4th COMMON REVIEW MISSION REPORT FOR UTTAR PRADESH 16 – 22 December 2010 National Rural Health Mission, Ministry of Health and Family Welfare, Government of India New Delhi.
Lakhimpur Kheri
Sonbhadra
Page 1 of 37
Acknowledgement
The Common Review Mission team sincerely expresses its deep appreciation and thanks to the officials of the Government of Uttar Pradesh, State NRHM Mission, Directorates of Health & Family Welfare, the staff of the health facilities visited by the team, officers of the regional Health Systems Resource Centre and other partners for the excellent cooperation and hospitality provided to the team. The team greatly appreciates the participation of the State Mission in the debriefing session and the positive openness with which various issues were not only discussed but also taken note of for consideration.
Page 2 of 37
Contents CHAPTER 1 ...... 4 TEAM: ...... 4 CHAPTER 2 ...... 5 2. A) INTRODUCTION ...... 5 2. B) BASE LINE OF PUBLIC HEALTH SYSTEM IN THE STATE ...... 5 CHAPTER 3 ...... 8 FINDINGS OF 4th CRM ...... 8 3. A) INFRASTRUCTURE UPGRADATION ...... 8 3. B) HUMAN RESOURCES ...... 10 3. C) Health Care Service Delivery – Facility Based - Quantity and Quality ...... 13 3. D) Outreach services ...... 19 4.E) ASHA - Programme ...... 21 3.F) RCH II (Maternal Health, Child Health and Family Planning Activities) ...... 22 3.G) NUTRITION ...... 24 3.H) National Disease Control Programmes (NDCP) ...... 25 3.I) PROGRAMME MANAGEMENT IN THE STATE ...... 28 3. J) FINANCIAL MANAGEMENT ...... 28 3. K) DECENTRALIZED LOCAL HEALTH ACTION ...... 30 CHAPTER 4 ...... 32 RECOMMENDATIONS ...... 32
Page 3 of 37
CHAPTER 1
TEAM:
The Fourth CRM Team visited the state of Uttar Pradesh from December 16th to 22nd 2010. The Team consisted of the following members;
S. No Names of the Team Designation & Address Tel/Email Members 1 Dr. Ajay Khera Deputy Commissioner, 9810226150/23061281 Ministry of Health & Family [email protected] Welfare, Govt. of India 2 Dr. P. Saxena Sr. Chief Medical Officer 9810249099 (SAG), Central TB Division [email protected] 3 Mr. Billy Stewart (Health Adviser), DFID, 9873660184 British High Commission, [email protected] New Delhi 4 Mr. V.K. Tiwari (Professor), National Institute 9312309283 of Health & Family Welfare [email protected]
5 Dr. Almas Ali (Independent Public Health 0674-2397124 Consultant) [email protected] 6 Dr. B. Subha Sri (Civil Society Member) 9840260715 [email protected] 7 Dr. Rakesh (Consultant), National Rural 9810546495 Rajpurohit Health Mission [email protected] 8 Ms. Isha Rastogi Finance Assistant (NRHM 9818716169 Finance ) [email protected]
The CRM team visited Lakhimpur Kheri and Sonbhadra districts in Uttar Pradesh. The facilities visited by the teams are detailed below.
Page 4 of 37
CHAPTER 2
2. A) INTRODUCTION Uttar Pradesh is the most populous state in the country accounting for 16.4 per cent of the country’s population. It is also the fourth largest state in geographical area covering 9.0 per cent of the country’s geographical area. The state of Uttar Pradesh has an area of 240,928 sq. km. and a population of 166.20 million. There are 71 districts, 813 blocks and 107452 villages. The State has population density of 689 per sq. km. (as against the national average of 312). The decadal growth rate of the state is 25.85 (against 21.54% for the country) and the population of the state continues to grow at a much faster rate than the national rate.
Number of Districts 71 Number of Sub Division/ Talukas 303 Number of Blocks 813 Number of Villages 107452
2. B) BASE LINE OF PUBLIC HEALTH SYSTEM IN THE STATE
There are five super specialty institutes and 18 medical colleges. There are 61 district male hospitals, 53 district female hospitals and 20 combined hospitals. Out of 438 functional CHCs, 413 CHCs are functioning as 24x7 units. There are 470 functional BPHs, 2680 functional additional PHCs and 20621 sub-centres.
The Total Fertility Rate of the State is 3.8. The Infant Mortality Rate is 67 and Maternal Mortality Ratio is 440 (SRS 2004 - 2006) which are higher than the National average. The Sex Ratio in the State is 898 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows:
Demographic, Socio-economic and Health profile of Uttar Pradesh State as compared to India figures
Page 5 of 37
S. Item Uttar Pradesh India No. 1 Total population (Census 2001) (in 166.20 1028.61 millions) 2 Decadal Growth (Census 2001) (%) 25.85 21.54 3 Crude Birth Rate (SRS 2008) 29.1 22.8 4 Crude Death Rate (SRS 2008) 8.4 7.4 5 Total Fertility Rate (SRS 2008) 3.8 2.6 6 Infant Mortality Rate (SRS 2008) 67 53 7 Maternal Mortality Ratio (SRS 2004 - 2006) 440 254 8 Sex Ratio (Census 2001) 898 933 9 Population below Poverty line (%) 31.15 26.10 10 Schedule Caste population (in million) 35.15 166.64 11 Schedule Tribe population (in million) 0.11 84.33 12 Female Literacy Rate (Census 2001) (%) 42.2 53.7
COMPLETE LIST OF FACILITIES VISITED BY THE TEAM
4th Common Review Mission 16th December 2010 to 22nd December 2010 Name of the State UTTAR PRADESH Names of the Districts Visited Sr. Name District HQ Name of DM Name of CMO No 1 Lakhimpur Kheri Lakhimpur Mr Sameer Verma Dr Rajendra Singh Dr J P Bhargav 2 Sonbhadra Robertsganj Sh. Pandhari Yadav Dr. Mahendra Kumar Dr. G.K. Kuril
Page 6 of 37
Health Facilities visited Sr. Name Address/Location Level Name of the Person No (SC/PHC/CHC in charge /Other) Lakhimpur Kheri District 1 District Male Lakhimpur kheri District Dr S. K. Mittal Hospital Hospital District Female Lakhimpur District Dr P. L. Singh Hospital kheri Hospital Palia Palia CHC/ FRU Dr R. K. Verma Gola Gola CHC/ FRU Dr G. P. Sharma Phardan Phardhan BPHC Dr A. K. Singh Samrai Phardhan APHC S.K. Kaushal Chandan Chowki Pallia SC Mannu Singh Rasalganj Phardhan SC Rajda Praveen Bahellia Buzurg Phardhan SC Shushila Mishra
Sonbhadra District 2 District Hospital Lodhi, Robertsganj District Dr. Akhilesh Kumar Robertsganj Hospital Urban Health Robertsganj Urban Health Dr. Daya Shankar Centre Centre Myorpur Myorpur CHC/ FRU Dr. U.N. Gautam Chopan Chopan CHC/ FRU Dr. A.P. Sinha Dudhi Dudhi CHC/ FRU Dr. U.P. Pandey Nagawa Nagawa BPHC Dr. P.K. Singh Babhani Babhani BPHC Dr. S. N. Sharma Bijpur Bijpur APHC Dr. A.K. Singh Kachanarawa Kachanarawa APHC Dr. Santosh Kumar Babhangawa Babhangawa SC Smt. Sona Devi Rathara Rathara SC Smt. Sheelam Yadav Kewal Kewal SC Smt. Chandrawati Devi
Page 7 of 37
Kirbil Kirbil SC Smt. Shusheela Devi
CHAPTER 3
FINDINGS OF 4th CRM
3. A) INFRASTRUCTURE UPGRADATION The progress of Health Infrastructure Upgradation in the State is slow. A total of 129 District Hospitals were identified for upgradation to IPHS standards during the last two years and it was noted that construction in only 3 District Hospital have achieved more than 50% completion and the rest are still in process.
There is a huge gap in the building position of CHCs, as still 308 more CHCs are required. Out of 50 CHCs chosen for upgradation for (2009-10), only 5 CHCs have been able to achieve more than 50 % completion and rest are still under construction. The State had set a target to establish 180 First referral units till 2011, and the state has established 154 FRUs till date. There are 3692 PHCs in the State, out of which 3187 are in Government building and construction of 505 PHCs are yet to be completed. Out of 942 JSY wards, 133 have been completed construction and rests 774 are under construction. 11 Regional Family Welfare Training Centres were to be strengthened for the year 2009- 10, but only 2 have achieved 50 % completion. Out of 26344 Sub Centres as per the sanctioned strength, 20621 centres are operational. Out of these functional Sub Centres only 13781 are operating in Government buildings. Construction of Sub centres is satisfactory. Out of 4104 construction taken, 3629 (88.43%) constructions have been completed. During the field visit in the districts it was observed that most of the Sub Centres were serving the population of approximately 15000 and with increase in number of deliveries due to JSY and operationalisation of sub centres in their own building with power back up and sufficient space for a stay after delivery is imperative to cater to the increased load of beneficiaries.
Page 8 of 37
Progress of New construction taken up under NRHM in the State (cumulative till Date)
Health Facility New Completed Under Comment Construction Construction/ Sanctioned under NRHM Upgradtion District Hospitals 129 0 129 Only 3 District (DH) Hospital have achieved more than 50% completion CHCs 50 0 50 Only 5 CHCs have achieved more than 50% completion PHCs (JSY Ward) 942 133 774 35 JSY wards are yet to start Sub-Centres 4104 3629 374 101
A total of Rupees Thirteen thousand seven hundred and seventy nine Crores have been spent for infrastructure improvement of health care facilities in Uttar Pradesh during the last 5 years. Out of the total funds utilized, NRHM has contributed to 72.7%, whereas the State has contributed 6.9% of the total expenditure.
Page 9 of 37
100 90 80 72.7 70 60 50 40 30 21.2 20 6.9 10 0 NRHM Other Central Ministry State Budget
Infrastructure upgradation is contracted at state level in accordance with established norms, but the mission did not see evidence that an appropriately prioritized and comprehensive strategy existed to meet the requirements of the state’s MCH plan and speedily operationalised facilities identified as MCH centres. The MCH plan for the district did not appear to be used to feed into planning for infrastructure developments. Besides this, there were some inaccuracies in the MCH plan. for example, in CHC Chopan renovations to staff quarters were urgently required, but this had not been identified in the MCH plan. The bad shape of the staff quarters in this facility was contributing to very poor staff morale. Similarly in CHC Palia-Kalan (Kheri) there were shortages of staff quarters. Only two staff quarters for doctors were available. In view of 24x7 facility more staff quarters in the campus was required.
3. B) HUMAN RESOURCES The ratio of doctors per thousand populations in Uttar Pradesh is much below the national figure and although the ratio of beds is almost the same as the all India figure of 0.7, their geographical distribution is highly skewed in favour of the urban areas, depriving the rural masses. Many of the required health facilities along with the required human resources are not in position. The considerable difference between “required” and “in position” facilities is reflected in the present health status of the people in the state.
Page 10 of 37
Manpower Situation Particulars Sanctioned In position Vacancies Posts Multipurpose worker (Female)/ANM at 23570 21024 (regular) 2546 Sub Centres & PHCs 813(contractual) Health Worker (Male) MPW(M) at Sub 8857 2160 6697 Centres LHV at PHCs 3690 3509 181 Doctor at PHCs/ CHCs/ DHM/ DHF/ 14103 8482 5621 DCH MOCH posted at PHCs 1110 Pharmacist 5222 4269 953 Laboratory Technicians 4205 316 + 467 3422 Staff Nurse 4948 4708 240 Source: MIS Cell, Directorate of Medical and Health, UP and HMIS cell, State Programme Management Unit, UP, December 2009
There is a tremendous shortfall of human resources in Uttar Pradesh as seen in the table above. This is particularly so in the case of doctors, ANMs, pharmacists and MPWs. Further the review was done on the basis of IPHS standards for Sonbhadra and Lakhimpur Districts which revealed significant gap in staff nurses, MPWs, lab technicians and pharmacist. During visit in Sonbhadra district, it was found that the district hospital has only half of the sanctioned number of specialists. Some facilities visited had a skewing of HR with sufficient doctors but totally insufficient numbers of nurses (e.g. Dudhi CHC had 8 doctors but only 6 nurses). This will impact negatively on quality of care, capacity of health facilities to provide needed care, particularly at night, and capacity to provide important counseling messages (e.g. on nutrition) to new mothers.
Sonbhadra Lakhimpur Kheri Existing Required Shortfall Gap Existing Required Shortfall Gap Category no. as per % number as per % IPHS IPHS norms norms Doctors 89 157 68 43% 147 277 130 47% Staff 38 324 286 88% 62 215 153 71%
Page 11 of 37
Nurses ASHAs 1497 1527 30 2% 3141 3420 279 8% MPW 01 89 88 99% 42 253 211 83% ANM 164 386 222 58% 379 772 393 51% Lab 18 91 73 Technicia 80% 26 86 60 70% n Pharmaci 21 95 74 st 78% 31 103 72 70% Ward 64 110 23 Staff 21% 77 139 62 45%
Although state and district authorities are making a number of moves to fill gaps, the state does not have a medium-long term planning framework for HR. Such a framework would consider prioritization and phasing of recruitment, future needs for pre service and in service training, and faculty in training centres. A HR database which is able to provide up to date information on the numbers of staff available, their location, and duration of service would be needed to back up this plan. Second ANMs are not yet in place in sub-centres which means a huge workload for existing ANMs, particularly in sub-centres with a high number of deliveries. In Sonbhadra district, 60 ANMs had been trained but had not yet been posted.
Some use of reforms in HR was evident as a strategy to meet required numbers. A large number of contractual staff is in place to reduce the gap between needed and available HR. A total of 3,248 Health care providers were made available through NRHM funds which include Doctors, Staff Nurses, ANMs and Lab Technicians. AYUSH doctors had been posted in new PHCs where allopathic medical officers were not available. However, they had not received additional in service training, although expected to provide mainly allopathic medical services. Requirements for second ANM positions had been relaxed to allow ASHAs to apply – and of the 60 newly trained (but not placed) ANMs in Sonbhadra nearly half were ASHAs. This will provide stronger career motivation. District level surgeons were providing services on a rotational camp basis – for example for eye surgeries.
Page 12 of 37
However, other HR reforms which are in existence in other states (e.g. 3 year trained rural medical providers, nurse practitioner, compulsory rural postings) were not being taken up. Incentives for staff in hard to fill postings are not yet in place but have been included in the new PIP for the state.
Pre-service training capacity is low across the state and critically weak in visited districts. In service training is at a low level and had recently been halted at state level. The rational use of staff that had been trained was also weak. For example, only two ANMs in the entire district of Sonbhadra had been trained in skilled birth attendance, and these were posted in wards, with no chance to use their training. ANMs in sub- centres with high numbers of deliveries are in urgent need of SBA training. Some multi skilling training is being done (e.g. EMOC training) but facilities identified for upgradation under MCH plans need urgently to utilize this means. MCH plans are not yet mainstreamed into overall HR planning for the district. No PPP arrangements are in place for training of the health staff.
In general sufficient numbers of support staff were in place – but in some sub centres which are seeing high numbers of deliveries, there is a need to ensure that cleaning, disposal of placenta etc, are done.
Finally in some facilities visited staff morale was very low – related to working and living conditions (including condition of staff quarters). This needs to be considered in the infrastructure plans. Well managed facilities which are displaying good team spirit (e.g. CHC Myurpur, Dudhi) could be used as model facilities for improving management in others.
3. C) Health Care Service Delivery – Facility Based - Quantity and Quality There is an increase in the utilization of health services, which is reflected by increased number of patients in OPD, IPD services throughout the State. There is an increasing trend of institutional deliveries happening in most facilities over the last few
Page 13 of 37 years especially since the launch of the Janani Suraksha Yojana. This was evident during the visit to the facilities where OPD and IPD caseloads have increased in a relatively short time, although there is seasonal variation in all the facilities with major load during the months of October- January.
4.5
4 Institutional Delivery 3.5
3 District Female Hospitals/OPD Patients 2.5 District Female Hospitals/IPD In Lakhs In 2 Patients 1.5 CHC/PHC OPD Patients 1 CHC/PHC IPD Patients 0.5
0 2006-07 2007-08 2008-09 2009-10
Most deliveries seem to be happening in the sub centres with some sub centres visited having conducted up to 75 deliveries a month. Most PHCs, Block PHCs and CHCs visited also reported an upward trend in OPD attendance, with a large seasonal fluctuation. While there seemed to be an increasing patient load, especially deliveries, there seemed to be a severe shortage of appropriate human resource. Doctors, especially specialists, and nurses were very few in the whole district and even where available, the doctor nurse ratios were extremely skewed. There were also issues noticed with matching human resources with the infrastructural resources available.
A pediatrician who was actively providing newborn care in a CHC (Dudhi) did not have any supportive equipment available, while some other CHCs (Chopan) were seen to have such equipment; an orthopedician was posted in one of the CHCs visited, but the X ray machine there was not fully functional. Emergency transport seemed a major issue. People living in villages had to hire private vehicles to reach facilities in case of any emergency - people we spoke to in the
Page 14 of 37 villages felt this was very expensive, and also contributed to delays, also given the generally poor condition of roads and public transport facilities. Facility to facility transport was better - most CHCs (Myonpur) and a few PHCs (had ambulances, some donated by local MLAs from their development funds. However, very often these were used for travel for VHNDs or mobile camps and were not especially dedicated for emergency transport. They also lacked emergency equipment and drugs and oxygen. The team was informed by the state officials that planning was underway to implement an EMRI kind of arrangement for emergency transport - vehicle procurement for this had begun and the team saw some of these vehicles in the district; however a centralized service provision for this was not yet in place. Given that this facility presently plans for only one vehicle in each block, some arrangements like the Janani Express scheme of Madhya Pradesh may be of use to provide transport from the community to the facility, especially the sub centre. Also, some civil society representatives the team interacted with felt that the charges of ambulances were high and a consideration of free transport for at least BPL patients and in cases of delivery needs to be made.
Drug supply seemed to be functional even in remote facilities with no major reports of stock outs or shortages. Transparent reporting of stock positions of various drugs was seen in most facilities visited in the form of wall painting and writing. There seemed to be an issue however with shelf lives of some of the drugs - for example, oral contraceptive supplies were seen to be expiring in January 2011 all over in the districts visited. The team also did not find essential drugs like Magnesium Sulphate in many of the CHCs, PHCs and even the district hospital visited. With sub centres conducting a large proportion of institutional deliveries, some thought needs to be given to providing sub centres with essential drugs like oxytocin, Misopreostol and magnesium sulphate.
No guidelines on rational drug use or standard treatment guidelines were found in the state. Another issue of concern noted was that of AYUSH practitioners in PHCs - in one of the PHCs visited, the lone doctor from the AYUSH team did not have any
Page 15 of 37 supply of AYUSH drugs and was using allopathic drugs without any training in the same. Given the crisis in terms of available human resource, some form of training for AYUSH practitioners in use of modern medicines may be considered and legal issues regarding this need to be addressed. Labs at PHCs and CHCs are well functional and provided essential services like malaria and TB screening in large numbers. However, even basic investigations for antenatal care like hemoglobin or urine testing was not being provided at the sub centre or at the VHND although this was the level at which most antenatal care was happening. Infrastructure for handling the increasing clinical load was seen to be lacking especially in the block PHCs, PHCs and sub centres. While new JSY wards were seen to be under construction in almost all the Block PHCs and CHCs visited to provide additional beds for postnatal women, space in the labor rooms in Block PHCs, PHCs and sub centres seemed to be a constraint. Most facilities had newborn corners, but very often these were cramped in one corner of the labor room. Except at CHCs, there were no scrub areas or toilets attached to the labor room. Privacy also seemed to be an issue with very few facilities visited having curtains in labor rooms. Given the small number of beds in the wards, a 48 hour postnatal stay was found to be impossible - an urban health post in the district headquarters in one of the districts visited had about 200 - 250 deliveries every month with only 7 beds and had to discharge postnatal women 4-5 hours after delivery for lack of beds.
The team also saw that most women delivering in institutions were accompanied by ASHAs who stayed with the woman till she was discharged. The delivered mothers mostly stay for 24 hours in the facilities, but none of the facilities provide free food for in patients. Also, there were no arrangements for the ASHA to stay in the institution nor were there any toilets for her use. One facility visited had converted a room with a toilet into an "ASHA GRAHA" using RKS funds - this was seen by the team as a positive example that could be upscaled.
Page 16 of 37
Cleanliness levels were generally satisfactory in most facilities visited. Infection control procedures were not seen to be widely followed in most facilities - even in sub centres and PHCs with a large number of deliveries every month, active sterilization of instruments were not seen to be happening. No biomedical waste segregation or disposal systems were in place in any of the facilities visited - an exception was one block PHC that had a sharps disposal pit constructed out of RKS funds. Interviews with patients showed generally high levels of satisfaction. The same was not however uniformly true of providers - this varied according to conditions at the facilities they were working in with some providers seen to be in a state of very low morale. The state reported that a 5 year annual maintenance contract was built into the purchase policy of large equipment over the last few years. Timely maintenance and repair of large equipment was seen to be a problem however at the district level with some recently purchased critical equipment seen to be out of use for some time. Minor repairs and maintenance were seen to be being done out of RKS funds. During the field visit to CHC Palia Kalan in district Lakhimpur kheri it was observed that muscle relaxant injection were kept ILR alas with measles vaccine. This is dangerous practice and must be avoided. It was seen that funds from RKS were being used in most facilities to provide support services like sanitation, security; laundry and 24 hour power back up. RKS funds had also been used in some facilities to provide patient waiting areas and shelter for attendants. No canteen or diet facilities for patients or telecom facilities were available in any of the facilities visited. While most facilities had signboards at their front gates, such signage was lacking in providing directions to reach the facility from the main roads. Most facilities had displays of timings, services provided, persons on duty, map of area covered. There was no display of grievance redressal mechanisms however in any of the facilities visited. Rogi Kalyan Samitis were in place in Block PHCs, CHCs and district hospital. These met fairly regularly and decided on use of untied funds. The RKS was however
Page 17 of 37 found to be constituted only of medical staff and block or district level officials from other sectors - participants from civil society and Panchayat representatives were found to be lacking. It was also found that the state had a policy of constituting RKS only from Block PHC level upwards. Untied funds of PHCs were being handled by the Block PHC and very often the medical officer of the PHC was unaware of how the funds were utilized. There is an urgent need to expand RKS membership, constitute RKS at PHC level and infuse these with the true spirit of communitization. While newborn care corners with basic equipment were present in most facilities, no training on essential newborn care had been provided in the district visited. Early breastfeeding was seen to have been initiated in most institutional deliveries; this was however not true of many home deliveries. Community based postnatal care was seen to be provided mainly by ASHAs and not the ANMs. While CHCs seemed to have enough toilets for use by patients, this was not true of PHCs and Block PHCs. Even when present in adequate numbers, toilets were not marked separately for male or female use. Wards were separately earmarked for men and women, but often were seen to be mixed in practice. Privacy of patients was an issue in the wards with no curtains or screens available. One facility had used RKS funds to provide bedside seating for patient attendants and bedside lockers - this could be up scaled. Safety of women service providers like nurses seemed to be an issue in many facilities. Very few facilities had separate rooms for women staff with attached toilets. Even in such cases, broken windows and doors compromised safety of the staff especially at night. Vishakha committees to address issues of sexual harassment at workplace were not found to be in place anywhere. Untied funds were mainly seen to be used for minor repairs and maintenance, buy fuel for generators, locally purchase emergency drugs when in short supply, provide shelters for patients and attendants, employ contractual staff for ambulances etc. These seemed to have improved quality of care by providing for local needs, especially when innovatively used.
Page 18 of 37
Record keeping was generally seen to be fairly good - regular records of deliveries, referrals, malaria, and tuberculosis were being maintained. The state had received formats for maternal death audits from the centre and had disseminated them to the districts - no sensitization or training had however been given and therefore no audits were seen to be happening in the field. Only one facility was seen to be maintaining records of maternal deaths in the facility.
3. D) Outreach services The sub centres and the VHND seemed to be the focal points for outreach services in the district visited. It was seen that the sub centres were conducting a large number of deliveries; however their infrastructure needs substantial upgrading to meet this load. It was seen that women were being discharged a few hours after delivery in sub centres for lack of space. Plans to add space for beds in the sub centres need to be though out. In addition, support structures like 24 hour power supply, may be through solar power, running water supply, provision of mobile phones for communication in emergencies need to be considered. According to reports from the state, 1911 new ANMs have been selected for training and posted as additional ANMs. However, given the huge vacancies in the state of ANMs, urgent efforts need to be made to recruit and train more ANMs. In one of the districts visited by the team, it was seen that the number of subcentres also fell severely short of requirement as per population norms - this would then mean building additional subcentres and train staff for these too. While the state has conducted exams for recruiting male workers, the team understood from state officials that the results of these have been delayed for more than 6 months - this needs to be expedited and training and recruitment of these workers ensured. The state officials informed the team that a plan was underway to establish Mobile Medical Units at block level and procurement of vehicles for the same was underway.
Page 19 of 37
There are 52,002 Gram Sabhas in UP of which 51,943 VHSCs have been constituted and have an operational bank account.
The good coordination between AWW, ANM, ASHA could be seen in the field, however this was not uniform in the two districts visited. This coordination, where present was seen to help the (Jaccha Bacha Surakchha Abhiyan ), VHND. Some staff of ICDS reiterated the need for cooking and serving utensils in Anganwadi centres to provide freshly cooked food.
All places visited had very detailed microplans for VHNDs. These sessions were seen to be the major points for provision of antenatal care. The quality of antenatal care provided was however seen to be very poor - BP checks and abdominal exams were not being conducted at the VHNDs visited. Birth planning for institutional deliveries seemed to be mostly happening with the help of ASHAs. However, quality of institutional deliveries at most facilities across levels seemed to be very poor - hardly any nurses or ANMs had undergone SBA training and the few who had undergone training were posted in areas where they were not conducting deliveries. Standard tools like partographs were not to be seen in any facility, emergency drugs like oxytocics and anticonvulsants were very often unavailable. Providers also reported use of intramuscular oxytocin for augmentation of labor in most facilities - this could be dangerous and could contribute to birth asphyxia and maternal problems. As mentioned earlier, postnatal stay was a problem because of constraints of space - most facilities reported a 24 hour postnatal stay.
Saas Bahu Sammelan – periodic meetings allowing interactions between mothers in law and daughters in law aims at involving families of women in their health care. This is a good practice and should be continued. This practice should be replicated in other parts of the country.
Page 20 of 37
4.E) ASHA - Programme
There are 1, 36,192 ASHAs in position against the sanctioned 1, 36,248 all over the State (almost 100%). More than 80% ASHAs are trained up to 4th Module. The fifth module trainings, which were planned for the year 2009-2010, have not been initiated in the State. At the state level the ASHA mentoring group is functioning. The group is headed by Principal Secretary and consists of 19 members. Members are drawn from 3 from DG, 1 from medical college, 1 from SIHFW, 1 from NHRC and 11 NGO. At the district level mentoring group is headed by district magistrate and members consist of 12 to 14 (including 8 NGO, 1 ICDS, 1 Education, 1 PRI, 2 Medical Officers, 2 Block Development Officers) members. Support for ASHA in the form of handholding by certain NGOs was taking place in some districts. In Kheri district, the team observed that at village Tehra, Palia, hand holding of ASHA is being done by Christian Health Association of India. (CHAI). “Comprehensive Child Survival Program” CSSP ie. IMNCI Plus has started since June 2008. CHAI is providing supportive supervision for CSSP District Coordinators. Palia has 60 Gram Panchayats and 198 ASHA’s are in position out of which 90 ASHA’s have completed CCSP training and hand holding is being done through CHAI. This training of hand holding is recommended to be continued. A quarterly Newsletter “Ashayein” is published and made available to ASHAs all through the state regularly – this is again a positive intervention that could be upscaled in other states. "ASHA GRAH " as seen in one facility and detailed earlier could be considered to support their stay with a postnatal woman in the institution. Electronic Transfer of money for JSY has been appreciated as compared to payment through cheque. While current payments to ASHAs seemed to be taking place on schedule, problems with past payments for JSY were reported by some ASHAs and need to be looked into. In one of the districts (Sonbhadra) visited by the team, ASHAs had been trained to prepare blood smears for malaria and were incentivized for this - this was a positive
Page 21 of 37 example of a wider use of ASHA. Incentives were also being given to ASHA for ensuring antenatal registration and routine immunization. ASHA’s are doing a commendable job in difficult situation. ASHAs are highly visible, motivated and effective in community.ASHA has been the pillar of the National Rural Health Mission. To quote a civil society representative stated; "Without the ASHA, the NRHM will collapse". It was seen that ASHA had significantly contributed to increasing awareness in the community on maternal and child health issues and also to increase the numbers of institutional deliveries, immunization coverage and demand for family planning services.
3.F) RCH II (Maternal Health, Child Health and Family Planning Activities) As per the table it can be seen that the State of Uttar Pradesh is still far from achieving the IMR, MMR and TFR goals. Also Family planning programme was found to be very week throughout the State.
Key indicators Source and year of reference IMR 67 (SRS 2008) MMR 440 (SRS 2004-06) TFR 3.8 (NFHS III) Total institutional 21% (NFHS III) delivery rate ANC Check up Rate 22% (DLHS III) Measles Immunization 47% (DLHS III) Rate Unmet Need for 33.8% (DLHS III) Family Planning
Comprehensive cards containing detailed antenatal care, postnatal care, immunization and growth monitoring details of women and children were seen to be issued to all pregnant women. It was however seen that these cards were not filled in
Page 22 of 37 completely in the field. Name based tracking of pregnant women was not being done - problems with the software were cited at state level as reason for this. It was seen that ASHAs were serving as linkages between demand generation and service delivery and creating an increase in demand for institutional deliveries, immunization and family planning. However several systemic constraints were seen impacting service delivery. IEC activities around Family Planning were seen to be weak - special focus on IEC activities especially focused on spacing methods and men needs to be made. The Male Worker proposed at subcentre level may be an important step towards this. The VHSC also needs to be actively involved in this. Absence of blood bank or storage facilities is another major deterrent to quality of care - there are no FRUs functional in the whole district of Sonbhadra because of this. Lack of adequate capacity building efforts and absence of a rational workforce policy also are hindrances to quality of care. No efforts are also made to improve engagement of the community on these services. Safe abortion services were not widely available – these were unavailable in the whole of Sonbhadra district except at the district hospital. Even where available, modern methods like MVA and medical abortion were not being used. There also seemed to be attitudinal problems in providers where abortion services were seen to be given conditionally with family planning surgeries. Family planning surgeries were provided largely though camps for laparoscopic tubal ligation and No scalpel vasectomy. In Sonbhadra, district officials reported that there was only one qualified laparoscopic surgeon in the whole district of Sonbhadra. However, camps reporting more than 200 women undergoing laparoscopic tubal ligation in a day were not uncommon. These are clearly against the Supreme Court guidelines for the same and gravely compromise the safety and lives of women. In addition, it was seen that targets were allotted at each level from the district right up to the ASHA to achieve in terms of different Family Planning services - these are again clearly against the national policy of Family Planning being seen as a reproductive right and run the risk of turning coercive at the ground level. It was also seen that minilap
Page 23 of 37 tubectomies were not being performed regularly. Male sterilizations were found to be very few comparatively. The use of IUD needs to be promoted. Emergency contraceptive pills supply was also not available. JSY seemed to have contributed to an upswing in the number of institutional deliveries. Payments for JSY were largely seen to be transparent and prompt and lists of beneficiaries were seen to have been put up for public display in one facility. A scheme to engage private providers for provision of free delivery service on a voucher basis for BPL women has been initiated, but has faced problems with withdrawal of providers shrinking the provider base. MCH centre plans have been drawn up for the state - however, the team felt that ownership of this programme was lacking at both state and district level. The rationale of selection of some centres for operationalisation as MCH centres was unclear - the team felt that the plan may need to be revisited taking into account the present infrastructure and human resource status of the facilities. No maternal death review processes were seen to be happening in the state. While the state had received guidelines for such review from the centre and disseminated it to the districts, no sensitization or capacity building for the same had been arranged. Given the usual reluctance by peripheral staff to report deaths for fear of punitive action, such sensitization workshops need to be urgently arranged. Details regarding how the data is going to be analyzed and used need to be worked out and communicated to lower level staff.
3.G) NUTRITION There are 16 functional Nutritional Rehabilitation Centres (NRCs) in the State out of which 8 NRCs are in Lalitpur, 1 in Farrukhabad and 7 in State Medical colleges. 4 Districts have been selected this year for establishing 2 NRCs per district in Banda, Badaun, Gonda and Pratapgarh. No Nutritional Rehabilitation Centres were present in either of the districts visited by the team.
Page 24 of 37
The state has instituted special measures to address malnutrition like the celebration of breast feeding week, Bal Swasthya Poshan Mah strategy, School Health Programme and the Saloni Swasth Kishori Yojana. However, regular growth monitoring and diagnosis and management of malnutrition did not seem to be happening through the Anganwadi Worker regularly. Microplanning for VHNDs were seen in all facilities visited and these plans were also seen publicly displayed in most facilities. There were some reports from civil society groups that the team met in one district however that these microplans were not necessarily followed regularly and some sessions were in fact missed. The team visiting Sonbhadra visited two VHND sessions - the nutritional component at the VHNDs seemed really weak. Coordination between the ANM and Anganwadi Worker seemed to be lacking. Weighing scales were not functional in one of the VHNDs visited and no IEC material on nutrition was available.
3.H) National Disease Control Programmes (NDCP) Overall Effectiveness of NDCPs: - Overall, the National Disease Control Programmes are operating under NRHM at both state and district levels. Though, the State Programme Management Unit (SPMU) is closely involved in coordination and monitoring with the various National Programmes, the District Programme Management Units (DPMU) in the two Districts visited by the team (Lakhimpur Kheri and Sonbhadra) are not fully involved to provide support and monitor the National Disease Control Programmes. ASHAs, ANMs, MPWs and other supervisory staff in the field level are involved in implementation of various NDCPs.
National Vector Borne Diseases Control Programme (NVBDCP): - Activities for Malaria Control are in place in all the Districts. Filarial Control in 50 Districts, Kala Azar in 4 Districts bordering Bihar and for Japanese Encephalitis (JE) in 34 Districts mainly in eastern UP. 476 deaths have been reported due to JE in the State and vaccination against JE has been reported to be given to approx 3.5 million children in 7 affected districts. The consumption of insecticides such as DDT & Malathion and Larvicides such as
Page 25 of 37
Temephos in the districts visited was low thereby indicating that Vector Control measures are sub-optimal. The state needs to take more pro-active measures for Vector Control.
Revised National Tuberculosis Control Programme (RNTCP): - Due to unavailability of contractual staff in State TB cell such as Medical Officer, Accountant, Statistical Asstt., IEC Officer etc., monitoring of the Programme from the State level has been affected. Also, RNTCP Drug logistics in the state has been affected due to vacant posts of State Drug Store (SDS) Pharmacists at 4 SDSs for almost more than a year. Out of total 71 districts in the state, only 30 districts have full time District TB Officers (DTOs), whereas 41 districts have only officiating DTOs. This has resulted in the quality of the Programme in many districts of the State being affected. Overall, there are vacancies of 21 Senior Treatment Supervisor (STS) and 42 Senior TB Lab Supervisor (STLS) in the entire State leading to lack of supervision in various TB units under the Programme.
Case Detection of TB cases under RNTCP is low compared to National Indicators. However, Treatment Success Rates of New Sputum Positive (NSP) cases are good. Community meetings are not held in the districts visited as per norms in spite of availability of sufficient budget provision. Therefore, IEC activities need to be increased and the available Budget be utilized to improve TB Case Detection Rate in the entire State.
National Programme for Control of Blindness (NPCB): - Goal is to reduce prevalence of Blindness from 1% (at present) to 0.5% by 2012. The state achieved 100% of the target for cataract surgeries in 2009-10. However, more than 50% of cataract surgeries were done in private sector which requires quality monitoring. Examination of school going children for Refractive Errors and provision of free glasses is taking place. State has established 18 Eye Banks. Shortage of Eye Surgeons at Block CHCs (IOL centres) is a bottleneck of the Programme. Trained manpower and equipment are also required for
Page 26 of 37 other eye diseases (i.e glaucoma, Retinal surgery, Squint, Low Vision, Pediatric ophthalmic surgery etc.) at District Hospitals.
National Iodine Deficiency Disorder Control Programme (NIDDCP): - 54 Districts in the State have been surveyed for Iodine Deficiency Disorders out of which 24 have been found to be endemic. At the District level, the Addl. CMO (Immunization) are also the nodal officer of the Programme and were trained in 2007-08. Posts under Iodine Deficiency Disorder (IDD) Cell & IDD Lab have to be filled on contractual basis as proposed by MoHFW (GoI). Awareness workshops at various levels for Medical & Paramedical personnel could not be held due to unavailability of funds. 25,000 diagnostic kits (for diagnosis of Iodine Deficiency Disorders) yet to procured (one kit to be provided to each ANM).
Integrated Disease Surveillance Programme (IDSP): - The State has established surveillance units at state level and in all districts. At State Surveillance Unit (SSU), posts of Epidemiologist, Consultant Finance, Entomologist, Consultant training and DEO are vacant. At District Surveillance Units (DSUs), posts of 2 Microbiologists, 25 Epidemiologists, 6 Data Managers & 32 DEOs are vacant and under the process of filling up. State has also established EDUSAT centres at state level and at 3 medical colleges i.e. Gorakhpur, Jhansi and Kanpur. In all Districts, data cell and training cell are available. From all Districts, regular monthly reporting of Communicable and Non Communicable disease to NCDC, Delhi being done. At DGMH, Regional Lab. established and Microbiologist working properly. Out of 289 episodes reported, 209 were reported same day, 77 within 24 hours, 2 within 48 hrs and 1 within one week.
National Leprosy Eradication Programme (NLEP): - Prevalence rate of Leprosy per 10,000 population in the State is 0.93 and the State proposes to achieve prevalence rate of 0.5 /10,000 by 2012. 44 districts achieved elimination level. Two districts Kanpur Dehat & Baharaich have Prevalence Rate more than 2 /10,000. Funds and drugs are available at all levels. Staff at State and District levels are available. Treatment
Page 27 of 37 completion rate at State and District levels is almost 100%. 376 Re-Constructive Surgeries (RCS) performed in 2009-10. Micro-Cellular Rubber (MCR) footwear is being procured in the districts.
3.I) PROGRAMME MANAGEMENT IN THE STATE The programme is manned by two Ministers, two Secretaries and DG (Medical Health) at state level and two CMOs at district level. There are two CMOs in the district. The CMO (Medical Health) looks after work of CHC, PHC, and Sub-centre. Various national health programmes are also looked after by the CMO (Medical Health). The CMO (FW) looks after NRHM related activities which also includes RCH and family Planning. In order to implement the programme, State and District Programme Units are established. The SPMU consists of Administration, Finance, M&E, IEC, PPP, MIS Cells and National Health Programme Cells. At the district level Programme Management Unit is also established in all the Districts. This unit consists of District Programme Manager, District M&E Manager, district Accounts Manager and District Data and Accounts Assistant.
However, at the 17 Division level also, Programme Management Unit is established which consists of Divisional Programme Manager and Data Assistant. At the Block level, posts of Block Programme Manager and Accounts Assistant do not exist. At some places, Health Education Officer is designated as Block Programme Manager. Post of Accounts Assistants is vacant. The work is managed by some clerical cadre staff under guidance of District Accounts Manager.
3. J) FINANCIAL MANAGEMENT The total approved budget of the state for financial year 201-11 under NRHM is Rs. 2788.93 crores against which the expenditure incurred by the state upto Sep’10 is Rs.917.83 Crore equivalent to 33% of the approved PIP. The various activities having less than 10% expenditure reported are Maternal Health (other than JSY), ARSH, Innovations/PPP/NGO, ASHA, Contractual Staff and Training. NIL expenditure
Page 28 of 37 reported under the activities of Procurements, Referral Transport, School Health Programme and New Initiatives under NRHM by the state.
There is huge finance manpower shortage in the state. Out of 71 districts 21 positions of Districts Account Managers are vacant and positions of 401 block accountants out of 823 blocks are vacant. All the funds are disbursed through e-transfer upto the PHC level which is a good practice followed by the state. This was confirmed that the payment to ASHA is done through e transfer in one of the block Phardhan (district Lakhimpur kheri). Tally software has been procured and training has been conducted upto the district level. But it is not implemented at the state and district level. Manual system of accounting is followed up across the state. Concurrent Audit has been conducted and 30 districts have submitted their concurrent report for Sep’ 10 in 2010-11. Training plan has been prepared for 2010-11 but does not include training programme of finance personnel. The state has issued delegation of financial powers upto the sub centre level. The state is not uploading the financial data on HMIS portal. Out of 71 districts only six has uploaded the FMR on HMIS portal.
During the visit to the districts it was noted that 7 Ambulances are deputed for the district but are not operational in Kheri District. During the visit to CHC Gola and CHC Palia Kalan, it has been observed that each ambulance is deputed to both the CHCs but the position of driver is vacant. RKS audit was not conducted in the districts visited. Positions of 15 block accountants are vacant in Kheri districts. Funds have been transferred to lower levels activity wise. Till December 2010 only 50% of the untied, AMG and RKS funds have been disbursed to lower levels. JSY payments are being made by bearer cheques in both the Districts. Fixed Assets register not maintained at any level. During the visit to Sub Centres, it is observed that no meeting of the VHSC is held during the financial year 2010-11. Huge unspent balance of the VHSC funds. At Ramnagar Rs. 30,000/- is unspent balance as on 31-03-10. Balance of Untied fund is Rs. 10,000/- as on 31-03-10. At CHC Palia Kalan, it has been observed that advances given for the Untied Fund, AMG and RKS Grants are treated as expenditure. No regular
Page 29 of 37 reporting of expenditure has been done by the Sub Centres, PHC/CHC to the District level.
3. K) DECENTRALIZED LOCAL HEALTH ACTION District health plans were available for each district - however these did not seem to be participatory made as envisaged in the spirit of community action. Sample village health plans were made available to the team but the process that was behind the planning seemed unclear. VHSC at village level are relatively weak and their capacity to develop and implement village plans needs to be strengthened. Instead of involving VHSC only in community monitoring they have to be involved in planning as well. At the state level instead of forming an action group on community monitoring it will be worthwhile to form an advisory group on community action involving the component of planning. This will help to improve the community processes for improved health and link it with the state for adequate support mechanism. Decentralized planning must involve capacity building of local NGOs and government officers so that realistic plans can be prepared. Agencies working in respective districts can be given responsibility to them in order to facilitate the planning process and actualize government to do the planning.
Since Panchayat elections had taken place only two months prior to the CRM, Village Health and Sanitation Committees were not yet in place anywhere in the state. However, the team found that the previous VHSC had been very weak - the community at large was unaware of the existence of the VHSC, regular meetings did not seem to be held and how decisions on fund utilization were made was unclear. The membership of the VHSC was also not broad based to include community and civil society representatives and those of marginalized groups. With imminent reconstitution of new VHSCs, there seems to be a window of opportunity to sensitize and activate this space of community action. Clear guidelines on broad basing membership need to be made along with a wide dissemination of the roles and responsibilities of the VHSC. Meetings with Pradhans at Pradhan Sammelans may be used for this. Also, VHSCs need to be
Page 30 of 37 cross sectorally linked at district level with Panchayati Raj and Rural Development activities.
Urban Health & Need for Health of Urban Poor Presently there are 131 Health Posts in urban areas of 67 districts. Currently there are 6 NGO in 5 districts working in urban area to spread awareness on family planning program. 2 Health posts are being run by 2 NGO in 1 district. District level post partum centre are being implemented in 5 districts. India’s as well as Uttar Pradesh urban poor are vulnerable to many health risks as a consequence of poor living conditions characterized by overcrowding, poor hygiene and sanitation. The health indicators of urban poor are often poorer than rural or urban non poor counterparts. The urban RCH requires improvement as populations have increased by many folds. The GIS mapping and baseline are to be completed. The vulnerability mapping of urban poor amongst urban slum dwellers is to be carried out. Population Foundation of India led consortium for “Health for Urban Poor” supported by USAID and Family Health International led “Urban Health Initiative” have been set up to render technical and program assistance to the state and these projects are working at the state level and district levels. They provide opportunity to the state to plan for urban component of the National Rural Health Mission till NUHM is initiated. ii) Progress of implementation of the PIP for financial year 2010-11 in the State
S.N. Activity Target (2010-11) Achievement (upto October, 2010) 1. Janani Suraksha Yojana 21 lacs 12.56 lacs (60%)
2. Complete Immunization 56.00 lacs 23.72 lacs (42.35%)
3. 24x7 Units 850 794 (93.41%)
4. First Referral Units (FRU) 180 154 (85.56%)
5. Pre-service training of ANMs 1911 Examination completed, training to be started soon
Page 31 of 37
6. Village Health and Sanitation 52002 51943 (99.88%) Committee accounts (V.H.S.C.) 7. School Health Programme 48000 schools 12682 schools (26.42%)
8. Family Planning Sterilizations 7.00 lac 0.60 lac
9. Cataract Operations 7.14 lac 1.83 lac (25.6%)
10. Up gradation of Hospitals as 89 New Hospitals (work to Work allotted per IPHS be completed in 26 months) New Activities in 2010-11 11 Pre-service training of MPW- 4960 Examination completed, M training to be started soon 12 Pregnant women and child MCP cards for 30 lac P.W. 9.70 lac (32.33%) tracking (from 15.8.10 to 31.3.11) 13 Emergency Medical 988 Ambulances Procured, Delivery started Transport Services (EMTS) in phased manner
CHAPTER 4
RECOMMENDATIONS INFRASTRUCTURE UP-GRADATION:
1 State and district level should review the MCH plan and check that infrastructure requirements are properly noted. MCH plan requirements should be mainstreamed within the overall infrastructure plans for the year in a phased way, to operationalise high load facilities first. 2 State should review the needs of sub-centres which are seeing a high number of deliveries and consider changing norms for construction for high volume facilities. Subcentres need to be strengthened through provision of regular power and running water supply. Sterilizers/autoclave need to be provided at subcentres. Drugs to manage obstetric emergencies should be made available at subcentres. 3 Time bound completion of civil works needs to be ensured.
Page 32 of 37
4 FRUs need to be operationalized as per guidelines at the earliest with special emphasis on blood storage availability. 5 Maintenance of infrastructure and equipment need to be improved - a caretaker system at district may be considered. Existing cold chain mechanics at district level may be trained to provide regular maintenance of critical MCH equipment.
HUMAN RESOURCES PLANNING
1 A sustainable long term policy for human resource planning needs to be developed including transfer and recruitment policies. Technical assistance might be useful for this. This could be used to identify need and modalities for pre service and in service training facilities. A HR database should be developed to aid this process. Pending recruitment of various positions, especially ANM, MPW and BPMU staff should be expedited. Temporary attachment of health staff needs to be discouraged. 2 Good practices from other states, for eg. Prioritization of rural service for PG admissions, special incentives for workers in remote areas etc. may be considered. 3 Capacity building of health staff needs to be initiated at the earliest. SBA trainings of ANMs, multiskilling of doctors need to be given high priority. Training programmes need to be resumed immediately. Engagement of private sector and civil society could be considered for pre/in service training (e.g. for MPWs), given the high load required. 4 Plans to increase capacity at the level of the districts need to be urgently made. The concept of training labs at each district with dedicated faculty providing hands on skill based training at various facilities needs to be considered and developed further.
Page 33 of 37
5 Recognition of meritorious staff may be considered to increase staff motivation levels. 6 Provision of 2nd ANM and male worker at subcentres should be expedited, especially in Accredited Subcentres. Requirement for a MPW in place to post a second ANM could be relaxed in order to expedite the posting of already identified ANMs. Recruitment and training of MPWs should happen in the meantime. 7 In service training for AYUSH doctors in provision of primary health care needs to be provided.
HEALTH CARE SERVICE DELIVERY
1 Mechanisms to ensure Quality of Care at all levels of facilities need to be instituted. Standard treatment guidelines need to be put in place for various levels – already existing guidelines from other states may be adapted for this purpose. Periodic monitoring and quality checks must be ensured. 2 Involvement of ASHAs in implementation of National Disease Control Programmes needs to be improved. 3 Emergency referral transport systems must be put in place at the earliest. Good practices from other states may be explored to ensure community based transport. 4 Accreditation of private hospitals for delivery and other services needs to be encouraged. 5 Biomedical waste disposal systems to be put in place, particularly in FRUs. 6 Maternal death audits need to be initiated at the earliest. 7 While family planning activities need to be improved, quality of care at camps needs to be ensured as per Supreme Court guidelines. Vasectomies and spacing methods need to be encouraged. Emergency contraceptive pills must be made available along with appropriate IEC activities.
Page 34 of 37
8 Emergency drug supply must be ensured at all levels of facilities, especially essential drugs to manage obstetric emergencies, eg. Magnesium sulphate. 9 Guidelines to prevent oxytocin misuse during labour must be put in place. Monitoring to ensure appropriate use of oxytocin must be ongoing.
OUTREACH SERVICES
1 VHNDs need to be strengthened further with more coordinated involvement of ASHAs and Anganwadi Workers. In addition to immunization, this must be used to provide appropriate antenatal care at village level – provision of kits for performing basic antenatal investigations in the field must be considered. 2 District Plans and local plans to be put into place and used for implementation. Community participation needs to be strengthened. Some recommended initiatives in this direction can be the following – block, village, district plans have to be disseminated so that community is more aware. Attempt to involve community in planning process at all levels must be made. 3 VHSCs need to be strengthened. Civil society and Panchayat representation needs to be ensured in VHSCs. Pradhan Sammelan which is planned to be implemented should be carried out at the earliest. Necessary technical and professional support must be secured and provided to SPMU U P so that good work can be continued. 4 Rogi Kalyan Samitis need to be constituted upto the PHC level. Civil society and Panchayat representation in RKS must be ensured and these must be infused with the true spirit of communitization. 5 Engagement of dais as support staff in sub centres may be done where there is increased number of deliveries.
Page 35 of 37
COMMUNITY PROCESS AND COMMUNITISATION
Saas Bahu Sammelan – this is a good practice and should be continued. This practice should be replicated in other parts of the country. 1 Training of ASHAs must be completed in the required modules. Successful models like the CHAI handholding of ASHAs must be replicated. Strengthening of ASHA mentoring group at all levels should continue. ASHA Sammelan is an effective forum and should continue further. 2 Gender sensitive working conditions for women staff must be ensured at facilities. Provision of separate toilets for women staff must be made. Secure place of stay for women staff on night shifts must be provided. ASHA Grahas for ASHAs accompanying women for deliveries is a welcome concept that can be upscaled. Vishakha committees to address sexual harassment at the workplace need to be set up at all levels as per Supreme Court guidelines. 3 Community monitoring should be initiated immediately.
MATERNAL HEALTH, CHILD HEALTH AND FAMILY PLANNING ACTIVITIES
1 Regular growth monitoring must be urgently put in place for early diagnosis of malnutrition. 2 There is need to develop BCC strategy focusing as much on provider behavior as on client health seeking behavior. A two way communication strategy needs to be focused on developing ways in which the voices of the poorest and voiceless could be communicated effectively to influence policies and inform about the provisions of existing health service schemes. 3 There is an urgent need to have a separate policy for tackling health and health determinants of urban poor. 4 The newborn care corners must be made operational by imparting training to all the health personnel involved in child birth.
Page 36 of 37
5 The ice line refrigerators and deep freezer must be used to store vaccines only.
FINANCIAL MANAGEMENT
1 The state should implement the customized version of Tally ERP 9 at the state and district level within the prescribed timelines. 2 Regular uploading of financial data on HMIS portal should be done. 3 Regular meeting and timely meeting should be held for the RKS and VHSCs so as to make the proper utilization of funds. 4 Proper accounting policies and maintenance of books of accounts should be followed as per the finance manual with regard to fixed assets, advances etc. 5 Urgent steps should be taken up by state for filling up positions of district and block level account managers and annual training programme of finance personnel should be made.
Page 37 of 37