Supportive Supervision Report to Bargarh, Orissa

Home , Barapali, Bargarh, Bhatli, Jharbandh, Paikmal

SUPPORTIVE SUPERVISION REPORT TO BARGARH, MOHFW ORISSA

Contents The Context ...... 3 Bargarh Healthcare ...... 4 Infrastructure Upgradation ...... 6 Human Resource ...... 7 Facility assessment ...... 8 DHH Baragarh ...... 8 CHC Barapali ...... 15 SDH Padampur ...... 20 CHC Sohella ...... 23 Talpali PHC ...... 26 Gaisilet NPHC ...... 29 PHCN Kamgaon ...... 32 SHC Gaisilet ...... 35 SHC Lenda (kadalipali Club) ...... 35 Phulapali Anganwadi (Kusanpuri Sub Centre) ...... 35 Maidhanumunda Village ...... 36 Findings and recommendations ...... 38

Bargarh, Orissa Page 2

Supportive Supervision Report on High Focus District Bargarh, Orissa

The Context

An inscription of the 11th Century A.D. mentions name of the place as "Baghar Kota.” It was called "Bargarh" headquarter of Balaram Dev, the Chauhan Raja of Sambalpur. The headquarter of the district is situated on the left bank of Jira River connected by National Highway 6.

Baragarh, spread across area of 5837 sq. Km, has 2 sub divisions, ten tahasils, twelve CD blocks, one Municipality, 248 Grampanchayat and 1208 Revenue Villages. The average annual rainfall in the district is 1527 mm.

Bargarh, Orissa Page 3

A Brief Profile of the District

Geographical Area 5837 (in Sq. Kms) No. of Subdivisions 2 (Bargarh & Padampur) No. of Tahasils 10 (Attabita, Bargarh, Barpali, Bhatli, Bheden, Padampur, Paikmal, Sohella, Bijepur & Gaisilet) No. of CD Blocks 12 (Ambabhona, Attabira, Bargarh, Barpali, Bhatli, Bheden, Bijepur, Gaisilet, Jharbandh, Padampur, Paikmal & Sohella) No. of Municipalities 1 (Bargarh) No. of Grampanchayat (GP) 248 No. of Revenue Villages 1208 Population 1242795 Population Density 231 per Sq. Km Literacy Rate 64% (Male: 77% Female: 50%) Population Distribution 92.3% rural, 7.7% Urban

Bargarh Healthcare

The blocks have been arranged in the descending order of the population. Baragarh block is 5th in terms of the area but has second highest population and has highest number of health facilities.

Blocks Area sq km Population DH CHC BPHC PHC PHCN HSC Attabira 404.96 153195 0 1 0 1 4 22 Bargarh 369.37 146407 1 0 0 1 4 23 Sohela 515.11 125570 0 1 0 0 6 19 Bheden 362.75 122362 0 1 0 0 6 21 Barpali 266.18 102323 0 1 0 1 3 19 Paikmal 564.64 100032 0 1 0 0 5 16 Padampur 488.4 99882 0 0 0 1 3 17 Bijepur 323.94 95843 0 1 0 0 3 14 Bhatli 355.55 84909 0 0 1 0 2 15 Gaisilet 354.93 79335 0 0 0 1 3 14 Jharbandh 422.97 69266 0 1 0 0 2 12 Ambabhona 182.26 63671 0 0 0 1 3 12 Total 1242795 1 7 1 6 44 204

Bargarh, Orissa Page 4

Bargarh, Orissa Page 5

Infrastructure Upgradation

A total of 27 health facilities are to be upgraded in the current year. Padampur SDH is to be upgraded to level 3 in the year 2010-11. Four CHCs of level I are to be converted to level II institutions.

Sr. Name of the Category Current Level Proposed No. Facility 1 Padampur SDH II III 2 Attabira CHC I II 3 Bheden CHC I II 4 Dava CHC I II 5 Bukuramunda CHC I II 6 Talpali PHC I II 7 Bhutka PHC I II 8 Bhatli PHC I II 9 Katapali PHC I II 10 Paikmal PHCN I II 11 Gaisilet PHCN I II

Two PHCN are to be upgraded to level II from current level I. There are 16 subcentres to be operationalised in the current year. Details of some of the institutions assessed during the visit shall be dealt in the facility assessment section.

One SNCU at the district hospital is to be fully operationlised in the year 2010-11. There are 11 health facilities (8 CHC, 2 SDH and 1 DHH) to be provided with a stabilisation unit in the current year.

Bargarh, Orissa Page 6

Human Resource

Post Sanctioned In Position Vacant Specialists 28 22 6 Total Medical Officers 89 72 17 Pharmacists 62 62 0 Staff Nurse 41 32 9 BEE 12 6 6 Male Supervisors 52 7 45 Female Supervisors 40 29 11 MPHW (Male) 145 122 23 MPHW (Female) 257 242 15 Lab Technician (Pathology) 18 15 8 PMW 34 16 18 Drivers 26 17 9

Human Resource Requirement in Bargarh

Numbers % of total required

50 53 44 45 35 28 23 21 22 16 1719 18 15 11 6 6 9 9 8 6

Eighty seven percent of the posts of male supervisor are vacant. For meeting the current requirement, 45 male supervisors are to be recruited. The district has 19 percent shortfall of the medical officers. Though number is not alarming, the medical officer is cardinal part of the service delivery and should be given apt attention.

Bargarh, Orissa Page 7

Facility assessment

The visit was made from 22.06.2010 to 25.06.10. During this period, following institutions were visited. There is ample repetition of the findings between each individual health facility. However, it is important to examine each facility on most possible indicators and record it. This may help when the authorities in charge of the particular health institution refer to the report. It is important that they find the recommendation specifically for their hospital and not the generic advises. The consultant has taken a chance to sound repetitious with the hope of incremental improvements in each of the visited hospital. It is also desired that the recommendations be conveyed to other hospitals in the district so as to improve delivery of services. Following health institutions were visited to assess the facility according to the given format. Anganvadi was visited to examine the functioning of immunization day.

 DHH Bargarh  CHC barapali  CHC Padampur  CHC Sohella  PHC Talpali  PHCN Gaisilet  PHCN Kamgaon  SC Gaisilet  SC Lenda (kadalipali Club)  AW Phulapali  Village Maidhanumunda

DHH Baragarh

The doctors are available round the clock for emergency cases and labour cases. Family planning services are also available at the facility. There are no fixed days for the ANC clinics or RTI/STI clinics. The health education messages were present on almost every wall of the hospital and have good visibility. There is no public display of the JSY beneficiaries.

The campus is relatively clean and does not have biomedical waste all over the campus as seen in most of the other facilities.

Facility Assessment

The facility scored 59% points based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

Bargarh, Orissa Page 8

DHH Bargarh 100 100 88 83 75 79 61 57

The facility scored well in terms of availability of the equipments, OT equipments and services. However, on other accounts, it did not fare well. Overall score of the facility is also on the lower side.

The walls and roof of the building were in good condition. The electric connections were well insulated and switch boards were in good condition. There were electric bulbs in the corridors and pathways to toilet. The wards had been whitewashed from inside. The signage was present at most of the necessary locations. The hospital rooms were not dumped with the condemned articles. Enough seating arrangement was present for the OPD waiting area.

The wards had intact window glasses. This was the only hospital where the mosquito screens were found on the windows. However, the windows did not have curtains for ensuring the privacy of the patient. Sufficient number of fans was present in the working condition. The bed sheets were not provided to all the patients. The number of stools for the attendant in the ward was not sufficient. Some of the cots in the ward need to be repaired. Some of the Mattresses also were in worn out state, torn and had coir coming out of them. Dust bins for the wards were not sufficient. IV stands were also not available in the sufficient number. Running water supply was present in the labour room and the toilets. However, the cleanliness of the toilets is a concern. The Patients have been provided with 2 water purifiers for OPD and IPD patients. The water purifiers have been installed inside metal cages to prevent stealing of taps which had happened in the recent past.

The hospital has trolley and stretcher but does not have a wheelchair in working condition. The hospital has enough supply of sterilised gloves. The supply of the drugs was also sufficient according to the medical officer.

The labour room has two spot lights. One of them was not in working condition. The labour room has 4 labour tables and the labour tables have been separated with the help of plywood

Bargarh, Orissa Page 9 separators which have wheels. These separators are portable and can be easily moved around in case the need arises.

The labour boards were not broken or rusted and were in a working condition. Labour room had resuscitation equipments for the newborn along with mucous sucker and baby weighing machine. Partograph was not maintained and display of the protocols for the active management of the third stage of the labour was missing in the labour room. There were curtains in the labour room to ensure privacy of the patients. There was no separate column in the delivery register for recording major complications leading to maternal death. The register mentions the status of the child at the birth but not the status of the mother after delivery. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

The operation theatre was in working condition. According to the hospital manager, the Boyle’s apparatus was not working. The OT had an ante room. Colour coded buckets were used but in separation and not as a set. The hospital had functioning autoclave.

The hospital has condemnation area for the biomedical waste but the area is not suitable for the purpose. The area shares one of its 4 walls with the toilets. The area within these walls is being used for dumping the medical waste.

Bargarh, Orissa Page 10

In rainy season, the waste flows out of the area and spreads outside the doors. The municipal authorities responsible to take away the garbage are irregular in clearing the waste.

The floor of the hospital was clean on the day of the visit. The drainage system for the facility was clogged and not functioning properly. As pointed out by the hospital manager, the drainage lanes in the outer portion are at greater height than the lanes of the inner drainage hampering the draining process and resulting in the clogging of the system. The Hospital has functioning telephone. The hospital had a generator with necessary fuel for operation.

As told by the hospital manager, the wards opposite to the labour room have been occupied for the administrative purposes of the family welfare department which should have been post delivery care ward.

Bargarh, Orissa Page 11

The Hospital Manager

Presence of the hospital manager was found to be one of the most positive factors at district hospital. Many good practices were seen which are considered hard to implement elsewhere.

Mosquito Screens for the Windows in Wards

Mosquito screens for the windows in the wards were present only in Baragarh hospital. It also discourages the practice of throwing medical waste out of the window. In almost every health facility, it was observed that the empty IV bottles, needles and broken ampoules were seen lying outside the windows. This was not the case here.

Coloured Bed Sheets

Almost all the beds in the hospital were provided with the bed sheets in 4 colours: pink (Monday-Tuesday), blue (Wednesday-Thursday), yellow (Friday-Saturday) and white (Sunday). On the day of the visit, yellow bed sheet were present on Friday. Thus, hospital bed sheets were being changed every alternate day.

Bargarh, Orissa Page 12

Maintenance Personnel

The list of the maintenance personnel like electrician, plumber, pump driver and cleaning supervisors was displayed in front of the wards with their phone numbers. This ensured that a call could be made from the ward itself to the maintenance for necessary action.

Keeping Footwear Outside the Wards

All the wards have the instructions at the entrance to keep the footwear outside the ward. It has become a common practice which helps in keeping the wards clean especially in the rainy season.

Bargarh, Orissa Page 13

Images of Idols on the Walls

Images of idols were used on wall and in the corners all over the hospital to discourage spitting. Though there have been instance where people have removed the poster and then used wall for spitting at some places, the overall effectiveness is high and can be recommended for other hospitals.

Portable Separators in the Labour Room

The Hospital manager had installed separators of plywood in the labour room for the privacy of the delivering women. The separators have wheels and can be moved around easily. Use of the separator was effective in optimum utilisation of the available space.

Bargarh, Orissa Page 14

For further improvement of the hospital and optimum use of the resources, the hospital manager has requested to arrange a visit of a committee for hospital planning and restructuring for rectifying many structural and functional anomalies in the hospital. Construction of the medicine ward in the premises needs reconsideration according to the hospital manager because of the location of the ward. The manager also requested the orientation about the manual arrangement of the medical records for easy retrieval.

In a nutshell, following issues have been identified for the attention of the authorities:

 Ensuring proper clearance of the biomedical waste  Ensuring correction of the drainage system  Timely disposal of the biomedical waste  System for manual arrangement of the medical records for easy retrieval and dedicated space for storing the medical records.  Correction of the drainage system of the hospital  Operationalization of the post delivery ward when administrative work for family welfare department is carried out.  Curtains for windows in the ward  Dust bins for each ward  Display of the JSY beneficiaries  Stools for the attendant of the patients  Repair of cots and mattresses in general ward  Repair of Spot lights in the labour room  Maintaining Partograph and display of active management of third stage of labour in the labour room  Separate column for the delivery cases to mention the complications during the labour  Use of colour coded buckets as a set and not in isolation  Sufficient number of IV stands

CHC Barapali

This 30 bedded CHC has been proposed for FRU status. It has one Obs/Gyn specialist, one paediatrician, one MOIC and one AYUSH doctor with SAB training. There are three staff nurses and one post is vacant. There is one ANM.

The doctors are available round the clock for emergency cases and labour cases. Family planning services are also available at the facility. There are no fixed days for the ANC clinics or RTI/STI clinics. The IEC messages are present on every wall of the hospital and have good visibility but there is no public display of the JSY beneficiaries. There are no user charges for the OPD and IPD but Rs. 5 are charged for lab services.

Bargarh, Orissa Page 15

The campus is relatively clean and does not have bio-waste all over the place as was seen in most of the other facilities.

Facility Assessment

The facility scored 67 points out of 120 (56%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

CHC BARAPALI 100

75 57 60 60

30 25

The facility scored well in terms of availability of the equipments. However, on the other accounts it did not fare well. Overall score of the facility is also on the lower side. The facility does not have a functioning operation theatre. Hence, the scoring for the same has not been shown.

The walls and roof of the building were intact but the flooring in the corridors and in the wards needs repairs. The floor is uneven and should be corrected.

Bargarh, Orissa Page 16

The electric connections were well insulated and the switch boards are in good condition. There were electric bulbs in the corridors and pathways to toilet. The wards have been whitewashed from inside. The signage is not present at all the locations. The reason may be the recent whitewashing of the wards. The hospital rooms were not dumped with the condemned articles. Enough seating arrangement was present for the OPD waiting area.

The wards had intact window glasses but not the mosquito screens. The windows also do not have curtains for ensuring the privacy of the patient. Sufficient number of fans was present in the working condition. The bed sheets were not provided to all the patients. The number of stools for the attendant in the ward was not sufficient. Some of the cots in the ward were not in good shape and need to be repaired. Some of the Mattresses also were in worn out state, torn and had coir coming out of them. There were no sufficient dust bins for the wards. Each ward should have a separate dust bin and instructions to use it.

Some of the beds did not have bed numbers on the wall. IV stands were also not available in the sufficient number.

Bargarh, Orissa Page 17

The Infections ward was in a very bad condition and has many broken cots stored. The ward is in use without the mattresses on the cots. It needs immediate attention for the optimum utilisation of the space available.

Running water supply was present in the labour room and the toilets. There is a water tank at the entrance of the hospital for use of OPD and IPD patients.

It is not purified water. Moreover, the tank did not show the date on which the tank was last cleaned. The Medical Officer in charge has committed to buy a water purifier through RKS.

The labour room does not have a spot light and vacuum extractor. The labour board was not broken or rusted and was in a working condition. Labour room has resuscitation equipments for the newborn along with mucous sucker and baby weighing machine. Partograph is not

Bargarh, Orissa Page 18 maintained and display of the protocols for the active management of the third stage of the labour was missing in the labour room. There are curtain in the labour room to ensure privacy of the patients. The pillow on the labour board had gone extremely dirty and a new pillow with a cover should be used so that the pillow cover can be cleaned regularly. There was no separate column in the delivery register for recording major complications leading to maternal death. The register mentions the status of the child at the birth but not the status of the mother after delivery. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

The operation theatre was under renovation. Colour coded buckets were used but in separation and not as a set. The CHC does not have a needle cutter. At some places in the campus, needles are seen lying on the ground but the campus was much cleaner than other hospitals visited. The hospital had functioning autoclave. There is no X ray or USG facility at the hospital. The space for drug storage is not sufficient and not suitable for storing the drugs. The hospital does not have an ambulance either. The hospital does not have a well fenced condemnation area for the biomedical waste which should be done on an urgent basis.

The floor of the hospital was clean on the day of the visit. The toilet doors and water taps were in a good shape. However, the basins and floor were not clean. The drainage system for the facility is not clogged and functioning properly. The Hospital has functioning telephone. The hospital has an inverter.

RKS

The RKS at Barapali was formed on March 13th, 2007. The RKS has done works related sewerage. The RKS also bought Baby warmer, resuscitation kit, ET tube, revolving stool, medicines during epidemics, bed tickets and inverter with a battery.

Total expenditure of the RKS in the year 2009-10 was Rs. 2,33,751. Details of the utilisation are as follows:

Head Expenditure in Rs. epidemic medicine 7,148 Bedhead ticket printing 9,500 Inverter 29,535 Baby Radiant Warmer 42,120 Phototherapy, Neonateal kit, stool, ET tube 45,448 Sewerage and site improvement 1,00,000 Total 2,33,751

The Medical officer in charge has noted down the points to be focussed and has committed to make necessary improvements possible through RKS.

Bargarh, Orissa Page 19

In a nutshell, following issues have been identified for the attention of the authorities:

 O.T. Operationlization  Display of the JSY beneficiaries  Floor in the wards and corridors needs repair  Proper signage for Toilets and wards.  Mosquito screens for the wards  Curtains for the ward windows  Bed sheets for the IPD cots  Stools for the attendant of the patients  Repair of cots and mattresses in general ward  The infection ward is dumped with broken cots without mattresses. The ward needs to be operationalized with repair of the cots and procuring the mattresses.  Water purifiers for the OPD and IPD patients  Spot light for the labour room  Maintaining Partograph and display of active management of third stage of labour in the labour room  Separate column for the delivery cases to mention the complications during the labour  Use of colour coded buckets as a set and not in isolation  Proper drug storage space  Dust bin for each ward  Bed numbers on the walls for all the beds  Sufficient number of IV stands  Last Date of cleaning on the water tank  Curtain in general male OPD for ensuring privacy of the male patient e.g. for hernia examination.  A well fenced condemnation area for disposal of bio waste on an urgent basis.  Hospital’s name at the entrance of the hospital.

SDH Padampur

The doctors are available round the clock for emergency cases and labour cases. Family planning services are also available at the facility. There are no fixed days for the ANC clinics or RTI/STI clinics. The IEC messages are present on every wall of the hospital and have good visibility but there is no public display of the JSY beneficiaries. The campus is relatively clean and does not have bio-waste all over the campus as was seen in other facilities.

Bargarh, Orissa Page 20

Facility Assessment

The facility scored 95 points out of 120 (79%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

SDH Padampur 100 100 88 83 75 79 61 57

The facility scored well on almost all the counts and the overall score of the facility is also on the higher side.

The corridors were recently renovated and had a pleasant feel. The walls and roof of the building were intact. The electric connections were well insulated and the switch boards were in good condition. There were electric bulbs in the corridors and pathways to toilet. The wards have been whitewashed. The signage was not present at all the locations. The reason may be the recent whitewashing of the wards. The hospital rooms were not dumped with the condemned articles. Enough seating arrangement was present for the OPD waiting area.

The wards did have intact window glasses but not the mosquito screens. The windows also do not have curtains for ensuring the privacy of the patient. Sufficient number of fans was present in the working condition. The bed sheets were not provided to all the patients. The number of stools for the attendant in the ward was not sufficient. There were no sufficient dust bins for the wards. Each ward should have a separate dust bin and instructions to use it. IV stands were also not available in the sufficient number.

Running water supply was present in the labour room and the toilets. There is no purified water facility for the OPD and IPD patients.

The labour room had a spot light but not in working condition. The labour board was not broken or rusted and was in a working condition. Labour room has resuscitation equipments for the newborn along with mucous sucker and baby weighing machine. Partograph is not

Bargarh, Orissa Page 21 maintained and display of the protocols for the active management of the third stage of the labour was missing in the labour room. There are curtain in the labour room to ensure privacy of the patients. The pillow on the labour board had gone extremely dirty and a new pillow with a cover should be used so that the pillow cover can be cleaned regularly. There was no separate column in the delivery register for recording major complications leading to maternal death. The register mentions the status of the child at the birth but not the status of the mother after delivery. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

The operation theatre was under renovation. Colour coded buckets were used but in separation and not as a set. The CHC does not have a needle cutter. The hospital had functioning autoclave.

The hospital does not have a well fenced condemnation area for the biomedical waste which should be done on an urgent basis.

In a nutshell, following issues have been identified for the attention of the authorities:

 A well fenced condemnation area for disposal of bio waste on an urgent basis.  Proper signage for Toilets and wards.  Mosquito screens for the wards  Curtains for the ward windows  Bed sheets for the IPD cots  Stools for the attendant of the patients  Water purifiers for the OPD and IPD patients  Spot light for the labour room

Bargarh, Orissa Page 22

 Maintaining Partograph and display of active management of third stage of labour in the labour room  Separate column for the delivery cases to mention the complications during the labour  Use of colour coded buckets as a set and not in isolation  Dust bin for each ward  Sufficient number of IV stands  A well fenced condemnation area for disposal of bio waste on an urgent basis.

CHC Sohella

This is a 30 bedded CHC. It has one Obs/Gyn specialist, one paediatrician, one MO-IC and one AYUSH doctor. There are three staff nurses and one post is vacant. There is one ANM contractual under NRHM and one post for contractual Nurse under NRHM is vacant.

The doctors are available round the clock for emergency cases and labour cases. Family planning services are also available at the facility. There are no fixed days for the ANC clinics or RTI/STI clinics. The IEC messages are present on almost every wall of the hospital and have good visibility but there is no public display of the JSY beneficiaries. The campus is relatively clean.

Facility Assessment

The facility scored 94 points out of 120 (78%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

Sohella CHC 100 100 100 83 74 78 67 57

Bargarh, Orissa Page 23

The facility scored well except outsourced services, medicals services and to some degree infrastructure. However, on the other accounts it did well. Overall score of the facility is also on the higher side as compared to other health institutions visited.

The walls and roof of the building were intact. The electric connections were well insulated and the switch boards were in good condition. There were electric bulbs in the corridors and pathways to toilet. The wards have been whitewashed. The signage is not present at all the locations. The reason may be the recent whitewashing of the wards. The hospital rooms were not dumped with the condemned articles. Enough seating arrangement was present for the OPD waiting area.

The wards did have intact window glasses but not the mosquito screens. The windows also do not have curtains for ensuring privacy of the patient. Some of the windows were in broken state. Sufficient number of fans was present in the working condition. The bed sheets were not provided to all the patients. The number of stools for the attendant in the ward was not sufficient. There were no sufficient dust bins for the wards. Each ward should have a separate dust bin and instructions to use it. IV stands were also not available in the sufficient number. Running water supply was present in the labour room and the toilets. The hospital has trolley, stretcher and wheelchair. The hospital has enough supply of sterilised gloves. The supply of the drugs was also sufficient according to the medical officer.

The labour room has a spot light. The labour board was not broken or rusted and was in a working condition. Labour room has resuscitation equipments for the newborn along with mucous sucker and baby weighing machine.

It was the only hospital where a simplified version of the partograph was being maintained but display of the protocols for the active management of the third stage of the labour was missing in the labour room. The instructions were pasted in the nurse duty room. It was advised to have another copy of those instructions pasted in the labour room as well. There were curtain in the labour room to ensure privacy of the patients. The hospital also maintains a detailed case paper of the labour cases which notes condition of the mother and baby at the

Bargarh, Orissa Page 24 time of the labour. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

This was one of the few hospitals where colour coded buckets were being used as a set. The CHC does not have a needle cutter. The hospital had functioning autoclave. The hospital has a well fenced condemnation area for the biomedical waste. However, the area was not securely locked giving access to common people to harmful biomedical waste.

The X ray technician of the hospital had been deputed to the DHH and hence there is no X ray facility at the health facility. The AYUSH doctor has concerns regarding supply of the medicine and storage place for the medicines that are supplied. The homeopathic drugs that are required in small quantities have been supplied in abundance and vice versa.

In a nutshell, following issues have been identified for the attention of the authorities:

 X ray technician  Supply of homeopathic drugs according to demand  Display of the JSY beneficiaries  Proper signage for Toilets and wards.  Mosquito screens for the wards  Curtains for the ward windows  Bed sheets for the IPD cots  Stools for the attendant of the patients

Bargarh, Orissa Page 25

 Water purifiers for the OPD and IPD patients  Display of active management of third stage of labour in the labour room  Dust bin for each ward  Sufficient number of IV stands Talpali PHC

The PHC has one MBBS Medical Officer and a AYUSH doctor. The PHC has six beds. There are no fixed days for the ANC clinics or RTI/STI clinics. There is no public display of the JSY beneficiaries but there is a list of ASHA mentioning incentives given to them. A list of GKS under the PHC is also displayed on the bulletin board of the PHC mentioning the contact details of the members.

Facility Assessment

The facility scored 54 points out of 94 (57%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

PHC Talpali

76 56 60 57 50 50 33

The facility scored well in terms of second category i. e. the available services but still on the lower side. The PHC does not have OT and hence the scoring for the same is not given. The facility scored poorly in terms of the labour room condition and needs attention. Overall score of the facility is also on the lower side.

Bargarh, Orissa Page 26 rooms were not dumped with the condemned articles. Enough seating arrangement was present for the OPD waiting area.

The ward was recently renovated and had a pleasant feel. It did have intact window glasses but not the mosquito screens. The windows also did not have curtains. Sufficient number of fans was present in the working condition. The bed sheets were provided to all the patients. There were no separate dust bins for the ward. There was running water available for the labour ward. The beds did not have bed numbers. There is a cement water tank above the labour room. The tank also does not have the last date on which the tank was cleaned. The hospital does not have purified drinking water facility for IPD or OPD patients.

The PHC has a water purifier but the equipment is not in use because of fear of getting stolen. The water purifier was lying dormant in the store room. The store also had some colour coded buckets which were not in use. The supply of the drugs was sufficient according to the medical officer.

The labour room did not have a spot light. The labour board was not broken or rusted and was in a working condition. Labour room had mucous sucker and baby weighing machine. The use of Partograph and display of the protocols for the active management of the third stage of the labour were missing in the labour room. There were curtain in the labour room to ensure privacy of the patients.

Bargarh, Orissa Page 27

The bathroom and toilet attached to the labour room were dumped with the condemned articles and were not in the condition of use. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

At some places in the campus needles are seen lying on the ground. The hospital had functioning autoclave. The health does not have a well fenced condemnation area for the

biomedical waste. Hence, the medical waste was seen lying around the campus. The floor of the hospital was clean on the day of the visit. The hospital had a generator.

In a nutshell, following issues have been identified for the attention of the authorities:

 A well fenced condemnation area for disposal of biomedical waste on an urgent basis Repair and Operationlization of the toilets attached to the labour room.  Proper signage for Toilets and wards.  Mosquito screens for the wards  Curtains for the ward windows  Stools for the attendant of the patients

Bargarh, Orissa Page 28

 Use of Water purifiers for the OPD and IPD patients (The hospital may use a metal wire cage to protect it from getting stolen.)  Spot light for the labour room  Maintaining Partograph and display of active management of third stage of labour in the labour room  Separate column for the delivery cases to mention the complications during the labour  Use of colour coded buckets as a set and not in isolation  Dust bin for ward  Bed numbers on the walls for all the beds  Sufficient number of IV stands  Last Date of cleaning on the water tank Gaisilet NPHC

This NPHC has one MBBS doctor and one staff nurse. There are two beds in one room of the Gaisilet NPHC. The doctors are available round the clock for emergency cases and labour cases. There are no fixed days for the ANC clinics, RTI/STI clinics or sterilisation clinics. The patients are treated as and when they approach the OPD every day. The IEC messages were not prominently visible in the NPHC. The campus does not have a dedicated condemnation area for the biomedical waste and hence bio medical waste is seen lying around in the campus.

Facility Assessment

The facility scored 51 points out of 85 (60%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

Bargarh, Orissa Page 29

GAISILET NPHC 100 75 57 60 60

30 25

The facility scored well in terms of availability of the equipments and to some extent in the infrastructure. However, on the other accounts, it did not fare well. Overall score of the facility is also on the lower side. The facility is not designated to have an operation theatre. Hence, the scoring for the same has not been shown.

The walls and roof of the building were intact and well furnished. The electric connections were well insulated and the switch boards were in good condition. The toilets have been constructed away from the main building and do not have signage for the separate use by male and female patients. The toilets were locked with a rational fear of being soiled by outsiders. This has led to non utilisation of the toilets. One of the toilets, though newly furnished, had dust and dirt in the toilets indicating its non utilisation. Enough seating arrangement was present for the OPD waiting area.

The two bed ward did have intact window glasses but not the mosquito screens. The windows had curtains for ensuring the privacy of the patient. A working fan was present. There were clean bed sheets provided for both the beds. Running water supply was available in the labour room and the toilets. Running water supply and a wash basin was available in the ward. There was no facility for purified drinking water for the OPD and IPD patients. The supply of the drugs was sufficient according to the medical officer.

The labour room did not have a spot light and vacuum extractor. The labour board was not broken or rusted and was in a working condition. Partograph is not maintained and display of the protocols for the active management of the third stage of the labour was missing in the labour room. There are curtain in the labour room to ensure privacy of the patients. There was no separate column in the delivery register for recording major complications leading to maternal death. The register mentions the status of the child at the birth but not the status of the mother after delivery. There should be a detailed case paper/ bed tickets of the deliveries mentioning details of the mother and child at the time of the delivery and at the time of discharge from the hospital. The paper should also mention if the discharge was given by

Bargarh, Orissa Page 30 doctor or it was Discharge on Request before the 48 hour after delivery. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

Colour coded buckets were not seen in use. The NPHC does not have a needle cutter. Many

needles and IV bottles were seen lying at the backside of the building. The NPHC does not have a well fenced condemnation area for the biomedical waste which should be done on an urgent basis.

The floor of the hospital was clean on the day of the visit. The toilet doors and water taps were in a good shape. However, the basins and floor were not clean. The NPHC does not have a telephone connection which is due under healthy Baragarh campaign. The hospital has a generator.

In a nutshell, following issues have been identified for the attention of the authorities:

 Display of the JSY beneficiaries  Proper signage for Toilets and ward  Mosquito screens for the ward  Water purifiers for the OPD and IPD patients  Spot light for the labour room  Detailed case paper/ bed tickets of the deliveries mentioning details of the mother and child at the time of the delivery and at the time of discharge from the hospital. The paper should also mention if the discharge was given by doctor or it was Discharge on Request before the 48 hour after delivery.  Maintaining Partograph and display of active management of third stage of labour in the labour room  Separate column for the delivery cases to mention the complications during the labour in the delivery register.  Use of colour coded buckets for biomedical waste segregation.  A well fenced condemnation area for disposal of bio waste on an urgent basis.  Zero tolerance to presence of biomedical waste in the campus. For once the campus should be cleaned and then good practices of handling the bio waste should be employed.

Bargarh, Orissa Page 31

 IEC posters in the waiting area and messages on the wall of the buildings.

RKS

The RKS at Gaisilet has bought generator, stabiliser for the ILR, minor repairs, curtains for windows. The RKS has proposed to buy water purifier, Chair for OPD patients, air cooler for the heat stroke patients. The RKS has also planned to do minor repairs for the ward and construction of the passage to the hospital. PHCN Kamgaon

This NPHC has one contractual MBBS doctor and one pharmacist. Sub centre Kamgaon is situated in the campus of the PHCN and has a SAB trained ANM. There are no fixed days for the ANC clinics, RTI/STI clinics or sterilisation clinics.

IEC messages and water purifier in the right corner of the photo

The IEC messages were prominently visible in the waiting are for OPD patients. The campus does not have a dedicated condemnation area for the biomedical waste and hence bio medical waste is seen lying around in the campus in abundance.

Facility Assessment

The facility scored 50 points out of 88 (60%) based on the facility assessment format. Due to heterogeneous nature of the indicators evaluated, the points scored by the facility have been converted into percentages to give a fair idea of the scoring on each account. (Raw scores can be seen in Annexure III)

Bargarh, Orissa Page 32

100

60 57 53 50 33 25

The facility scored well in terms of availability of the equipments. However, on the other accounts, it did not fare well. Overall score of the facility is also on the lower side. The facility does not have an operation theatre. Hence, the scoring for the same has not been shown.

The walls and roof of the building were intact and well furnished. The electric connections were well insulated and the switch boards were in good condition. Enough seating arrangement was present for the OPD waiting area. The IPD wards of the PHCN were locked and not in use. The wards were being used for storing the condemned articles. Running water supply was available in the labour room. Facility of purified drinking water for the OPD and IPD patients was available. The supply of the drugs was sufficient according to the Pharmacist of the PHCN.

The labour room did not have a spot light and vacuum extractor. The labour board was not broken or rusted and was in a working condition. Partograph was not maintained and display of the protocols for the active management of the third stage of the labour was missing in the labour room. There were curtain in the labour room to ensure privacy of the patients. There was no separate column in the delivery register for recording major complications leading to maternal death. The register mentions the status of the child at the birth but not the status of the mother after delivery. All the JSY beneficiaries were paid after the delivery and there was no backlog of the JSY payments.

Colour coded buckets were not seen in use. The NPHC does not have a needle cutter.

Bargarh, Orissa Page 33

A pile of needles and IV bottles were seen lying at the backside of the building. The NPHC does not have a well fenced condemnation area for the biomedical waste which should be done on an urgent basis. The floor of the hospital was clean on the day of the visit. The toilet doors and water taps were in a good shape. However, the basins and floor were not clean. The NPHC does not have a telephone connection which is due under healthy Baragarh campaign.

Quarters that have been built for the staff at the PHC are far away from the hospital and have not been completed. Hence, the doctor and other staff do not stay at the hospital. Hence, the services are not available for the patients for 24 hours.

The PHC does not have a nurse. The Pharmacist assists the doctor for conducting the deliveries and also handles the OPD in absence of the doctor. The pharmacist also prepares the malaria slides. The microscope for the PHC is also not functional.

In a nutshell, following issues have been identified for the attention of the authorities:

 Use of the wards for patients and not for dumping the condemned articles.  Microscope  Display of the JSY beneficiaries  Spot light for the labour room  Maintaining Partograph and display of active management of third stage of labour in the labour room.  Separate column for the delivery cases to mention the complications during the labour in the delivery register.  Use of colour coded buckets for biomedical waste segregation.  Screen for the OPD examination table to ensure privacy of the OPD patient  A well fenced condemnation area for disposal of biomedical waste on an urgent basis.  Zero tolerance to presence of biomedical waste in the campus. At first, the campus should be cleaned and then good practices of handling the bio waste should be employed.

Bargarh, Orissa Page 34

 Detailed case paper/ bed tickets of the deliveries

SHC Gaisilet

The sub centre is situated near the Gaisilet PHCN. The Sub centre does not have a building and all the functions of the SHC are carried out from home by the ANM. The ANM was interviewed about the conduction of immunization days and VHNDs. The blood pressure instrument was found to be dysfunctional. ASHAs under the sub-centre were also interviewed for their functioning. The ASHAs had a good knowledge about ANC counselling. SHC Lenda (kadalipali Club)

Kadalipali club was visited where immunization session was being conducted. All but one eligible child had come for the immunization. The session was conducted by three ASHA, one ANM, one Anganwadi worker and one male helper. Timings of the session were displayed on a board outside the club hall.

No Space for Conducting the Sessions

The ANM does not have a dedicated place for conducting the immunization sessions. She faces regular resistance from the club members. The ANM has requested for the dedicated space for conducting the sessions. The table and the curtains used at the session have been bought from the funds of AMG and GKS which have become a part of the club hall. It is important to have a place for conducting immunization session for Lenda Sub-Centre ANM. Phulapali Anganwadi (Kusanpuri Sub Centre)

VHND

The Angawadi was visited to observe the functioning of the immunization day at the Angawadi Centres on the Wednesdays. The vaccines are supplied from CHC Barapali. VHND had been carried out a day before on the Tuesday. (June 22nd, 2010) It was conducted from 08:00 am to 04:00 pm. The VHND was conducted by ANM, three Anganwadi Workers and one ASHA. Fourteen women availed ANC services whereas ten women availed PNC services. Twenty eight children within one year and 135 children between 0-5 are registered in the Anganwadi. One grade III girl child also attends the angawadi. One TB patient is availing DOTS services from the centre.

The ANM, Anganwadi Workers and ASHAs were interviewed to probe general functioning of the Sub Centre, Anganwadi, the immunization days and VHNDs. The ANM had sufficient

Bargarh, Orissa Page 35 stock of medicines, Oral Contraceptive Pills, IUDs and condoms. While providing ANC services, blood pressure of the pregnant woman is measured, lie of the baby is checked, TT injections are given, weight of the mother is measured and IFS tablets are distributed. While providing the PNC services, weight of the mother and child is measured. Iron syrup is given according to the need. The mothers are counselled for balanced diet and breast feeding.

The untied grant for the Sub Centre was used for colouring, boundary wall repairs, latrine repairs, HB apparatus, Stethoscope, BP apparatus, weighing machine and examination table for the VHNDs.

On each VHND, the women are briefed about a health issue. Last VHND’s topic was Tuberculosis. The women were told about the mode of transmission and symptoms of the disease. The women were properly oriented to the disease.

Gaon Kalyan Samiti (GKS) at Phulapali

The GKS was formed on August, 22nd, 2009. The members were briefed about the functioning of the GKS by the Block Program Organizer. There are 12 members in the GKS: One NM, one ANM, one ASHA, one AWW, one club member, four members from SHG, one SEM and one Ward Member constitute the GKS. Fourteen meetings were conducted last year. The ward member irregularity in attending the meetings was the only problem cited. The meeting is carried out every month along with awareness session for women and adolescent girls. Topics like Malaria, TB, cleanliness and awareness about AIDS have been covered in these meetings. Twenty five to thirty women attend such sessions.

Swasthya Kant

The date and timing of the VHND, immunization day and GKS meetings is written on a blackboard outside the Anganwadi. The board is called Swasthya Kant and is followed by the people in the village. The Initiative is very effective and can be replicated by other villages where such practice does not exist. Maidhanumunda Village

Infant death

It was decided to visit beneficiary of the NPHC Gaisilet in a village few kilometres away. The woman had delivered 48 hours before the visit in the NPHC. The delivery register mentioned male child weighing 3 Kg. When visit was made to the home of the woman, it was found that the child had died after around 24 hours of birth. Only selected questions were asked to the family as the death of the child had taken only a few hours ago and the family was still in the shock. The family had disposed the referral slip issued at the time of discharge. The discharge was requested by the family few hours after the delivery. There was no request made to the family to keep the baby and mother at NPHC for at least 48 hours. The mother told that after reaching home, the baby had difficulty in the breathing. From the

Bargarh, Orissa Page 36 description of the family, the baby might have cleft lip and hence was having some difficulty in breastfeeding. Baby was visited by the ASHA.

There is no government transport facility from the village to the PHC. The family has to hire a private vehicle each time for going to hospital putting extra burden on the family. This acted as deterrent for accessing the healthcare even after observing some difficulty in breathing by the baby.

The case was discussed with the concerned doctor. The doctor explained that the patient do not stay at the hospital for 48 hours even after such request. This was also confirmed by ASHAs who were asked about the behaviour of the patients. However, there was not official proof that such request was actually made. It was also hard to determine that the child and mother were normal at the time of the discharge. The delivery register was the only document available with the health facility. The delivery register mentioned date and time of birth, weight of the baby and address of the mother.

It is necessary to maintain a detailed case sheet mentioning details of labour, medications, details of the mother, and details of the child after a thorough examination along with the Partograph. The case sheet should mention if mother was discharged after 48 hours or DoR (Discharge on request) or DAMA (Discharge against Medical Advise). In case of DoR or DAMA signature of the family member is essential after explaining the health status of the mother and child with possible risks involved.

The medical officer was requested to visit the family and investigate the possible cause of death. It was also decided to look into the feasibility of providing diet to the mother from RKS for 2 days of observation after delivery as a tool to retain them at the health facility.

Healthcare functionary of Orissa and Bargarh district must receive due recognition for setting up a firm foundation for the healthcare delivery considering multidimensional challenges that are confronted by the system. The consultant is grateful for all the cooperation and help by the state and district authorities especially by the State Planning Manager, District Program Manager and District Health Information Officer.

Bargarh, Orissa Page 37

Findings and recommendations

Relevant findings have been indicated in each individual section. Present section deals with the overarching findings and recommendations for the district.

 Twenty seven health facilities are to be upgraded in current year. Padampur SDH is to be upgraded to level III. Four CHCs of level I are to be converted to level II institutions. Two PHCN are to be upgraded to level II from current level I. There are 16 subcentres to be operationalised in the current year. Progress for the first quarter may be sought for these institutions.  One SNCU at the district hospital is to be operationlised. There are 11 health facilities (8 CHC, 2 SDH and 1 DHH) to be provided with a stabilisation unit. Progress for the first quarter may be sought for these institutions.  Eighty seven percent of the posts of male supervisor are vacant (45 in number). The district has 19 percent shortfall of the medical officers (17 in number). Recruitment for these posts may be considered in the current year.  Biomedical waste treatment needs immediate attention. Each hospital may be advised to have well fenced containment area and to use the colour coded buckets for segregation of the waste.  Unavailability of purified drinking water for patients was found to be a universal problem. The RKS of the health institutions in the district may be guided to buy a water purifier.  Presence of hospital manager was one of the most positive factors at district hospital, Bargarh. The manager may further be encouraged to take up more initiatives.  Broken cots should be removed from the infection ward at CHC Barapali and made functional to admit the patients.  SHC Lenda ANM does not have a proper site for conducting the immunization sessions. Some arrangement for the same may be done.

Bargarh, Orissa Page 38