Tamil Nadu Monitoring Report

NATIONAL HEALTH SYST EMS RESOURCE CENTER

Integrated Monitoring Report, April to June 2013

Venkatesh Roddawar 07/08/13

This report is based on health providers and beneficiary interviews and HMIS data analysis of Tamil Nadu state and Viluppuram district. The monitoring visit includes all levels of health facilities in the district. One needs to be cautious in interpretation of HMIS data, the state and districts may have good health service delivery but there might be problem in reporting data. Table of Contents Executive Summary ...... 4 1. Introduction ...... 7 2. State and District profile ...... 7 3. Key health and service delivery indicators ...... 8 4. Health Infrastructure ...... 10 5. Human Resources for Health ...... 11 6. Maternal Health ...... 13 6.1 ANC and PNC ...... 13 6.2 institutional deliveries ...... 13 6.3 Maternal Death Review ...... 15 6.4 Janani-Shishu Suraksha Karyakram (JSSK) ...... 15 6.4.1 User fee in OPD and IPD ...... 15 6.4.2 Drugs and Consumables ...... 15 6.4.3 Diagnostics ...... 15 6.4.4 Diet ...... 16 6.4.5 Referral Transport ...... 16 6.4.6 Display of entitlements ...... 17 6.4.7 Awareness of community ...... 18 6.4.8 Grievance Redressal Cell ...... 18 6.4.9 Out of pocket expenditure / informal charges ...... 18 7 Child Health ...... 18 7.1 SNCU ...... 18 7.2 Infant deaths ...... 19 7.3 Immunization ...... 20 8. Family Planning ...... 21 9. Adolescent Health ...... 22 9.1 WIFS and Sanitary Napkins ...... 22 9.2 School Health ...... 22 10. Quality in Health Services ...... 22 10.1 Infection Control and Bio-Medical Waste Management ...... 22 10.2 Emergency preparedness ...... 23 10.3 Information Display ...... 23

11. Mobile Medical Units and Referral Transport ...... 23 12. Integrated Disease Surveillance Project (IDSP) ...... 24 12. Community Processes (ASHA) ...... 25 13. Disease Control Programme ...... 25 13.1 Revised National Tuberculosis Control Programme ...... 25 13.2 National Vector Borne Diseases Control Programme ...... 26 13.3 National Programme for Control of Blindness (NPCB) ...... 27 13.4 National Leprosy Eradication Programme (NLEP) ...... 27 14. Non-Communicable Diseases ...... 28 15. Others ...... 29 15.1 OPD and IPD ...... 29 12.2 Information Systems ...... 29

Tables Table 1 Description of the area and facilities visited in Viluppuram, Tamil Nadu ...... 7 Table 2 State and district profile ...... 7 Table 3 Key health and service delivery indicators ...... 9 Table 4 Health facility mapping – Tamil Nadu and Viluppuram ...... 10 Table 5 Block wise health facilities in Viluppuram, Tamil Nadu ...... 10 Table 6 Delivery points – Tamil Nadu and Viluppuram ...... 11 Table 7 Human resources status in Tamil Nadu ...... 12 Table 8 Selected maternal indicators of Tamil Nadu and Viluppuram from Jan to May 2013 ..... 13 Table 9 Functional delivery points in public health facilities – Tamil Nadu and Viluppuram ... 14 Table 10 Causes of maternal deaths – Tamil Nadu and Viluppuram, Jan to May 2013 ...... 15 Table 11 Status of different type of new born care facilities in Tamil Nadu and Viluppuram .... 18 Table 12 Immunization session held in Tamil Nadu and Viluppuram from Jan to May 2013 .... 21 Table 13 Family Planning Key Indicators – Tamil Nadu and Viluppuram from January to May 2013 ...... 21 Table 14 IDSP form L monthly report of Viluppuram district, TN from April to 2 nd week of June 2013 ...... 24

Graphs

Graph 1 Human resource status in Viluppuram, Tamil Nadu ...... 12 Graph 2 Institutional deliveries from Jan to May 2015, Viluppuram, TN ...... 14 Graph 3 Duration of stay after delivery in Viluppuram, TN from March to May 2013 ...... 16 Graph 4 Month wise ambulance service against reported deliveries from Jan to March 2013– Vellore, TN ...... 17 Graph 5 Cause of infant deaths in Viluppuram HUD from April 2012 to March 2013 ...... 19

Graph 6 Immunisation coverage against estimated live births – TN and Viluppuram from Jan to May 2013 ...... 20 Graph 7 distribution of sanitary napkins from Jan to May 2013, Viluppuram, TN ...... 22 Graph 8 performance of MMU, Viluppuram, TN ...... 24 Graph 9 RNTCP month wise performance of Viluppuram district, TN ...... 25 Graph 10 Year and month wise Dengue case detection, Viluppuram, TN ...... 26 Graph 11 Year wise malaria cases – Viluppuram, TN ...... 26 Graph 12 Public health facility and NGO wise performance of cataract surgeries, Viluppuram 27 Graph 13 Leprosy case detection from January to May 2013, Viluppuram, TN ...... 27 Graph 14 Screening of NCDs from July 2012 to May 2013, Viluppuram, TN ...... 28 Graph 15 Disease specific positivity rate (July ’12 to May ’13), Viluppuram, TN ...... 29

Executive Summary

• The MMR of Tamil Nadu and Viluppuram indicate 97 and 128 maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy. • Tamil Nadu IMR is 22 per 1000 live births, which is 22 points lower than national average and 0.8 points lower than Viluppuram district. Tamil Nadu and Viluppuram have already achieved the MDG goal of IMR. • Tamil Nadu and Viluppuram reported 27 and 26.6 U5MR as per SRS, which is 50% above the expected level of achievement as per MDG goal by 2015. • Services delivery indicators like ANC, PNC, institutional deliveries, TFR and unmet needs for family planning indicates Tamil Nadu performance above national average. • % of three ANC check-ups and institutional deliveries against estimated deliveries in Tamil Nadu is 26.6% and 32% higher than national average. • The state of the health infrastructure shows highest level of coverage, which is one of the essential factor for improving public health outcomes in the state. • There are total 10,347 health facilities available at different level in the state, of which 84% of them are HSC. 48% of the remaining 1641 health facilities are delivery points as per maternal health guidelines. • In Viluppuram district, out of 666 health facilities, 84% of them are HSC. 95% of remaining 109 health facilities in the district are delivery points. • Large number of vacancies in regular posts in Tamil Nadu – medical officers 1630, LT 1063, staff nurses 629, pharmacist 445, LHV/PHN 228, and ANMs 68. • Out of 1352 sanctioned human resource for health, 90.2% of them are available in Viluppuram district. • Institutional deliveries of Viluppuram district is higher by 13% in comparison with state. The district needs to review the low performance of C Section deliveries, which is mere 3.5%. • There are total 270 blood banks and 211 blood storage units are licensed and functional in the state. • Out of total deliveries, PHC’s (include APHCs and UPHCs) alone contributes 86% and rest of the health facilities contribute 14% in the district. • Strategically 4 to 5 PHCs are located in every block serving 30 to 60 thousand population, which are best positioned to meet the demand of maternal services in the district. • Viluppuram contributed around 5% of total 181 maternal deaths in the state from Jan to May ’13. • 72% of maternal deaths fall under the category ‘other’, that includes causes not known. Second major cause of death is hemorrhage followed by severe hypertension and obstructed/prolonged labour.

• All beneficiaries (ANC mothers) are ware of ambulance services but due to various reasons they could not avail the facility. • It is evident from the reported data that only 7% to 10% of the beneficiaries are availing the ambulance facility and remaining of them are dependent on private vehicles which is one of the major contribution for out of pocket expenditure among the PWs. • TN State has 1766 NBCC’s, 73% of 156 sanctioned NBSU and 61 SNCU’s. • Still birth constitute 1.57% of total live births recorded (23,063) from April 2012 to March 2013 in Viluppuram HUD. • Around 50% of infant deaths occurred in government medical college and remaining deaths occurred at home (17.34%), public health facilities (6.53%), private hospitals (6%) and 5% occurred during transmit in Viluppuram district. • The full immunization coverage of district is 100%, which is 20% higher than state average. • Both state and district outperformed in providing IUDs against total reported FP users, which is 44% to 45% from January to May 2013. • Total 1.01 lakhs napkins distributed, which include 56,338 through Village Health Nurse (VHN) and 45,593 through schools from Jan to May 2013. • During last financial year total 2.15 lakh boys and 2.10 lakh girls were screened for disease, deficiency and disability and suspected 120 boys and 95 girls were referred to health care centers in Viluppuram. • The district needs additional trainings and robust monitoring as far as infection prevention practices are concerned. • There is increasing trend in number of emergency case in urban areas of the district. • The district has 22 MMU in 20 blocks and on an average each MMU covers 4050 OPD load per month. • The average response time per call was 21 minutes and on average 110 trips per month per ambulance. • Average number of emergencies handled per month per ambulance for BLS, ALS and RT is 110, 120 and 90. • RNTCP programme suspected and diagnosed 95 Multi Drug Resistant (MDR) cases in the district as on May 2013. • Malaria positive cases increased from 32 in 2008 to 153 in 2012 over a period of five years. • Out of 27,000 thousands target, the district could achieve 71% of total cataract surgeries up to March 2013. • NCD project of Viluppuram district screened 3.94 lakh hypertensive, 2.54 lakh type-2 DM, 1.88 lakh breast cancer and 93 thousands cervical cancer from July 2012 to May 2013. • On an average 828 OPD per 1000 population at state level and 996 OPD per 1000 population at district level reported for the first five months of 2013.

• AYUSH and dental procedures constitutes 2.1% and 1.89% of the total OPD of the state from Jan to May 2013.

1. Introduction The report is based on monitoring visit carried out in Viluppuram district of Tamil Nadu from 26 th to 28 th June 2013. The monitoring visit include all levels of health facilities – Health Sub Centre (HSC), Additional Primary Health Centre (APHC), Primary Health Centre (PHC), Community Health Centre (CHC), SDH and District Hospital (DH). PHCs and CHC/ SDH are catering to the health needs of the people. Details of visit provided in the below table. Table 1 Description of the area an d facilities visited in Viluppuram, Tamil Nadu

Block Description Facilities visited Vikravandi CHC, Ayyur Comprise of 5 PHCs, 21 HSC, 53 VHWSC Vikravandi Agaram HSC, which caters to 1.27 lakh population Kuchikolathur AWC Comprise of 4 PHCs, 17 HSC, 53 VHWSC Olakkur Olakkur PHC which caters to 87 thousands population Comprise of 4 PHCs, 24 HSC, 53 VHWSC Koliyanur Koliyanur PHC which caters to 1.45 lakh population Comprise of 5 PHCs, 31 HSC, 45 VHWSC Kandamangalam Ka ndamangalam PHC which caters to 1.35 lakh population Comprise of 4 PHCs, 26 HSC, 62 VHWSC Marakkanam Thindivanam SDH which caters to 1.61 lakh population

2. State and District profile Table 2 State and district profile

Tamil Nadu state and Viluppuram district profile State/District Tamil Nadu Viluppuram State/Dist. HQ Chennai Viluppuram No. of Blocks 401 22 No. of Panchayats 12,620 1104 Population (2011) 72,147,030 3,463,284 Literacy 80.09% 71.88% Sex Ratio 996 987 Density of 555/km 2 481/km 2 Population State/District Boarder North AP Kanchipuram East BoB Puducherry West Karnataka Tiruv’malai Cuddalore South (West) Kerala and Salem Tamil Nadu is eleventh largest state by area and seventh most populated state in the country . State has 76 revenue divisions, 215 taluks and 32 districts.

Tamil Nadu population constitute 5.96% of total India population. The state has 401 blocks, and 12620gram Panchayats. Viluppuram is one of the 32 districts located at northeast of the state with a population of 3.46 million, which is 4.8% of the state population. The district literacy rate is 71.88%, which is 8.21% lower in comparison with state literacy rate, 80.09%. Tamil Nadu state density of population is 555/km 2, which is higher by 74 persons/km 2 in comparison with Viluppuram district, 481 persons/km 2.

3. Key health and service delivery indicators The key health indicators of Tamil Nadu reflects excellent performance in comparison with national level. Tamil Nadu recorded 97 Maternal Mortality Ratio (MMR) per 100,000 live births, which is 115 points lower in comparison with national average, 212/100,000 live births. However, when compare with Viluppuram district, 84 points lower than national average and 31 points higher than state average. The MMR of Tamil Nadu and Viluppuram indicate 97 and 128 maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy. Maternal health is one of the eight goals of Millennium Development Goals (MDG’s) that targets to reduce MMR by three quarters (of 1990) by 2015. India has substantially reduced the MMR from 523 in 1990 to 212 in 2007-09. Despite the progress, India tends to fall short to achieve MDG maternal goal by 135 per 100,000 live births in 2015. However, Southern states like Tamil Nadu has already achieved success in arresting incidence, whereas northern states like Bihar, Uttar Pradesh, Madhya Pradesh and Rajasthan might fall behind the targets. The April 2013 edition of Lancet records appreciation for Tamil Nadu in its article “Good health at low cost 25 years on: Lessons for the future of health systems strengthening” . Broadly, four factors that led to change in health care system in the state. Firstly, the highest level of coverage by a network of 1614 PHCs and 8706 HSCs across the state. Secondly, well trained village health nurse based at HSC for preventive and promotive health care. Thirdly, reliable supply of essential drugs through Tamil Nadu Medical Service Corporation (TNMSC) and lastly wide coverage of the immunization in the state.

IMR for the country declined by nine points between 2008 and 2011 with IMR at national level being 44 in 2010. However, the set target of MDG is to reduce IMR by 27 per 1000 by 2015. Tamil Nadu IMR is 22 per 1000 live births, which is 22 points lower than national average and 0.8 points lower than Viluppuram district. Tamil Nadu and Viluppuram have already achieved the MDG goal of IMR.

Table 3 Key health and service delivery indicators

Sl. No. Health indicators India Tamil Nadu Viluppuram* MMR 212 1 97 128 (per 100,000 live births) 2011 (SRS '07-09) CBR 21.8 2 15.9 18.8 (per 1000 population) 2011 (SRS 2011) CDR 7.1 3 7.4 5.8 (per 1000 population) 2011 (SRS 2011) IMR 44 4 22 22.8 (2011) (SRS 2011) 33 5 Neo- natal Mortality Rate 16 22.8 (SRS 2010) 59 6 Under Five Mortality Rate 27 26.6 (SRS 2010) 7 Antenatal Care (AHS 2011) a ANC Check-up in first trimester 76.8% 81.7% 69% b 3 or more ANC Check-up 95.6% 92.0% (HMIS '11-12) 8 Postnatal Care (AHS 2011) a Breastfed within 1 hour of birth 76.1% 91.7% 9 Instit. Deli. Against Esti. Deliveries 62% 94.0% 94.3% 2.5 1.7 Total Fertility Rate (SRS 2010) (SRS 2010) 82 10 Full Immunisation 80 86 (HMIS '11-12) 12.8 11 Unmet Need for FP 18.1 16.1 (DHS '05-06) a Spacing 6.2 5.4 3.5 b Limiting 6.6 12.7 12.6 Source: SRS, *Provisional based on 2008 vital event survey, Viluppuram, TN

Under 5 Mortality Rate (U5MR) in India for the year 2010, stands at 59 and it varies from 66 in rural areas to 38 in urban areas. Given to reduce U5MR to 42 per thousand live birthsby 2015, India tends to short of 28.8% at the current rate of U5MR. However, Tamil Nadu and Viluppuram reported 27 and 26.6 U5MR as per SRS, which is 50% above the expected level of achievement as per MDG goal by 2015. Services delivery indicators like ANC, PNC, institutional deliveries, TFR and unmet needs for family planning indicates Tamil Nadu performance above national average. % of three ANC check-ups and institutional deliveries against estimated deliveries in Tamil Nadu is 26.6% and 32% higher than national average. Tamil Nadu state unmet need for FP is 18.1%, which is 5.3% higher than national unmet needs.

4. Health Infrastructure Tamil Nadu has adequate health infrastructure as per population norms. In terms of required facilities, there is a deficit of 16%, 6% and 19% of health sub-centers, PHC’s, FRU/CHC hospitals in the state. The state of the health infrastructure shows highest level of coverage, which is one of the essential factor for improving public health outcomes in the state. Similar picture reflects in Viluppuram district, in terms of required facilities, above 90% of all levels of health facilities available in the district. Only 7%, 7% and 14% of health sub-centers, PHC’s and FRU/CHC short fall as against required facilities in the district. Table 4 Health facility mapping – Tamil Nadu and Viluppuram

Tamil Nadu Viluppuram Required Existing Short fall Required Existing Short fall District Hospital 31 31 0 1 1 0 FRU/CHC 385 310 75 22 19 3 PHC 1725 1614 111 100 93 7 HSC 10342 8706 1636 601 557 44 Source: TN state PIP 2013-14

Viluppuram district has 22 blocks with a population of 3.4 million. Block population range from minimum 62 thousands in Vellimalai block to maximum 2 lakhs in Mugaiyur block. On average every block has 23 health sub-centers and each sub-center covers minimum five thousands to maximum seven thousand population. The catchment area of PHCs covers minimum 30 thousands to maximum of 40 thousand in Viluppuram district.

Table 5 Block wise health facilities in Viluppuram, Tamil Nadu

Sl. No Block Population PHCs HSC VHWSC 1 Olakkur 340686 4 17 52 2 Marakkanam 161613 4 26 62 3 Vanur 173767 4 17 73 4 Mailam 110839 7 20 47 5 Vallam 114980 4 22 66 6 Melmalayanur 131382 4 25 55 7 Gingee 172011 5 28 69 8 Vikravandi 126984 5 21 53 9 Kanai 131851 4 30 51 10 Koliyanur 145745 4 24 53 11 Kandamangalam 135514 5 31 45 12 T.V.Nallur 146724 5 29 52 13 Mugaiyur 204068 5 30 66 14 Tirukoilur 155218 3 24 61 15 Thirunavalur 129205 3 20 44

16 Ulundurpet 178260 2 24 59 17 Thiyagadurgam 122328 3 18 45 18 Rishivandiyam 142942 3 21 53 19 Sankarapuram 167891 4 26 48 20 Kallakurichi 216618 4 24 46 21 Chinnasalem 181854 6 30 64 22 Vellimalai 61922 4 18 15 Total 3452402 92 525 1179 Source: State PIP 2013-14

There are total 10,347 health facilities available at different level in the state, of which 84% of them are HSC. 48% of the remaining 1641 health facilities are delivery points as per maternal health guidelines. These 48% health facilities supposed to cater to 5.25 lakhs expected pregnancies and 4.83lakhs expected deliveries during first five months of 2013 in the state. By this calculation every delivery point in the state need to cater 295 deliveries per month. The situation is different across different delivery points and mostly PHCs and above level facilities accommodate the needs of pregnant women. There is a need for strategy to strengthen HSC as delivery points in the state. The situation remains the same at district level, for example in Viluppuram district, out of 666 health facilities, 84% of them are HSC. 95% of remaining 109 health facilities in the district are delivery points. These delivery points supposed to cater 25,239 expected pregnancy and 23,220 expected deliveries during these five months. The below table provides facility level institutions and delivery points. Table 6 Delivery points – Tamil Nadu and Viluppuram

Health Facilities Tamil Nadu Viluppuram State Delivery District Delivery Points Points HSC 8706 0 557 0 PHC 1227 559 86 76 CHC Non FRU 154 100 9 9 CHC/FRU 231 103 13 9 DH/DWH 29 29 1 1 Total 10347 791 666 95 Source: State PIP 2013-14, 5. Human Resources for Health Large number of vacancies in regular posts in Tamil Nadu – medical officers 1630, LT 1063, staff nurses 629, pharmacist445, LHV/PHN228, and ANMs 68. State has huge gap of medical, nursing and paramedic staff in terms ofsanctioned and in position at different level health facilities. The number of sanctioned posts is much less than the HR requirement of the State. For example, the requirement of ANM post is 10480 but the state has only 8706 sanctioned

11 posts. Similarly 4316 sanctioned posts for SN against 10112 required, 471 OBG posts against 599 required, 221 Paediatrician posts against 947 required and 230 Anaesthetist against 599 required posts in the state.It is appreciable that except specialists, there is no shortfall of HR (ANMs, SNs, LTs and MOs) at the delivery points.

Table 7 Human resources status in Tamil Nadu

Sanctioned In position HR categories Shortfall Posts (R+C) Regular Contractual Total ANM 8768 8706 0 8706 -62 SN 12130 4160 7341 11501 -629 LHV/PHN 2036 1808 0 1808 -228 LT 3355 1890 402 2292 -1063 Pharmacist 1645 1323 89 1412 -445 MO 6195 3441 1124 4565 -1630 AYUSH MO 1429 815 475 1290 -139 Specialist 958 761 0 761 -197 Source: State PIP 2013-14; R=Regular; C=Contractual

Viluppuram district has adequate HR in all levels of health facilities. There are around 1219 various medical and para-medical personnel available across different health facilities. Out of 1352 sanctioned HR, 90.2% of them are available in the district. Regarding medical officers, out of 206 sanctioned posts, around 78.2% of them are in position. Graph 1 Human resource status in Viluppuram, Tamil Nadu

HUMAN RESOURCES- SANCTIONED VS POSITIONED VILUPPURAM, TN 2013 600 557

500

400 283 300 553 206 200 114 94 100 70 237 28 161 114 53 93 0 8 Specialists LT Pharmacists ANMs Mos Nurses VHNs

In position Sanctioned

6. Maternal Health 6.1 ANC and PNC ANC registration against expected pregnancies and ANC in first trimester against reported ANC of Viluppuram district recorded above state average. Both, state and district indicators shows good performance of ANC and PNC services. The severe anemia cases at state and district stood at 2.3%, which might be the result of iron sucrose injection provided to Iron Deficiency Anemia (IDA) cases in the state. Hypertension cases against reported ANC in Viluppuram is 5.2% higher than the state average. The NCD programme of the state may well intervene in identifying the cases and providing treatment for ANC hypertensive cases. Table 8 Selected maternal indicators of Tamil Nadu and Viluppuram from Jan to May 2013

Sl. No. Key Indicators Jan to May 2013 Tamil Nadu Viluppuram 1 ANC Registration against Expected 85% 100% Pregnancies 2 ANC Registration in first trimester 88% 89% against Reported ANC registration 3 Severe anemia (Hb<7) treated against 2.3% 2.3% reported ANC registration 4 Hypertension in pregnancy- detected 6.4% 11.6% against ANC reported 5 Institutional Deliveries against Estimated 78.2% 91.2% Deliveries 6 Home deliveries( SBA& Non SBA) against 0.4% 1.5% estimated deliveries 7 C Section deliveries against institutional 19.3% 3.5% deliveries

6.2 institutional deliveries As shown in the table 8 above, institutional deliveries of the district is higher by 13% in comparison with state. The district needs to review the low performance of C Section deliveries, which is mere 3.5%. However, to improve the situation, the state has trained 58 medical officers in EmOC and 244 MOs in LSAS. 84% of total health facilities in the state and district are HSC, which are not delivery points. Remain 48% of 1641 and 87% of 109 health facilities are delivery points in the state and district. State and district needs to prioritize and strengthen additional PHCs to improve the number of institutional deliveries. There are total 270 blood banks and 211 blood storage units are licensed and functional in the state.

Table 9 Functional delivery points in public health facilitie s – Tamil Nadu and Viluppuram

Sl. No. Health Facilities Tamil Nadu Viluppuram

Total No. of SCs/conducting >3 deliveries 1 8706/0 557/0 per month Total No. of 24X7 PHCs/conducting >10 2 1227/559 86/76 deliveries per month Total No. of CHCs ( Non FRU) conducting 3 154/100 9/9 > 10 deliveries /month /C -section Total No. of CHCs (FRU) conducting > 20 4 231/103/24 13/09/0 deliveries /month /C -section Total No. of any other FRUs (excluding 5 CHC-FRUs) SDH/conducting > 20 deliveries 127/70/99 0 per month with C-section Total No. of DH conducting > 50 deliveries 6 29/28/28 01/01/01 /month with C-section Total No. of Medical colleges conducting > 7 18/18/18 01/01/01 50 deliveries/month with C -section 8 No. of Blood bank licensed / functional 270/270 3/3 No. of Blood Storage Units licensed / 9 211/211 7/6 functional Source: State and district PIP 2013-14

Out of total deliveries, PHC’s (include APHCs and UPHCs) alone contributes 86% and rest of the health facilities contribute 14% in the district. Strategically 4 to 5 PHCs are located in every block serving 30 to 60 thousand population, which are best positioned to meet the demand of maternal services in the dis trict. The state has made mandatory to rationally deploy HR in all facilities. A policy decision has been taken to deploy 2-3 MOs in PHCs and 5 MOs in CHC . Specialist available only at level II MCH center in each health unit district in the state.

Graph 2 Institutional deliveries from Jan to May 2015, Viluppuram, TN

Institutional Deliveries, Viluppuram, Jan to May 2013

14%

86%

PHC above PHC

6.3 Maternal Death Review Tamil Nadu established robust mechanism to review maternal deaths in the district and state level. Facility based MDR committees are constituted in the district but yet to constitute community level MDR committees. Viluppuram contributes around 5% of total 181 maternal deaths in the state from Jan to May ’13. Total 9 maternal deaths reported and reviewed at facility level during these five months in the district. Last financial year, the Viluppuram district reported total 17 MDs. However, the district magistrate is not regularly reviewing MDs in the district. Regular review of MDs at facility level and facility based MDR committees have provided useful insights and follow-up action to reduce MMR in the state and district. Of total 181 reported MDs in the state during Jan to May 2013, 72% of cases fall under other causes that includes causes not known. Second major cause of death is hemorrhage followed by severe hypertension and obstructed/prolonged labour. Priority of the state is to train district, block MOs, and private hospitals on maternal death review in regular interval to strengthen MD reviews, to understand major cause of death and to reduce MMR burden. Table 10 Causes of maternal deaths – Tamil Nadu and Viluppuram, Jan to May 2013

Maternal Deaths Tamil Nadu Viluppuram Abortion 0 0 Obstructed/prolonged labour 3 0 Severe hypertension/fits 18 2 Bleeding 27 3 High fever 2 0 Other Causes 131 4 (including causes not known) Total 181 9 Source: HMIS

6.4 Janani-Shishu Suraksha Karyakram (JSSK) 6.4.1 User fee in OPD and IPD OPD and IPD services are free in all health facilities.

6.4.2 Drugs and Consumables It is observed that there is no shortage of drugs in all health facilities in the district. No beneficiaries has reported buying any medicine from private medical store.

6.4.3 Diagnostics Diagnostic services are free at all levels of facilities, which include routine blood and urine examination, and scanning. Pregnant women are exempted from paying money for laboratory tests. At primary level all

15 facilities are organizing ANC meeting with all listed pregnant women in that catchment area. The meeting is a platform to educate ANC mothers about ANC care and also provide information on available schemes of state and central government. During these meetings ANC mothers undergo routine examination. The health facility provides lunch for all ANC mothers who attend the clinic.

6.4.4 Diet Provision of free diet available in all health facilities. PHCs are tie -up with local hotel to provide three time diet for PNC mothers and the cost per head is Rs.80 per day. The menu include, morning – 4 idli with glass of milk, afternoon – rice, sambar, cooked vegetable and cured and evening dinner. CHCs and DH have separate kitchens to cook food for the inmates of the hospital. Staff nurse would general take additional charge of these kitchens. Almost all interviewed beneficiaries were satisfied with the food provided by the health facilities.

It is observed across all the facilities that at least50% of the beneficiaries stay 2 days in the health facilities after delivery. Remaining 50% of the beneficiaries discha rge after three days, which indicates good intake of diet provision in health facilities. Almost all mothers are aware that they will be discharged after three days.

Graph 3Duration of stay after delivery in Viluppuram, TN from March to May 2013

DURATION OF STAY - VILUPPURAM, TN 4500 4251 4000 3767 3381 3500 3000 2452 2500 2206 1817 2000 1500 1000 500 0 March '13 April '13 May '13

Deliveries conducted at Public Institutions Discharged under 48 hours of delivery Source: HMIS

6.4.5 Referral Transport Only 19% (n=16 ) of the beneficiaries availed the ambulance service to reach the health facility andremaining 13 beneficiaries either used their own vehicle (Auto) or used local bus. For drop - back 50 percent beneficiaries would be utilizing the service and remaining 8 beneficiaries would be using their own vehicle or public transportation . However, during exit interview, all beneficiaries informed that they are aware of ambulance services but due t o various reasons they could not avail the facility. Around 50 percent respondent said that they visited health facility during full-term for usual check -up but admitted in the hospital for delivery.

Graph 4Month wise ambulance service against reported deliveries from Jan to March 2013– Vellore, TN

AMBULANCE SERVICE AGAINST DELIVERIES - VILUPPURAM, TN 4251 3767 3381 403 324 232

MARCH '13 APRIL '13 MAY '13

Deliveries conducted at Public Institutions Ambulance was used for transporting patients

Source: HMIS

The cost for transportation range from Rs. 15 (bus) to Rs. 150 (auto) depends on distance and time. There is no exclusive ambulance for referral transport but they dependent on 108 ambulance service, which already overburdened with high number of RTA causalities. Beneficiaries also reported that the response time for 108 ambulance has delayed than expected time from 15 minutes to 35 or more minutes. Administration and finance department informed that the fund has been released to all level health facilities to implement JSSK but secondary and tertiary level hospitals do not have clarity on transportation scheme under JSSK.

It is evident from the reported data that only 7 to 10 percent of the beneficiaries are availing the ambulance facility and remaining of them are dependent on private vehicles which is one of the major contribution for out of pocket expenditure among the PWs.

6.4.6 Display of entitlements The signage of JSSK displayed at state health society premises (see photo) but not displayed in health facilities visited. However, when discussed with the district officials, they informed that JSSK progamme started in January 2013 in the district. However, display of JSY is visible in all health facilities visited and display of state health schemes such as Dr. Muthu Lakshmi Reddy Maternity Benefit Scheme and CM comprehensive health insurance schemes well displayed in all health facilities.

6.4.7 Awareness of community When enquired about JSSK entitlements with beneficiaries, they are aware about entitlements under different schemes including JSSK. Weekly ANC meeting at PHC level is a good platform to create awareness about different schemes and also for ANC checkup. Village Health Nurse (VHN) also act as catalyst to create awareness among communities. Socially and politically communities are empowered to demand health services. State has also maternity benefit schemes, which provides Rs.12,000 for BPL families. The scheme provides amount in three instalments, 1 st installment after completion of ANC check-up, 2 nd after delivery and 3 rd instalment after complete immunization of child.

6.4.8 Grievance Redressal Cell There is no formal grievance redressal mechanism available in the visited facilities, when enquired with the beneficiaries, 33 percent said MO, 42 percent VHN and 25 percent said they will approach nurse. No one has said that they don’t know but there is no formal system to address beneficiary grievances in health facilities.

6.4.9 Out of pocket expenditure / informal charges Interaction with beneficiaries revealed that out of pocket expenditure arise mostly on transportation. Around 82% interviewed beneficiary have used their own vehicle or public transportation for convenience even though they know the availability of ambulance services. State level programme officer informed that they are in the process of pooling ambulance to place at health facility with centralized call center for assured referral services for eligible mothers.

7 Child Health 7.1 SNCU IMR of TN is 22 points lower than the national average 44 as per SRS 2011. The district and the state IMR recorded similar rate, 22 per 1000 live births. TN State has 1766 NBCC’s, 73% of 156 sanctioned NBSU and 61 SNCU’s. The Viluppuram district has 97 NBCC’s, 3 NBSUs and 3 SNCUs. These NBSUs and SNCUs are located in medical college, district hospital and sub- district hospital with 20, 10 and 16 bed capacity in the district. Table 11 Status of different type of new born care facilities in Tamil Nadu and Viluppuram

NBCC NBSU SNCU Status Sanctioned Functional Sanctioned Functional Sanctioned Functional Tamil Nadu 1669 1669 153 111 61 61 Viluppuram 97 97 3 3 3 3 Total 1766 1766 156 114 64 64 Source: PIP 2013-14

7.2 Infant deaths The district constituted maternal and child death task force, which review child deaths every month in the district. Still birth constitute 1.57% of total live births recorded (23,063)from April 2012 to March 2013 in Viluppuram HUD. The male infant deaths are slightly higher (1.08%) than female infant deaths (0.8%) in Viluppuram HUD. 41.4%, 1.57% and 56.98% of total infant deaths occur in Schedule Caste (SC), Schedule Tribe (ST) and others. Around 50% of deaths occurred in government medical college that caters to complications. Remaining deaths occurred at home (17.34%), public health facilities (6.53%), private hospitals (6%) and 5% occurred during transmit. 52% of deaths reported within one week of birth and remaining 48% deaths occurred within 52 weeks of birth. Graph 5 Cause of infant deaths in Viluppuram HUD from April 2012 to March 2013

Cause of infant deaths in Viluppuram HUD from April 2012 to March 2013 Meningitis Diarrhoea Accidents / bites 1% Post asphyxial death 1% 3% 3% Mutiple congenital anomalies 5%

Others (specify) Pneumonia 35% 6%

Congenital heart disease 10%

Sepsis 12%

Birth asphyxia 24%

Major cause of deaths include birth asphyxia 24%, sepsis 12% and congenital health diseases 10% in Viluppuram HUD. State initiated comprehensive intervention plan to reduce neonatal deaths in blocks with high IMR. Neonatal care and referral services strengthened in the state by establishing Neonatal Intensive Care Unit (NICU) in 15 high IMR identified blocks of the state. Pediatricians as nodal officers of NICUs visits these blocks to monitor and to provide onsite support.

7.3 Immunization Cumulative figures of Viluppuram from Jan to May 2013 shows improved performance as compared to Tamil Nadu state. The full immunization coverage of district is 100%, which is 20% higher than state average. Immunization coverage in the district comparably higher than state’s average. BCG to DPT3 dropout observed in Tamil Nadu and Viluppuram by 97% and 100%. However, BCG-measles drop out percentage decreased by 5% and 11% in Tamil Nadu and Viluppuram. Facilities visited had functional ILR and deep freezer with temperature card duly filled and adequate temperature maintained. In Viluppuram, due to short of power supply, most of the ILR/deep freezer dependent on power generator.

Graph 6 Immunisation coverage against estimated live births – TN and Viluppuram from Jan to May 2013

IMMUNISATION ( 0 TO 11MNTHS)AGAINST ESTIMATED LIVE BIRTHS- JAN'13 TO MAY'13

Tamil Nadu Viluppuram 100% 100% 100% 94% 83% 82% 80% 79%

B C G O P V MEASLES FULLY IMMUNISED

Source: HMIS 2013 (June)

The district shows good performance of planned versus held immunization sessions which correlates with immunization achievement in the district. However, in comparison with state, district sessions held more than target. It is concern to note that only 2% to 6% of immunization sessions were attended by ASHAs who are supposed to do community mobilization. HIMS show very low number of ASHAs attend immunization session because ASHAs were new and most of them placed in tribal areas of the district. However, all sessions were attend by village health nurse who does community mobilization.

Table 12 Immunization session held in Tamil Nadu and Viluppuram from Jan to May 2013 % of immunization sessions % of immunization sessions Immunization Sessions where ASHA were present held vs planned (out of the held sessions) Tamil Nadu 96.25% 2.83% Viluppuram 102% 6.53%

8. Family Planning Performance of family planning programmes reflects good outcome in the state and district. As per the DLHS III, state and district has 18.1% and 16.1% total unmet needs and on the basis of district population, total eligible couples for unmet need calculated for the first five months of 2013. 16% of the total unmet needs were catered in the district, which is 3% higher than the state average in meeting family planning needs. Both state and district outperformed in providing IUDs against total reported FP users, which is 44% to 45% from January to May 2013. However, state performance of postpartum sterilization out of total female sterilization is higher by 23% in comparison with district. Table 13 Family Planning Key Indicators – Tamil Nadu and Viluppuram from January to May 2013 FP Key Indicators Tamil Nadu Viluppuram Unmet Need 18.1 16.1 Eligible Couples for unmet need- Calculated 2219964 94790 Using DLHSIII Unmet need Total reported FP Users against estimated 283159 14748 eligible couples [13%] [16%] Total IUDs reported against total reported FP 123264 6685 users [44%] [45%] 8267 440 Total OCP users against total reported FP users [3%] [3%] of Total sterilization (against Estimated Level of 113031 5060 Achievement) [40%] [34%] Postpartum sterilization out of total female 91811 2934 sterilizations [81%] [58%] 712 44 Male sterilizations out of total sterilizations [1%] [1%] 112319 5016 Female sterilizations out of total sterilizations [99%] [99%] Source: HMIS 2013 (June)

99% of total sterilization are female sterilization and there is a need for proper counselling for male partners to improve the male sterilization. OCP users remain the same across state and district and there is a need to promote OCP for spacing.

9. Adolescent Health 9.1 WIFS and Sanitary Napkins Health sub-center level, VHN maintains line listing of all adolescent population, which include school going and out of school girls. WIFS progamme of Viluppuram HUD covers around 92,704 girls and line listing of adolescent girls are available across all HSCs. WIFS programme include distribution of IFA and albendazole tablets. Total 1.01 lakhs napkins distributed, which include 56,338 through Village Health Nurse (VHN) and 45,593 through schools from Jan to May 2013.

Graph 7 distribution of sanitary napkins from Jan to May 2013, Viluppuram, TN

Distribution of Sanitary Napkins from Jan to May 2013, Viluppuram, TN

[VALUE], [[PERCE NTAGE]] [VALUE], [[PERCE NTAGE]]

VHN School

Source: DDHS, Viluppuram, TN

9.2 School Health The district covers around 1999 government and 268 aided schools covering 1.93 lakhs students from 1 st grade to 12 th grade in the district. The approach of SHP in Viluppuram is PHC based doctor supported by staff nurse across 22 blocks in the district. Every block has four dedicated SHP teams to screen the children. Total 2.15 boys and 2.10 girls were screened for disease, deficiency and disability and suspected 120 boys and 95 girls were referred to health care centers for health services.

10. Quality in Health Services 10.1 Infection Control and Bio-Medical Waste Management There is a clear cut distinction between primary and secondary care facilities in terms of bio- medical waste management. None of the PHC have proper protocols for disposal of bio- medical waste. These PHCs are still dependent on deep burial pits, where they dump bio- medical waste including placenta. Usually, health workers take the responsibility for the disposal of hospital waste. However, secondary care facilities have tied up with third party agency to dispose bio-waste and CHC meet the expenditure from RKS or AMC grant.

Secondary care facilities have proper color coded buckets in OT, labor and lab rooms and in some facilities they are in partial use. Needles and syringes are properly mutilated and disinfected before putting in waste bin. However, the district needs additional trainings and robust monitoring as far as infection prevention practices are concerned. 10.2 Emergency preparedness District headquarter hospital has dedicated casualty division to attend the emergency cases. There is increasing trend in number of emergency case in urban areas of the district. Some of the primary and most of the secondary care facilities have emergency preparedness but there is scope to improve the emergency preparedness as per standard protocol.

10.3 Information Display Information related to health programs are well displayed except JSSK entitlements, which started in January 2013 in the district. Visited facilities have displayed citizen charter, facility catchment area with number of HSCs, RKS and month wise facility performance of institutional deliveries. However, state schemes like Dr. Muthu Lakshmi Reddy Maternity Benefit and CMs comprehensive health insurance scheme were well displayed outside of all visited facilities. Health sub-centers are also well display information on health related activities. It seems most of the film fraternity are actively engaged in RNTCP and HIV/AIDS awareness. HSC like Ayyur agoram has a display of Expected Date of Deliveries (EDD) and also a chart depicting type of deliveries – normal and LSCS. 11. Mobile Medical Units and Referral Transport The district has 22 MMU in 20 blocks and on an average each MMU covers 4050 OPD load per month. The lowest OP being 494 and the highest OP 9289 per month. Every block has a micro plan with fixed dates at block level. VHN also plays an important role in social mobilization for MMUs. Out of two HUDs in the district, Viluppuram HUD yet to start diagnostic services whereas Kallakurichi HUD started diagnostic services. Kallakurichi HUD covers 11 blocks with an average 48 diagnostic tests per month. On an average each MMU cover 42 villages per month and 53 Anganwadi Centers across 22 blocks of Viluppuram. Viluppuram district has 23 Basic Life Support (BLS) ambulance and 2 Advance Life Support (ALS) ambulance that covers on average 1.4 lakh population per ambulance. The average response time per call was 21 minutes and on average 110 trips per month per ambulance. Apart from these, there are two Referral Transport (RT) vehicles available in the district.

Average number of emergencies handled per month per ambulance for BLS, ALS and RT is 110, 120 and 90. Similarly, average number of pregnant women transported per month per ambulance for BLS, ALS and RT is 35, 40, and 40. Graph 8 performance of MMU, Viluppuram, TN

Performance of MMU, Viluppuram, TN 60 54 48 50 42 40

0 Avg. No. of Diag. Test /Mon Avg. No. of Vilgs. Covered Avg. No. of AWCs. Covered /Mon /Mon

12. Integrated Disease Surveillance Project (IDSP) District has robust IDSP programme, which is reviewed every month. Government and private health facilities are reporting L-form and P-form in the district. All S-forms are reporting to the district surveillance officer (DSO). Total 21 cases of dengue reported, 9 in Kallakurichi and 12 in Viluppuram division from April to 2nd week of June 2013. Around 70% of the reported total cases fall above 14 years of age. However, there is no mortality reported among dengue cases. The below table provides disease wise status of IDSP in Viluppuram district.

Table 14 IDSP form L monthly report of Viluppuram district, TN from April to 2 nd week of June 2013

IDSP ST SP % Dengue/DHF/DSS 229 21 9.17 Chikungunya 36 18 50.00 JE 5 1 20.00 Typhoid Fever 4086 508 12.43 Shigella Dysentry 3 0 0.00 Viral HepatitisB 147 3 2.04 Viral Heapatitis E 3 0 0.00 Leptospirosis 15 1 6.67

Malaria 76880 7 0.01 TB 3081 215 6.98 HIV 10984 53 0.48 Source: IDSP, Viluppuram

12. Community Processes(ASHA) The state currently has about 2650 ASHAs and Viluppuram district has 10% of total ASHAs (255). All ASHA were trained up to module 4 and 9.4% (24) of ASHA were trained in first round of module 6 and 7, which is fully residential. Round 3 rd , 4 th , and 5 th of module 6 and 7 yet to start. Around 72% of AHSAs have drug kits in the district and no HBNC kits distributed.It is observed that none of the elected members (local governing bodies) are members of the Rogi kalyan Samithi (RKS)

13. Disease Control Programme 13.1 Revised National Tuberculosis Control Programme Viluppuram district has 6 Treatment Units (TUs), 31 Designated Microscopic Centers (DMCs) with 6 Senior Treatment Supervisor (STSs) and 6Senior TB Laboratory Supervisor (STLS). Out of 31DMCs, one DMC is managed by Joseph hospital, Viluppuram under scheme 5 of RNTCP and 1NGO for IEC scheme covering 10 lakh population. However, out of 31 DMCs only 2 RNTCP LT are posted and rest of them are vacant.Due to shortage of RNTCP LTs, many of the DMC are dependent on other lab technicians (ICTC) in the health facility for sputum examination.As per the population norms there should be one DMC for every 100,000 (50,000 per tribal and hilly areas) population and one TU per 5 lakh population (2 to 2.5 lakhs tribal and hilly areas. As per the population norms, the district has inadequate RNTCP facilities available for screening, diagnosis and treatment. Graph 9 RNTCP month wise performance of Viluppuram district, TN

RNTCP Performance - Viluppuram, TN 200 189 180 170 160 158 145 140 138 120 126 100 100 86 86 86 80 76 78 72 68 60 64 40 20 0 Jan '13 Feb '13 March '13 April '13 May '13

NSP NSN EP

Source: DTCO, Viluppuram, TN

RNTCP programme suspected and diagnosed 95 Multi Drug Resistant (MDR) cases in the district as on May 2013. Of them 73 confirmed as MDR, 1 cured, 6 completed treatment, 5 cases defaulted and 10 died. DTCO office informed that there one Extreme Drug Resistance (XDR) confirmed in the district, which is a major concern for the district. 13.2 National Vector Borne Diseases Control Programme As on 2 nd week of June, Viluppuram district suspected and diagnosed 46 dengue cases. However, annual cases decreased from 19 cases in 2010 to 9 in 2011 but from 2012 onwards the cases load increased. During 2012 total 81 cases registered and up to 2 nd week of June 2013 46 cases were confirmed in the district.

Graph 10 Year and month wise Dengue case detection, Viluppuram, TN

Year wise Dengue Cases, Viluppuram, TN Month wise Cases up to 2nd week of June 2013 100 81 80 20 17 60 46 15 40 10 19 8 8 20 9 5 5 5 3 0 0 2010 2011 2012 2013 Jan Feb Mar Apr May Jun

There are number of positions vacant under vector borne disease control programme. Out of 5 sanctioned malaria inspectors, none of them are recruited and out of 35 LT only 66% of them are positioned. There are 132 sanctioned multipurpose health supervisors, of which 60% available in the district. Malaria positive cases increased from 32 in 2008 to 153 in 2012 over a period of five years.

Graph 11 Year wise malaria cases – Viluppuram, TN

Malaria Positive Cases, Viluppuram, TN 180 160 153 140 120 111 100 80 55 60 No. of of No.Cases 56 40 32 31 7 20 0 4 2 7 9 12 0 6 6 6 0 5 4 4 2008 2009 2010 2011 2012

Malaria AES Dengue Chikungunya

Source: Monthly report of RoHFW, June 2013

13.3 National Programme for Control of Blindness (NPCB) Viluppuram district has annual target of 27,000 cataract operations for the financial year 2012-13 that include NGOs 18,000 and government 9,000 cataract operations. Out of 27,000 thousands target, the district could achieve 71% of total cataract surgeries up to March 2013. However, in comparison with NGO partner government facilities achieved 32% of 9000 cataract operations whereas NGOs achieved 90% of 18,000 target of cataract operations in the district. There are 10 ophthalmic surgeons available in the public health facilities that include government medical college, district hospital and sub-district hospital, Tindivanam. Out of 22 blocks, 21 ophthalmic assistant available for outreach activities in the district.

Graph 12 Public health facility and NGO wise performance of cataract surgeries, Viluppuram

NGO performance of cataract surgeries Public health facilities performance of ataract surgeries Sankara eye centre

Aravind eye hospital GVMCH Other (Private) GH Kallakurchi Ramana Maharishi eye PIMS Pondy GH Tindivanam Sri Venkateshwara …

C 0 2000 4000 6000 8000 0 500 1000 1500

13.4 National Leprosy Eradication Programme (NLEP) Tamil Nadu achieved the status of elimination of leprosy and the current prevalence rate is 0.42 per 10,000 population. District Leprosy Officer (DLO) supervise the leprosy activities in the district. Inadequate staff for leprosy detection at PHC level. Graph 13 Leprosy case detection from January to May 2013, Viluppuram, TN

New Leprosy Cases from Jan to May 2013, Viluppuram, TN

January

February

March

April

May

0 2 4 6 8 10 12 14 16

Child Child Adult Adult

There is no skin smear test available in any health facility and almost all cases were detected based on nerve and skin patches. From January to May 2013, total 90 new cases detected, which include 46 MB and 44 PB. In district headquarter, total 265 cases are under treatment by the end of March 2013, which include 116 MB and 175 PB. Total 279 leprosy cases released from treatment by the end of March 2013. However, these health facilities do not have capacity to treat deformities and they refer to nearby leprosy referral center.

14. Non-Communicable Diseases Tamil Nadu is currently contending with the double burden of disease, infectious and non- infectious diseases. Tamil Nadu Health System Project (TNSHP) initially undertaken NCD pilot project in few district. NCDs include hypertension, type-2 diabetes mellitus, cervical and breast cancer. After successful implementation of pilot project the state extend NCD project to all districts of Tamil Nadu.

Graph 14 Screening of NCDs from July 2012 to May 2013, Viluppuram, TN Screening of NCDs from July 2012 to May 2013, Viluppuram

450000 394224 400000 350000 300000 254259 250000 188187 200000 150000 93573 100000 50000 58237 28085 0 5519 2735 Hypertension Diabetes Mellitus Cervical cancer Breast cancer

Screening positive

NCD project of Viluppuram district screened 3.94 lakh for hypertensive, 2.54 for lakh type-2 DM, 1.88 lakh for breast cancer and 93 thousands for cervical cancer from July 2012 to May 2013. The positive rate of NCDs among the screened population was 14.8%, 11%, 5.9% and 1.5% for hypertension, diabetes mellitus, cervical and breast cancer.

Graph 15 Disease specific positivity rate (July ’12 to May ’13), Viluppuram, TN

NCDs specific Rate fron July '12 to May '13

Hypertension 14.8

Diabetes Mellitus 11.0

Cervical cancer 5.9

Breast cancer 1.5

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0

15. Others 15.1 OPD and IPD On an average 828 OPD per 1000 population at state level and 996 OPD per 1000 population at district level reported for the first five months of 2013. 17 and 21 IPD per 1000 population recorded at state and district level. Of the 1.2 million IPD in the state, 7.2% underwent major operations with anesthesia and 35% underwent minor surgeries. AYUSH and dental procedures constitutes 2.1% and 1.89% of the total OPD of the state from Jan to May 2013. Similarly, out of 72 thousands IPD of Viluppuram, 3.9% underwent major operations with anesthesia and 33% underwent minor surgeries in the district. AYUSH and dental procedures constitutes 1.6% and 2.13% of total OPD from Jan to May 2013 in Viluppuram.

12.2 Information Systems The weakest aspect in the health programme of Tamil Nadu is data capturing and its utilization. The state has its own TN Health Management Information System (TNHMIS) developed by the TCS. Until recently the data entered in web portal was validated by DHIS-2 and then uploaded in the GoI HMIS web portal. The TNHMIS portal is based on area reporting (using Form 9). The coverage is not complete as the secondary, tertiary and private institutions are not fully covered. Even after validation some errors were found in the up-loaded data in the GoI HMIS portal. This procedure has since been changed and the Assistant Directors have been instructed to upload the PHC/CHC data in the GoI HMIS web portal. In this context, the data from other Health delivery institutions like District Hospital/Taluk /Non-Taluk hospitals and private hospitals have largely been missed out, leading to inconsistencies and decline in the reported figures in HMIS portal. A similar situation exists in reporting Mother Child Tracking System (MCTS) too. The state specific portal, PICME, is used to enter data at the periphery. The data is uploaded into the GOI

29 portal MCTS periodically. On examination of the data downloaded from the MCTS portal it was found that many of the required information are missing. Also the women’s particulars are duplicated with different serial numbers (unique IDs). It is learnt that one data entry operator was assigned to each block level PHC to upload the MCTS data. This person was engaged for four months during last financial year and the data pertaining to the Dr.Muthulakshmi Reddy Maternal Benefit Scheme was mainly uploaded in the portal. The entered data is not analyzed or validated at any of the institutions. Reports generated from the portals are used to submit ‘periodic’ reports. The reports are not effectively used for review / planning. Many inconsistencies in the reported data was observed and pointed out to the concerned officials. Even though the medical officers of PHCs reported that they were trained on HMIS / MCTS, interpretation of data but lack the skills in using the data for planning. Moreover, there is no clear plan for facility based reporting in the HMIS portal. In the absence of data it is difficult for facility based monitoring.