N R H M COM M ON REVIEW M ISSION BIHAR REPORT 15TH - 20TH NOVEM BER 2007
THE TEAM
The team m em bers of the Com m on Review Mission (CRM) to Bihar visited the State from 15th to 20th Novem ber 2007. The team consisted of Dr.Thelm a Narayan, Public Health Specialist, Dr. D. Tham m a Rao (Mission Director, NRHM, Puducherry), Dr.M.S.Jayalakshm i (DC, MOH&FW , GOI), Dr. Dileep Kum ar (Nursing Advisor, MOH&FW , GOI) and Shri Am arjeet Sinha (Joint Secretary, Ministry of Health and Fam ily W elfare (MOH&FW ), Governm ent of India). The team assem bled in New Delhi on 14th Novem ber 2007 and attended the day long briefing at the National Level by all the Program m e Divisions and also had the benefit of som e State specific briefing.
THE SCHEDULE
On 15th Novem ber 2007 the team reached Patna and participated in a m eeting at the Bihar State Health Society (BSHS) office. The Team was aware that it was visiting the State at the tim e of Chhatth festival which is one of the m ost im portant festivals of Bihar when every thing closes down for a few days. Detailed presentations were m ade by Ms. Mona Gupta, Consultant, BSHS and State Program m e Managers Dr. D K Ram an, Dr. (Maj) K.N. Sahai, Dr. A. K. Tewari, Dr. Y. N. Pathak, Dr. N K Bhim saria, Dr. Gopalakrishna, Dr. Anil Kum ar, and Dr. Varsha Singh. Since all the presentations could not be com pleted that day, they continued on the 19th of Novem ber 2007. The Additional Director from the Directorate of Health, Dr. Ram an, was present during the presentations and also during the field visits on 16th Novem ber 2007. The State Program m e Managers presented the activities of their units, highlighting the NRHM
achievements in the im plementation of RCH and Disease Control program m es. The SHS data collection centre, which is outsourced, was also visited by the team .
It was agreed that the team would visit Patna Medical College Hospital, Nalanda Medical College, Rajendra Memorial Research Institute of Medical Sciences (RMRI) of ICMR and its KalaAzar ward at Patna, one PHC and one Sub- district Hospital in Vaishali district on 16th Nov 2007 and subsequently one CRM team would visit Gaya, Jehanabad, Nalanda & Patna districts and the other team would visit Vaishali & Muzaffarpur districts.
The Team – A visited Sub-centre (Moriara), six 24x7 PHCs/Referrral Hospitals at Dhanarua, Makhdumpur, Belaganj, BodhGaya, Manpur, Vazirganj, Harnaut, Lalganj, and Rajgir. It also visited the District Hospital at Jehanabad, Hajipur and the Pilgrim Hospital at Gaya.
The Team – B visited Sub-centre, Anganwadi Centre ay Jayanthigram , 24x7 PHCs at Lalganj, Goraul, Sarai, Paru & Vaishali, two District Hospitals (Sarai &Hajipur) as well as Patna Medical College, Nalanda Medical College and SN Medical College, Muzaffarpur.
Detailed wrap up m eetings were organized over the last two days of the Mission. Besides interacting with the Health Minister of the State, the team interacted with the Health Secretary, Mission Director, Additional Director Health Services, Program m e Coordinators, NGOs, etc.
OVERALL ASSESSM ENT
After extensive visits to health facilities in six districts of Bihar and interactions with a wide cross section of people, the team places on record its appreciation for the tremendous work done in a strategic and innovative manner to
translate the NRHM framework for implementation into reality. This is impressive given the neglect of the public health sector in the State over the past 15-20 years.
Demand side financing, the ASHAs and other rural health initiatives have led to a large increase in utilization of health services. Increase in Block PHC OPDs from 39 per month 2 years’ ago to over 2500 per month now for many months, and from 7000 institutional deliveries in government institutions in October 2006 to over one lakh such deliveries in October 2007, confirms the significant increase in number of people accessing the public system. Given the low utilization of public services in Bihar as reported by NSSO 60th Round 2004-05 (5% out patient and 11 per cent in patient treatment in Government institutions), this is indeed outstanding. There is a confidence that the public system shall deliver quality health care services and people are flocking the public system to utilize services even on holidays and over weekends. There is still scope for improvement in the supply side and quality of services, which, hopefully, will receive priority attention in the months to come.
The Bihar State Health Society has steered the process despite frequent change of leadership with seven EDs over a two year period. The staffing of the BSHS has been sm all for the task entrusted to them. The appointm ent and functioning of PMUs at every level is m aking a difference. District and Block level Managers have added new energy to the system of health care delivery. Infrastructure renovation and expansion has taken place in a remarkably short tim e and the setting up of a Construction Corporation for the health sector is a good step to handle new constructions.
The strengthening of Block PHCs has been a step to handle the increased patient load. W hile the case load has tremendously increased, there is room for further rationalization of doctor postings as there is under utilization of doctors in som e places, including Specialists. The thrust should now be to ensure surgeries and in patient care on a m uch larger scale. It needs a change of m ind set as well as m any
government hospitals are still not prepared to take responsibility for in patient cases. A lot of investment on up-gradation of facility at Block PHCs have been completed or are near completion. RKS resources have reached Hospitals. The challenge is to utilize untied resources to give clean and well equipped wards and labour rooms, prioritize quality health care, cleanliness and in patient care. For the NRHM goal of access to com prehensive prim ary health care, the Additional PHCs need to be m ade functional in a tim e based m anner. Human resource development, especially Nursing, and m anagement needs to be the top priority over the next two years. The State Government plans to m ake all Additional PHCs and Sub Centres fully functional from January 2008. This will really im prove the outreach and access in difficult areas.
THEM E W ISE ASSSESSM ENTS
1. Load in Institutions (SHC, 24x7 PHC, District Hospitals & Medical Colleges):
There is clearly a significant increase in the case load in all Hospitals of Bihar. Even at the tim e of Chhatth and on holidays, patients were com ing to the Hospitals and deliveries were taking place. The Block PHCs have becom e 24X7, even though 3 Staff Nurses are not in place as yet. Roster duty at Block PHCs ensures the availability of a m edical personnel round the clock. The health facility’s load varied for different facilities of the sam e category depending upon the location, availability of infrastructure and acceptability.
Every Block PHC has witnessed increase in case load. Repair and construction of new buildings in Block PHCs have prepared them for the higher work load. The outsourcing of Generators and am bulance at the PHCs is working very well and it has helped in m aking the Block PHC take the additional load. There is a long way to go in im proving the cleanliness of Labour Room s and provision of basic equipments. The dedication of staff at the Dhanarua, Makhdumpur and Rajgir Hospitals reflected the new m otivation with which health personnel have started working.
The MO in-charge of Block PHCs need to have m ore powers to give service guarantees. The current system whereby they are dependent on the Civil Surgeon for m any outsourcing arrangements and cleanliness needs to be reviewed. MOs should be given m ore powers with m ore responsibilities for ensuring quality and care standards. Resources provided under NRHM for upgradation of CHCs to Indian Public Health Standards, at the rate of Rs. 20 lakhs per institution, as first advance, needs to be utilized to fill up the m issing gaps in infrastructure, equipment and m anpower in the Block PHCs (that are being upgraded as CHCs). The State Government has spent Rs. 23 lakhs per Block PHC from the Finance Com m ission funds to im prove the physical infrastructure of Block PHCs. W ith the unspent NRHM funds with the States for CHCs, it would be possible to cover the m issing gaps in a very short period.
The In-Patient load was very high in all the three Medical Colleges. The quality of care is not adequate on account of a huge shortage of Nurses, so critical for quality health services. W hile recruitm ent of Nurses are at an advanced stage after m any, m any years, the gap is very huge. To illustrate, the case of PMCH’s Paediatric W ard is as follows : The Pediatric departm ent of Patna Medical College is functioning with 22 Specialists, 8 General duty doctors with PG qualifications in Pediatrics, and com plim ent of 60 PG Residents. However there is acute shortage of Nurses as the 80 bedded wards in Ground Floor (Pediatrics Casualty, Pediatric ICU and Neonatal ICU) has 3 nurses. On an average 50 to 60 children are admitted daily and there are 2 to 5 attendants per child. Most of the drugs, IV sets etc. are not provided by the hospital and are procured by the patients from outside on prescription. There are no Apnoea m onitors as well as Pediatric AMBU resuscitators and an adult AMBU bag is being used for a 2 m onth old child. All the four Phototherapy Lam ps are non functional, only one of the eight Incubators is functional, only one of the eight Baby W arm ers was functional and Electric bulbs are used as warm ers.
The Obstetrics & Gynaecology departm ent is functioning with 17 Specialists, 6 Chief Residents, 60 Senior Residents and 30 Internees There are 42 beds in Labour W ard including ICCU. The 12 Labour tables do not have IV stands and leg stirrups. On an average 30-40 patients are admitted and 20- 25 deliveries are conducted daily including 5 to 10 Caesarean Sections. During the past 24 hrs, 30 patients were admitted and of them 17 had norm al deliveries, 3 had episiotom y deliveries, 3 Laporotom ies and 5 Caesarean deliveries.
2. Health facilities preparedness including m anpower availability and utilization
Bihar State has 38 districts, 72 subdivisions, 533 blocks, 32 towns and 45098 villages. Health care is provided through 10,332 SHCs 1,247 additional PHCs (Doctor & Pharm acist only), 533 PHCs, 27 Sub District Hospitals, 25 District Hospitals and 6 Medical College Hospitals. The State Government is proposing to upgrade the 24x7 Block PHCs as CHCs and the proposal is included in PIP 2007-08. The Referral Hospitals are reported as CHCs at present.
The physical infrastructure and availability of human resources are grossly inadequate to provide the m inim um preventive and curative needs of the population. New construction was seen in all the Block PHCs and District Hospitals visited. There is clearly a m ajor push in the State to create adequate health infrastructure. The Labour tables, Operation Tables, Operation Theatre Lights, Suction Apparatus etc., need to be provided for all the 24x7 PHCs. W hile large buildings have com e up, som e key inputs to im prove the quality of services are needed. The team was inform ed about the Operation Labour Room initiative whereby efforts to provide basic quality care are being attempted. W ith resources to Rogi Kalyan Sam itis and other untied funds to Block PHCs, it is possible to m eet the basic gaps on a priority. The Rupees twenty lakhs provided under NRHM for each CHC as a first instalment should be m ore than sufficient to m eet the up-gradation to Indian Public Health Standards. The State
Government has already put in Rs. 23 lakhs per Block PHC from the Finance Com m ission funds.
The Vaishali District Hospital (Hajipur) with 120 beds and 13 specialists & 13 Medical Officers drawn from Additional PHCs is provided with 8 nurses only. At present no surgeries are perform ed even though Obstetricians -2, Anaesthetists -2, Eye surgeon etc available. The essential surgical instruments and equipments are not available. The imm ediate need is to begin surgeries wherever possible and to encourage in patient care in Government Hospitals.
The Muzaffarpur District Hospital (Sadar) with Bed Capacity strength of 228 has 117 functional beds only is grossly underutilized m ainly due to acute shortage of Nurses even though Specialists are available (13 Specialists including Obst. -3, Surgeons -2, Anaesthetists -2). The daily OPD is 29 - 114 per day, deliveries of 30- 40 per m onth, operations of 20 to 30 per m onth, MTP 4 - 5 per m onth. The Team was assured by the State Government officials that appointm ent of ANMs and Nurses is at a final stage and there should be im provement in the situation shortly. Over 7000 ANMs and 3800 Nurses’ appointm ent on contract is in the process of finalization and will be com pleted within a m onth. Bihar really needs to plan its Nursing care need on a priority to be able to provide quality health care to the people who are now flocking the public systems.
The Blood Banks are yet to be established in m ost of the hospitals and 24x7 PHCs. It was inform ed that the Licenses were issued for blood banks for several hospitals but yet to be operationalised. The investigation facilities are inadequate in the government sector. The State Government has therefore got into a partnership with two reputed Labs for facilities in each district hospital with collection centres in each of the Block PHCs. The partnerships with the private partners for diagnostics appear to be working well. The security services, linen services and electrical supply are now ensured by outsourcing.
3. Quality of Services:
Presently the state has planned to strengthen services at block levels due to acute shortage of human resources to facilitate operationalization of 24x7 PHC and subsequently up-grade them as 30 bedded CHCs. In all the facilities visited by the CRM teams, the availability of Specialists and general duty doctors was either adequate or surplus except at Nalanda Medial Colleges and SN Medical College. In all the 24x7 PHCs, 6 to 10 doctors were m ade available by withdrawing them from Additional PHCs. The quality of services is affected due to non-availability of nurses at 24x7PHCs, District Hospitals and Medical Colleges. All the deliveries are conducted by ANMs or lower staff and discharged within 2-3 hrs of delivery. There is considerable increase in institutional deliveries and is m ainly due to im plementation of JSY scheme and introduction of ASHAs . For the average number of 5-10 deliveries per day in the PHCs, 1to2 nursing personnel seem adequate. However the quality of service provided needs a lot of attention:
- Basic cleanliness of the centre, with particular regard to delivery area, - Adherence to clean procedures - Disposal of waste matter, - Minim al hospital stay for 24 hours at least after delivery - Follow im m ediate neonatal care, especially to resuscitation procedures
These interventions do not require m uch additional inputs but sensitization of the health personnel and constant m onitoring. This is also an opportunity to instill basic hygiene and cleanliness in the people by setting up these centres as role m odels. Greater thrust on IEC for basic Labour Room facilities and BCC for cleanliness and sanitation, will be useful.
The proposed one day training of nursing personnel, including ANMs, in basic neonatal care is a good strategy to address to quality service in neonatal care.
4. Imm unisation systems & visible changes in the field:
All the vaccines are available in adequate quantities. The Cold Chain is in position in all health facilities. The registers were m aintained for all ILRs as well as im m unisation sessions and im m unisation cards. The AD Syringes are in use in all the facilities. The hub cutters were m ostly rusted and unused. The syringes and needle are not decontam inated and proper disposal m echanism s for needle disposal in Pits are not in place. The Village Health Nutrition Days are proposed to be started soon.
Polio:
Health officials com plained that the pulse polio program m e drains a lot of their human resources for a substantial proportion of tim e every m onth or two. This has very adverse effects on all other work. Of the 3 polio cases in the state, about 24 had received 4-5 doses of OPV. Many children receive around 10 doses of OPV. The Government of India were requested to take this up as a policy issue. W hile so m any resources focus on this problem the m uch m ore widespread and serious problem of anemia and malnutrition are relatively neglected.
5. Diagnostic facilities and their effectiveness:
The health facilities have very m eager strength of 170 Lab. Technicians and 700 Lab Technicians under TB Control program m e. In view of the gross shortfall, the State opted for private sector participation in provision of laboratory services. These services have been outsourced and the tim ings of sam ple collection are well displayed at the health facilities. The available x-ray m achines are provided to the outsourced agency. The outsourcing has been effective in ensuring the services at 24x7 PHCs. These services are in the process of being extended to all other PHCs and other health facilities including Medical Colleges.
There is acute shortage of Lab. Technicians in all the health facilities. The privatization of Lab. Services has considerably m et the im m ediate needs in m any of the health facilities. However the m echanism s have to be further strengthened to reach vulnerable groups in rural areas.
6. Performance of ASHAs:
The ASHAs were active in all the Health Centres visited by the team s for m ultifold increase of institutional deliveries even though the JSY benefit is provided at the tim e of delivery. The orientation training of ASHAs was adequate as m ost of the ASHAs are well aware of ANC, Routine Imm unisation, JSY scheme etc. The ASHAs have been appointed from the local com m unity in the areas visited.
Selection & Retention
The number of ASHA’s selected in 63654 from a target of 74313. Based on a letter from the DMs, the selection was done through the Mukhiya of the Gram Panchayat, with the help of the ANM. The consultation process with Gram Sabhas was not done. It is reported than an evaluation study of the JSY done by CORT covers the ASHA program m e. Drop outs are reported, som etim es due to expectations of financial returns not being m et. Som e say that ASHAs do not receive the entire am ount of the performance linked honorarium paid to them.
The ASHA’s m et were m ature wom en who seemed fairly m otivated, playing a social m obilization role at this stage. The drug kits will be given after the next training phase. Their knowledge regarding ANC and childhood im m unization was adequate for their facilitating role. Several reported providing DOTS to TB patients. A few doctors, NGO and others said that DOTS payment was delayed.
Training – First Phase (11 days)
A state team was trained by the NIHFW who in term did the TOT for district teams drawn from the Health Departm ent. W hile som e sources reported that the training was not adequate, it appears that on the job learning is taking place with the ANMs in the course of their work. The second training phase is m ore im portant both in term s of content and skill development. The proposal for this developed by the Bihar State W ater and Sanitation Mission (BSW SM) by the Public Health Engineering Departm ent has been reportedly approved by the Governing Board of the SHS and the training is scheduled to start in January 2008 at a cost of rupees thirty eight croes, ninety seven lakhs, twenty five thousand only. Training resource teams at State, district and block level are planned, with a 12 day training for the District Learning Team. The ASHA training is proposed to be done through a 12 day non0residential course in all 534 blocks over a six m onth period. The training will be conducted by the BW SM and SHIFW. The NGO network through which the Total Sanitation Cam paign was conducted will play a role. Given the im portant role of the ASHA for the head of the com m unity and the large investm ent being m ade, the following suggestions could be considered:
(i) Key trainers could visit the Mitanin program m e to exchange experiences and share training m aterial. The Mitanin Evaluation available on the website www.sochara.org could provide insights;
(ii) A concurrent review within Bihar for the second phase could help in continuously refining the program m e;
(iii) At the ASHA’s training level a continuous 12 day program m e m ay not m eet the learning goals and m ay not suit the wom en. It could be done in 2-3 phases and should include field work. Residential training is proven to be m ore effective and empowering. An active learner is critical. The role and capacity of the trainer at Block level is im portant. A person experienced in health work is best suited for som e com ponents. PHED, staff & network
would be best for dealing with water and sanitation issues, com m unity organization etc. Form ation, linkage with the ICDS is im portant as they will be working together in the field later;
(iv) It is im portant to plan for a follow up – in house ongoing training during the year after the training;
(v) ASHAs are m ost effective when working in close collaboration with a supportive system;
(vi) Participation of NGOs experienced in com m unity health work would enhance the quality of ASHA capabilities;
(vii) Since this is the first tim e the PHED is training in health, a pilot run of the training could be conducted for 4 days in a few areas to gain experiences;
(viii) The focus on empowering the m ost socially excluded groups in society and of reducing inequalities should be given priority;
(ix) Health worker/ASHA m elas to exchange experiences and visit a few field sites could be offered to som e who show leadership and capacity to gain;
(x) Introducing Yoga and personality development exercises has been found to greatly help the ASHA develop self confidence.
The SHS could think through the future of the ASHAs over a 2,3 and five year period and plan inputs at different tim es. The logisitcs of the program m e are fairly com plex and a strong state level team with high m otivation would help to see the ASHAs m ake a significant difference to health. Provision and replenishment of ASHA drug kits in a tim ely m anner should be ensured. Training of PRI m embers about the ASHA role and the NRHM could be integrated with that ongoing training. It is learnt
from the Health Minister that 60% of Gram Panchayt m embers are wom en and he was very interested in PRI involvement in the NRHM.
PHED is planning integration of village W ater and Sanitation Com m ittees with Village Health and Sanitation Com m ittees. Their training in com m unity planning and m onitoring (CP&M) needs to be taken up. The m erging of ASHA resource groups at State, District and Block levels with the CP&M resource should be considered and NRHM resource groups set up.
7. Disease Control Programm es - Surveillance, Vector Control and Effectiveness:
Kala Azar:
Bihar State has the largest number of 29,711 cases in Indian States. Kala Azar is endemic in 33 districts of the 38 districts with 7.20 crore population is at risk of Kala Azar. An expert com m ittee under the Chairm anship of Dr. C. P. Thakur, form er Union Health Minister, was form ed. The state Government ensured their prim ary thrust on control of Kala Azar through provision of free transport, free testing, free supply of drugs, free diet to patient attendants and payment of Rs. 50 per day for the loss of wages. All the PHCs visited have admitted Kala Azar patients, tested the patients and confirm ed cases are treated as per the protocols. The procedures for payment of Rs.50/day are yet to be stream lined as lump sum payments are m ade instead of daily payment for loss of wages. The team s visited the MSF Kala Azar unit established in District Hospital, Vaishali and the patients were fully satisfied with the facilities provided.
Kala- Azar is present in 31 districts. Kala-azar control has regained priority since 2 years. Spraying with DDT which was not done for 16 years has been restarted. A systematic plan has been drawn up. Spraying this year was delayed reportedly due to floods and Diwali. Integrated vector control is advised with spraying to be done at the right tim e with trained sprayers who need to be provided the necessary protective
gear. Com m unity education, and participation is an essential com ponent requiring m ore attention. This could be integrated into the training of PRI m embers, ASHA’s and ANM’s, Male health worker/health assistant. Adequate arrangement have been m ade for treatm ent, assured drug supply and financial support for patients and one attendant. Partnerships have been established with MSF (Doctors without Borders). The RMRI, (ICMR research institute) does a variety of good research including basic laboratory, entom ological, sociological and operational field research. Close collaboration is beneficial to the program m e.
Tuberculosis:
W hile progress has been m ade case detection could im prove. The ASHAs have been helping in DOTS provision. Their payment for this needs attention. 700 Lab technicians are available statewide for RNTCP. Moreover it was found that they do not do routine lab tests such as HB, TC, DC, urine and stool tests. Their daily work load is low and needs to be enhanced. A weak structure at the subcentre and PHC (APMC) level delays/denies case detection and treatm ent. The RNTCP has a systematic approach. Close integration with the health system would benefit both.
The IDSP Program:
Due to the inadequacy of trained human resources, as well as other infrastructure gaps the IDSP is not yet initiated. Com puter centres are being established in the District Health Societies. This will be run on an outsourced basis. The CBHI staff is conducting training on the ICD (International Classification of Diseases). The State Program m e Manager inform ed that the ACMO of the districts have been declared District Surveillance Officers and Data collection Centres sites were identified. These efforts have to be prioritized for early im plementation.
Blindness Control:
The screening of school children has been decreasing over the past three years. The cataract surgeries were not being perform ed in m ost of the District Hospitals visited by the team s m ainly due to the reluctance of specialists and non-availability of nurses. The im provement in the functioning of Block PHCs and District Hospitals should now translate into better perform ance in these institutions.
Leprosy:
The SHSB reported the Leprosy Prevalence Rate of 1.24 /10,000 as on 30th Sept. 2007 (< 1.0 in eight districts only). The Case load is 12,078 and cases released from treatm ent (RFT) are 8,758 (Apr.-July2007). The prevalence in vulnerable groups is relatively high as the new cases n SC/ ST population were 1,694 in a total of 7,013 detected cases. The services of dermatologist and drugs were available in all the district hospitals visited by the CRM team . The involvement of ANMs would be feasible after the appointm ent of 2nd ANM for SHCs as at present there is acute shortage of ANMs.
IDD:
The State is in the process of establishing IDD Cell and IDD Monitoring Laboratory. Many of the posts are yet to be filled resulting in accumulation of GOI funds of Rs.12.50 crores.
In conclusion a few points are noted. a) Planning for m ale health assistants requires attention. They would have a role both for com m unicable and non com m unicable diseases and for health prom otion. b) The doctors are concerned only with clinical care with senior and m iddle level staff spending just a few hours a day. It seemed to us that the ANM’s’, nurses, and junior health doctors and ‘sim ple’ MBBS doctors are actually handling even m uch of this work. Continuing education, a conducive working environment and firm administrative handling is required. However there is also a need for a Public
Health Perspective and com petencies which seem to be fairly absent. Building a critical m ass of Public health specialists is critical. Linkages with the PHFI would be helpful in this regard. c) Diagnostic services are outsourced and 2 lakh investigations are reported to have been done over the past year. But this does not feed into any system for epidemiological analysis. d) Social justice in health or reduction in health equalities is basic to public health. The state and NRHM initiatives during the past two years are very im portant steps towards redressing this. This deserves appreciation, encouragement, support. Research studies would help to m easure progress in this regard. Health system research would also be useful.
8. M CH & Family Planning:
M aternal Care
There is substantial increase in institutional deliveries at the level of District hospital, Sub district Hosp. and PHCs. The CRM team’s interactions with ANMs and ASHAs indicated that the quality of ante natal care needs to im prove. W hile untied funds for Sub Centres and ANM Equipment kit has been finalized and funds released to the States, the utilization is just beginning. The team was assured that the Sub Centres would be m ade fully functional by January 2008, with the provision of equipments, etc. In all the health facilities, the m others and new born children are discharged within 2-3 hours of delivery on the pretext of shortage of beds, lack of toilets etc. even though beds were available during CRM team visits. 48 hour hospital stay after delivery needs to be m ade a priority. The Labour Room s need to be better equipped and a greater thrust on cleanliness is needed.
Child Care:
The present neonatal services at all levels are very poor. Even Patna Medical College is providing only Level II services to the neonates though it has an FRCS doctor specialized in Neonatology. All the equipments supplied earlier in the 90’s are lying unutilized and rusted in District, sub district and PHCs. The State envisaged the plan for com prehensive care of newborn in collaboration with UNICEF for training for:
• District level - creating Sick newborn care unit • PHC level - creating Neonatal stabilization unit • Village level - creating IMNCI trained worker
Imm unization services
The newborns are being provided with BCG vaccination before discharge. An innovative program “Muskan” is planned for scaling up im m unization through ANM, AW W , ASHA by tracking the pregnant wom en and children below 5 years for which incentives are provided to the workers for attaining the targets.
Family Planning:
The services provided are m ostly term inal m ethods and seasonal though fixed day approach (once a week sterilizations) were adopted at PHCs Makdampur & Jehanabad and Referral Hospitals at Rajgir & Nalanda. In other centres visited still a cam p approach, concentrated between Dec to March, is adopted. The Minilap/ Interval/ Post Partum sterilization is being conducted with ether and the presence of an anesthetist. There are not enough trained service providers for providing the m inilap service though it could be provided by a trained MBBS doctor under local anaesthesia without the requirement of an anaesthetist. There is a great demand for sterilization services am ong the beneficiaries visiting the facilities which the system is unable to address to.
The myths and wrong conceptions that needs to be corrected are:
-Demand is only seasonal -Presence of anaesthetist is essential for conducting m inilap services
W ith the availability of adequate number of m edical officers in the PHCs now , the state can easily plan for once a week,, assured, quality sterilization services in all PHCs
Male Sterilisation – The State is planning for a systematic scaling up of service providers through planned training process.
The partnership with Janani is also helping the State Government to push the Fam ily Planning focus. There is a need to sort out any problems in this partnership to ensure that fixed day services are readily available to people.
9. Am bulance Services / M obile M edical Units:
The provision of emergency and referral transport services for W om en & Children has been successfully im plemented by outsourcing through RKS. The ASHAs were bringing the wom en for deliveries and transporting back to their residence. This provision has also facilitated tim ely referral to the District Hospitals and Medical Colleges. The Mobile Medical Units scheme is yet to be initiated by the State.
10. Infrastructure Development:
The establishment of physical infrastructure of buildings for SHC, up-gradation of Additional PHC as PHCs, up-gradation of 24x7 PHCs as CHC, strengthening of Sub-district and District Hospitals as well as Medical Colleges.
11. Procurement &Logistics:
The procurement of drugs and equipments has been deentralised as the civil Surgeons and officer i/c of district hospitals were empowered to place supply orders and procure from the approved tenders finalized at state level. The local com m unity in rural areas, patients in health centres & hospitals expressed im provement in the availability of drugs.
12. N.G.O. Partnerships:
The CRM team invited the NGOs for discussions. The Janani group, a reputed NGO offering good quality fam ily welfare services said that the MoU for 19 districts was renewed after m uch delay. They have done 4,035 tubectom ies and 1200 NSVs. They work through franchised clinics. They m entioned that cam p dates were frequently changed at the last m inute despite advance scheduling, adversely affecting their credibility with the com m unity. They have faced difficulty in getting papers signed by Civil Surgeons and have a pending payment of Rs. 35 lakhs. They would be willing to offer services through the Surya clinics if permission is granted.
A nurse from a m ember institution of Bihar Voluntary Health Association from Patna who coordinates health work for a few districts noted that there have been visible positive effects including increased access to health care for people at BPHCs and im provements in the Patna Medical College Hospital etc. after the NRHM was launched. She highlighted the high prevalence of severe under-nutrition of under-five children which has been worsened by the floods. W hile im portant initiatives such as two Nutrition Rehabilitation Centres have been initiated by the state she offered the possibility of collaborative partnerships with NGO/ m ission hospitals and health centres in providing hospital/inpatient care as well as com m unity based care. It was felt that addressing childhood under-nutrition should be given high priority as it was a m ajor public health problem. There are 3 institutions that conduct ANM training program m es in the network. They would be willing to consider an increased intake for
the ANM course if required. Nursing Council permission and form al MoU would be required.
Another BVHA m ember from East Cham paran m entioned that com m unity health workers trained by them have been selected as ASHAs. She would be willing to support the ASHA training program m e at district or state level. They have faced difficulty in getting anti-TB m edicines under the DOTS program m e of the RNTCP, She m entioned the high prevalence of severe anemia am ong wom en including pregnant wom en and the shortage of iron and folic acid tablets that has been reported state- wide.Kit A and B were not available. Officials m entioned that procurement is being processed and supplies will be m ade available very shortly. Distribution and utilisation needs to be m onitored state-wide. The progress m ade in reduction of anemia and under nutrition could be good im pact indicators of NRHM as this is necessary for reduction of IMR and MMR.
An NGO who took up ten APHCs under a PPP arrangement for three years said that it was difficult to work and the funds were insufficient. He said that they were due a payment of almost sixty lakh from the district health society for want of counter signature by the CS. They have discontinued the contract since March 2007.
An MNGO from Aurangabad also running PHCs as a PPP under RCH 1 also has payments due to them since three years. After form ation of the SHS funds have not been released to old MNGOs. Another NGO working in Sheikhpura and Bagusorai also has 7 m onths payments due to it. Overall, about Rs. one crore dues are outstanding for the 36 PHCs that were earlier outsourced. The introduction of conditionalities to ensure Government responsibility and accountability in partnerships was suggested. A nodal person responsible for m anagement of NGO partnerships preferably at state level was suggested. The PMUs could also m anage this using the TNMC approach in which payments are m ade electronically within a stipulated number of days. Third party
appraisal and com m unity m onitoring which is part of the NRHM fram ework for im plementation, needs to be im plemented.
In conclusion it was felt that NGO and civil society partnerships and involvement which are a part of the com m unitisation com ponent of the NRHM within a PRI fram ework should be given greater priority and reviewed after a year.
13. Augmentation of efforts to m eet Human Resources:
The Secretary (Health) inform ed that recruitm ent of 200 doctors has been com pleted and they will be positioned. Sim ilarly the recruitm ent process for appointm ent of 3,800 Nurses for DHs & PHCs and 800 Nurses for Medical Colleges has also been com pleted. The Society is contemplating on line recruitm ent of staff.
The Hon. Health Minister is well appraised of the shortfalls of Human Resources and the up to date actions in regard to the provision of additional doctors, nurses, ANMs and other param edical staff. The Hon. Minister directed to expedite the recruitm ent process and depute nurses for B.Sc. and M.Sc. courses to institutes in other states.
The SPMU reported positioning of posting of 2nd ANM in 40% of Sub-Centres. The state efforts have reportedly been successful in selecting 80% of the ASHAs and have com pleted the orientation training to 70% of ASHAs. During the field visit, the presence of ASHAs was found in all the field sites. They had bags and ID cards and a good relationship with the PHC ANMs and doctors said their work was very helpful. The ASHAs were accom panying wom en for deliveries. They have adequate knowledge of ANC, and Imm unisation, It was reported by som e that they were not receiving the full payment due to them. This would need to be investigated. Dropouts were also reported and the proportion and causative factors would need study. There is a big gap between the first and subsequent trainings, W ith UNICEF support a training m anual incorporating m odules two to five has been developed by the SHS staff. This pictorial
m anual was appreciated by the team . The next phase of ASHA training for twelve days is being outsourced to the Public Health Engineering Dept. which has a training centre and has a network of NGOs for the Total Sanitation Cam paign. They would require a core group of experienced health trainers to undertake the training as per the NRHM fram ework. Developing good linkages with the health and related departm ents is critical for the training as well as their follow-up work in the field,
14. ANM Training Schools & other Nursing Institutions:
The acute shortage of ANMs is proposed to be m et by reopening of 12 ANM schools. The team s visited three of these schools restarted during the academic year. The School buildings and hostels are functioning in dilapidated buildings as these buildings were unutilised for over a decade. The students were cocking their food. The infrastructural facilities including teaching aids need to be provided and teaching faculty also require reorientation trainings. The UNICEF has taken initiatives to strengthen the schools in the next few m onths.
15. Programm e M anagement Structures:
The State and District Health Societies have been established and functional with m anagement skills. The program m e Management structures at State and District levels are in position. The state program m e m anagers for RCH, Imm uninisation, IDSP, NVBDCP, RNTCP, Blindness Control, IDD and Nutrition are available. The District Program m e Management Units are in position. The team observed that there is an im m ediate need to sensisitese the District Civil Surgeons and other senior level officers for regular m onthly m eetings of DMUs for taking decisions and release of funds for urgent civil works, procurement of drugs and equipments etc.
16. M anpower position in Health Facilities:
As per the data furnished by the State Health Society, there is acute shortfall of human resources for health. The availability of physical infrastructure is to be
im proved to provide SHCs, PHCs, CHCs and Hospitals as per the National norm s. The rural population of 7.43 crores (Census 2001) requires 14863 SHCs (8,858 available), 2477 PHCs and 619 CHCs. The operationalisation of these centres would require large number of additional doctors, nurses and other param edical staff as detailed below -
Essential M an Power Requirements as per IPHS (for Census 2001 population) SHC PHC CHC District Hospitals * Required 14,863 2,477 619 38 Total (IPHS/GOI) Available SHC PHC & 24x7 100 300 500 (8858) Addl. PHC PHC beds beds beds - ( 398+1243= (533) (12) (18) (8) 1641 ) 1 Specialists - - 240 648 368 5,589 4,333 2 “ - - 619 24 36 16 695 AYUSH 3 Doctors - 7,431 3,714 108 360 192 11,805 4 “ - - 619 12 72 16 719 AYUSH 5 “ Dental - - 619 12 18 8 657 6 Nurses - 12,385 11,761 672 2,070 1,800 28,688 7 PHN - - 619 - - - 619 8 ANM 14,863 2,477 619 48 72 32 18,111 9 LHV - 2,477 619 - - - 3,096 10 Health W orker– 14,863 2,477 619 - - - 17,959 Male 11 Health Assistant - 2,477 619 - - - 2,493 12 Pharm acist - 4,954 1,857 48 144 64 7,067 13 “ - - 619 12 18 16 665 AYUSH 14 Lab. Technician - 4,954 1,857 60 216 88 2,189 15 O.T. Technician - - 619 72 180 80 951 16 Radiographer - - 1,238 36 90 160 1,524 /DRA 17 Ophthalmic - - 619 12 36 16 683 Asst. 18 Physiotherapist - - 619 12 18 16 665 19 Nursing 9,908 3,714 68 612 400 14,702 Orderly/
Dresser/ W ard Attender 20 Sweeper 9,908 3,095 72 486 288 13,849 * Excluding Medical Colleges (6)
As part of the infrastructure development, the state is in the process of upgrading 1,243 Additional PHCs as PHCs, up-gradating 533 PHCs (24x7) as CHCs and upgrading 31 Sub-district & district Hospitals. In addition, there are considerable vacancies in the sanctioned posts. The State created 2189 posts of specialists and 308 posts of MOs. The state created 2189 posts of specialists and 308 posts of MOs. As an im m ediate intervention, the State appointed 231 specialists, 4029 ANMs, 63454 ASHAs as well as 477 Block Health Managers and during November 2007, com pleted selection of 1252 MOs, 231 Specialists, 3800 Nurses and 1092 ANMs. The appointm ent of 1,552 AYUSH doctors as well as nurses for Medical Colleges is also under process.
Manpower - Requirements, Sanctioned posts & Vacancies (Excluding Medical College Hospitals) Category Required Sanctioned In- Vacancy Total as per position Required IPHS 1 Specialists 5,589 2,189 NA NA - 2 Medical Officers 11,805 5,124 3,860 1,264 7,945 3 Nurses 28,688 734 534 200 28,154 (PHC/CHC/DH) 4 ANMs 18,111 11,033 9,481 1,552 8,630 5 “ 14,863 - 2,700 12,163 12.163 Contractual 6 ASHAs ( per 1000 - 74,317 63,454 10,863 10,863 population) 7 LHVs 3,096 1,126 662 446 2,434 8 Health W orker – 17,959 2,562 1,298 1,264 16,661 Male 9 Lab. Tech. 2,189 1,420 264 1,156 1,925 (PHC/CHC/DH) 10 Pharm acist 7,067 1,646 449 1,197 6,618 (PHC/CHC/DH) 11 X-Ray Tech. 1,524 127 84 43 1,440 (PHC/CHC/DH)
12 Ophthalmic Asst. 683 664 129 535 554 (PHC/CHC/DH) 13 O.T. Technician 951 99 13 86 938
The State capacity for human resources is very lim ited as at present there are only six Medical Colleges and very few functional nursing and param edical educational institutions available in the State. There is urgent need to evolve short term and long term strategies to ensure the essentially required Human Resources for Health. In this regard the State Society initiated actions for reopening of 12 ANM schools with UNICEF support. There is an im m ediate need to provide Nursing consultant at state level for ensuring adequate Nursing colleges, GNM schools and ANM schools. Sim ilar m easures would be required for provision of other param edical professionals such as PHNs, LHVs, Pharm acists, Lab. Technicians, Radiographers, Ophthalmic Assistants, O.T. Assistants etc.
17. Utilisation of RKS & Untied Funds:
The Rogi Kalyan Sam athis have been established in all hospitals and health centres and their im pact is clearly visible in outsourcing of Am bulance services, uninterrupted electricity through Generators, dietary services, provision of Linen supplies, cleanliness services and environment. The funds were available at Medical College hospitals, District hospitals and 24x7 PHCs.
The outsourcing of services have led to general satisfaction as electricity is provided for over 23 hrs a day in PHCs through Generators, Am bulances are plying up and down with patients to provide referral services, diet is provided to patients as well attendants of Kala-Azar patients etc. However, outsourced cleanliness services and linen services are to be im proved.
There is an apparent reluctance for utilisation of funds and the Civil Surgeons / MO i/c / District Program m e Managers are not fully aware of their empowerment. Eg.
Sadar hospital is to convene the RKS m eeting for approval of m ost im m ediate needs of broken doors, repair of toilets, water stagnation in hospital premises etc. The AC sheet roofing could have been easily replaced at PHC with in powers delegated to the MO i/c.
18. PRI Involvements in health system:
The elected representatives of the PRI are m embers of the RKS and PHC Com m ittees. The nam e, designation and contact telephone / m obile numbers of all the m embers of various com m ittees are displayed at respective health facilities. The team s could not interact further due to the annual Chhatth festival season. The initiatives for inter-sectoral convergence for public health activities including involvement of PRIs & VHSC are to be taken up.
19. Preparation of District Health Action Plans:
The District Health Plans have been prepared for two districts and is in process for the remaining districts. The UNICEF is assisting the state in preparation of the District Health Action Plans in these two districts. In the rest of the districts, work had been assigned to EPOS, a consulting agency. The m atter however, has gone in for arbitration. The State Government needs to com plete all its plans quickly as the process has been com pleted in nearly all the other States.
20. Financial M anagement:
The Finance Manager and other supportive staff at State level are in position. The District Program m e Managers and District Accounts Managers are positioned in 34 of the 38 districts. The District officials expressed satisfaction for availability of funds. The allocated funds are released by cheques (SBI) only as the e-banking procedures are yet to be established. The financial powers were delegated adequately to the districts, MOs i/c and various com m ittees. The DPM and District officials are reluctant to utilize the funds or unaware of their empowerm ent. In Muzaffurpur district the funds are
unutilized as the District society is yet to be registered. In Vaishali district the MOs i/c expressed non-availability of funds as the expenditures are incurred by the district. Many of the activities such as provision of diet, equipment, furniture including patient cots, water supply etc., as well as m inor civil works could be easily ensured.
In both the districts of Muzaffurpur and Vaishali, the JSY benefit and payments to ASHAs are not provided at the tim e of delivery as m oney is not available with MOs i/c. It is observed that JSY payments are m ade by cash to JSY beneficiaries and ASHAs.
The State Health Society furnished the status as on 15th October 2007. The DPMs could not furnish the statements. The FMR for I Qr. 2006-07 due on June 2007 and the UCs for 2006-07 are under finalization.
21. Rational Use of M anpower for better outcomes:
The State provided the MOs for 24x7 PHCs by relocating from Additional PHCs and duty rosters were available at all health facilities for 6 -10 doctors. The MOs possessing PG qualifications were posted to hospitals to ensure m anpower availability. The specialists in District Hospitals need to be provided with GDMOs and nurses. The surplus ANMs for SHCs under the PHC were m ade available for the 24x7 services at PHCs and in centres with shortages the ANMs of SHCs are posted at 24x7 PHCs on rotation basis. This provision ensured availability of ANMs for the institutional deliveries. Sim ilarly the pharm acists from additional PHCs were relocated at 24x7 PHCs. The newly recruited nurses and other param edical staff would require induction trainings as m any of them have been non-functional.
The ratio of Doctor (Specialists&GDMO) : Nurses, LHV: ANM etc need to be looked into as m ost of the places the numbers are inadequately m atched. In Vaishali district there are 140 specialists, 44 GDMOs supported by 391 nursing staff, m eager 10 pharm acists, 8 Lab. technicians, 2 X-ray technicians, 8 dressers and without any OT Assistants. In the entire district, only PHC Lalganj is provided with 2 nurses and all the
other 8 PHCs do not have even one nurse. The 24x7 PHC at Vaishali is provided with 8 specialists and 2 GDMOs where as the 24x7 PHC Lalgunj is provided with 4 specialists and 4 GDMOs. and only GDMOs at 24x7 PHC Goraul. The available personnel need to be relocated for optim um delivery of services with the available human resources.
22. HM IS and effectiveness:
The State Health Society data collection centre was visited and appraised of the daily collection of data from the Health Centres including number of deliveries, utilization of am bulance services, telephone, 24 hrs electric supply, working condition of Generators, etc.. The Data Centre has been very useful in im proving the feedback on program m e perform ance and in also reducing absenteeism at health facilities.
Most of the data for RCH and disease control program m es is collected by the data centre of the State Health Society over phone from the society staff posted at health facilities. The State needs to set up com puters at Block PHCs so that data can be regularly updated and web based m onitoring systems can be operationalized. W ith a 24 hour power supply through generators, Block PHCs have becom e a vibrant place where a lot m ore of HMIS related work is possible using com puters.