: 2012 - 13 • Module five 300 • Module six 305 • Module seven 305

3) Tasks ASHA is supposed to perform are as follows:

• JSY delivery in PHC or any recognized hospital (Tribal & Non-Tribal Areas) • Motivation of BPL/SC/ST beneficiary for tubectomy • Motivation of any beneficiary for vasectomy • Completion of DOTS (RNTCP) • Radical treatment of malaria Positive case • Leprosy treatment • Control of epidemic (outbreak) • Escort of pregnant women for HIV testing in PPTCT centers, Admission of HIV +ve mother for delivery in PPTCT center, Follow up of HIV positive mothers at 6 week, 6 and 18 months • Immunization at Village Level • Motivation of community for toilet construction • Birth Information Registration of Birth • Death Information of Age group 0 to 5,Information of women death for the age group between 15 to 49 years • For recording of Maternal death in the age group of 15 to 49 yrs, Yearly Immunization, • Bringing critically ill child to hospital (for tribal areas only) • Sickle Cell control program

4) The key problems identified were: • Lack of HBNC kits. • Lack of regular drug kits and antimalarials. • Lack of system of drug refilling. • Lack of supervisory visits. • Lack of training of Mentor Facilitator. • Lack of alternate system of payment in case the mother cannot avail the services of JSSK (transport etc) due to poor connectivity, emergency and lack of vehicle. • Lack of Travel Allowance for the Mitanin. A flexible system of travel allowance based on distances to be travelled and transport facilities is extremely necessary.

5) Conflict Situation and its effects: There are several instances of the Left Wing Extremists asking for medicines to the health staff as well as the Mitanins. At the same time, the security forces also question the Mitanin regarding the stock and supplies they carry from the block of district HQ meeting to their villages with the doubt the medicines they carry would be for the Maoists. Considering this, it should be ensured that the Mitanin receive regular supplies inside the village to escape from the questioning from security forces.

Overall, in places like Narayanpur where the formal health system is weak, it is extremely crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system, which is feasible locally, extend their training, provide them the necessary supplies and expand the roles. They are the last connection with the people of the health system, especially in districts like Narayanpur where the regular other health system is limited due to several reasons.

Similarly, the tasks of ASHA in Narayanpur need to revised and reviewed in view of the local priorities. Accordingly, the ASHA incentive structure should be restructured .

5) VHSNC: • Gram Panchayat are not fully functional and strengthened in Narayanpur. Due to the opposition by the Maoists to elections, Sarpanch and Gram Sevak hardly reside in villages. It was pointed that a Sarpanch gets elected by less than 10 votes, and immediately leaves the village after election and generally stay in Narayanpur. This hampers functioning of VHSNC and difficulty in expenditure of the funds. Sarpanch are also not aware of the funds. • Mitanin find it difficult to work in-sync with the Sarpanch considering their consistent unavailability. The method of release of their payment through Panchayat also does not function. It was feared that with the implementation of the system of payment through Panchayat; the minimal incentives the Mitanin were getting so far will also get stopped. Hence due consideration must be given regarding the feasibility of implementation of this mechanism in these areas where the Panchayat are dysfunctional. • It was also suggested that in view of the unavailability of the Sarpanch and Gram Sevak, Bearer Cheque may be considered for payments of Mitanin, or an alternative.

6) IEC: It was pointed out by the IEC officer that the orientation camps undertaken in the past with rigorous group discussions was a better model to communicate with tribal and convince them. This was a more personalized approach considering the culture and literacy level. Compared to this the current program is more vertical where the contents, IEC material are all directly sent from Raipur and are not in the local language (neither Gondi nor Madia). In fact considering the overall literacy level, written material does not serve much purpose for IEC in the areas like Narayanpur.

7) NGO: Ramkrishna Mission is functional in Narayanpur district in the most interior parts, providing extremely useful services. In fact, at several places, the ICDS run by the mission are the only functioning component of the system. Hence more convergence and involvement of the RK Mission with health services will be useful.

S) Program Management:

1) Key issues emerging were: • Can the several reporting systems be integrated and automated? • Can there be dynamic rate for fuel? Considering that, increment is the trend. Can the distance from district HQ be considered for calculating the budget for the facility? • Can there be Induction training for NRHM staff and the DPM? There can be a bond for DPM to continue after receiving the training. • Can there be adequate block program management structure (which is currently almost absent)? • The criteria of allowing recruitment only from the district is probably acting as a bottleneck in filling the vacancies as there is significant lack of the trained HR for the respective positions in the district. Hence, can this rule be relaxed, probably on a case basis, and / or allowing recruitment from adjoining districts such as Kanker, Dantewada, Bijapur, Sukma, Kondagaon and Bastar? • A review meeting at the block level generally requires travelling by the staff for 3 days due to poor logistics and terrain. This affects the review as well as leads to waste of the working days of the outreach staff. Can there be a solution to this?

2) PIP Planning and setting priorities: The process of setting priorities for Narayanpur should rigorously take into consideration the local morbidity pattern, and not enforce other priorities. For example, it was observed that the BMO or Orcha, who is the only MBBS doctors in the entire block, and is holding the additional charge of District Malaria Officer, had to go to Raipur to attend a meeting on ‘YAWS’. This would lead to his absence from the facility and the block for almost 3 days, depriving the people of crucial health services. It is also highly questionable whether YAWS is a priority in general and specifically for the districts such as Narayanpur.

T) Quality of Services and supportive services:

1) Clinical care protocols and management AND Quality Assurance: The key constrains were lack of: • Proper case papers for patients and maintaining the case records. • Standard guidelines for clinical management. • Hand-over and signature when duties change, leading to lack of complete information of the patients and accountability of clinical staff. • Isolation wards. • Firefighting facility

Other issues: Infection prevention practices were relatively inadequate in the facilities visited. For example, the Ambu bag and baby warmer not sterilized. The Quality Assurance committee and teams are absent, and there is no separate system or human resource. Overall, there is significant need of quality measure to improve the quality of curative services in all the public health facilities.

2) Solar: The regular functionality of the solar back-up system is a positive finding from Narayanpur. Generally, the system was well functional, and was extremely crucial considering the recurrent episodes of power failure. Hence, there should be an integrated plan for regular maintenance and troubleshooting of solar system. Currently the complaints are lodged with CREDA, but the response and troubleshooting is delayed and hence alternative should be considered.

3) Biomedical waste disposal: Overall, there was lack of proper segregation and management of biomedical waste and lack of knowledge. The color-coded bags were available at the DH, the CHC visited, though the method, and protocols were not followed rigorously. A tender was under process for incinerator at Jagadalpur where all the waste will be taken for disposal. Hence establishing an Incinerator in Narayanpur should be considered for each of biomedical waste management.

4) Mobility facilities: • Logistics and mobility is a major problem in Narayanpur. Roads are already in poor condition and are completely blocked in monsoon. In such conditions, no regular 4- wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel. The only vehicles that can pass are Tractor (or tractor like vehicles), a Jeep with 4 Wheel gear system and motorcycle. • There is significant lack of public transport in these areas. • Ambulances cannot travel due to poor roads and less ground clearance of the vehicle severely affecting the availability of emergency medical transport system. This prevents the health system of performing its crucial task and eliminates the possibility of the representation of the State in a human form at the most crucial and required hour. • The ANM, Mitanin Block Resource Persons, MPW, LHV need have to unfortunately travel on cycle or feet, forcing them to walk large distances, affecting the outreach and timeliness of services. • A key constrain emerging was the absence of funds for the repair of vehicles including tires and battery which limits the functioning of the vehicle. • Though the general life cycle of vehicle in plain areas is considered 10 years, in the extremely difficult terrain of Narayanpur, the life cycle of vehicles is not more than 5 years, including recurrent and major expenditure on maintenance. This should be considered and provided for in the PIP.

Possible solution: • Can the field cadre be given Motorcycle considering the roads and distances? Similarly, the facilities should have vehicles, which are Jeep with 4 Wheel gear system and / or a Tractor which is actually the most all weather vehicle in such terrains. It has high ground clearance, and is any ways used to free vehicles stuck up in mud and poor roads. • Additionality it should be considered to provide POL for the outreach cadre in these areas. 5) Mobile and Internet connectivity: • Lack of connectivity is one of the major problems in Narayanpur. Cell connectivity is limited within a radius of few kilometers of the district HQ. Even that is absent when the security forces go for patrolling to avoid information being spread about the whereabouts of the security personnel and avoid an ambush. • Internet connectivity is only in the district HQ, even where reliable network is generally limited to the offices of Collector and CEO. On the day of visit, internet connection was absent in the CMHO office since past 48 hours. • In view of this, provision of VAST facility is crucial in Narayanpur. Additionally, the health facilities and CMHO office should be included in the SWAN system.

6) Infrastructure creation, maintenance and public works department: • The work of the PWD was poor and maintenance was unsatisfactory in several of the facilities visited. Uniformly everywhere, water seepage, lack of staff quarters and delayed construction were problems. • Apart from other bottlenecks in constructing PHC and SHC in the interior, the opposition from the Left Wing Extremists is a major additional problem in this area. Any structure, which has solid walls with flat roof, is opposed by the Maoists due to the possibility of the structures being used by security forces to establish their bases. This is one of the major cause of the inability to do the necessary expenditures. In fact, the constructions from 2010 – 11 are still ongoing in Narayanpur, and lack of construction is a key constrain in the utilization of health services. • In view of this, the district administration has proposed a novel structure of Bamboo, which is treated to be fireproof, waterproof and anti termite with reasonable strength to last for up to 30 years. These structures are being constructed in Bijapur and so far are unopposed by the extremists. In view of this, the construction of these structures can be considered for support in the PIP.

7) HMIS / MCTS: The key observations were: • It is extremely difficult to establish and operationalize internet-based systems such as MCTS which assume reasonable speed and penetration of internet facilities in places like Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur is probably affecting the regular functioning of the system. • Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to only the district HQ (not even block HQ) for such entry, as district HQ is the only place with overall internet facility. For such, she would require to travel and spend 3 days considering the lack of transport facilities in the district. At the same time, there is no assurance that the internet would be functioning on that particular day when the ANM has reached the district HQ. • There was significant confusion in the minds of ANM regarding the HMIS and MCTS reporting. This adds to even lesser enthusiasm about MCTS. • There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero dose in the manual format but its inclusion in the software. • Additionally there is the persistence problem of villages of a certain PHC / block shown under different PHC / Block resulting in more problems in reporting. • Offline entry should be made possible in MCTS.

In view of this, it is extremely crucial to reconsider the reporting systems, which take into considerations the peculiarity of these conflict areas. The systems should aid, not pose challenges in providing regular clinical services, which are most necessary.

Other Health Priorities / programs in Narayanpur 1) Mobile Medical Unit: In Narayanpur district 1 MMU is operational with average daily OPD of 52 patients. Daily on an average 14 lab tests were conducted. The average number of villages covered each month was 20 with 20 functional days per month. It will be useful to explore how to improve the diverse functionality of the MMU, including services for NCD. A key problem was the large size and poor ground clearance of the MMU which would lead to the vehicle getting stuck several times on the roads.

2) Surgical morbidities and referral Tertiary Care: • Considering the surgical morbidities expected in the population but the lack of the surgical human resource in the district, camp approach to provide surgical care should be actively considered. This is especially important considering the experience from the monitoring visit that tribal from quite interior village were willing to receive medical care for their morbidities, but unable to due to several other reasons in addition to lack of surgical care at the district HQ. • It was observed in the monitoring visit that tribal from interior villages are willing to receive benefits from the health system, especially in case of tertiary care. It is hence recommended that a system and special fund covering the entire cost with the necessary provision of support for referral care and tertiary care including transport, a trained medical social worker as accompanying person should be established. This will also send a very positive message to the tribal from the health system.

S) Disease Control Programs: 1) IDSP: The district program management unit had recruited a person after significant efforts as IDSP I / c who was functioning. Nevertheless, due to the recent change in the HR criteria, which makes it mandatory to have 3 years of experience to be eligible for the post, the current IDSP manager would be terminated. It is important to understand that at places like Narayanpur, it may not be feasible to insist on 3 years of prior experience. It may effectively mean that the post would remain vacant. Instead, on job training can be considered as an alternative, if the person is committed and willing to learn and work.

2) Malaria: Narayanpur district, especially the tribal, remote and left wing extremist affected area are endemic for malaria, especially falciparum. Though the commitment of the outreach staff who are willing to work in a mission mode in cases of malaria epidemics is remarkable, following key concerns and emerged:

• There was no integrated malaria prevention and management plan. Schedule of IRS was absent. Similarly, LLIN or ACT and other antimalarials were not supplied. • A repeated problem faced is the lack of Syrup of ACT (the recommended drug for falciparum malaria in endemic zones like Narayanpur) for treating children. It is very difficult to ensure compliance with tablets in children. • There must be urgent provision of RDK, LLIN and IRS. • There must be an annual timeline of distribution of LLIN and IRS.

3) RNTCP: Considering that the burden of TB would be quite high in tribal district like Narayanpur (as is the experience from other tribal districts), the suspected cases examined are less, with a proportion of only 140 / 1,00,000. Overall, the screening and case detection needs to be increased. This is possible through: - Ensuring TB screening through the MMU. - Mass-selective screening of patients of cough through ANM and ASHA - Increasing the access to sputum collection through ANM and ASHA - Considering establishing advanced diagnostic method like DNA / PCR.

Indicator Narayanpur Total population Covered (In Lakhs) 1.40 TB Suspects examined per lack of population per quarter 196 Total Patients registered for treatment 226 Total no smear positive patients diagnosed 100 Treatment outcomes, new smear positive rates (%) 54.21

Annexure:

Annexure 1: Human resource status in Narayanpur under NRHM District Name :- Sr. Programme Sr.No Narayanpur Post Name No. Name . Sanction Filled Vacant Post Post Post 1 2 3 4 5 6 7 1 Dist.Programme Manager 1 1 0 2 Dist.Account Manager 1 1 0 1 DPMU 3 Data Entry Operator 2 1 1 4 Statstical Investigator 0 0 0 4 M&E Officer 0 0 0 2 M&E 5 Statstical Investigator 0 0 0 6 IPHS Co-Ordinator 0 0 0 3 IPHS 8 Programme Assistant / DEO 0 0 0 10 Lab.Technician 0 0 0 11 Accountant (C.S.) 0 0 00 4 FMG 12 Accountant (Z.P.) 0 0 0 13 District Community Mobilizer 0 0 0 5 ASHA 14 District Asha Assistant 0 0 0 15 Block Community Mobilizer 0 0 0 16 Asha 0 0 0 6 RKS 17 RKS Co-Ordinator 0 0 0 18 Programme Supervisor 0 0 0 19 Programme Assistant 0 0 0 School 7 20 Medical Officer (Male) 0 0 0 Health 21 Medical Officer (Female) 0 0 0 22 Pharmasist 0 0 0 23 Medical Officer (Aurved) 0 0 0 24 Medical Officer (Homeopathy) 0 0 0 25 Medical Officer (Unani) 0 0 0 26 Masajist (Male) 0 0 0 8 AYUSH 27 Masajist (Female) 0 0 0 28 Pharmasist 0 0 0 29 Ayush Nodal Officer 0 0 0 30 Data Entry Operator 0 0 0 31 Sickelcell Co-Ordinator 0 0 0 9 Sickel cell 32 Lab Technician 0 0 0 33 Deputy Engineer 0 0 0 10 IDW 34 Junior Engineer 0 0 0 35 Accountant Cum Operator 0 0 0 36 Accountant 2 00 2 11 BPMU 37 Programme Assistant 0 0 0 Procurement 12 38 Pharmasist 0 0 0 / Store Infrastruture 39 ANM (N.& T) 33 4 0 13 Human 40 LHV (N.& T.) 11 1 Resorce 41 Staff Nurse (N.& T.) 0 0 0 14 Urban RCH 42 ANM 0 0 0 15 Arsh 43 Arsh Supervisor 0 0 0 16 Telemedicine 44 Facility Manager 0 0 0 17 PCPDNT 45 Legal Advisor 0 0 0 Referral 18 46 Call Assistant 0 0 0 Transport Rutine 19 Immunizatio 47 Data Entry Operator 0 0 0 n 48 Epidemic Officer 0 0 0 20 IDSP 49 Data Entry Operator 1 1 0

Annexure 2: Human Resources

Regular Contractual In position In Category / Sanctioned In Sanctioned (through position Total in Vacancy type of posts position posts state/other from position (%) personnel sources) NRHM (E) 1st ANM 74 72 0 0 0 72 97.30% 2nd ANM 0 0 33 0 4 4 12.12% MPW/ Male 66 25 0 0 0 25 HW 37.89% Staff Nurse 50 14 11 0 1 15 total 24.59% DH 30 15 0 0 0 15 50% Regular Contractual In position In Category / Sanctioned In Sanctioned (through position Total in Vacancy type of posts position posts state/other from position (%) personnel sources) NRHM (E) FRU 0 0 0 0 0 0 0% 24X7 PHCs 2 0 0 0 0 0 0% Other 18 0 0 0 0 0 facilities (Pls. specify) 0% LTs 10 5 0 0 0 5 50% DH 2 2 0 0 0 2 100% FRU 0 0 0 0 0 0 0% 24X7 PHCs 2 1 0 0 0 1 50% Other 6 1 0 0 0 1 facilities (Pls. specify) 16.66% Pharmacists 14 7 00 0 0 7 50% MOs total 24 11 0 0 0 0 45.84% AYUSH 0 0 0 0 0 0 MOs 0 DENTAL 1 0 0 0 0 0 MOs 0% Specialists 26 1 0 0 0 0 total 3.84%

Obstetricians 1 1 0 0 0 1 & (PGMO) Gynaecologist 100% Anaesthetist 1 1 0 0 0 0 (PGMO) 100% 1 1 0 0 0 0 Paediatrician (PGMO) 100%