1 Bihar 1. District- Begusarai Major Observations of Regional

Bihar

1. District- Begusarai

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

I. Details of the visited Institutions:

District visited PHCs visited HSCs visited Begusarai PHCs: Matihani, Bakhari, Bagdav, Hanspur, Godargama, Ratar, Mohanpur, Bachchawara & Bhagawanpur Salauni, Chianjivipur, Chauth, Rasalpur & Maharauli

II. Major Observations:

1. Human Resources: Though the detail information on the staff position was not made available in the district, some of the posts like 44 posts out of the 122 sanctioned posts of Specialists / Medical Officer and 4 posts out of the 28 sanctioned posts of Lab Technician were lying vacant in the district.

2. Rogi Kalyan Samiti (RKS) &Village Health Sanitation Committee (VHSC): a) Rogi Kalyan Samiti (RKS) was constituted at all visited institutions in the district but their meeting were not conducted regularly. b) 257 Village Health & Sanitation Committees (VHSCs) were constituted in the district. 3. Service of Janani Suraksha Yojana (JSY): a) During visit to the centres in the district, it was observed that most of the deliveries under JSY were recorded as institutional but in fact in the visiting areas large number of home deliveries were conducted by untrained persons. b) 11 (28%) JSY beneficiaries were contacted out of 40 newly delivered mother selected for interview. All beneficiaries were having MCH cards. It was found that timely payment of JSY packages were not made due to irregular allotment of funds. c) It was observed that necessary information was not recorded in JSY cards. Some mothers had not received three consecutive PNC checkups. d) JSY status in the visited PHCs Bakhari & Bachchawara as reported is given below: Sl. Particulars PHC Bakhari PHC Bachchawara No. 20010-11 2011-12 20010-11 2011-12 1. No. of deliveries eligible 3777 2910 1836 2253 for payment under JSY 2 No. of beneficiaries to 3777 2850 1836 2253 whom JSY fund were paid 3 Total fund received 1,24,94,500 81,12,400 63,31,400 49,04,500 4 Expenditure incurred 1,24,92,800 81,11,900 49,26,900 41,54,300 under JSY 1

4. Functioning of ASHA scheme: a) As against the target of 2629 ASHAs, 2325 ASHAs were in position in the district. All selected ASHAs were having drug kits. Training in all modules was not yet provided to the ASHAs. b) Role of ASHA in the activities under JSY to accompany the mother to hospital was observed to be not up to the mark. 5. Untied funds: a) The team could not assess the provision and expenditure of Untied Fund in the district as District Programme Management Unit did not provide the details of fund in this regard. b) Status of untied fund in the visited PHCs was reported as below: (in Rs.) Name of 2010-11 2011-12 PHCs Fund Expenditure Balance Fund Expenditure Balance available available Bakhari 80,000 80,000 Nil 50,000 Nil 50,000 Bachchawar 50,000 11,666 38,334 38,334 37,996 338 a

6. 24 Hours Delivery Care Services: 24x7 hours delivery service was implemented in the district. As reported 13 institutions were working as 24x7 hours service provider in the district. 7. Physical Infrastructure and Stock Position: I. PHCs: a) PHCs visited at Matihani, Bakhari and Bachchawara have own building but the maintenance of the hospital buildings was not up to the mark. There was regular water supply, electricity and also telephone facility in the PHCs. b) At visited PHCs, most of the equipments, supplies and furniture etc were available. However Vit ‘A’ (tab) in PHC Bachchawara and AYUSH-MO in PHC Bakhari was not available. III. HSCs: a) Mohanpur and Ratar HSCs were having their own building. Electricity/water supply, labour room etc. were not available at both the HSCs. These HSCs have no MPW (M) posted. b) Both the SCs had no examination table, Benches for Clients, Ambu bag, Torch, Stove and Weighing Machine (Adult and Infant). c) Short supply of Metronidazol, Misofrostol, Magsulth, Oxitocine, Co-trimoxazole tablets, Ampicillin Capsule, Gentamycine injection and EC pills was observed in the visited Sub Centres. 8. Knowledge and Opinion of the Community on Health Service: a) 18 mothers having child of upto one year age were interviewed in the area of visited HSCs Mohanpur and Ratar. Mothers informed that ANMs are available when needed and also conducted

2 immunization clinic in regular basis. ANMs provided IFA and TT injections to pregnant women. Home deliveries were being conducted by trained persons in the area. It was observed that mothers had utilised DDK during home delivery. b) Most of the mothers had no knowledge about ARI. The ANC/PNC services need to be strengthened. 9. Sample Verification of Family Welfare Acceptors: a) Out of 101 selected FW acceptors, 31 (30.6%) could be contacted for Sample verification in the district. Minor discrepancy in the recorded age of acceptors/spouse and total /male children was found during sample check. b) No follow up services were observed to be provided to the 16 (51.6%) acceptors. c) 25 (80.6%) acceptors were satisfied with the method, as they had not faced any major complication. Out of 13 selected acceptors IUD acceptors, 10 (77%) cases were contacted and out of them 9 were continuing the method without any complication till the date of interview. One acceptor discontinued the service due to bleeding. d) The team could not draw OP & CC user sample due to non maintenance of records. 10. Maintenance of Registers & Records: a) Eligible Couple register was not maintained properly and up to date at Bachhawara PHC. This register was not made available at Matihani, Bakhari and Bhagwanpur PHCs. b) Sterilization service cum payment Register was not maintained properly at Matihani and Bhakhari PHCs and the same register was not made available at Bachhawara PHC. c) Cu-T service register and Oral pills & Nirodh distribution register were not made available at all the visited institutions. Cu-T figures reported for the year 2009-10 and 2010-11 could not be verified for want of service register at PHC head quarters. d) ANC Register was not maintained properly at Matihani, Bakhari and Bachhawara PHCs and the same was not made available at Bagwanpur PHC. e) Stock Register of IUD, OP and CC was not maintained properly at Bakhari and Bhagwanpur PHCs.

11. Other Observations and Suggestions: a) Monitoring and supervision in the district need to be enhanced especially for the activities taken up at Sub Centre level. b) JSY records at the visited centres reflected that most of deliveries are conducted in the hospital. Services of ASHAs in this regard were poor. To improve the services, effective coordination should be developed between ASHAs & ANMs.

3 c) Budgetary provision and utilization under various activities i.e., Untied Fund, AMG, JSY, ASHA and VHSC etc. were not made available by the DPMU. The team observed that, the members of NRHM Management Supporting Units at district as well as at PHC/CHC and the officials at district headquarter were not having adequate knowledge about the latest guidelines of different Programme under NRHM. The entire units need re-orientation training to improve the work.

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2.District- Muzaffarpur

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

I. Details of the visited Institutions:

District visited PHCs visited HSCs visited Muzaffarpur PHCs: Minapur, Mushahari & Salaha Jalalpur, Madhopur, Narauli, Saraiya Paharpur, Nawada, Munza & Mustafapur

II. Major Observations:

1. Human Resources: Though the information regarding the staff position was not made available in the district, some of the posts i.e., 87 out of the 233 sanctioned posts of Specialists / Medical Officer, 226 of the 1168 sanctioned posts of ANMs and 35 out of sanctioned 184 posts of GNMs were lying vacant in the district.

2. Rogi Kalyan Samiti (RKS) & Village Health and Sanitation Committee (VHSC): a) Rogi Kalyan Samiti (RKS) was constituted at the visited institutions in the district and its members meet quarterly. b) As per District profile, 374 Village Health & Sanitation Committees (VHSCs) were working in the district. All VHSCs have ASHA as a member. c) In the district VHSC funds to the tune of Rs. 1,21,14,639 were provided during the year 2009-10, but only Rs. 9,97,500 (8.2%) were spent till March, 2011. 3. Services under Janani Suraksha Yojana (JSY): a) JSY was functioning in the district. For this, the District received JSY funds to the tune of Rs. 8,34,69,052 during 2009-10 and an amount of Rs.6,50,57,716 (77.94%) was spent during the year. b) In the visited PHCs Minapur, Mushahari & Saraiya, JSY status as reported is given below: Sl. Particulars Distt. Hospital PHC Minapur PHC Mushahari No. 20010-11 2011-12 20010-11 2011-12 20010-11 2011-12 1. No. of deliveries eligible 43322 55180 1766 2078 1625 546 for payment under JSY 2 No. of beneficiaries to NA NA 1766 1438 NA NA whom JSY fund paid 4 Total fund received 7362218 NA 5696739 3188500 2845450 3386100 5 Expenditure incurred 65057716 NA 2802600 3173100 2169000 3371700 under JSY NA: Not available.

5 c) As many as 19 JSY beneficiaries were contacted in the district, MCH cards were issued and most of them were registered in the earliest stage of pregnancy. ANC/PNC checks up were completed in time. d) It was observed that most of the beneficiaries were not paid due to irregular allotment of funds under JSY. e) It was found that necessary information was not recorded in JSY cards but immunization cards were filled up properly by the concerned ANMs. 4. Functioning of ASHA scheme: a) There were 3504 ASHAs as against the requirement of 3984 ASHAs in the district. It was reported that 2787 ASHAs out of total no. of 3504 were trained in 4th modules. b) It was also reported that as many as 3298 ASHAs (more than trained ASHAs) were having drug Kit in the district. 5. Untied Funds: Details of untied fund are reported as below: (in Rs.) Type of Institution 2009-10 Fund Expenditure Balance % of funds available Utilized APHCs/PHCs 12,36,307 5,61,585 6,74,722 45.4% Sub centre 43,78,300 21,29,400 22,48,900 48.6% Total fund for whole district 56,14,607 26,90,985 29,23,622 59.8% a) The district had received untied funds to the tune of Rs. 45,01,907 during 2009-10 and out of that Rs. 26,90,985 was spent. b) Apart from above, Rs. 1288159 as Annual Maintenance Grant for the year 2009-10 were provided to the district, out of which Rs. 4,71,193 were spent. c) The details of Untied Funds and Annual Maintenance Grant (AMG) for the year 2010-11 were not made available by District Programme Management Unit (DPMU), Muzaffarpur. 6. 24 x 7 Hours Delivery Care Services:- a) 24x7 hours delivery care services for promotion of institutional deliveries in rural areas were set up in 16 institutions in the district. b) Total number of deliveries conducted in Mushahari PHC were 1481 and 1625 during 2010-11 & 2011-12 respectively. The actual no. deliveries conducted in the night hours were 766 and 843 during 2010-11 & 2011-12 respectively in Mushahari PHC. 7. Physical Infrastructure and Stock Position: I. PHCs: a) The visited institutions viz. Minapur, Mushari and Saraiya PHCs had own building having regular water supply, electricity connection and telephone facility.

6 b) Most of the required Equipments, Apparatus and Vital/Essential drugs etc were available in the visited PHCs. II. HSCs: a) Paharpur and Mustafaganj HSCs were having their own building. Electricity, water supply and labour room etc. were not available at both the HSCs. Paharpur HSC has no post of MPW (M). b) Ambu bag/Suction, Steam Sterilizer, Stove and Kerosene Oil were not available at Paharpur and Mustafaganj HSCs. Similarly, Foot Stool and Delivery Table were not available at Paharpur HSC. Examination table, benches for clients, Torch, Weighing machine, Thermometer and Gloves were not available at Mustafaganj HSC. Magsulth, Oxitocine and Co-trimoxazole tablets, Ampicillin Capsule, Gentamycine injection and EC pills were not available at both of visited Sub Centre. Nischay Pregnancy Test Kit, Haemoglobinometer, IUD, Oral Pills, Kits -A & B were not available at Paharpur HSC. IFA tablet/syrup, condom, Metronidazole and Misofrostol tablets were not available at Mustfaganj HSC. c) ANMs of the visited centres had not received SBA training. 8. Knowledge and opinion of Community on health service: i. Towards PHC’s service: a) In the area of the visited PHCs, villager, AWWs, ASHAs and ANC/PNC mothers were interviewed to assess their opinion regarding the quality of services provided at PHC level. Public opinion was good on the services being rendered by the PHCs visited by the team. b) It was observed that the services and health education in respect of Ante Natal Care (ANC), ARI & ORT and about AIDS and HIV needed to be improved. ii. Towards ANM’s service: a) 18 mothers having child upto one year of age were interviewed in the area of both HSCs Paharpur and Mustafaganj. Mothers replied that ANMs are available when needed and also conducted immunization clinic on regular basis. ANMs provided IFA and TT to pregnant women. Home deliveries were conducted by trained persons in the area. It was observed that mothers had utilised DDK during home delivery. b) Most of the mothers had no knowledge about ARI and ORT. 9. Sample Verification of Family Welfare Acceptor: a) 19 FW acceptors were contacted for sample verification in the selected area of the centres. Some discrepancies were found in the age of spouse and in the age of last child of the acceptors. b) Follow up services were provided to 13 (68.5%) acceptors. c) All contacted acceptors were satisfied with the method, as they had not faced any major complication. e) Some beneficiaries of child immunization were contacted by the team and found that services provided were satisfactory. 10. Reconciliation of Reported Performance:

a) The Sterilization and IUD reported at district office and concerned PHCs are given below: S. Name of the 2009-10 2010-11 No. Centre Sterilization Figure IUD Figure Sterilization Figure IUD Figure Reported Reported Reported Reported Reported Reported Reported Reported by Distt. by the by Distt. by the by Distt. by the by Distt. by the Off. PHC Off. PHC Off. PHC Off. PHC 1 Minapur 734 765 149 66 1402 1470 343 312 PHC 2 Mushahari 4932 234 144 144 4442 4067 459 643 PHC 3 Saraiya PHC 542 528 140 135 697 559 82 175

b) Nirodh performance reported by district office for the PHC Mushahari for 2009-10 was 3517 but as per the PHC records the figures were 7976.

c) Service register for IUD at the headquarters of PHCs were not maintained with complete details for both the years 2009-10 and 2010-11.

11. Maintenance of Registers & Records: a) Eligible Couple Register was not maintained at all the visited institutions in the district. b) Sterilization Service cum Payment Register was not maintained properly at all visited institutions in the district. c) Printed Service Register for Cu-T, was not available in the visited institutions. d) Printed Oral pills & Nirodh distribution registers were maintained but essential columns were missing at Mushahari PHC. e) ANC Register was printed but not maintained properly at Minapur PHC. Stock Register of FW items were not maintained properly at Minapur and Mushahari PHCs. f) Printed JSY beneficiaries register was available but not maintained properly at all visited centres. 12. Other Observations and Suggestions: a) Monitoring and supervision in the district need to be enhanced. Supervisory staffs need to check the overall activities of SCs including coordination between ASHAs & AWWs and all the records and registers. Staff of DPMU/BPMU be need immediate re-orientation under NRHM. d) Submission of utilization Certificate and Statement of Expenditure in respect of various funds provided at the SCs, PHCs and CHCs was very irregular and whatever submitted, it was without any details. In this connection, prescribed formats and guidelines should be provided to SC, PHC, CHC and District Hospital and concerned staff should be oriented for proper filling up of these formats /statements. e) During visit to the different centres the team, noticed lack of cleanliness in OPD, IPD, Labour Room and Maternity Wards. On enquiry, the concerned head of the centres informed about lack of manpower. The computer room was full of dust. Due to insufficient space, ANC/PNC clinics were not being conducted properly in the SC which is attached with the BPHCs.

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District- Samastipur

Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Samastipur District of Bihar State in the month of June, 2011.

I. Details of the visited Institutions:

District visited PHCs visited HSCs visited Samastipur PHCs: Samastipur, Bibhutipur Sub centres were not visited by team as Kalyanpur & Ujiyarpur all the ANMs were engaged continuously in pulse polio activities in their areas during the period of visit to the district.

II. Major Observations: 1. Human Resources: a) The details about the health human resources were not made available fully in the district. As reported, 190 Medical Officers and Specialists were working in the district against the sanctioned strength of 187. However, some posts i.e. 177 out of 962 sanctioned posts of ANM both regular and contactual, 60 of 170 sanctioned posts of GNM (regular and contractual) and 45 of 60 sanctioned posts of Lab Technician were lying vacant in the district. b) The sanctioned strength of MO was filled by the posting contractual MO in the district. 2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation Committee (VHSC): a) As reported by the district office, Rogi Kalyan Samiti (RKS) has been constituted at PHC, BPHC, RH and District Hospital functioning in the District. Meetings of RKS were being convened on required basis. b) Only 370 Village Health & Sanitation Committees (VHSCs) were formed against the 1239 villages in the district. 3. Service of Janani Suraksha Yojana (JSY): a) The team has visited PHCs Ujiyarpur, Bibhutipur and Kalyanpur in the district. In PHC Ujiyarpur, status of availability and utilisation of JSY fund and performance was no made available for previous years. But this PHC has received Rs. 9,76,500 for the current year 2011-12 under the scheme and the whole amount was lying unspent at the time of visit made by the team. In PHC Bibhutipur, there were 1100 beneficiaries waiting for their cash assistance in 2010-11 out of total 5306 beneficiaries in the year; the PHC had spent Rs. 91,54,050 out of the fund available to the tune of Rs. 1,24,07,500 during 2010-11. However, it was observed that all 626 beneficiaries were provided with the cash assistance in the year 2011-12 in this PHC. In PHC Kalyanpur, there were 4146 and 444 JSY beneficiaries in the year 2010-11 and 2011-12

respectively and the PHC has spent Rs. 64,31,400 and Rs. 15,88,800 out of available funds of Rs. 90,18,597 in the year 2010-11 and Rs. 2,58,97,197 in the current year 2011-12. b) As per the records available in the visited centres, most of the deliveries were institutional. But while visiting some villages, the team found that most of the mothers delivered at their homes with the help of untrained person. c) 13 recently delivered women who were JSY beneficiaries were contacted in the area selected for sample check. All respondents reported that they had received TT & IFA (L) during AN period. Most of them attended three checks up in their nearest service centre and necessary advice like Breast feeding & child nutrition were provided to them. Most of them were delivered in the hospital and also received JSY cash incentive. However post natal visits by the field workers need to be increased. 4. Functioning of ASHA scheme: a) As against the requirement of 3835 ASHAs for 1239 villages, 2442 ASHAs were in position in the district. Training to the ASHAs was not provided in the district, but Drug Kits provided to all ASHAs. b) It was observed by the team that the involvement of ASHA in assisting mothers for institutional delivery was very poor. c) Status of ASHAs scheme in the visited PHCs is as under: Sl. Particulars PHC PHC PHC PHC No. Ujiyarpur Samastipur Bibhutipur Kalyanpur

1 No. of villages taken up for 64 95 41 116 ASHA 2 Required no. of ASHA 267 261 324 301 3 No. of ASHA in position 241 213 250 247 4 No. of trained ASHA Nil Nil 248 211

5 Untied Funds: a) As reported, District Health Society distributed Untied Funds to the SCs, PHCs, CHCs and District Hospital but submission of utilization Certificate and Statement of Expenditure from these Institutions was very irregular and not up to the mark. b) During visit to the PHCs, it was observed that PHC Bibhutipur received Untied Funds to the tune of Rs. 2,63,290 and spent Rs. 2,40,000. No other PHCs had been given United Funds in the year 2010-11. Untied Fund for the current year 2011-12 was not distributed to the periphery level centres till the visiting month.

6. 24 x 7 Hours Delivery Care Services:

As reported, 25 Institutions were working as 24 x7 hours service provider in the district. No further details available in the report. 7. Physical Infrastructure and Stock Position: i. PHCs: a) The visited PHCs at Samastipur and Ujiyarpur had own building with regular water supply, electricity connection, power back-up and Toilet facility but maintenance of the hospital building was poor. Telephone facility, Vehicle and Microscope were also not available at both the PHCs. b) Auto Clave/Steam-Sterilizer, Oxygen Cylinder, Minor Surgical Equipments with other appliances for delivery purpose were not available at Samastipur PHC. c) Stock of Contraceptive in PHC Samastipur was nil on the day of visit. Prophylactic drugs i.e. IFA (small) a large/syrup and Vitamin ‘A’ were also not were available at Samastipur PHC. d) There was no residential accommodation available at both the visited PHCs. 8. Community Satisfaction about overall PHC Services: a) The team interviewed 10 community members including ANC, PNC and mothers having up to two year’s child, AWW, ASHAs etc. in the area of the PHCs visited at Ujiyarpur and Samastipur. It was found that the mother and child care services provided to the beneficiaries. b) Mothers did not have enough knowledge about ARI & ORT. The children were not taken for routine immunization in right time to the hospital. Community was not aware about AIDS and HIV. c) All the respondents were generally satisfied with the services provided at PHC level by the PHC staff and Medical Officers. 9. Sample Verification of Family Welfare Acceptors: a) The team selected 39 F.W. cases, out of which 20 (51%) cases could be contacted for sample verification in the district. Discrepancy in the age of spouse, number of total children and age of last child was found in all contacted (18) sterilisation cases. b) Follow up services were not provided to 12 acceptors. c) The team also interviewed 13 child immunisation beneficiaries out of 20 selected in the district. All of them confirmed receiving the doses and no discrepancy was found in the recorded data.

10. Reconciliation of Reported Performance: a) There were 824 and 24 Sterilisation cases reported for the year 2010-11 and 2011-12 (upto May) repctively by the PHC Ujiyarpur. Similarly, this PHC reported 110 and 6 IUD acceptors during same period. But the Service register for Sterilisation and IUD acceptors for the year 2010-

11 and 2011-12 (upto May, 2011) was not made available at the PHC Ujiyarpur for checking the figures. b) Due to incomplete service registers of IUD acceptors, the reported figures for the year 2010-11 could not be verified at PHCs Samastipur, Bibhutipur and Kalyanpur. 11. Maintenance of Register & record: a) Eligible Couple register was not made available to the team at all the visited institutions. b) ANC, PNC and JSY beneficiary register were maintained properly at Samastipur and Kalyanpur PHCs but not at Bibhutipur and Ujiyarpur PHCs. c) Stock Register of Cu-T, OP and CC were not maintained at Kalyanpur PHC and its Sub Centres and the same were not made available to the team at Samastipur, Bibhutipur and Ujiyarpur PHCs. 12. Other Important Observations and Suggestions: a) The team observed that due to absence of supervision at periphery level, maintenance of records and registers in respect of various health schemes was poor in whole of the district. Monitoring and supervision in the district needs to be enhanced. Cash book for untied funds, JSY, FW & MCH registers were not reviewed by supervisor. Registers and records whatever maintained by concerned worker for payment of JSY mothers were also not checked by concerned Medical Officers. b) Co-ordination between ASHAs and ANMs must be reviewed regularly so that institutional deliveries could be promoted further in rural areas.

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3. District- Patna

Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Patna District of Bihar State in the month of November, 2011.

I. Details of the visited Institutions:

District visited PHCs visited HSCs visited Patna Bakhtiyarpur, Paliganj, Bakhtiyarpur, Paliganj, Elahibagh, Sampatchack & Mokama Bahuara, Baireya & Mokama

II. Major Observations:

1. Human Resources:- The Staff position of the technical categories in the district was as follow:

Particulars of Post Post sanctioned In position Vacant Specialist 92 78 14 MO 423 265 158 LHV/HS(F) 60 34 26 Lab Technician 76 65 11 ANMs 527 506 21 MPW(M) 63 52 11

The above table showed that the district was facing acute shortage of Medical Officers, Specialists and supervisory posts. 2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation Committee (VHSNC):- a) 26 Rogi Kalyan Samitis were reported to have been set up in the district. RKS were registered in 3 SDH/FRU and 23 PHCs. Regular meetings of RKS were not being conducted in the visited institutions. b) As reported, Sufficient RKS Fund was available during financial year 2010-11 and 2011-12 in the District. The District utilized Rs. 22,89,165 and Rs. 2,84,856 during the year 2010-11 and 2011-12 (up to Oct, 11) respectively.

c) It was reported that 331 VHSNCs and 3937 Anganwadi Centres were functioning in the district.

3. Service of Janani Suraksha Yojana (JSY):- a) Janani Suraksha Yojana was being implemented in the district. The District spent Rs. 3,81,88,728 during 2010-11 and Rs. 8,99,03,817 during 2011-12 up to October, 2011 from the fund provided under flexi-pool budget. b) The team found that the services under JSY at visited PHCs were satisfactory. But cash incentive to JSY beneficiaries in the visited centres areas was not released in time. c) 15 JSY beneficiaries were contacted by the team in the area of the visited centres. All beneficiaries were satisfied with the services. All beneficiaries were provided TT & IFA (L) during A.N period and most of them received three Checks-up in their nearest service centre. Necessary advices like Breast feeding and child nutrition were also provided to them. Most of contacted mothers were delivered at Hospital and received monetary benefit under JSY scheme. However, post natal visit of field workers is required to be increased. d) JSY Cards and Immunization Cards were not filled with the complete information by concerned ANMs in the visited area. It was also observed that some of the mothers had not received the three consecutive checks up during ANC. a. 4. Functioning of ASHA:- a) 2981 ASHAs were working as against target set for 3233 in the district. 1695 ASHAs were trained in all modules but Drug Kit was provided to all 2981 ASHAs. b) ASHAs were receiving incentive money per month in the district. 5. Untied Funds and Annual Maintenance Grant:- a) It was reported that sufficient fund was available in the district. District spent Rs. 14,08,501 during 2010-11 and Rs. 51,232 during 2011-12 up to October, 2011as untied fund from the fund provided under flexi-pool budget. b) In addition to Untied Fund, the district spent Rs. 17,49,424 during 2010-11 and Rs. 6,49,960 during 2011-12 up to October, 2011 as Annual Maintenance Grant from the flexi-pool fund received by the district. b. 6. 24 x 7 Hours Delivery Care Services:- 15

As reported, 24x7 hours delivery care service was being provided in 30 institutions in the district. c. 7. Physical infrastructure Stock Position:- d. i. Health Sub Centres: a) The team visited Sub centres at Bahuara and Bairiya under PHC Sampatchak and observed that both were functioning in Govt. building but water, Electricity and toilet facility was not available at both the Sub Centres. Labour room was also not available at both the Sub Centres. b) ANMs of the visited Sub centers were not residing in their head quarter. Also, mobile phone was not provided to ANM. Additional ANM (2nd ANM) was available at both Sub Centers. c) Most of the equipment, drugs and other supplies were not available at Bairiya Sub Centre. Only B.P. Apparatus, Vit.A solution, IFA Tab/Syrup and paracetamole tablet were available there. d) Bench for clients, Cupboard for drugs, Foot stool, Ambu bag/suction, Delivery kits, RDT Kit, Weighing Machine, Thermometer, ORS Packet, DDKs, IFA Tab/Syrup, EC Pills, Misofrostol tab, Oxitocine tablets, Ampicillin capsule, Gentamycin injection and Kits- A & B were not available at Bahuara sub centre. e) SBA training was not received by the ANMs of visited Sub Centres. The posters for public awareness were not displayed on the wall of Sub Centres. f) Post of MPW (M) was lying vacant since more than 5 years in both visited Sub Centres. ii. PHC: a) Bakhtiyarpur, Paliganj, Sampatchack and Mokama PHCs were visited to assess the availability of infrastructure, services etc.. All visited PHCs were functioning in Govt. building with regular water supply, electricity with power back up, Telephone and Toilet facility. Vehicle was not available at Sampatchack PHC. b) Stock of Contraceptive, Vaccines and Prophylactic Drugs were available at all visited PHCs. IFA (syrup) and Vit. A tab were not available at the PHCs visited. 8. Community Satisfaction on overall Service:- i. Towards HSCs service: a) 20 mothers were contacted in both SCs Bairiya and Bahuara. Contacted mothers replied that ANMs were not available as per their need. Field visit was not made by the ANMs during last month. But they conducted ANC and Immunization clinic regularly. They provided IFA and TT to A.N mothers.

16 b) ANC and PNC services needed to enhance and to conduct regular basis in prescribed time. Most of the contacted mothers were aware about the use of contraceptive methods, ORT and symptoms of ARI. c) Home deliveries were conducted by untrained persons. d) All contacted mothers were aware of government health facilities where they can get all health facilities. ii. Towards PHC Servicees: Villagers interviewed in the area of the PHCs informed that the services at PHCs are satisfactory. MOs and staff are regularly available at the PHCs, they spend sufficient time in examining the patients and made available medicine & drugs satisfactory. It was found that M.O of Bakhtiyarpur PHC visits his villages on regular basis but M.O of Mokama, Sampatchack and Paliganj PHCs do not visit their villages regularly. 9. Sample Verification of Family Welfare Acceptors:- a) The team selected 86 Family Welfare acceptors (Sterilization, IUD, OP and Nirodh) out of which 35 (41%) acceptors could be contacted for sample verification in the district. It is a very serious matter that as many as 40 (47%) acceptors could not be contacted due to wrong/incomplete addresses. During sample check, age of spouse of the acceptors of all 35 contacted cases was found to be wrongly recorded. b) 25 (71%) acceptors found to have not been provided with follow-up services where as 5 (14%) acceptors replied as not known. 22 (92%) sterilization acceptors received full amount of compensation money whereas 2 (8%) acceptors replied that they do not know about the compensation amount. c) 14 Beneficiaries of child immunization were contacted in which all confirmed receiving the doses and also received follow up services. No complication was found among contacted beneficiaries and were satisfied with the services. 10. Reconciliation of Reported Performance:- There was no coordination between District office and reporting centres in respect of performance reported in the year 2010-11 and 2011-12 (up to October, 2011) The details are as follows: i) 500 Sterilization and 49 IUD cases were reported by PHC Bakhtiyarpur for the year 2010-11 whereas the figures showed in the report of district office were 211 and 45 respectively for the

17 same period. Performance report for OP and Nirodh was not made available at this PHC. ii) 848 IUD cases, 4741 OP cycles/user and 11764 Nirodh were reported by PHC Paliganj for the year 2010-11 whereas the figures shown in the report of district office were 682, 490 and 490 respectively for the same period. iii) 1628 Sterilization, 246 IUD cases, 578 OP cycles/user and 816 Nirodh were reported by PHC Sampatchack for the year 2010-11 whereas the figures shown in the report of district office were 597, 596, 95 and 376 respectively for the same period. iv) 99 Sterilizations, 81 IUD cases, 602 OP cycles/user and 4390 Nirodh were reported by PHC Mokama for the year 2010-11 whereas the figures shown in the report of district office were NIL, 37, 380 and 317 respectively for the same period. v) IUD figures reported by the visited PHCs for the year 2010-11 and 2011-12 could not be verified for want of IUD register maintained at the reporting centres. Incomplete IUD registers were found at PHCs Bakhtiyarpur and Paliganj whereas no register was maintained at PHCs Sampatchack and Mokama. vi) Similarly, mismatch in the performance was observed in figures reported by the district offices for the centres and reported by the centres for 2011-12. 426 IUD cases, 1361 OP cycles/user and 11167 Nirodh were reported by PHC Paliganj for the year 2011-12 (up to October, 2011) whereas same figures shown in the report of district office were 499, 1819 and 9188 respectively for the same period. vii) 567 sterilization, 178 IUD cases, 381 OP cycles/user and 412 Nirodh were reported by PHC Sampatchack for the year 2011-12 (up to October, 2011) whereas the figures shown in the report of district office were 596, 95, 376 and 520 respectively for the same period. viii) 28 IUD acceptors, 573 OP cycles/user and 1300 Nirodh were reported by PHC Mokama for the year 2011-12 (up to October, 2011) whereas the figures shown in the report of district office were 380, 317 and 600 respectively for the same period. 11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, 1 BPHC and 9 PHCs. b) MCH tracking formats was available at Sub Centre level. Health functionaries of District Office, BPHC and PHC were sensitized in MCH formats, but the same was not done at Sub Centre level. Data entry was being made at District, BPHC and PHC level. 12. Maintenance of Registers & Records:-

18 a) Eligible Couple & Child Register was maintained properly and up to date at Mokama PHC but the same was not maintained at Sampatchack PHC. This Register could not be verified at Bakhtiyarpur and Paliganj PHCs due to non availability of the register. b) Eligible Couple Register, Family planning service register, Stock register, Cash book of untied fund and JSY card were not available at both visited Sub Centresat Bahuara and Bairiya. Formats for Monthly Reporting were also not available at Bairiya Sub Centre. c) Sterilization Register was maintained properly and up to date at Bakhtiyarpur and Paliganj PHCs but the same was not maintained properly and up to date at Sampatchack and Mokama PHCs. d) IUD Register was maintained properly and up to date at Paliganj PHC, but not updated at Sampatchack and Bakhtiyarpur PHCs and not maintained at Mokama PHC. e) PNC, PNC & Immunization Register were maintained properly at all visited PHCs. f) OP & CC Registers were not maintained at Mokama PHC, not maintained properly and up to date at Paliganj and Sampatchack PHC but maintained properly at Bakhtiyarpur PHC. g) Stock Register was not maintained properly and up to date at all visited PHCs except Sampatchack PHC. h) Sterilization Case Card was not available at the visited PHCs. 13. Other Observations:- i) Supervision with necessary guidance at grass root level centres was lacking in the district. Regular meeting on HMIS should be conducted for improving reporting system in the district. ii) The condition of Labour Rooms and Maternity Wards at Paliganj and Mokama PHCs was found to be very poor and unhygienic. It was observed that there was no restriction for general public facility members to enter Labour Rooms which is important for delivery of quality services and privacy of mothers.

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5. District- Nalanda Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Nalanda District of Bihar State in the month of November, 2011.

I. Details of the visited Institutions:

District visited PHCs visited HSCs visited Nalanda Harnout, Sermera, Noorsarai & Harnout, Gopalbad, Ahiyarpur, Merinagar, Tora, Hilasa Daruwara & Lahanda

II. Major Observations:

1. Human Resources:- There was acute shortage of man power in some category of posts. 42 of the 150 sanctioned posts of Medical Officer, 74 out of the 766 sanctioned posts of ANM, 25 out of the 41 sanctioned posts of Lab Technician and 14 out of the 32 sanctioned posts of LHV/HS(F) were lying vacant in the district. 2. Rogi Kalyan Samiti (RKS) & Village Health, Sanitation and Nutrition Committee (VHSNC):- a) 26 Rogi Kalyan Samitis were set up at the DH, CHC and PHC level in the district. It was registered in DH, in 2 SDH, in 3 CHCs and in 20 PHCs. Regular meetings of RKS were not being conducted in the visited institutions. b) The District received RKS fund to the tune of Rs. 44,53,520 for the year 2011-12 out of which Rs.10,00,188 (22%) was spent up to October, 2011. c) It was reported that 249 VHSNCs and 2319 Anganwadi Centres were functioning in the district. Regular meetings of VHSNCs were not conducted as per prescribed Govt. guidelines in the visited institutions. d) The District received VHSNC fund to the tune of Rs.63,87,500 for the year 2011-12 out of which Rs. 45,90,000 (72%) were spent up to October, 2011. 3. Service of Janani Suraksha Yojana (JSY):- a) Janani Suraksha Yojana was being implemented in the district. The District spent Rs. 61,33,180 out of the available fund of Rs. 5,43,63,595 during 2011-12 (up to October, 2011). b) It was reported that sufficient fund was available in the district, but cash incentive to JSY beneficiaries in the visited centres was not being released in time.

c) JSY Cards and Immunization Cards were not filled with the complete information by concerned ANMs in the visited area. It was also observed that some of the mother had not received the three consecutive checks up during ANC while, post natal visits need to be increased. d) Prescribed reporting format related to physical performance and expenditure of JSY scheme was not properly maintained. As a result it was not possible to determine the actual status of programmes implementation in the district. e) 8 beneficiaries were contacted by the team and all beneficiaries reported satisfaction with the services. All beneficiaries were provided with TT & IFA (L) during A.N period and most of them received three Checks-up in their nearest service centre. Necessary advice like Breast feeding and child nutrition were also provided to them. Most of contacted mothers were delivered at Hospital and received monetary benefit under JSY scheme. However, post natal visits by field workers need to be increased. e. 4. Functioning of ASHA:- a) 2340 ASHAs were working as against target of 2365 ASHAs for the district. 2317 ASHAs were trained in all modules but Drug Kit was provided to 2314 ASHAs. b) ASHAs were receiving incentive money per month in the district. 5. Untied Funds and annual Maintenance Grant:- a) It was reported that sufficient funds were available in the district. The District received untied funds to the tune of Rs. 41,86,751 for CHCs, PHCs and Sub Centres for the year 2011-12 out of which Rs. 11,39,285 (27%) were spent up to October, 2011. b) The team observed that the ANM/MPW (M) were not so clear about guidelines of utilization of Untied Funds as well as submission of utilization certificate to their higher authorities in prescribed formats. c) In addition to Untied Fund, district received Annual Maintenance Grant to the tune of Rs.16,50,833 for CHCs, PHCs and Sub Centres for the year 2011-12 out of which an amount of Rs. 9,35,247 (57%) was spent up to October, 2011. 6. 24 Hours Delivery Care Services:- As reported, total 20 institutions were working as 24x7 hours delivery care service providers in the district. f. 7. Physical Infrastructure Stock Position:-

21 g. i. Health Sub Centres: a) Sub centres at Ahiyapur and Gopalbad of Sarmera PHC were visited for physical verification. Gopalbad Sub Centre was functioning in Govt. building but Ahiyapur Sub Centre was functioning in a private building. Water and Electricity facility was not available at both the Sub Centres. Toilet facility was not available at Ahiyapur SC. Labour room was available at Gopalbad Sub Centre but deliveries were not being conducted there. b) ANMs of the visited Sub Centres were not residing in their head quarter. Also, mobile Phone was not provided to ANM. Additional ANM (2nd ANM ) was not available at Ahiyapur Sub Centre. c) Examination table, Delivery table, McIntsh Sheet, Ambu bag/suction, Steam Sterilizer, Delivery kits, RDT Kit and Heamoglobinometer were not available at both Sub Centres viz. Ahiyarpur and Gopalbad. IUD Insertion Kit was not available at Ahiyapur SC whereas Nischay Pregnancy Test Kit and Weighing Machine were not available at Gopalbad Sub Centre. d) Gloves, Slides for blood test, ORS Packet, DDKs, Co-trimoxazole tab, IFA Tab/Syrup, EC Pills, Bleaching powder, Chloroquine tab, Metronidazole tab, Misofrostol tab, Magsulth tab, Oxitocine tablets, Ampicillin capsule, Gentamycin injection and Kits- A & B were not available at Ahiyarpur and Gopalbad Sub Centres. AD Syringes, Vit. A solution and Paracetamole tab, were not available at Ahiyapur Sub Centre whereas Thermometer, Oral Pills Cycles, Condom and Antiseptic Solution were not available at Gopalbad Sub Centre. e) SBA training was not received by the ANM of visited Sub Centres. The posters for public awareness were not displayed on the wall of Sub Centres. f) Posts of MPW (M) were lying vacant for more than 5 years in both the visited Sub Centres at Ahiyarpur and Gopalbad. h. ii. PHC: a) Harnaut, Sermera and Noorsarai PHCs were visited to observe the availability of facilities. All visited PHCs were functioning in Govt. building with regular water supply, electricity with power back up, Telephone and Toilet facility. Vehicle was not available at Sermera and Noorsarai PHCs. b) Stock of Contraceptive, Vaccines and prophylactic Drugs was available at Sermera and Noorsarai PHCs but IFA (syrup) and Vit.A tab were not available at both PHCs. However, Stock position could not be verified by the team at Harnaut PHC.

8. Community Satisfaction on Overall Service:- i. Towards HSCs Service: a) Contacted mothers in the area of Ahiyarpur and Gopalbad Sub Centres replied that ANMs were not available as per their need, but they conducted Immunization Clinic regularly. They provided IFA and TT to A.N. mothers. b) ANC and PNC services need to be enhanced and provided on regular basis in prescribed time. Most of the contacted mothers were aware about the use of contraceptive methods, ORT and symptoms of ARI. c) Home deliveries were conducted by untrained person. d) All contacted mothers were aware of the government health facilities where they can get all health facilities. ii. Towards PHC Service: a) Villagers interviewed in the area of PHCs informed that the services at PHCs were satisfactory. MOs and staff were regularly available in the PHC, services and drugs were being provided satisfactory. It was found that M.O of Sermera PHC was visiting his villages on regular basis but M.O of Harnout and Noorsarai PHCs was visiting their villages regularly. b) The team interviewed some mothers, AWW, ASHAs, and village leaders in the area of each institutions and found that ANC services were given to pregnant women but early registration was very poor in the district. The newly delivered women did not have much knowledge about ARI & ORT. Mothers were not aware about AIDS and HIV. Some Institutionally delivered mothers did not receive their incentive in due time. c) Most of the mothers had no knowledge about the benefit for institutional delivery. d) The children were not being taken in right time to hospital for routine Immunization. 9. Sample Verification of Family Welfare Acceptors:- a) The team selected 148 Family Welfare acceptors (Sterilization, IUD, OP and Nirodh) out of which 92 (62%) acceptors could be contacted for sample verification in the district. 30 acceptors left their house temporarily and 20 were not traceable due to wrong/incomplete addresses whereas 3 recorded FW acceptors were not living that area. During sample check discrepant entries in some case were found about age of last child and total number of children. b) 29 (46%) acceptors were not provided follow-up service where as 7 (11%) acceptors replied as not known. 36 (84%) sterilization acceptors received full amount of compensation money

23 where as 7(16%) acceptors replied that they don’t know about the compensation. 54 (86%) acceptors were satisfied with the methods. c) Out of the 70 selected acceptor of spacing methods (Cu-T -51, OP-7 and Nirodh-12), 49 (Cu- T-39, OP-5 and Nirodh-5) acceptors were contacted. Out of contacted 39 Cu-T users, 29 denied using the method. Rest all users were continuing the method without any complication. d) Out of the 20 selected Beneficiaries of child immunization, 14 were contacted and all confirmed receiving doses and follow up services. No complication was found among contacted beneficiaries. All were satisfied with the service. 10. Reconciliation of Reported Performance:- There was no coordination between District office and reporting centres in respect of performance reported in the year 2010-11 and 2011-12 (up to October, 2011). The details are as follows: i) 746, 374, 741 and 339 Sterilizations were reported by PHC Harnout, Sermera, Noorsarai and Hilsa for the year 2010-11 whereas the figures shown in the report of district office were 759, 577, 755 and 345 respectively for the same period. ii) 275, 180, 292 and 23 Sterilizations were reported by PHCs Harnout, Sermera, Noorsarai and Hilsa for the year 2011-12 (up to October, 2011) whereas same figures showed in the report of district office were 287, 179, 294 and 32 respectively for the same period. iii) Service registers in some of the centres were not complete. Steilization register had 330 cases against 339 cases reported by Hilsa PHC. 160 IUD acceptors were reported by PHC Sermera for the year 2010-11 whereas the team verified the total acceptors 28 in the service register. 440 IUD acceptors were reported by PHC Noorsarai for the year 2011-12 (up to October, 2011) whereas the team verified 65 IUD acceptors in the service register only. 11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, BPHC, CHC and PHCs. b) MCH tracking formats was available at Sub Centre level. Health functionaries of District Office, BPHC, CHC, PHC and Sub Centres were sensitized about MCH formats. Data entry was being made at District, BPHC, CHC and PHC level. 12. Maintenance of Register & Record:- a) Eligible Couple & Child Register was maintained properly at Hatnout PHC, not maintained at Noorsarai PHC and not made available at Sermera and Hilsa PHCs.

24 b) Sterilization Register was not maintained properly and updated at all visited PHCs, through particulars of acceptors along with payment documents were maintained in the same register, but the register was not timely updated. c) IUD, OP and CC Registers were not maintained properly and up to date at all visited PHCs. d) ANC, PNC & Immunization Register were maintained properly at Harnout and Hilsa PHCs but the same were not maintained properly at Sermera and Noorsarai PHCs. e) Stock Register was not maintained properly at Harnout and Noorsarai PHCs whereas the same was not made available at Sermera and Hilsa PHCs. f) Sterilization Case Card was not found at the visited centres. g) Family Planning Service Register, Stock Register and Formats for Monthly Reporting was not available at both visited Sub Centres i.e., Ahiypur and Gopalbad. MCH Register and Immunization & ANC Cards were not available at Ahiyapur Sub Centre whereas Eligible Couple Register and Cash book of untied fund were not available at Gopalbad Sub Centre. 13. Other Observations:- i) Supervision with necessary guidance at grass root level centres was lacking in the district. Regular meeting on HMIS should be conducted for improving reporting system in the district. ii) The condition of Labour Rooms and Maternity Wards at Harnout and Sermera PHCs was found very poor and unhygienic. There is no privacy of mother as any one can enter labour room at any time. iii) Orientation Training to the staff of District Programme Management Unit and to the Block Accountant at PHCs may improve their performance.

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6. District:- Madhepura

Highlight from the Regional Evaluation Team Report of Madhepura District of Bihar

The Regional Evaluation Team, located at Regional Office for Health and Family Welfare Patna, Ministry of Health and Family Welfare, Government of India carried out sample checks of activities covered under NRHM / RCH in Madhepura District of Bihar State during January, 2012. I . Details of the visited Institutions: District Visited SDH/PHCs Visited SCs Visited Madhepura PHCs: Chausa, Madhepura ( Murho), Chausa, Murho, Murowaha, Alamnagar and Singheswar. Bhelawa, Alamnagar, Ratwara and Narthea.

II. Major Observations:

1. Human Resources:- a) As reported Staff position of the district in the key categories was as follows:

Post Post sanctioned In position Vacant M.O 177 66 111 Specialists 165 7 158 ANMs 349 134 215 LHV/HS(F) 32 2 30 Health supervisor(M) 92 25 67 Nurse Grade- A 67 17 50 Lab Technician 56 6 50

The above table shows that the district was facing acute shortage of skilled personnel in the health sector for providing health services in the district. b) In PHC Chausa, 8 out of the 13 sanctioned posts of Medical Officer, all 6 sanctioned posts of Pharmacist, 5 out of the 6 posts of Lab. Technician, 2 posts of LHV, 41 out of 52 posts of ANM/HW(F) and all 6 sanctioned posts of Nurse grade-A were lying vacant. c) In PHC Alamnagar, 3 out of 5 sanctioned posts of Medical Officer, all 3 post of LHV, 41 out of 45 sanctioned posts of ANM/HW (F), all 3 posts of Health Worker and 1 post of Nurse grade-A were lying vacant.

d) In PHC Madhepura, 1 out of the 7 sanctioned posts of Medical Officer, all 5 sanctioned posts each of Pharmacist and Lab. Technician, 39 out of the 54 sanctioned posts of ANM/HW(F), 53 out of the 54 sanctioned posts of Health Worker and all 5 sanctioned posts of Nurse grade-A were lying vacant. e) In PHC Singheswer, 1 out of the 3 sanctioned posts of Medical Officer, sanctioned post of S.I., all 3 sanctioned posts of LHV, 20 out of 27 sanctioned posts of ANM/HW (F), all 3 sanctioned posts of MPW(M) and 4 sanctioned post of Nurse grade-A were lying vacant. f) 3 out of 4 the posts of MO, 4 out of the 39 posts of ANM and 3 out of the 4 posts of Nurse grade-A were filled up on contract basis in the Alamnagar PHC. Similarly, 1 out of the 5 posts of MO and 5 of the 19 posts of ANM were available on contractual basis in PHC Singheswer. All 4 identified posts of Nurse grade-A for contractual appointment were not filled in this PHC. g) It was observed that one ANM is there to look after 5-6 Sub Centres who is overloaded with the clinical and field work in her respective areas. 2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation and Nutrition Committee (VHSNC):- a) Rogi Kalyan Samiti was reported to be set up in 14 institutions (13 in PHCs and 1 in District Hospital) in the district. It was observed that the meeting of RKS was being conducted in the visited institutions. b) The budget provision and expenditure of the RKS in the entire District and in the visited PHCs are as under: (Amount in Rs.) Name of Institution 2010-11 2011-12 ( Up to Dec.2011 ) Fund Expenditure Balance Fund Expenditure Balance available available District 22,11,847 18,14,669 (82%) 3,97,178 21,64,948 15,75,411 (73%) 5,89,537

PHC Chausa 2,09,631 1,76,452 (84%) 33,179 1,33,179 1,33,164 (100%)15 PHC Madhepura (Murho)1,03,928 95,132 (92%) 8,796 53,489 27,900 (52%) 25,589 PHC Alamnagar 2,03,825 2,01,464 (99%) 2,361 1,02,361 78,834 (77%) 23,527 PHC Singheswer 2,36,249 1,82,649 (77%) 53,600 1,01,306 1,00,098 (99%) 1,208

c) The team reported that the funds are mostly spent for purchasing the medicines and also in the activity of the cleanliness in the Hospital.

27 d) As reported, 170 VHSNCs were constituted in the district. It was observed that utilization of funds by VHSNCs was very poor in the district. Details of the fund of VHSNCs in the District as well as visited PHCs is as under: (Amount in Rs.) Name of Institution Fund Available Fund Available Expenditure for 2010-11 for 2011-12 Up to Dec. 2011 * District 42,20,000 33,40,000 28,500 PHC Chausa 4,30,000 3,70,000 19,500 PHC Madhepura (Murho) 4,90,000 4,70,000 NIL PHC Alamnagar 2,90,000 2,80,000 NIL PHC Singheswer 2,70,000 2,80,000 NIL

* Expenditure for both the years. a) JSY beneficiaries were being provided services as well as cash incentives in the district. It was reported that Rs. 1000 in urban area and Rs. 1400 in rural areas are being given to the beneficiaries for institutional delivery. It was also reported that Rs. 500 are being given to the BPL beneficiary in rural and urban areas for home delivery. b) The District spent Rs. 5,50,02,042 out of available JSY fund of Rs. 6,40,93,377 during financial year 2010-11 and Rs. 4,69,99,256 out of available fund of Rs.5,55,42,422 during financial year 2011-12 under JSY. Utilization certificate was also submitted to higher Authority for both years. c) Utilization of JSY Fund at the visited PHCs (Amount in Rs.) Name of PHCs 2010-11 2011-12 ( Up to Dec. 11 ) Fund Expenditure Balance Fund Expenditure Balance available available PHC Chausa 61,88,376 55,47,778 6,40,598 38,80,289 35,47,100 3,33,189 PHC Madhepura (Murho) NIL NIL NIL 8,00,000 2,27,000 5,73,000 PHC Alamnagar 41,61,050 41,61,000 50 42,00,050 38,93,100 3,06,950 PHC Singheswer 53,27,349 40,94,400 12,32,949 44,32,949 42,02,400 2,30,549 d) 6 out of 17 selected beneficiaries were contacted by the team and found that MCH Cards issued to all of them and most of them were registered in earlier stage of ANC. Three consecutive checks up were completed in time. JSY package to the beneficiaries was paid in prescribed time.

e)Post natal services should be increased in the visited areas. Efforts may also be made to enhance the Institutional Delivery and Family welfare services in these areas. During field verification, the team observed that most of home deliveries were conducted by untrained persons at the home. f) The condition of Labour Rooms and Maternity Wards at Jainagar and Satgawa CHCs was found very poor and unhygienic. Moreover, no restriction for general public was there to enter Labour Room. This matter is deep concern for keeping of privacy of mothers and quality of services. g) It was observed that necessary information was not recorded in JSY Card. Immunization Card were also not filled up by the concerned ANM. Concerned Medical Officer and Supervisor did not visit frequently to visited institutions for effective monitoring. i. 4. Functioning of ASHA:- As reported by the team, 1540 ASHAs out of requirement of 1711 ASHAs for 452 villages were in position in the district. 1459 ASHAs were trained in 5 modules but drug kits were provided to only 1165 ASHAs. 5. Untied funds:- a) Untied funds to the tune of Rs.19,75,000 and Rs. 28,35,000 for APHCs & HSCs were available in the District during financial year 2010-11 and 2011-12 respectively. Out of available fund of Rs. 48,10,000 for both years, Rs.1,14,100 at APHCs level and Rs. 4,07,605 at HSCs level were spent up to December, 2011. b) Submission of Utilization Certificate and statement of Expenditure was also found irregular at HSC level. For this purpose prescribed formats were not provided to the HSCs. c) Utilization of Untied Fund at visited PHCs was also not satisfactory which can be seen from the following table: (Amount in Rs.) Name of Fund Available Fund Available Expenditure Up to PHCs for 2010-11 for 2011-12 Dec. 2011 * For APHC For HSCs For For HSCs APHCs HSCs level APHC level PHC Chausa 75,000 2,40,000 75,000 2,50,000 24,000 36,500 PHC Madhepura 50,000 2,10,000 50,000 1,90,000 24,000 37,000 (Murho) PHC Alamnagar NIL 2,20,000 50,000 3,50,000 NIL 56,500

PHC Singheswer 25,000 1,80,000 25,000 1,90,000 NIL NIL * Expenditure for both the years. 6) Annual Maintenance Grant:- a) As reported, Annual Maintenance Grant (AMG) to the tune of Rs. 5,00,000 for Sadar Hospital and Rs. 13,00,000 for PHCs was available in the District for financial year 2010-11, out of which an amount of Rs.4,99,906 at Sadar Hospital and Rs. 8,77,282 at PHCs was spent during the year. Similarly, Rs. 6,75,845 have been spent at PHCs out of available AMG of Rs. 10,72,720 during the year 2011-12 (up to December, 2011). No fund was given to Sadar Hospital in the year 2011- 12 up to the date of visit. b) AMG @ 1,00,000 each for the year 2010-11 was provided to PHCs visited at Chausa, Madhepura, Alamnagar and Singheshwer; out of which an amount of Rs. 80,674, 30,869, 99,810, and 98,335 was spent. During 2011-12, AMG of Rs. 69,328, Rs. 1,19,131, Rs. 50,190 and Rs. 51,665 was available at PHCs visited at Chausa, Madhepura, Alamnagar and Singheshwer respectively; Out of which Rs. 68,301, Rs. 76,150, Rs. 37,972 and Rs. 3,000 was spent up to December, 2011. 7. Physical Infrastructure and Stock Position: I. PHCs: a) Visited PHCs at Chausa, Madhepura, Alamnagar and Singheshwer were functioning in Govt. building with Regular water supply, Electricity facility with power back up, Toilet facility and Telephone facility. Maintenance of the Hospital Building was found satisfactory. Ambulance/Jeep was available at all visited PHCs. b) Most of the equipments and apparatus were available at the visited PHCs c) Stock of contraceptive, Vaccines vials and Prophylactic drugs were available at all visited PHCs except Madhepura PHC. DT Vaccines vials and Vit. A Tab were not available at all the visited PHCs where as IFA Syrup was available only at Singheshwer PHC. d) Cleanliness in Operation Theatre and Labour Room was not up to mark at PHCs. II. HSCs: a) Out of three visited Sub Centres at Ratwara, Narthwa and Maruwaha, only Maruwaha Sub Centre has Govt. building. ANMs of all visited Sub Centres were not residing in Sub Centre or Sub Centre area. Additional ANM and MPW (M) were not posted at visited Sub Centres under NRHM.

30 b) Mobile phone was not provided to ANM of visited sub centres. Facilities like water, Electricity connection and Toilet facility were not available at all visited SCs. c) Required Furniture and Equipments were not available at visited Sub Centres. d) Co-trimoxazole tablet and Vit. A solution were available in all visited SCs, IUD, Paracetamole and Metronidazole tab. were available in Ratwara and Narthwa SCs. No other Drugs/Medicines were available at visited Sub Centre. e) The posters for public awareness were not displayed at any of the visited Sub Centre. f) SBA training was not received by the ANM of any of the visited Sub Centre. g) Overall supervision during last three month was not done in any of the visited Sub Centres. 8. Community Satisfaction on Overall Service: i) Services of ANMs: a) During field check in the sub centre area, it was stated by some of the mothers that ANM was available as per their need. Services of ANC and PNC were satisfactory but check up of ANC and PNC mothers need to be increased for covering all the mothers in the area. b) Home delivery was conducted by trained personnel by using DDK. Mothers did not know sufficiently about danger sign of ARI. c) MPW (M) was not posted at any visited Sub Centres. ii) Service of PHC: a) Public opinion regarding behaviour and presence of staff at PHCs, treatment to the patients and availability of drugs was found satisfactory. It was found that M.O of Madhepura and Chausa PHC visited their villages in regular basis but MOs of Alamnagar and Singheshwer did not visit their villages regularly. 9. Sample Verification of Family Welfare Acceptors: a) Out of 120 selected family welfare acceptors (Sterilization-87 and IUD-33), 56 (47%) (Sterilization-44 and IUD-12) acceptors could be contacted for sample verification in the district. While examining the details of the contacted cases, discrepancy in age of spouse and age of youngest child were found in all contacted cases. b) 41(73%) acceptors found to have not been provided follow-up service. 37(84%) sterilization acceptors received full amount of compensation money whereas 7(16%) persons did not reply about compensation money as the acceptors themselves were not present at the time of interview. c) Out of 12 contacted Cu-T users, all were continuing the method without any complication.

31 d) Out of 26 selected beneficiaries of child immunization, 20 were contacted. All contacted beneficiaries confirmed receiving doses but, only 8 (40%) beneficiaries received follow up services. No complication was found among contacted beneficiaries. All were satisfied with the services.

10. Reconciliation of Reported Performance of Family Planning: A) There was no coordination between District office and reporting centres in respect of reporting of performance of family planning. The details are given below: i) Performance report for the year 2010-11: a) The district office reported Sterilizations figures 821 and 915 as against the figures 823 and 908 reported by PHCs Alamgarh and Singhaswer respectively. b) The district office reported IUD figures 344, 342, and 59 as against the figures 319, 269, and 108 reported by PHCs Chausa, Alamgarh and Singhaswer respectively. c) The district office reported OP figures 2788 and Nirodh 1295 as against the figures 136 and 10696 reported by PHCs Singhaswer and Chausa respectively. ii) Performance report for the year 2011-12 ( up to Dec. 2011): a) The district office reported Sterilizations figures 393 and 291 as against the figures 391 and 298 reported by PHCs Alamgarh and Singhaswer respectively. b) The district office reported IUD figures 20 and Nirodh 14186 as against the figures 33 and 12756 reported by PHCs Singhaswer and Chausa respectively. c) The district office reported OP figures 1331 and 884 as against the figures 1204 and 875 reported by PHCs Chausa and Singhaswer respectively B) Also, the figures reported by PHCs did not match with the number of cases recorded in the service registers in the PHCs. a) There were 641 and 217 Sterilizations cases reported in the service register at PHC Chausa for the year 2010-11 and at PHC Singhaswer for the year 2011-12 ( up to Dec.2011) as against the reporting of 650 and 298 Sterilisation respectively. b) Due to not maintenance of IUD register at the PHC, reporting figures could not be verified for the year 2010-11 and 2011-12. Without service register reporting of IUD cases create doubt on the figures.

11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, BPHCs and PHCs. b) MCH tracking formats were available at Sub Centre level. Health functionaries of District Office, BPHCs, PHCs and Sub Centres were sensitized in MCH formats. c) Data was being captured in MCH formats and found to be completed during visit of the team. d) Data entry was being made by District office, BPHCs and PHCs in the district. 12. Maintenance of Register & Records:- a) Sterilization Register was maintained properly and up to date at PHC Alamnagar but the same was not maintained properly at PHCs Chausa, Singhaswer and Madhepura. b) OP and Nirodh registers were not maintained properly at PHC Chausa, Singhaswer and Alamnagar. c) MCH Register was maintained properly and up to date at the visited institutions except Chausa PHC. d) Stock Registers with essential information like date of Manufacturing & Expiry, Batch No. and Model No. of Cu-T etc were not recorded at the visited PHCs. 13. Other Important Observations and Suggestions:- a) District Health plan for 2010-11 was prepared and submitted to higher Authority in proper time, but the same was not prepared by visited BPHCs in the district. b) The condition of Labour Rooms and Maternity Wards at visited PHCs at Madhepura, Chausa and Alamnagar was found to be very poor and unhygienic. It was observed that there was no restriction for to entering Labour Room for general public/family members. It was a matter of deep concern about keeping the privacy of mothers and quality of services c) Distribution of OP and Nirodh under F.W programme at SC level was very poor. The team could not select the OP/Nirodh samples for field verification due to non availability of the cases at the visited centres. d) The team observed that Sub Centres attached to PHC were not having sufficient space for their routine ANC/PNC clinics. e) Orientation Training to the staff of DPMU and at CHC/PHC can improve the quality of services in respect of proper maintenance of Records, Registers, SOE/Cash Book and proper implementation of the schemes under NRHM.

33 f) ANMs and Medical Officers were noticed having not submitted their monthly performance report in HIMS format in time. This may be regularised.

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7. District:- Bhagalpur

Highlight from the Regional Evaluation Team Report of Bhagalpur District of Bihar

The Regional Evaluation Team, located at Regional Office for Health and Family Welfare Patna, Ministry of Health and Family Welfare, Government of India carried out sample checks of activities covered under NRHM / RCH in Bhagalpur District of Bihar State during January, 2012. I . Details of the visited Institutions: District Visited SDH/PHCs Visited SCs Visited Bhagalpur S.D.H: Navgachhiya. Bhawanipur, Pakara, Tetari, PHCs: Navgachhiya, Kahalgaon and Anti Chack, Ghogha, Janidih, Pirpainti Kahalgaon, Simanpur, Laxmipur and Sadikpur.

II. Major Observations:

1. Human Resources; a) 206 out of the 263 sanctioned posts of Medical Officer, 43 out of the 397 sanctioned posts of ANM and 50 out of the 65 sanctioned posts of LHV/HS (F) were lying vacant in the District. Staff position of other Officers and Staff was not made available to the team b) It was also reported that 63 Medical Officers and 320 Additional ANM were posted on contract basis in the district. c) In PHC Navgachia, 5 out of the 6 sanctioned posts of Medical Officer, sanctioned post each of Pharmacist and Sanitary Inspector, all 3 sanctioned posts of Lab. Technician and all 2 sanctioned posts of LHV were lying vacant. d) In PHC Pirpaiti, 11 out of 13 sanctioned posts of M.O, all 6 sanctioned posts of Pharmacist, 1 sanctioned post of S.I., 5 out of the 6 sanctioned posts of LHV, 8 out of the 47 sanctioned posts of ANM/HW (F) and 1 out of the 4 sanctioned post of Nurse Gr.-A were lying vacant. e) In PHC Kahalgaon, sanctioned post each of Pharmacist, S.I. and Lab Technician, 2 out of the 3 sanctioned posts of LHV and 1 out of 36 sanctioned posts of ANM/HW were lying vacant.

Name of the Naugachia PHC Pirpaiti PHC Kahalgaon PHC post Sanction Posted Vacant Sanctioned Posted Vacant Sanctioned Posted Vacant ed Medical 7 2 5 13 4 9 4 4 0 Officer Lab.Tec. - - - 4 1 3 1 1 0

L.H.V. - - - 6 0 6 - - - A.N.M. / 16 13 3 47 38 9 8 8 0 H.W.(Female ) Nurse 3 3 0 8 7 1 5 5 0 Grade-A

f) Contractual Staff position as reported in the visited PHC is as given below:

2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation and Nutrition Committee (VHSNC):- a) Rogi Kalyan Samiti was constituted in District Hospital, SD Hospital, 3 CHCs/FRUs and 16 in PHCs in the district. Meeting of RKS was being conducted quarterly in visited centres. b) An expenditure of Rs.14,73,498 under RKS was incurred from Flexi-pool fund during 2010- 11 and Rs.12,79,202 were utilised from Flexi-pool fund during 2011-12 (up to December, 11) in the district. It was reported that most of RKS budget had been utilised for purchasing the Medicine and maintenance of cleanliness in the hospitals. c) District spent funds from Flexi-pool fund for VHSNCs. Rs. 1473498 in the year 2010-11 and Rs.10, 000 in the year 2011-12 (up to December, 11) were utilised in the district in this regard. 3. Service of Janani Suraksha Yojana (JSY):- a) i) JSY beneficiaries were being provided the services as well cash incentives in the district. It was reported that Rs. 1000 in urban area and Rs. 1400 in rural areas are being given to the beneficiaries. It was also reported that Rs. 500 are being given to the beneficiary in rural and urban areas for home delivery. ii) For providing the transportation to the JSY beneficiaries, ASHAs/AWWs are given Rs. 200 per cases. Likewise, ASHA/AWW is given RS. 200 in urban areas and 400 in rural areas in per case for coordinating all the activities as per JSY provision. b) The District spent funds for JSY from Flexi-pool fund. Rs. 7,01,03,430 in the year 2010-11 and Rs.4,96,46,093 in the year 2011-12 (up to December, 11) were utilised in the district. c) 10 out of 37 selected JSY beneficiaries were contacted by the team and found that MCH Cards were issued to all of them and most of them were registered for ANC in early stage of pregnancy. Three consecutive checks up were completed in time. JSY package to the beneficiaries was paid in prescribed time.

d) It was observed that post natal services should be increased in the visited areas. Efforts may also be taken to enhance the Institutional Delivery and Family welfare Services in these areas. During field verification the team observed that most of home deliveries were conducted by untrained persons. e) It was observed that necessary information was not recorded in JSY Card. Immunization Card were also not filled up by the concerned ANM. Concerned Medical Officer and Supervisor did not frequently visit the institutions for effective monitoring. f) The condition of Labour Rooms and Maternity Wards at Naugachia CHC and Pirpainti PHC was found poor and unhygienic. Moreover, there was no restriction for general public to enter Labour Rooms. j. 4. Functioning of ASHA:_ As reported by the team, 2209 ASHAs out of requirement of 2311 ASHAs for 1520 villages were in position in the district. All ASHAs were provided with drug kit but only 1770 ASHAs were trained up to 5th module in the district. 5. Untied funds and Annual Maintenance Grant:- a) It was reported that district utilised an amount of Rs. 9,92,634 in the year 2010-11 and Rs. 7,582 in the year 2011-12(up to Dec.11) as untied fund at PHCs from Flexi-Pool funds. Similarly an amount of Rs. 13,66,661 in the year 2010-11 and Rs. 20945 in the year 2011-12 (up to Dec.11) was utilised as Annual Maintenance Grant at PHCs level from Flexi-Pool fund. 6. Physical infrastructure and Stock Position:- I. Sub- Divisional Hospital: a) Sub Divisional Hospital Navgachiya was functioning in Govt. building with Regular water supply and Electricity facility with power back up. Maintenance of the Hospital Building was found satisfactory. Ambulance & Jeep were available there. b) Oxygen Cylinder, Neonatal Resuscitation equipment, Anesthesia equipment, Arteether injection and quinine injection etc were not available in the hospital. c) Out of 16 sanction posts, not a single Specialist was posted at the Hospital. II. PHCs: a) Visited PHCs at Naugachiya, Pirpainti and Kahalgaon were functioning in Govt. building with Regular water supply, Electric facility with power back up, Toilet facility and Telephone facility.

Maintenance of the Hospital Building was found satisfactory. Ambulance/Jeep was available at all visited PHCs. b) Microscope, Oxygen Cylinder, Minor surgical equipment, Labour Room, Appliances for delivery, Resuscitation equipment and IUD Insertion Kit were not available at PHC Navgachiya. c) Cleanliness in Operation Room and Labour Room was not satisfactory at all the visited PHCs. d) Stock of contraceptive, Vaccines vials and Prophylactic drugs was available at all visited PHCs, but DT/DDT Vaccine vials and Vit. A Tab were not available at all the visited PHCs. IFA Syrup was not available at Naugachiya and pirpainti PHCs. e) AYUSH Medical Officer was available at all visited PHCs. f) Residential Accommodation for Medical Officer was not available at Naugachiya and Pirpainti PHCs.

III. HSCs: a) Out of three visited Sub Centres, Antichack and Sadipur Sub Centres have Govt. building. ANMs of all visited Sub Centres were not residing in Sub Centre or Sub Centre villages. Additional ANM under NRHM was not posted at the visited Sub Centres. MPW (M) was posted only at Antichack Sub Centre. b) Mobile phone was not provided to ANMs of visited Sub Centres. Water and Electricity connection were not available at all visited SCs whereas Toilet facility was available only at Antichack Sub Centre. c) Nischay Pregnancy Test kit, RDT, Weighing Machine and Haemoglobinometer were not available at Antichack Sub Centre. Essential Furnitures and Equipments were lacking at Ghogha and Sadipur Sub Centres. d) DDKs, Sanitary Napkin, Clorin Solulution, Misofrostol, Magsulth and Oxitocine tablets, Ampicillin Capsule, Gentamycine injection and Kit-A & Kit-B were not available at all the visited HSCs. Thermometer, Gloves, Slides for blood test, ORS packet, IFA Tablet/Syrup, Oral Pills Cycle, E.C.Pills, Condom, Antiseptic solution and Chloroquine tab were not available at Ghogha and Sadipur HSCs. Co-trimoxazole tab and Vit.A solution was not available available at Antichack Sub Centre, whereas Disposal syringes, IUD, Paracetamole tab and Metronidazol tab were not available at Sadipur HSC.

38 e) Poster for public awareness was not displayed at any visited Sub Centre. f) SBA training was not received by the ANM of all visited Sub Centres. g) No supervision was dpne during last three month in any of the visited Sub Centres. 8. Community Satisfaction and Opinion on Health Services:- I. Towards HSCs services a) The interviewed mothers of visited HSCs informed that ANMs were available when needed and also conducted immunisation clinics in the villages. ANMs also provided IFA and TT to pregnant women in time. b) It was reported to the team that home deliveries were being conducted by trained person using DDK but service quality of ANC & PNC should be increased. c) Most of Mothers had no idea about ARI. II. Towards Medical officer: Interviewed villagers informed that the services at visited PHCs are satisfactory. PHC MOs and staff are regularly available in the centre for treatment of patients and drugs are provided to them in the PHCs. It was found that MO of Navgachhiya and Kahalgaon PHCs visit their villages on regular basis but MO of Pirpaiti PHCs and Navgachhiya SDH do not visit their villages regularly. 9. Sample Verification of Family Welfare Acceptors: a) The team selected 150 Family Welfare acceptors (Sterilization, IUD, OP and Nirodh) out of which 48 (32%) acceptors could be contacted for sample verification in the district. It is a matter of concern that as many as 70 (47%) acceptors could not be contacted due to wrong/incomplete addresses. During sample check, age of spouse of the acceptors in 20 and age of last child in 21 contacted cases was found to be wrongly recorded. b) Out of 22 genuine cases, 10 (45%) acceptors were not provided follow-up services. 19 (96%) sterilization accepters were received full amount of compensation money where as 1 (4%) acceptor showed ignorance about the compensation amount. c) It was also found that of the 28 contacted acceptors of spacing methods (Cu-T-15 and OP-13) as many as 26 (15 Cu-T acceptors and 11 OP users) did not receive any service in this regard. d) Out of selected 25 beneficiaries of child immunization, not a single beneficiary could be contacted due to wrong/incomplete address. 10. Reconciliation of Reported Performance:-

There was no coordination between District office and reporting centres in respect of performance reported for the same figures in the year 2010-11 and 2011-12 (up to Dec, 2011) The details are as follows: i) 374 Sterilization, 454 IUDs, 1073 OPs and 7916 Nirodhs were reported by PHC Naugachhiya for the year 2010-11 whereas these figures shown in the report of district office was 556, 434, 644 and 1645 respectively for the same period. ii) 437 Sterilization cases were reported by SDH Naugachhiya for the year 2010-11 whereas these figures shown in the report of district office as 421 for the same period. iii) 1068 Sterilization, 177 IUDs, 910 OPs and 2105 Nirodhs were reported by PHC Kahalgaon for the year 2010-11 whereas these figures shown in the report of district office as 2767, 339, 1567 and 12180 respectively for the same period. iv) 1526 Sterilization and 293 IUD cases were reported by PHC Pirpaiti for the year 2010-11 whereas these figures shownin the report of district office as 1838 and 403 respectively for the same period. v) 9, 241, 265 and 595 sterilization cases were reported by PHC Navgachhiya, SDH Navgachhiya, PHC Kahalgaon and PHC Pirpaiti for the year 2011-12 (Up to Dec, 11) whereas these figures shown in the report of district office as 318, 245, 455 and 307 respectively for the same period. vi) 306 and 462 IUD cases were reported by PHC Kahalgaon and PHC Pirpaiti for the year 2011-12 (Up to Dec, 11) whereas these figures shown in the report of district office as 344 and 505 respectively for the same period. vii) 615 and 2300 OP cycles/user were reported by PHC Kahalgaon and Pirpaiti for the year 2011-12 (up to Decr, 2011) whereas these figure shown in the report of district office as 4779 and 3402 respectively for the same period. viii) 1720 and 26140 Nirodh pieces/users were reported by PHC Kahalgaon and Pirpaiti for the year 2011-12 (up to Decr, 2011) whereas these figure shown in the report of district office as 10782 and 25158 respectively for the same period. 11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office, BPHCs and PHCs. b) MCH tracking formats was available at Sub Centre level. Health functionaries of District Office, BPHCs, PHCs and Sub Centres were sensitized in MCH formats.

40 c) Data was being capturing in MCH formats and found to be completed during visit of the team. d) Data entry was being made by District office, BPHCs and PHCs and also through NIC. 12. Maintenance of Register & Records:- a) Eligible Couple & Child Register could not be verified at the selected institution as the registers were not maintained by the centres. b) No register was available at Ghogha and Sadipur SCs whereas Family planning service register, Stock register, Cash book of untied fund and mother & child tracking formats /registers were not available at Antichack Sub Centre. c) Sterilization Register was maintained properly at Kahalgaon and Pirpaiti PHCs but the same was not maintained properly and up to date at Navgachhiya PHC and SDH Navgachhiya. d) IUD Register was not maintained properly at Navgachhiya and Pirpaiti PHCs and the same was not made available at Kahalgaon PHC and SDH Navgachhiya. e) OP & CC distribution registers were not maintained properly at Navgachhiya, Pirpaiti and Kahalgaon PHCs. f) No prescribed Performa was maintained in respect of Cu-T, OP & Nirodh services and also for ANC/PNC registers in the visited institutions in the district. g) ANC, PNC & Child Immunization Registers were maintained properly at Pirpaiti PHC but not maintained at SDH Naugachhiya. ANC & PNC register were not maintained properly at Naugachhiya PHC whereas this register was not available at Kahalgaon PHC but Immunization Register was maintained properly at both PHCs. h) Stock Register was not maintained properly at Kahalgaon and Pirpaiti PHCs whereas the same was not available at Naugachhiya PHC and Navgachhiya SDH. 13. Other Observations:- a) The financial and physical progress report under various components of NRHM such as RKS, Untied Fund, Annual Maintenance grant, VHSNCs, JSY and ASHA for Sub Centre, PHCs and CHCs was not given by the District Programme Management Unit of the district for 2010-11 and 2011-12 (up to Dec,11) to the team. b) The condition of Labour Rooms and Maternity Wards of SDH Naugachhiya and Pirpaiti PHC was found to be very poor and unhygienic. It was observed that there was no restriction for general public/family members to enter Labour Rooms which is a matter of deep concern.

41 c) Distribution of OP and Nirodh under F.W programme at SC level was very poor. The team could not select the OP/Nirodh samples for field verification due to non availability of records of FW acceptors at the visited centres. d) ANMs and Medical Officers were found to have not submitted their monthly performance report in HIMS format in time. This may be regularised. .

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8. District:- Shekhpura Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Shekhpura District of Bihar State in the month of March, 2012. I. Details of the visited Institutions: District visited PHCs visited HSCs visited Shekhpura Chewara, Ghatkusumbha, Andaulo, Ghatkusumbha(HQ), Panwar, Ariyari and Shekhpura Chorwar Hasangarh and Dilkusumba

II. Major Observations:

1. Human Resources:- The Staff position in the key categories in the district was as follow:

Names of the Posts Post sanctioned In position Vacant Medical Officer 43 25 18 LHV/HS(F) 16 5 11 Lab Technician 8 6 2 ANMs 112 104 8 MPW(M) 7 3 4 GNM 6 1 5

The district may fill up the vacant post urgently. 2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation and Nutrition Committee (VHSNC):- a) Rogi Kalyan Samitis have been constituted in 7 institutions in the district. RKS were registered in 1 DH and 6 PHCs. Regular meetings of the RKS were not being conducted in the visited institutions. b) As reported, sufficient RKS Fund was available in the district and Rs.7, 99,897 in the year 2010-11 and Rs.1, 82, 20,881 during 2011-12 had been utilized under this head. c) It was reported that 54 VHSNCs were functioning in the district. The district had utilised the VHSNC fund to the tune of Rs.24, 03,750 in the year 2010-11 and Rs. 23, 14,000 during the year 2011-12. 3. Services under Janani Suraksha Yojana (JSY):-

a) Mothers in rural and urban areas were being covered under Janani Suraksha Yojana in the district. It was reported that the district had sufficient budget to meet the total expenditure under this head. b) 16 JSY beneficiaries during field verification could be contacted by the team in the area of the visited centres. All beneficiaries were found to be satisfied with the services. Beneficiaries were mostly accompanied by ASHAs to the hospitals and JSY Packages were provided timely to the beneficiaries. c) JSY Cards and Immunization Cards were not completed by the concerned ANMs in the visited area. It was also observed that some of the mothers had not received three consecutive checks up during AN period. Post Natal visit was also poor. d) Records and registers of JSY were not being checked frequently by concerned MOs and Supervisory staff. k. 4. Functioning of ASHA:- a) It was reported that 361 ASHAs were working out of 363 ASHAs selected, through the target set was 409 in the district. The ASHAs were not adequately trained but Drug Kit was provided to all 361 ASHAs. b) The district had spent Rs. 20, 86, 378 in the year 2010-11 and Rs.7, 49,814 in the year 2011- 12 under this head. 5. Untied Funds and Annual Maintenance Grant:- a) It was reported that the district had spent Rs. 5, 05,717 in the year 2010-11 and Rs. 8, 61,000 during 2011-12 as untied fund at SDH, CHCs, PHCs and Sub Centres. b) In addition to Untied Fund, the district also utilized Rs. 2, 79,754 during 2010-11 and Rs. 2, 56, 993 during 2011-12 as Annual Maintenance Grant at CHCs, PHCs and Sub Centre level. l. 6. 24 x 7 Hours Delivery Care Services:- m. It was reported that 6 institutions were providing 24x7 hours delivery care services in the district. n. 7. Physical infrastructure Stock Position:- o. i. Health Sub Centres (HSCs):- p. a) The team visited Sub centres at Panwar and Dihkusumba. Both centres were functioning in non-Govt. building .Supply of water, electricity and toilet facility

44 was not available at both the Sub Centres. Labour room was also not available at both of these Sub Centres. b) ANMs of the visited Sub centers were not residing in their head quarter. Also, mobile phone was not provided to ANMs. Additional ANM and MPW (M) were not posted at both the centres. Post of MPW (M) was lying vacant since more than 3 years in the visited Sub Centres. c) Bench for clients, Examination-table, Cupboard for drugs, Foot stool, Ambu bag/suction, Delivery table, RDT Kit, Weighing Machine, Thermometer, ORS Packet, DDKs, Misofrostol tab, Oxitocine tablets, Ampicillin capsule, Gentamycin injection ,Kits- A & B and Condoms were not available at both the visited sub centres. . ii. Primary Health Centre (PHC): a) Chewara, Ghat Kusumbha, Ariyari and Shekhpura PHCs were visited to assess the availability of infrastructure and services etc. All visited PHCs were functioning in Govt. building with regular water supply (except Ghat Kusumbha), electricity with power back up, Telephone (except Ghat Kusumbha and Shekhpura) and Toilet facility. Vehicle was available , is running and regular driver was available only at Chewara and Ariyari PHCs. b) Stock of Contraceptive, Vaccines vials was generally available at all visited PHCs. IFA (small Tab/syrup) and Vit. A (tab/syrup) were not available at most of the PHCs visited. c) Residential accommodation for MO at PHC Ghat Kusmbha was not available. 8. Community Satisfaction on overall Service:- i. Towards HSCs service: a) 20 mothers having child up to one year age were contacted in the area of SCs Panwar and Dhikusumba. Most of contacted mothers replied that ANMs were available as and when needed. ANC services to the mothers were satisfactory. b) Use of DDK while conducting home deliveries was found satisfactory. Knowledge about ARI and check up of mothers during AN and PN periods needed to be enhanced. ii. Towards PHC Services :- During field verification, some of the villagers were interviewed. They informed that MO of PHCs and staffs are regularly available. They spend sufficient time in examining the patients and they made available medicines .It was observed that Medical Officers of PHCs at Shekhpura, Chewara, Ghat Kusumbha and Ariyari were not visiting their villages on regular basis. 9. Sample Verification of Family Welfare Acceptors:-

45 a) The team selected 102 Family Welfare acceptors (Sterilization, Cu T and OP) out of which 74 (72.6%) acceptors could be contacted for sample verification in the district. Discrepancy of age of spouse in 68 (91.8%) acceptors and age of last child in 44 (59.4%) cases were found. b) A very few Nirodh users were observed in the visited centres. c) Only 35(48%) contacted acceptors were provided follow up services. d) 2(18.2%) beneficiaries of child immunization were contacted out of 11 beneficiaries selected for sample verification. 9 (82%) beneficiaries could not be contacted due to incorrect address. 10. Reconciliation of Reported Performance:- a) There was no proper coordination between District office and reporting centres in respect of performance reported needs to be improved as may be seen for the year 2010-11 and 2011- 12.The details are as follows: i) Name of PHC Methods For the year 2010-11 For the year 2011- reported by 12 reported by District The District The Centre Office Centre Office 1. PHC Sterilisation 244 255 235 193 Chewara Cu T 174 564 675 613 2.PHCAriyari Cu T 547 426 528 504 ii) For the year 2010-11 figures reported differently in Name of PHC Methods District Office The Centre Ghat Kusumbha Sterilisation 264 230 For the year 2011-12 figures reported differently. 1. Chewara OP 955 940 Nirodh 11000 2574 2. Ghat Kusumbha Cu T 280 272 OP 872 682 b) Performance reported for IUD at visited centres for the year 2010-11 and 2011-12 did not tally with the figures recorded in service registers, IUD Service Register was not made available at PHC Ariyari and Sadar PHC Shekhpura against IUD performance reported for the year 2010-11.

11. Information on IT Infrastructure and MCH Tracking System:- a) It was reported that the data entry was being done at District Office, BPHC and PHCs by outsourcing. b) MCH tracking formats was available at Sub Centre level. Health functionaries of District Office, BPHC and PHC were sensitized in MCH formats. Data entry was being made at District, BPHC and PHC level. 12. Maintenance of Registers & Records:- a) Eligible Couple register was not maintained at all visited institutions. b) Sterilization register was maintained properly at all visited institutions. c) IUD Registers were mostly incomplete at all visited PHCs. d) Immunization register & cards were maintained at all visited PHCs but addresses were not correct as observed during sample verification. e) ANC & PNC service register were provided but not maintained at PHCs Chewara and Shekhpura. f) OP & CC Registers were not maintained at PHCs Chewara and Ghatkusumbha whereas the same was not updated at Shekpura PHC. OP &CC Register was not available at PHC Ariyari. g) Stock Register of IUD and OP were maintained properly at PHC Chewara but not maintained at PHCs Ghatkusumbha and Ariyari. 13. Other Observations:- a) Regular supervision at grass root level centres was lacking in the district. Regular meeting on HMIS should be conducted for improving reporting system in the district. The team observed that ANMs and Medical Officers were not submitting monthly performances report timely in HIMS formats. b) The condition of Labour rooms and Maternity Wards at all PHCs was found very poor and unhygienic. It was also observed that there was no restriction for general public /staff members to enter labour rooms, which is important to maintain privacy of mothers and new born care. c) The details on the expenditure under UF, VHSNC, ASHA, AMG, JSY and RKS were not made available to the team as such proper assessment could not be done in the utilisation of fund in these schemes under NRHM.

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9. District:- Nawada Major observations of Regional Evaluation Team (RET), Patna on the evaluation work carried out in Nawada District of Bihar State in the month of March, 2012. I. Details of the visited Institutions: District visited PHCs visited HSCs visited Nawada Akberpur, Rajauli, Kasichack Pachrukha, Baksanda, Mahinar, Dhomani, and Kawakol Amawar, Patrang, Dhanwar, Purwati, Bhawanibigha, Kawakol(HQ), Bisanpur and Nawadih

II. Major Observations:

1. Human Resources:- The Staff position of the key technical categories in the district was as follow:

Name of the Post Post sanctioned In position Vacant Medical Officer 249 74 175 LHV/HS(F) 25 14 11 ANMs 433 345 88 MPW(M) 30 19 11

GNM 257 65 192 Lab Technician 54 14 40

The above table shows that the district is facing acute shortage of Medical Officers, LHVs GNMs, Lab technicians etc.. 2. Rogi Kalyan Samiti (RKS) & Village Health Sanitation and Nutrition Committee (VHSNC):- a) Rogi Kalyan Samitis have been constituted in 17 institutions in the district .RKS were registered in 1 DH, 2 SDH and 14 PHCs. Regular meetings of the RKS were not being conducted in the visited institutions. b) An amount of Rs. 8, 25, 000 was available for RKS in the district for the year 2010-11, but no amount was spent up to March, 2011. Similarly, fund to the tune of Rs. 48,58, 333 was available in the district for the year 2011-12 out of which an amount of Rs. 26,84,669 (55.25%)was spent. c) 967 Village Health, Sanitation & Nutrition Committees (VHSNCs) have been constituted in the district. 48 d) The VHSNC fund to the tune of Rs. 4, 70,000 for the year 2010-11 and Rs. 87, 63,333 was available for the year 2011-12 in the district. It was reported that the district had spent an amount of Rs. 85, 80,000 in the year 2010-11 and Rs. 1, 71, 00,000 during 2011-12. The excess amount of 81, 10,000 in the year 2010-11 and Rs. 83, 36,667 in year 2011-12 were adjusted from flexi pool fund. e) During visit to the centres, the team observed that the meetings in the VHSNCs were being conducted regularly. 3. Service of Janani Suraksha Yojana (JSY):- a) Janani Suraksha Yojana was being implemented and the district spent Rs. 40,00,000 (95%) out of the available fund of Rs. 42,77,289 during 2010-11.The expenditure was Rs. 2,76,653 (11%) out of available amount of Rs. 35,22,000 during 2011-12 in the district. b) 11(55%) JSY beneficiaries out of 20 selected could be contacted by the team in the area of the visited centres during field verification. All beneficiaries were found to be satisfied with the services. Beneficiaries were mostly accompanied by ASHAs to the hospitals and JSY Packages were provided timely. c) MCH cards were completed by the concerned ANMs in the visited area. Mostly mothers received three consecutive checks up during ANC and PNC visits. Records and registers were not being checked frequently by concerned MOs and supervisory staffs. 4. Functioning of ASHA:- a) 1774 ASHAs were working out of 1,936 selected ASHAsthrough the district target was 2,001 ASHAs. The number of trained ASHAs in all modules in the district was NIL but Drug Kits were provided to all 1774 ASHAs. b) The district had spent Rs.1, 42,719 in the year 2010-11 and 2467881 in the year 2011-12 under this head. 5. Untied Funds and Annual Maintenance Grant:- a) It was reported that no amount was spent out of available Untied Fund of Rs. 2, 34,467 in the year 2010-11 and only Rs. 4, 13,029 were spent out of available amount of Rs.45, 32,916.66 during 2011-12 from the Flexible Pool Fund in the district. b) In addition to Untied Fund, the district utilised Rs. 1,29,531(3%) out of its available AMG of Rs.43,22,120 during 2010-11 but no amount has been spent out of available Amount AMG of Rs.72,32,500 during 2011-12.

49 q. 6. 24 x 7 Hours Delivery Care Services:- r. As reported, 24x7 hours delivery care service was being provided in 14 institutions in the district. s. 7. Physical infrastructure Stock Position:- t. i. Health Sub Centres (HSCs): a) The team visited Sub Centres at Dhomani and Amawar. Both were functioning in Govt. building but Electricity and toilet facility was not available at both the Sub Centres. Labour room was also not available at both the Sub Centres. Water facility was only available at Amawar Sub Centre. b) ANMs of the visited Sub centers were residing in their head quarter. Mobile phone was not provided to ANM. Additional ANM and MPW (M) were not available at both the visited Sub Centers. c) Delivery table, McIntosh sheet ,Ambu bag/suction, NP test Kit, Delivery Kit, Haemoglobinometer, DDKs, Sanitary Napkin, Bleaching Powder, Chloroquine Tab..Mosofrostol Tab., Magsulth Tab., Oxitocine Tab., Ampicilline Capsule, Gentamycin Inj. Kits-A and B were not available at both the Sub-Centres. d) PHC or district level officials hardly inspect their SCs for reviewing performances and availability of equipments and drugs. ii. Primary Health Centres (PHC): a) Kawakol, Rajauli and Akberpur PHCs were visited to assess the availability of infrastructure and services etc. All visited PHCs were functioning in Govt. building with regular water supply, electricity with power back up, Telephone and Toilet facility. Vehicle along with regular duty driver was available at all PHCs but vehicle was functioning only at PHC Akberpur. Provision of Petrol/Diesel was insufficient to run the vehicle as stated by the MOs PHCs. b) Cold Chain equipments, Weighing machine, Microscope & lab equipment, Oxygen cylinder, B.P. apparatus, Labour room table& Resuscitation equipment etc. were available at all visited PHCs. Stock of Contraceptive, Vaccine vials and Prophylactic Drugs was also available at all the visited PHCs. c) Stock of IUD, IFA (small) and Vit A was not available on the day of visit at PHCs Rajauli and Akbarpur.

8. Community Satisfaction on overall Service:- i. Towards HSCs Services: a) The team interviewed the villagers of both Dhammi and Amawan SCs. They told that ANMs were available when needed and conducted immunization session regularly. They also conducted ANC and Immunization clinics regularly. b) Use of DDK while conducting home deliveries was found satisfactory. Knowledge about ARI and check up of mothers during AN and PN periods need to be enhance in the area visited. ii. Towards PHC Services: During field verification, some villagers were interviewed .They informed that MO of PHCs and staffs are regularly available and they spend sufficient time in the examining of patient and made medicines are available. It was observed that MOs of visited PHCs were not visiting their villages on regular basis. 9. Sample Verification of Family Welfare Acceptors:- a) The team selected 106 Family Welfare acceptors (Sterilization, IUD, OP and Nirodh) out of which 73 (68.8%) acceptors could be contacted for sample verification in the district b) 43 (59%) acceptors were found to have not been provided with follow-up services. Sterilization acceptors mostly confirmed receiving compensation amount. c) 18 (81.8%) beneficiaries of child immunization were contacted in which all confirmed receiving the doses and also received follow up services. No complication was found among contacted beneficiaries and they were satisfied with the services. 10. Reconciliation of Reported Performance:- There was no proper coordination between district office and reporting centres in respect of performance reported in the year 2010-11 and 2011-12. The details are as follows:

Name of Centre M For the year 2010-11 reported For the year 2011-12 reported et by by h District Office The Centre District Office The Centre o d s 1. PHC, S 430 534 207 326 Akberpur te 434 564 835 1095 ri 5536 4719 1204 1390 li 16547 31120 14300 19000 z

at i o n C u T O P N ir o d h 2.PHC, S 685 618 482 609 Rajauli te 408 711 147 175 ri 608 337 1491 3444 li 20002 4027 4138 17978 z at i o n C u T O P N ir o d h 3. PHC S 189 Report was 105 159 Kashichak te 213 not made 190 270 ri 1470 available at 1316 1403 li 3113 PHC 2822 8501 z at i o n C u T O P N ir o d 52

h 4. PHC S 498 Report was 304 515 Kawakol te 927 not made 290 283 ri 3023 available at 3478 2646 li 15889 PHC 14562 20369 z at i o n C u T O P N ir o d h b) Performance reported for all methods at visited centres for the year 2010-11 and 2011-12 did not tally when compared with the figures recorded in registers. 11. Information on IT Infrastructure and MCH Tracking System:- a) Computer with Internet connection was available at District Office and BPHC only. b) MCH tracking formats were available at Sub Centre level but not all places. Health functionaries of District Office and BPHC were sensitized in MCH formats, but the same was not being done at PHC& Sub Centre level. As observed, data entry was not completed/updated at District, BPHCs and PHCs. 12. Maintenance of Registers & Records:- a) Eligible Couple register was not made available at all visited PHCs. This register was not maintained at Sub Centre level. b) Sterilization Register was maintained properly and up to date at all visited PHCs except Kawakol whereas it was not made available. d) IUD Register was not maintained& updated at all visited PHCs. e) ANC Register was not maintained & updated at PHCs Kawakol and Akberpur but maintained & updated at Kasichack PHC, whereas ANC register was not available at PHC Rajauli. PNC register was not maintained at all visited PHCs & Immunization Register was maintained properly at all visited PHCs.

53 f) OP & CC Registers were not maintained at all visited PHCs. g) Stock Register was not maintained properly and up to date at all visited PHCs except Kasichack PHC. h) Immunization Cards and the register were available at the visited PHCs. 13. Other Observations:- a) Supervision with necessary guidance at grass root level centres was lacking in the district. Regular meeting and monitoring should be improved in the district. b) The condition of Labour Rooms and Maternity Wards at all visited PHCs was found very poor and unhygienic. It was also observed that there was no restriction for general public/staff members to enter Labour Rooms which is important to maintain privacy of mothers and born care. c) PHC or district level officials hardly inspect their SCs for reviewing performances and facilities for providing guidance to the field functionaries.

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