SIHFW Parimahal, Shimla 9 2
PREFACE The SHFWTC, Parimahal, Shimla is happy to present this final District Action Plan (Health) (DAP) for the district of Shimla. It may be put in records that a team of Resource Persons visited the district on the 10 th to 13 th April 2008, where the CMO, M.O. (H), Programme officers, Block Medical Officers, Officers of other departments that have direct bearing upon the health in the district along with the field functionaries of the HFWD were sensitized in various aspects of National Rural Health Mission under which the DAP was to be prepared. Through a random sampling, 128 of the total 363 Panchayats in the district were selected where using the technique of Focus Group Discussions (FGD); various issues relating to health were raised with the people of different strata, age group, vocations and background. This along with the status of the health activities became the foundation on which the present DAP stood. Shipshaping the entire available data, a draft Action Plan was prepared at SHFWTC which was presented before the members of the District Health Mission. The DHM, under the Chairmanship of the Deputy Commissioner, met on the 29th September 2008 and we are pleased to record that the DHM not only considered the issues of concern and key messages but also studied further in greater detail the issues raised in the Plan against the backdrop of the socio economic conditions of the district. The conclusions of these deliberations are presented in this Final DAP. At first sight, the recommendations may seem rather detailed, extensive and wide ranging. However, in view of the importance of health as probably the most important element in the effort to achieve an acceptable standard of quality of life for all, the consideration of issues had to cover all aspects of the health services and closely inter related sectors of development. It is rarely that such opportunity arises, especially for the district health management, which permits examination of issues in full of the health services and in conjunction with the sectors that lend these services strength and support. A holistic view of health services as an integral part of the entitlement of the people to basic services has, therefore, been taken. Consequently, the Final DAP has considered the content, quality and reach of the health services right up to the most vulnerable section of the people and administrative and management issues in the social and economic context of the district. 3
In the course of examination of the issues relating to health services in the district it has repeatedly become apparent that the key factor that influences the efficiency of these services and ensure the social accountability of the system is the availability of general and specialist doctors in the Health Institutions opened here in adequate numbers. Efforts of sending doctors to these institutions are being made by creating a different cadre of doctors that will be institution based and paid by the Rogi Kalyan Samitis. The adverse behaviour of the health staff posted in the district has also been attacked by the people in general. It is true that professional skills, financial allocations and departmental infrastructure, important as they doubtless are, can contribute to performance only up to a point. The core issue, however, remains of the attitude and behaviour towards the patients and motivation and commitment of the staff. There is need to nurture the young health professionals and other allied health workers, supervising and facilitating them. There is also need to instutionalise discipline tempered by with morale building, peak performance and accountability to the public, together with the involvement of the Panchayati Raj Institutions and the people in attaining and maintaining their own health. All the recommendations on restructuring of the health services in Shimla district have been made keeping these essential parameters in view. The SHFWTC speaks with full confidence that changes and gap fulfillment suggested in the DAP are not merely desirable, but essential, and would be viewed by those in the health system in this light. Implementations of many of these recommendations by the Government would take some time, but there are many that can be implemented without delay by the orders of the Director, Health Services, Chief Medical Officers or the Deputy Commissioner. It is hoped, and indeed urged, that the same sense of urgency and concern on NRHM, that induced the preparation of DAP, would continue to prevail and that no time would be lost in establishing mechanisms for implementation of the recommendations. 4
ABBREVIATIONS
AA Appropriate Authority AEFI Adverse Effect following immunization AHC Ayurvedic health Centre AIDS Acquired Immuno Deficiency Diseases AMC Annual Maintenance Contract ANC Ante natal care ANM Auxillary Nurse Midwife APD Acid Peptic Disorder API Annual Parasitic Incidence ARI Acute Respiratory Infections ARSH Adolescent Reproductive and Sexual Services AYUSH Ayurvedic Yoga Sidha and Homeopathy AWW Anganwadi Worker BCC Behaviour Change Communication BEE Block Extension Educator BHC Block Health Committee BMO Block Medical Officer BPL Below Poverty Line CBO Community Based Organisation CC Conventional Contraceptives CD Community Development CDPO Child Development Project Officer CH Civil Hospital CHC Community Health Centre CL Cutaneous Leishmaniasis CMO Chief Medical Officer CMR Child Mortality Rate CPR Contraceptive Prevalence Rate DHM District Health Mission DHS District Health Society DHS Director Health Services DLHS District Level Household Survey DOTS Directly Observed Short term Treatment DPT Diphtheria Pertussis Tetanus EBF Exclusive Breastfeeding EmOC Emergency Obstetric Care ENT Ear Nose Throat FHS Female Health Supervisor FHW Female Health Worker FGD Focus Group Discussion FP Family Planning FRU First Referral Unit GPs Gram Panchayats GTZ German Technical Support HMIS Health Management Information System HIs Health Institutions HIV Human Immunodeficiency Virus HE Health Educator HP Himachal Pradesh 5
IDD Iodine Deficiency Disorders IDSP Integrated Diseases Surveillance Programme IEC Information Education and Communication IFA Iron and Folic Acid IGMC Indira Gandhi Medical College IRDP Integrated Rural Development Project IPH Irrigation and Public Health IPHS Indian Public Health Standards IMR Infant Mortality Rate IOL Intraocular lens ISM Indian System of Medicine IUD Intra Uterine Device ICDS Integrated Child Development Services JSY Janani Suraksha Yojna JSR Juvenile Sex Ratio LT Laboratory Technician MBA Master of Business Administration MCH Maternal and Child Health MEIO Mass Education and Information Officer MGM Mahatma Gandhi Medical Complex MO Medical Officer MOH medical Officer of Health MHS Male Health Supervisor MHW Male Health Worker MPSS Mahila Panchyat Swasthya Sahayika MMR Maternal Mortality Rate or Ratio MMU Mobile Medical Unit MNGO Mother NGO MSS Mahila Swasthya Sangh MTP Medical Termination of Pregnancy NICD National Institute of Communicable Diseases NRHM National Rural Health Mission NFHS National family Health Survey NGO Non Governmental Organisation NSV No Scalpel Vasectomy OBG Obstetrics and Gynaecology OP Oral Pills OPD Out Patient Department OPV Oral Polio Vaccine ORS Oral Rehydration Solution ORT Oral Rehydration Therapy OT Operation Theatre PC and PNDT Pre conception and Prenatal Diagnostic Technique PHC Primary Health Centre PRI Panchayti Raj Institution PARIKAS Parivar Kalyan Salahkar Samiti POL Petrol Oil Lubricants PNC Post natal Care PPP Public Private Partnership PMOA Para Medical Ophthalmic Assistant RH Regional Hospital 6
RTI Reproductive Tract Infections RKS Rogi Kalyan Samiti RBD Registration of Birth and Death Act RNTCP Revised National TB Control Programme RRT Rapid Response Team STD Sexually Transmitted Disease SHFWTC State Health and Family Welfare Training Centre TBA Traditional Birth Attendants TSA Technical Support Agency TT Tetanus Toxoid USG Ultrasono Graphy VCTC Voluntary Counseling and Treatment Centre VHWSC Village Health, Water and Sanitation Committee
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CONTENTS
Chapters Topic Page
1. Background information of district 11
2. Situational analysis 14
3. Planning process 27
4. Focus group discussion summary 28
5. Goals and objectives 38
6. Technical components 41
7. Inter sectoral convergence 65
8. Community action plan (VHWSC) 71
9. Public private partnership 73
10. Gender and equity 74
11. Capacity building 76
12. Human resource plan 77
13. Procurements and logistics 79
14. Demand generation (IEC) 80
15. Financing of health care 81
16. HMIS (monitoring and evaluation) 82
17. Budget 83
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18. Annexures 90 Fact sheet Facility survey analysis Reccomendations of Block Focus group discussion block wise Block Health Plans Number of Panchyats select for FGD block wise Manpower status Health Institutions conducting deliveries Health Institutions conducting MTP Health institutions notified as 24X 7 RTI Clinics Award of project to SHFWTC Parimahal List of contributors
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CHAPTER 1. Background information of district
Shimla District lies in between the longitude 77 o 0" and 78 o 19" East and latitude 30 o 45" and 31 o 44" North. It is bounded by Mandi and Kullu in the North, Kinnaur in the East, the state of Uttarakhand in the South, Sirmaur District in the West. The elevation of the district ranges fromd 300 to 6000 metres. The topology of the District is rugged and tough. Shimla District in its present form came into existence on 1st Sept, 1972 on the reorganization of the Districts of the State. After the reorganization, the erstwhile Mahasu District lost its entity and its major portion was merged with Shimla. Shimla District derives its name from Shimla town, which was once a small village, and now the district headquarter and the state capital of Himachal Pradesh.
Present day Shimla District comprises 19 erstwhile Hill States including mainly Balson, Bushahar, Bhaji and Koti, Darkoti, Tharoch and Dhadi, Kumharsain, Khaneti & Delath, Dhami, Jubbal , Keonthal, Rawingarh, Ratesh and Sangri.
Administration Shimla District is divided into 7 Sub divisions, 9 Blocks, 12 Tehsils, 7 Sub tehsils and 363 Gram Panchayats. Total number of revenue villages is 2914 out of which 2520 are inhabited and 394 are non inhabited .
Shimla Town Shimla is the Capital Town of Himachal Pradesh. It was formerly the summer capital during the British Rule. The town of Shimla is built over several Hills and connecting ridges. The important Hills are Jakhu(8050 ft), Prospect Hill (7140 ft), Observatory Hill ( 7050 ft), Elysium Hill (7400 ft), and Summer Hill (6900 ft). There is a great controversy over the origin of the name Shimla. The name Shimla was derived from 'Shyamalaya' meaning blue house said to be the name of house built of blue slates by a faqir on Jakhu. According to one version Shimla takes it name from 'Shamla' meaning a blue female, another name for Goddess Kali. The place was on the Jakhu Hillside, where there was a temple of Goddess Kali. During the British period, the image of the Goddess was shifted to a new place, now famous Kali Bari Temple. Shimla remained unnoticed during the Gurkha War. It was only in 1819 A.D. that the then Assistant Political Agent of Hill States Lt. Ross set up first British residence, a mere wood cottage. His successor Lt. Charles Patt Kennedy’ erected the first pucca house in 1822, named after Lt. Kennedy as 'Kennedy House'.
SOCIO ECONOMIC PROFILE:
LITERACY: Literacy rate for the district is 79.12% (64.61% in 1991). While the literacy rate for males is 87.19%, it is 70.07% for females (51.77% in 1991). Figures for literacy rate are much higher as compared to state literacy rates. High literacy rates, especially for women, affect the utilization of health services leading to improved status of health.
ECONOMY: 12
The number of below poverty line families is 33.39%. Per capita income of the state is Rs. 33600/ and of the district is Rs.28481/ at 1993 94 to 2001 02 prices. At 2006 07 prices, the per capita income of the state is Rs. 36657/ but the figures for the district are not available.
AGRICULTURE AND HORTICULTURE:
Agriculture is the main occupation of the people. Apple cultivation is of special significance for the economic emancipation of the people living in the district. Stone fruits and citrus fruits are also grown. Crops like wheat, maize, potatoes and pulses are also grown in some parts. Some areas in the district have taken to the initiative of producing off season vegetables. Agriculture and horticulture being the major activities in the district, the use of insecticides and pesticides has increased tremendously. The number of organo phosphorus poisoning cases has increased significantly in the district.
PHYSIOGRAPHY AND CLIMATE;
The District belongs to humid sub temperate zone. The annual rainfall is about 1252 mms. Temperature ranges from sub zero to 33.3 o C. Viewing from health service delivery point of view, the terrain is difficult and rough with interlocking spurs, narrow and rugged mountains. Climatic conditions vary from very cold season extending from December to March, with snowfall in upper heights of Theog, Kumarsain, Rohru, Rampur, Jubbal and Kotkhai and Chopal, and rainy season extending from July to September. Both seasons influence accessibility to health care as well as the disease pattern. In the rest of months the climate is moderate, of course, some areas experience summer heat from May to June.
RURAL ROADS AND COMMUNICATION SYSTEM:
Total road length in the district is 4171 kms out of which 4010 is motorable. 2048 kms road is metalled and 1172 kms is kutcha. In absolute terms, road length works out to be 78.15 kms per 100 sq. kms against the state’s average of 46.64 kms. Distance from a health institution, travel time, means of transport have an effect on the utilization of services in health facilities and also affect the timely referral of emergencies. Telephone density is 74.5 per 2000 population but telecommunication revolution in the state has increased the communication network to a great extent. It has helped in quick response to disasters and emergencies. Rapid communication prevented any loss of life during flash floods in Satluj River caused by breach of Parechu Lake in Tibet in 2005.
WATER SUPPLY IN RURAL AREAS: Availability of piped and potable water supply affects the health of people. As on December 2006, the number of partially covered villages was 479 and the number of fully covered villages was 6031. None of the villages in the district remains uncovered. In addition, 938 hand pumps were functional in the district. By and large, piped water supply is ensured but quality of water is still a question mark. Water borne diseases constitute the single largest group of all diseases.
ELECTRIFICATION: 100 percent rural electrification has been achieved in the district.
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POPULATION As per Census 2001, population of the district is 722502. Rural population is 555269 and urban is 167233, which is 23.1 %. Males are 380996 and females are 341506. Sex ratio is 896. Juvenile sex ratio is 929. Density of population is 141 per sq kms. Decennial growth rate is +17. 02. (For more information about the district, please refer to Fact File at Anneure 1)
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CHAPTER 3 SITUATIONAL ANALYSIS
A. HEALTH INFRASTRUCTURE
Following health institutions are located in district Shimla:
1. Zonal Hospital DDU Shimla 1 with 150 beds (sanctioned 300) 2. Civil Hospitals 12 with 650 beds in position 3. Community Health Centres 7 4. Primary Health Centres 76 5. Sub centres 250 6. Regional ISM Hospital Shimla 1 with 50 beds 7. ISM Hospitals 2 at Rampur and Rohru 8. ISM/ Ayurvedic Health Centres 145 + 1 Unani + 1 Homeopathy = 147
Table1. Health Institutions in the District, Block wise
Sr Block Pop CHs CHCs PHCs CDs SCs AHCs Ayurv. No 2001 (ISM) Hosp. 1 Mashobra 85943 1 . 9 42 19 2 Basantpur 31425 1 5 15 9 3 Theog 77954 1 9 31 11 4 Kumarsain 40577 2 8 20 8 5 Rampur 97180 2 1 14 33 24 1 6 Jubbal 67804 1 1 11 33 22 Kotkhai 7 Chirgaon 45177 1 5 22 12 8 Rohru 57477 1 1 7 24 10 1 9 Chopal 76410 2 .. 8 27 21 10 Shimla 91859 4 9 3 19 1 Urban Total 722502 12 7 76 9 250 145 3
Zonal Hospital DDU Shimla has sanctioned bed strength of 3 00 , but it has only 150 beds in position. It provides specialized services, with commensurate diagnostic facilities. It is also providing essential and emergency services as all specialists are in position in the ZH.
Civil Hospitals : There are 12 CHs in the district. The bed strength ranges from 30 beds at CH Chopal and Junga to 200 at MGM Complex Rampur. CHs provide OPD and indoor facilities, including emergency services. CHs at Rampur and Rohru also provide specialized services.
Community Health Centres : Seven CHCs, though are housed in Govt. buildings, yet are inadequately staffed and equipped. Each CHC covers about 85, 000 population, which is nearly to the norm applied to a hilly state. Only three CHCs are having prescribed bed strength of 3 0 beds. CH Nerwa is housed in an old PHC building and has only 6 beds. Two CHCs are without Operation Theatres.
Primary Health Centres : There are 76 PHCs each covering a population of less than 2 0, 000. 15
31 PHCs are housed in Government buildings while 45 are in private or donated buildings and require new buildings. 52 PHCs do not have minimum 6 indoor beds. 66 PHCs are without vehicle. 58 PHC are without Labour Rooms and 55 are without Operation Theatres
Health Sub centres : These are 250 in number, majority covering on an average population of less than the norm of 3 000 . 137 Sub centres are in Govt buildings and 113 in private buildings. 16 are in rented buildings.132 Sub centres require major repairs. 6 sub centre, Shingla, Baldeyan, Kohbag, Chanawag, Bainsh and Kansakoti cover more than 3OOO population
Total number of beds in the district Total number of beds in the district is about 2450 which includes 750 beds for tertiary care in Medical College hospitals. 800 beds are for Secondary Health Care in 9 hospitals. About 600 beds are at primary Health Care level. 52 Primary Health Centers do not have sanctioned bed strength of six beds. There are 235 beds in private hospitals and 70 beds in ISM hospitals. Overall, there are sufficient beds in the district and conforms to the norm of one bed for 1000 population. Imbalance between secondary and primary care level needs to be corrected
Indian System of Medicines There is one Regional Ayurvedic Hospital at Shimla with 50 beds. There are two Ayurvedic Hospitals at Rampur and Rohru, with indoor facilities, with 10 beds each. In addition, there are 145 Ayurvedic Health Centres, one Unani HC and one Homeopathy HC which provide only day care curative services. Functional integration of ISM department for implementation of National Health Programmes as notified in the year 1999 by Himachal Pradesh Government has been implemented partly.
It needs to be emphasized that there is a nuisance of quacks in the district. They are popularly known as ‘Bengali Doctors’ and carry medicines in their bags. However, they provide day care and mobile services. Such practices are illegal and can cause adverse medical problems and therefore, need to be curbed through proper legislative measures.
COVERAGE BY HEALTH INSTITUTIONS:
Coverage norms for opening of Primary Health Care institutions as fixed by the Govt. of India have, by and large, been achieved as revealed by the table given below: Table 2: Coverage by Primary Health Care Institutions in the district Institution National State Number in Population* norm Norm the district Covered by each Sub centre 5,000 3000 250 3211 Primary Health 30,000 20,000 76 10564 Centre Community 1.20 Lakhs 80,000 7 114689 Health Centre *Mid Year Estimated Population (2007) is 802826
Seven CHCs in the district are unequally distributed in the blocks. Kumarsain block has 2 CHCs while 3 blocks, namely, Chopal , Mashobra, and Theog are without CHCs . However, this deficiency is made up by Civil Hospitals in these blocks. 16
Requirement of health institutions by 2012
Table 3. Estimated rural population of the district and requirement of health institutions till 2012*
Rural Population as in 2007 08 2008 09 2009 10 2010 11 2011 12 2001) (555269) Projected Population 616262 625506 634889 644412 654079 CHC 7 7 7 8 8 PHC 76 31 31 32 32 Sub centre 250 209 212 215 218 • * population estimated @ growth rate of 1.5%
Going by population norms for opening new institutions, no new institutions would be required in the district till 2012 CHCs Considering the present seven CHCs and rural population growth, there would be need for one new CHC; However, strengthening of existing health institutions will be more appropriate to meet the medical requirement. CH Nerwa, CH Junga, and CH Theog could be developed as proper FRUs in Block Chopal, Mashobra, and Theog respectively. Further strengthening of CH Rampur, Chopal, Sarahan, Jubbal and Rohru will meet the additional medical needs of the people in rural areas. PHCs Primary Health Centres are serving less population than the prescribed norms and therefore, there is no need to open any new PHC. However, existing institutions need to be relocated and strengthened in such a way so that no area is left unserved or underserved. In this regards, recommendations given by the blocks in block plans will have to be considered
Sub Centres As per population norms, there is no shortage of Sub centers .In case, MPSS scheme is launched in the state, 113 Gram Panchayats without sub centres will be covered . However, some Sub centres will have to be relocated or shifted to a suitable place, as per recommendations from the concerned block in their block plans, to provide better coverage to the area or Gram Panchayat. There are 3 sub centres in urban Shimla town. (For block plans recommendations, please refer to Annexure …)
Over concentration of health institutions
1. In Tikker block, PHC Dharada is close to PHC Pujarli 3 and 4 (within 4 kms) and CHC Tikker, is just 10 kms away from it. As such, there is no justification for this PHC.
2. In Kumarsain block, PHC Virgarh, which is located close to PHC Thanedhar, PHC Bhutti and CHC Kotgarh, covers very small area and as such could be shifted to another G. Panchayat i.e. Khaneti.
3. There are 22 Gram Panchayats in the district having more than one health institution. 17
Block wise, the number of such Panchayats is Kotkhai 1, Mashobra 2, Sunni 10, Matiana 2, Nerwa 2, Chirgaon 2, Kumarsain 1, and Nankhari 2. Detail is as under
1. In Theog block, 2 Gram Panchayats , Kelvi and Deorighat Panchayats are having two sub centres each 2. In Mashobra, 2 Gram Panchayats Chanaog and Chailli has more than one sub centres 3. In Nankhari block, 2 Gram Panchayats, Kinoo and Koot Gram Panchayats have more than one institution 4. In Sunni 10 Gram Panchayats, Domehar, Darogra, Ogli, Bagh, Karyali, Pahal, Khatnol, Himri, Dumhi and Reyog have more than one institution 5. In Nerwa, 2 Gram Panchayats, Lani Bamta and Sari have more than one institutions 6. In Chirgaon block 2 Gram Panchayats, Janglik and Kaloti have more than one institutions 7. In Kotkhai block, One Gram Panchayat Tharola has more than one institution. 8. In Kumarsain block, one Gram Panchayat Jar has more than one institution.
Gram Panchayats without any health institution
There are 39 Gram Panchayats without any health institution. Villages in these Panchayats generally remain deprived of primary health care. However, immunization services are provided by deputing the staff from nearby health institutions. There is a strong need to open health institution in these Gram Panchayats.
Gram Panchayats without health sub centre There are 113 Gram Panchayats without Health sub centers and as such are partially covered for preventive and promotive services by deputing the health staff. These Gram Panchayats also include those Panchayats which are not having any of the health institutions. For ensuring optimum health care, either Health sub centre should be opened or MPSS may be recruited in these Panchayats.
Table 4: Block wise information about Gram Panchayats and health institutions
Block GPs without sub GPs without any HI GPs with more than centre one sub centres Matiana 18 7 2 Nankhari 15 3 2 Kumarsain 7 1 1 Mashobra 20 8 1 Basant Pur 5 2 10 Nerwa 18 10 2 Tikkar 8 2 1 Chirgaon 7 1 1 Jubbal Jotkhai 15 5 1 Total 113 39 22
MANPOWER STATUS District is suffering from manpower shortage. Summary of manpower situation is given below
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Out of 250 Sub centres, only 128 are with both health workers. 30 Sub centers are vacant. 68 Sub centres have only FHW and 33 Sub centres are with only MHW.
Out of 76 PHCs, 12 are without a MO. 48 PHCs are without Pharmacists . All PHCs are without Health Educator (HE) or Block Extension Educator (BEE). 49 PHCs are without Staff Nurse. 64 PHCs are without Lab. Technicians (LT). 75 PHCs are without Male Health Supervisors (MHS) and 76 PHCs are without Female Health Supervisors (FHS). 68 PHCs are without Female Health Workers (FHW). 23 PHCs are without Class IV.
All 7 CHCs are without specialists. One CHC Tikkar is without a MO. 2 CHCs are without Pharmacists. 6 CHCs are without HE or BEE. 2 CHCs are without LT. 2 CHCs are without MHS. 4 CHCs (Tikkar, Chirgaon, Kotkhai and Nankhari) are without FHS. 4 CHCs are without FHW.
Table 5 Staff position as on April 2OO8
Sr Category Sanctioned In position Vacant posts No 1 Medical Officers 195 158 37 (19 Specialists) 2 FHWs 214 172 42 3 MHWs 211 119 92 4 Pharmacists 124 48 76 5 Staff Nurses 160 109 51 6 Lab Technicians 87 39 48 7 FHS 44 13 31 8 MHS 30 20 10
Above table shows Categories of staff which are in acute shortage. However detailed information is available in facility surveys of each institution.
BUILDINGS Facility Survey for all health institutions has revealed the following position in respect of buildings: Health Sub centres Of 250 Sub centres , 137 Sub centres are in Government buildings and 113 in private buildings. 16 Sub centres are in rented buildings.132 Sub centres need major repairs. 97 Sub centres are without water supply and 123 are without electricity. 113 Sub centres lack separate toilet facilities for patients.
Primary Health Centres 31 PHCs are housed in Government buildings while 45 are in private or donated buildings and require new buildings. 18 PHCs require major repairs. 26 PHCs are without water supply and 21 are without electricity. 58 PHC are without Labour Rooms 19 and 55 are without Operation Theatres. 41 PHCs are without separate toilets for patients. 52 PHCs do not have minimum 6 indoor beds. 66 PHCs are without vehicle.
Community Health Centres All 7 CHCs are in Government buildings but all require repairs. 4 CHCs do not have 30 bed capacity. All CHC are provided with water supply, electricity and Labour Rooms. 2 CHCs are without Operation Theatres. All have separate toilets for patients, bio medical waste management system, and Laboratories. FRUs also do not have sufficient accommodation. For example CH Nerwa has only 6 beds.
(PLEASE REFER TO FACILITY SURVEY AT ANNEXURE 2)
Utilization of Institutions
Table 6: Number of Out door Patients Per day, District Shimla 2007*
Average No Of Health Name of Health Institution OPD/day Institutions
≤ 10 23 PHC Kharan, Dhargaura, Kuthara, Katlaha, Dharara, Chabba, Ghaini , Balsan, Ghund, Mahori, Tharoch, Jinnha, Giltari, Gurna, Barthata, Garaug, Himari, Gumma, Malaindi, Deudi, Pandoa, Pujarli III, Mandal
11 25 42 PHC Deothi, Bahali, Gopalpur, Naraingarh, Belupul, Samej, Lower Koti, Summerkot, Pujarli IV, CHC Tikker, Ko tighat, Shamathla, Veergarh, Bhutti, Jalog, Naldhera, Dharampur, Chhaila, Balag, Bani, Maraog, Kholighat, Tikkari, Sarain, Kalbog, Saraswati Nagar, Devgarh, Mandhol, Badiara, Goshali, Kwar, Jangla, Kufri, Koti, Annadel, Ghanahatti, Jatol, Gumma, CD Dhar Phagli, Jakhu, High Court, ESI Shogi (Rippon),
26 50 13 CHC Nankhari, PHC Ghanvi, Lalsa, Taklech, Narkanda, Baragaon, Thanedhar, Matiana, Dharech, Kupvi, Kiari, Dhami, CD Vidhan Sabha 51 75 12 CH Junga, Sarahan, Choppal, CHC Chirgaon, Kotgarh, Seoni, PHC Mashobra, Shoghi, Jeori, CD Chotta Shimla, Kassumpti, UTC Boileauganj 76 100 3 CH Nerwa, CHC Kotkhai, CHC Kumarsain, 101 150 4 CH Theog, CH Jubbal, CD Sanjauli, HP Sectt. 345 396 2 CH Rohru, DDU Shimla Maximum 1 MGMSC Rampur (403) 3 Institutions: PHC Kungalbalti, Rewalpul and Larru have nil OPD *Source Annual General Administrative Report
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Table 7 : Number of Indoor Admissions, District Shimla 2OO7*
Yearly admission No Of Health Name of Health Institution Institutions <50 2 PHC Jeori, Bahali
51 100 2 PHC Balag, Kholighat
101 150 1 PHC Baragaon
150 200
201 300 3 PHC Chhaila, Matiana, Kiari,
301 800 3 CHC Chirgaon, PHC Mashobra, Dhami
800 2000 4 CH Sarahan, CHC Sunni, Kotgarh, Kumarsain, 2001 4000 4 CH Theog, Nerwa, CHC Nankhari, Kotkhai, (6) Institutions: CH Chopal (4966), CH Junga (5720), CH Jubbal (6966), CH Rohru (30520), MGMSC Rampur (46040), DDU Shimla (53052) Rest of the Health Institutions are not providing indoor services *Source Annual General Administrative Report
Out of 76 PHCs, only 1O PHCs provide indoor facilities. CHC Tikker has no indoor facility
Table 8 : Top ten diseases, District Shimla 2OO7 *
Diseases Number Respiratory Diseases 216808 Injury 56470 Eye Diseases 55888 Diarrhoeal diseases 50939 Worm Infestation 17728 Anemia 13575 Otitis media 6181 Pneumonia 5141 Typhoid 1775 Tuberculosis 1176 *Source Annual General Administrative Report Above report gives an idea of morbidity pattern or burden of diseases in the district. Respiratory diseases are most common. Trauma is laced at second position. Communicable diseases like Diarrhoea, Tyhoid, and worms are indicative of water borne diseases. 21
LOGISTICS District has a problem of stores and logistics. There is no warehouse in the district, and drugs, equipments, supplies are stored in different rooms scattered all over the hospital buildings. There is inadequate accommodation in CMOs office and store facility at block level is also lacking. However, there is a sufficient space for addition of a warehouse in blocks.
Available Health Services:
Table 9. AVAILABILITY OF VARIOUS SERVICES IN DISTRICT SHIMLA
Sr Services ZH CHs CHCs PHC No 1 Medicine + +2 .. .. 2 Surgery + +2 .. .. 3 OBG + +3 .. .. 4 Pediatrics + +2 .. .. 5 Anesthesia + +2* .. .. 6 24 hour Emergency + + + .. Services 7 24 hour delivery + + + 4 + 9** services 8 Emergency Obst. Care + +3 .. .. 9 Emergency neo natal + +2 .. .. care 1O Emergency care of sick + + + .. child 11 Full range of FP + +3 .. .. services, incl Laparoscopic services 12 Safe abortion services + +3 .. .. 12 Treatment of RTIs and + + + +*** STDs 13 Blood Bank or storage + +2 .. .. facility 14 Essential Laboratory + + + +35 services 15 Referral Transport + + + +1O 16 Maternal Care services + + + …
* Short course Anasthetist ** Only 6 out of 12 PHCs are 24 x 7 hours functional *** Syndromic case management
VULNERABLE POPULATION IN THE DISTRICT 22
Given below is the detail of vulnerable population and areas in the district:
1. Migrant labour Nepali labour is present in almost throughout the district, working in orchards and potato fields. There are also migrants from Bihar and UP who are mostly engaged in various Hydroelectric Projects and other construction activities. They usually live in temporary hutments and unhygienic conditions. They are more vulnerable to various health problems like TB, leprosy, RTI/STIs, diarrhea, ARIs, skin diseases, malnutrition etc. The local population also can not remain unaffected by the presence of migrants in the areas. Being socioeconomically poor, health services are not easily accessible to them.
2. Remote and inaccessible areas with difficult terrain District has some remote and inaccessible areas with difficult terrain particularly in following blocks:
1. Nankhari : Kashapath and 15/20 area with approximately 8000 population 2. Kumarsain: Jadoon Panchayat with 1200 population not connected with road. 3. Mashobra: Maliana, Galot, Charun, Dharun Kotla, Okhru , Dargi, Chanaog, Nehra, Shatlai, Dublu, Piran tarai, Thund, Naul koti and Bharandi Panchayats with approximately 9000 population 4. Basant pur: Darogra, Keyaloo, and Himri Panchayats having 6000 Population 5. Nerwa: Dhar Chandana, Bhot, Kattaunth, Guoy, Bohar, Telar Panchayats 6. Tikker: Deorighat, Tutu pani and Shalan Panchayats 7. Chirgaon: Rohal, Janglik, Deudi, Shiladesh Panchayats and area of Dodra Kwar .
Dodra Kwar sub division is a land locked area of the district. It is still not connected with roads and one has to walk for about 40 kms through Uttarakhand to reach PHC Kwar. The population (appx.5661) of the area, residing in two Gram Panchayats, is served by one PHC with 10 beds at Kwar, 3 sub centres and three AHCs at Dodra, Ziskun and Pujarli. Helicopter services are provided for shifting medical emergencies as and when required.
3. Snow bound areas Some areas in Jubbal Kotkhai block i.e. Gram Panchayats Baghi, Kalbog, Deori Khaneti, area from Palchhan to Sanapa remain snow covered for two to three months. Similarly some areas in Nankhari, Chopal and Theog blocks also remain snow covered for a few weeks.
4. Hydro electric projects
Andhra and Gumma Projects in Chirgaon, NJPC Projects at Jeori, Jakhri and Bayal in Nankhari block employ labour from outside the district and State. Migrants in these projects form part of the vulnerable population.
5. Tourist resorts
Places in the district like Kufri, Naldehra, Narkanda, Sarahan and Tatapani are hot spots for tourist activities. While Tourism is one of the pillars of State’s economy, at the same time it also exposes the local population to various health problems like, RTI/STI, HIV/AIDS, TB, ARIs etc. and environmental pollution.
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6. Endemic Focus for Plague District Shimla has an endemic focus for plague. The plague belt extends from Kharapathar and Mural Forest Range in Jubbal Kotkhai block to Tangnu village in Chirgaon block. Some cases were reported for the first time in seventies and later in nineties. Some deaths also occurred. However, during the second outbreak, due to vigilance on the part of doctors in Civil Hospital Rohru, preventive measures were taken well in time and no time was wasted in diagnosing the outbreak. Now a Plague Surveillance Unit has been set up in CH Rohru which conducts surveillance activities in this belt.
7.Focus for Cutaneous Leishmaniasis Cutaneous Leishmaniasis is a vector borne locally endemic disease occurring in Rampur, Kumarsain and Sunni blocks along side the river Satluj
TRAINING FACILITIES
District has two training schools for pre service training of Male Health Workers at Mashobra and Staff Nurses Training School at Rampur. These schools are understaffed. In service trainings are conducted by the in house faculty from local hospital and District Programme Officers. No training has been conducted at Mashobra since 2002. Staff nurses training is going on at Rampur. This is the first batch undergoing training in this school.
IEC / BCC INFRASTRUCTURE
IEC structure is inadequate in the district. There is no MEIO or Dy. MEIO in CMO office. However, one BCC Coordinator has been appointed under RCH Programme. There are only two Health Educators in the district. Some IEC activities are carried out by health staff under state guidelines but there is no evidence of any communication strategy or IEC plan of action in the district. Major focus is on HIV/ AIDS and Leprosy.
205 Mahila Swasthya Sanghs, are functional in the district. Last year Rs. 2,46, 000 were received from DHS. Funds have been disbursed to BMOs. Meetings were held. However HWs resent delayed release of funds for conducting meetings. Shortage of budget is a problem.
B. PRIVATE HEALTH FACILITIES Four private hospitals in Shimla town provide curative care. These are: 1. Sanatorium Hospital with 60 beds, 2. Indus Hospital with 100 beds, 3. Tara Hospital with 20 beds, and 4. Shiriram Hospital with 25 beds. In addition, there are a large number of day care clinics in the town. Diagnostic clinics have been established in different parts of town.
A Number of private clinics have come up in the interior of the district too. There are clinics or nursing homes in sub divisional towns of Theog, Rampur, Rohru and Chopal. Chemist’s shops exist even in small towns. Number of beds in private clinics in these towns is 22. Total beds in private sector are around 235.
ROLE OF INDIAN SYSTEM OF MEDICINES (ISM)
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There is a 50 bedded Regional Ayurvedic Hospital in Shimla. In addition, there are two Ayurvedic Hospitals at Rampur and Rohru with 10 beds each. Total bed strength is 70. The day care facilities are provided by 145 Ayurvedic Health Centres, one Unani Dispensary and one Homeopathic Dispensary. ISM institutions in addition to curative services provide some preventive services also. Under the reform process, functional integration with mainstream Allopathic Department has taken place and accordingly ISM institutions take part in National Health Programmes like RCH, TB, HIV / AIDS, Malaria, IDSP, Blindness Control, School Health etc. Thus ISM system contributes to Primary Health Care significantly.
C. Role of ICDS
There are 1987 Anganwadis (AWCs) in the district. 1951 Anganwadi Workers (AWWs) and 1951 helpers are engaged in providing nutritional services. One DPO, 10 CDPOs, and 3 ACDPOs and 88 Supervisors are in position. In addition to nutritional services, AWCs are also providing treatment for minor ailments to beneficiaries. There is a good coordination between the Health and ICDS Deptt. Sector level meetings between health staff and ICDS are being held regularly .
Beneficiaries of ICDS scheme in District Shimla during the year 2007 08
The number of beneficiaries includes 5329 pregnant women, 5779 lactating mothers, and 29454 children in the age group of 6 months to 3 years and 30319 children in the age group of 3 years and above.
Prevalence of Malnutrition The number of children weighed were 37937, out of which 8821 had Grade 1 malnutrition, 1243 had Grade 2, 13 had Grade 3 and 3 had Grade 4 malnutrition. It indicates that approximately 25 % of children are suffering from malnutrition in the district. ICDS Project authorities assert that malnutrition is declining in the district. However, NFHS Survey figures for the state reveal a different story.
Balika Smridhi Yojna
ICDS projects are also implementing Balika Smridhi Yojna, in which girls born after 15 august 1997 are provided scholarships at the rate of Rs.3 00 , 5 00 , 7 00 , 800 , 1 000 per year and the same is deposited in post office or bank. 3583 beneficiaries have been covered since 2000 01 onwards.
Kishori Shakti Yojna IRDP adolescents in the age group of 11 18 years are provided supplementary nutrition and IFA tablets. Last year, out of 47786 registered girls, 124O9 were provided supplementary nutrition and all were provided IFA tablets.
There is a significant prevalence of anaemia among the adolescents in the district. Out of 16732 girls tested, 3953 had less than 10 gm Hb (23.6%).
D. Panchayti Raj Institutions
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There are 363 Gram Panchayats in 2520 inhabited villages, 9 Block Development Committees and One Zila Parishad. There are approximately 3630 members at Gram Panchayat level.
E. NGOs and CBOs A number of Non Government Organizations participating in health care are present in the district. While most of the NGOs are field level small NGOs and cover few villages or Gram Panchayats, some of them are well established and provide a range of services like curative, preventive and promotive. The main NGOs working in the district are as follows :
1. Himachal Pradesh Voluntary Health Association Shimla (HPVHA) HP VHA, a state level federation of voluntary organizations, one of the biggest NGO in the district, is engaged in health and development activities. Being a Mother NGO under RCH programme, it not only implements RCH projects but also supports small NGOs in Mandi and Bilaspur districts. In addition, it is involved in ISM, prevention and control of HIV / AIDS / STDs, disability, child health and rights, capacity building of NGOs, advocacy and information dissemination. HPVHA is a member of various state and district level Government Committees.
2. SNS Foundation at Parwanoo SNS Foundation is the Mother NGO for the district. It supports smaller NGOs in RCH programme in district Shimla namely Gramodyog Workers Welfare Association (GWWA) covering Nankahari and Kumarsain blocks, Manav Kalyan Sewa Samiti (MKSS) covering block Nerwa, SAHYOG covering Matiana block and Parivartan covering Chirgaon block.
3. Himachal Gyan Vigyan Samiti Shimla (HGVS) HGVS is a state level organization which works on various issues like literacy campaign, social issues like dowry, declining sex ratio, agriculture, etc.
4. Institutions for Integrated Rural Development (IIRD) IIRD, located in village Shanan, near Shimla, works in health and other social sectors. Community participation is their main focus. 5. Lok Kalyan Mandal, Theog 6. SAHYOG, Theog 7. Maharana Pratap Jan Kalyan Sansthan, Jubbal 8. USHA, Shimla 9. Association for Social Health in India, (ASHI) Shimla 10. YMCA, Shimla 11. Gramodyog Workers Welfare Association, Theog 12. Manav Kalyan Sewa Samiti (MKSS), Chopal 13. Parivartan, Chirgaon 14. Sewahar, Shimla
Status of some Health Indicators While important health indicators are not available for the district, DLHS report for the year 2004 provides very useful information, which is given as below:
Health Indicators for District Shimla (DLHS 2004)
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Sr. No Indicators District HP India 1. Mean age at marriage for girls(ys) 22.3 21.7 19.5 2. Girls married before legal age 18 years (%) 3.8 2.9 28 3. Knowledge of any modern FP methods (%) 78.6 80.4 49.2 4. Current use of any modern FP methods 76.7 65.4 45.7 5. Female Sterilization 51.0 41.1 34.3 6. Male Sterilization 3.4 5.3 0.9 7. IUD 3.4 2.0 1.9 8. Oral Pills 7.0 3.8 3.5 9. Condoms 11.9 12.9 4.8 10. Unmet Need Limiting 5.2 8.4 12.7 11. Unmet Need Spacing 3.5 3.4 8.5 12. Unmet Need Total 8.7 11.8 21.1 13. No antenatal check up 12.6 8.7 26.5 14. Who had no TT injection during pregnancy 11.1 8.1 19.2 15. Full ANC 71.6 68.0 50.1 16. Institutional Delivery (Govt./ Pvt.) 62.5 45.1 40.5 17. Safe Delivery 65.2 51.4 47.6 18. Children 12 35 months Fully Immunized 84.1 79.4 47.6 19. Children received ORS during Diarrhoea 59.1 NA NA 20. Mothers aware about danger signs of Pneumonia 15.5 27.3 41.2 21. Women aware about RTI/STIs 21.2 37.2 44.2 22. Women aware about HIV/AIDS 76.3 79.0 53.6 23. Women visited by ANM/Health worker 2.4 4.6 10.0 24. Women who had delivery complications 24.83 NA NA 25. Women who had post delivery complications 18.98 NA NA 26. Women reported any symptom of RTI/STIs 23.8 31.0 32.9 27. Women with Birth Order 3+ 17.8 24.4 42.0 28. % of mother who squeezed out the first breast milk 43.05 NA NA 29. Institutional deliveries (Private) 2.61 NA NA
As per DLHS 2004, IMR estimated for the district stands at 18.4 per 1000 live births. Neo natal mortality rate is 8.4 per thousand live births and post neonatal mortality rate is 10.1 CDR is 3.84 per 1000 population. TFR is 1.369.CBR is 12.78 per 1000 population.
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CHAPTER 4. PLANNING PROCESS
The State has adopted the following planning process:
1. Preparation of broad framework of planning based on assessment of current situation, resources, NRHM priorities; drafting outline of block health plans; disseminating these to Block health authorities, PRIs and block level NGOs; collection of secondary data
2. Consultative process, involving discussion on key block planning issues with a few groups of selected village stakeholders such as Panchayat heads, HWs, and CBO representatives in each block, to get community level feedback about major local priorities and
3. Consultative process, involving discussion of draft block plans with Block Health Authorities, PRI representatives and block level NGOs.
4. Consolidation of block and district health plans based on 1, 2, and 3;
5. Technical appraisal of the Draft District Plan by District Plan Appraisal Team of the State Core Team for checking quality, standards, norms etc and taking corrective actions by the District Planning Committee.
6. Presentation of the proposed District Health Plan to the District Health Mission for final approval.
7. Submission of District Plans to State Government 28
CHAPTER 5. FOCUS GROUP DISCUSSION SUMMARY , DISTRICT SHIMLA
FGD 1. MATERNAL AND CHILD HEALTH CARE AND INSTITUTIONAL DELIVERIES Justification Preventive and promotive health care services are provided through a network of health institutions to improve the health status of mothers and children. Some cases requiring specialized care are taken care of by hospitals. However, the impact of the programme remains poor as indicated by high MMR and IMR.
Objective of the Programme To enhance the utilization of MCH services by all women.
Objective of FGD To assess the understanding of women about the services and reasons for their low utilization. Respondents Women having reproductive experience
Responses 1. To have deliveries in the government hospitals is a costly affair. It costs around Rs.2000/ 2. Sometimes a S/C refers an emergency delivery case to the hospitals in Shimla or elsewhere. The hospitals do not accept such references. It should be done away with. 3. Generally ‘approach’ is required for getting admission in KNH. 4. Ambulance charges for all institutional deliveries should be reimbursed. In hospitals, more medicines are prescribed during delivery whereas far less is consumed. This should be checked. 5. Midwives are really helpful in post natal care. They do the massaging and inform the mother about the use of ‘gaachi’. 6. JSY money is not given prior to the delivery. 7. Carrying woman to the main road from the village is a problem. Men are available to carry on payment but it is a costly affair. 8. There are areas where cowshed for giving birth to children is considered pious and still being used as ‘delivery place’. 9. Respondents agreed to make small payments (up to Rs. 4000/ ) to private doctors coming to the nearest hospitals for conducting deliveries. 10. Many deliveries are conducted in private hospitals in Block Kotkhai. 11. Behaviour of staff in Government hospitals is unpleasant. 12. Elders have the say to where the child will be delivered. 13. In CHC Chirgaon, experience is that Class IV employees have delivered the babies. The doctors and nurses had remained away from the labour rooms. Suggestions
1. JSY benefits may be extended to all those who want to have deliveries in Government hospitals. Well off go to private hospitals. 2. A settled hierarchy on references of delivery cases has to be established. 3. The entire health system has to be built on equity, quality and integrity. 4. Institutional deliveries can increase if actual payment made on carrying a pregnant woman to Government hospital is reimbursed to all. This payment should include the carriage of the pregnant woman from the village to the main road. 5. Local dais should be given training in conducting safe deliveries. 6. The residue medicines, after delivery, should be returned to the patient so that she does not carry 29
the impression that there is mismanagement of medicines in the hospitals. 7. The importance of antenatal and postnatal check ups needs to be emphasized during group meetings with mothers. 8. JSY benefits have undergone many changes probably to satisfy the auditors and accountants. Felt need is that money under it should be given prior to the birth of a child. 9. PPP may be exploited as the beneficiary also agrees to be a partner. 10. Those private hospitals that maintain the set standard be accredited for the benefits of JSY. 11. Behaviour Change Workshops for health staff are required. 12. Trained staff should be posted in hospitals. 13. Ambulances should be provided to all CHC/PHCs.
FGD 2. Low level of Oral Rehydration Therapy , Delayed Health Care seeking behaviour in ARI and in newborns
Justification Infant Mortality Rate for the state of HP remains static for the last few years. Neonatal mortality contributes more than 60% to IMR. A major chunk of deliveries take place at homes through untrained attendants, thereby denying the medical services required to deal with the risks a new born faces. This scenario is presented by various reports and studies. There is a low acceptance of ORT, delayed health care seeking behavior for children suffering from ARIs and increased risk to new born during neonatal period. Objective of the programme To bring down IMR to 3 0 per 1 000 live births by the year 2 012, by providing universal immunization, timely ORT and ARI treatment to all infants, by providing essential newborn care and ensuring emergency neonatal services, and by improving institutional deliveries to 1 00 %. Objective of the FGD is to ascertain the awareness and beliefs, issues, reasons, barriers etc responsible for the current scenario of health care seeking behaviour about neonatal and infant care.
Respondents Women having small children
Responses Women know about the diseases of the newborn but they do use home remedy in the beginning. Dahi Pudina (curd mint) and salt sugar solutions are given. ‘Kachoor’ is also given to the child. Steam inhalation is given to improve breathing in ARI. There is, therefore, some delay in taking the child to hospital or doctor. Immunization for infants is universal. Use of colostrum is very well understood. Though ORS is given, yet respondents wanted to have more knowledge about it. All knew about the usefulness of taking boiled water, still the tap water, as it is, is consumed. Mothers feel that it causes tonsillitis in children. Certain mothers have toxins in their breast milk called ‘Moch’ in the area and if such mother feeds her child with breast milk, the child dies. The myth is that such mothers go to Pandit and he cures her with ‘mantras’ and then she can give milk to the child. The main reason for delay in health care is shortage of money. Knowledge of neo natal care is poor.
Suggestions 1. Neo natal care is the area where much has to be done in the Block. Special awareness camps should be organized. 30
2. There are certain myths associated with breastfeeding. To explain the truth, group meetings on breast feeding are required to be arranged for mothers. 3. Self Help Groups be encouraged so that women have money of their own and delayed health care is checked because respondents have complained about shortage of money. 4. ORS is given but more knowledge about it is required. The TBAs, because home delivery is common, should be given special training on the use of ORS.
FGD 3. LOW ACCEPTANCE OF SPACING METHODS Justification Various reports and studies reveal that there is a low acceptance of spacing methods along with some unmet needs for them. This situation also contributes to maternal and child morbidity and mortality as proper interval is not maintained between births. Objective of the programme is to improve the acceptance of these methods since these are user friendly and easily available. Objective of the FGD is to ascertain the reasons, choices, preferences, barriers etc responsible for the current situation of low acceptance of spacing methods of contraception, which need to be addressed under NRHM initiatives. Respondents Eligible couples, two groups, Husbands and Wives Responses The points for availability of condoms have to be enhanced. Condoms among men and Oral Pills among women are the most popular spacing methods. Use of Copper T brings all sorts of miseries to the health of the user. There is a belief among the people that if the gap between two children is longer then the woman would not conceive again. Use of condom lessens the interest of men and often it gets torn off. Condoms are available in plenty in Health Institutions but are not used by the public. Elders, especially, mothers –in law have their say in making the young couple adopt a particular form of spacing methods. Tubectomy is the traditionally accepted form of FP but NSV can become popular, as it is catching the imagination of the public, if its proper IEC is done now. A problem arises in small villages – all are related to each other and if a young lady is working in S/C or AW, people feel shy of going to her and asking for condom. Offices of the Panchayats can be the alternatives in such cases. In certain areas, one child norm for the family is also coming up. Nirodh has problems before use (where to keep it?), during use (it gets torn off) and after use (where to throw it?). Character of women is at stake if she gets pregnant after vasectomy for whatever reasons, so females prefer their operation.
Suggestions 1. Condoms should be available at Panchayats, with Mahila Mandals and AWCs. 2. Proper skill based training has to be given to FHWs/FHSs in inserting Copper T so that there is no sufferance to the user. 3. Quality of condoms provided by the Health Department is not good and that restricts its use. Better quality condoms should be provided. 4. There is need of IEC for the elders in spacing methods because the young couples are under their influence. 5. NSV can increase if proper IEC is done. The myth attached to Vasectomy that it affects the genitals of man and that it debars a man from doing hard work in the fields or roads has to be removed. 6. One of the suggestions was that spacing injectables (as used in Nepal) be introduced in this district. 31
FGD 4. NUTRITION AMONG MOTHERS AND CHILDREN
Justification
Malnutrition is rampant among the pregnant women, women in the reproductive age group and children. A good number of newborns are underweight i.e. less than 2500 Grams. This status affects IMR and MMR in the state.
Objective of the programme To improve the maternal and child survival through better nutrition practices and services.
Objective of FGD To ascertain beliefs, attitudes, customs and dietary practices prevalent in the rural areas and to identify deficiencies in the delivery of services aimed at improving nutritional status of women and children Respondents Women having reproductive experience Responses 1. Elders fix the menu of a pregnant woman in the village and often cook food for them in iron utensils. It is believed that iron vessels pass on iron contents to the food. 2. Women lack knowledge about the quantity and quality of food to be taken during pregnancy and lactation period. 3. Generally they ask women to avoid taking IFA tablets, tonics etc and concentrate on home cooked food. 4. Poverty is widespread in certain areas and often it is difficult to get two square meals. How can nutritious food be given to the woman who is to deliver a child? 5. In well to do houses, Khinda Ghee, laddus made of Panchmewa and Ajwain Pani is given. 6. It is a belief that sweet increases the quantity of milk in a new mother and also cures of the wind in the stomach, so ‘Khira’, wheat flour cooked in milk, is given. 7. ‘Bari’ wheat flour cooked in ghee, is the first diet that is given to a mother who has just delivered. 8. Faith on Pandits is there and they decide on the basis of ‘lagna’ when the weaning of the child would start and when a newborn be taken out. 9. The myth that a woman cannot take milk and these are men and children who can take milk is there in Chirgaon Block. 10. The children are kept hungry at homes because they get food to eat from the AWCs. 11. Mothers do not know the disadvantages of bottle feeding. 12. In some places mother’s milk and water are given to the child side by side. Only mother’s milk is not considered beneficial. 13. Women have poor knowledge about the IFA tablets.
Suggestions 1. Elders in the families should be educated to the extent that they should not object to ante natal check ups and the tonics, vitamins prescribed by the doctors during pregnancy. 2. Women should be educated about the requirement of additional nutritious food during pregnancy and lactation. 3. Husbands should also be educated about the dietary needs of pregnant and lactating women. 4. Health workers should give full information about IFA through interpersonal communication. They should also explain disadvantages of bottle feeding. 32
5. AWWs should educate women in groups on various aspects of nutrition. 6. IEC activities should focus on various myths prevalent in the community.
FGD 5. Community Perce ption about Tuberculosis, RTIs/STIs, and Diarrhoea Justification Three above diseases are most common the people suffer from as is evident from morbidity and mortality data. Interventions carried out to control these diseases bring out mixed results. TB remains a major killer in the state. Delayed health care seeking behavior is quite common.
Objective of the programme
To reduce the prevalence and incidence of these health problems by promoting health care seeking behavior and availability of health services.
Objective of the FGD FGD brings out the perceptions of community about the diseases. Respondents M ixed group of men and women
Tuberculosis 1. A patient is treated for 10 to 12 days at home and then taken to hospital. 2. Knowledge about the TB is superfluous. 3. DOTS medicines should be available at the nearest place, AW or S/C. 4. TB has been a problem in Matiana Block and deaths due to TB are in the knowledge of the respondents. 5. TB patients are isolated in some of the villages. Utensils of the patients are kept separately. 6. More awareness camps are required on TB. 7. TB is more prevalent in areas where there is poverty.
RTI / STIs 1. Husbands do not take STIs medicines even when the doctor prescribes it for women. 2. Domestic treatment always precedes regular treatment in hospitals. 3. Multi partner sex among a few cannot be ruled out. 4. IEC needs for RTI/STI. 5. Leucorrhea is a common symptom among women and usually it is ignored. 6. It is easier to talk to and express themselves to Lady Doctors or MPW (F) though women hesitate less in talking to males about their diseases. 7. Doctors do not pay heed to the patients’ woes especially in Theog and Matiana hospitals. 8. No privacy in hospitals. 9. Apply toothpaste in the vagina to check leucorrhea (‘garmi ki bimari’). 10. Polyandry is practiced in Nerwa Block. 11. Women do Pranayam to have benefits for various diseases. 12. STI is kept as a secret and that is also one of the reasons for delayed health care seeking behaviour. 13. More awareness about HIV/AIDS than RTI/STIs. 14. Women also use herbs for treating RTI/STI. 15. Husbands start suspecting the wives if they suffer from RTIs/STIs. 33
Diarrhoea 1. Respondents had knowledge about taking water after boiling it but, in practice, they do not follow it. 2. Regular treatment from the HI is followed only after domestic treatment has failed. 3. Diarrhea is common during rainy seasons. 4. ORS / Jeevan Rakshak Ghol is given whenever there is an attack of diarrhea. 5. ORS packets are not available during odd hours in the village. 6. Mint water and sugar salt solution are given freely. 7. Seriousness of a child patient is there when its ‘talu’ drops and then people take the child to the hospital.
Suggestions 1. IEC should focus on seeking early health check up and complete treatment. Cover all the prevalent myths. 2. The number of DOTS providers should be increased and located at nearest place so that old and infirm walk the distances easily for taking medicines. 3. Elimination of poverty can reduce TB. Income generation programmes should be effectively implemented. 4. IEC should also focus on partner treatment, especially husbands, in case of RTIs/STIs treatment. 5. Posting of lady doctors in areas where RTIs/STDs are rampant.
6. Prior to the rainy season, awareness camps on treatment of diarrhea and improved sanitation should be arranged.
7. ORS packets should be nade available in AWCs, with Mahila Mandals and PRIs.
8. Service providers need to be trained in management of above diseases.
FGD 6. HEALTH CARE SEEKING BEHAVIOUR IN RURAL AREAS
Justification The infrastructure and human resource available in the state is better than the national average but shortage of service providers is felt. The data from a good number of health institutions (CHCs, PHCs) reveals low utilization of services.
Objective of the FGD To elicit information, opinions, views, satisfaction of services, availability of workers, etc in rural areas.
Respondents Mixed group of men, women and adolescents
Responses 1. Doctors should visit S/C once a week. 2. The behaviour of the staff in Government Health Institutions is awful. 3. Costly medicines beyond the purchasing power of the patients are generally prescribed. 4. Behaviour of the nurses has been found wanting. 34
5. There is no privacy in Government Hospitals. 6. Sub centres are at far off places. The staff there is not competent to give injections to the patients. 7. IRDP families should get free medicines. 8. To have knowledge about donating eyes has come from Block Mashobra. 9. The hospitals should be neat and clean. 10. In Theog and Kamla Nehru Hospital Shimla, urban patients are better attended to. 11. There were divided opinions about the control of Panchayats over S/Cs. 12. Well equipped S/Cs attending to all basic health problems is the expectation of the respondents. 13. Money has to be taken on loan for getting the patients treated. 14. There is no arrangement of informing the higher ups if there is a domestic casualty in the villages. 15. Hospital toilets should be clean. 16. Security arrangements for HIs should be there. 17. There is no check on Bangali doctors. 18. The PHCs are locked at nights. There is no residence for the doctors. 19. Faith on deities is there and the patient goes to the hospital when the deity says so. 20. In Kumarsain Block, Parchi fee is being charged. 21. Long dates are given for x rays and patient’s condition gets deteriorated during that period.
Suggestions 1. A schedule be designed as to when and how the doctors would visit the S/Cs. 2. Behaviour Change Workshops are required for service providers. 3. The accepted Drug Policy requires medicine to be prescribed according to their generic names. Medicines would be much cheaper that way. The Drug Policy needs to be effectively implemented. 4. It is the privilege of a patient to discuss his illness in privacy. If space is the hindrance then untied funds or funds under NRHM may be used. 5. There is a felt need for S/Cs to be at central places. The staff needs to be trained in giving injections. 6. All treatments to IRDP families are free. Possibilities of providing them medicine from the market through RKS or untied funds may be assessed. 7. There is no dearth of funds and cleanliness of HIs can now be attended to. 8. The emphasis on equity, quality and integrity be there and partial behaviour be checked. 9. It is imperative that supervision of S/Cs be under the Panchayats while the financial and administrative control is with the Department. 10. MPWs should be oriented towards the proper functioning of S/Cs which will lessen the chances for complaining. 11. The telephone number of all HIs and personal mobile numbers of doctors should be available with the Panchayat Pradhans. 12. Security of patients in the hospital has to be ascertained. 13. A list of all quacks should be with the BMO and necessary action to check the quackery should be taken. 14. The notification regarding doing away with Parchi fee should be sent again to all the BMOs. 15. Citizen’s Charter showing the availability of various services in the HIs should be displayed at the entry to the hospital campus. 16. Residences for doctors and the key health staff should be constructed on priority to improve accessibility and availability of medical care. 35
FGD 7. ADOLESCENT RERODUCTIVE and SEXUAL HEALTH
Justification Adolescents are among the vulnerable sections of the community with regards to risk taking behavior. They have a tendency to indulge in drug abuse, alcoholism, smoking and premarital sex leading to ill effects on their health.
Objective of the programme To safeguard the adolescents from ill effects of drug, alcohol, smoking and sex.
Objective of the FGD To understand adolescents ‘perceptions about drugs, alcohol, smoking and sex and to identify any indulgence in such risky behaviors. Further, it is important to identify health care seeking behavior of adolescents.
Respondents Boys and Girls in the age group of 14 to 19 years. Responses 1. Respondents knew the benefits of good and nutritious diet that was required during this period. 2. Friends’ circle was liked and they wanted to spend time with those of their age group. 3. All problems related to ARSH are discussed in friends’ circle. 4. More and detailed information on the topic be given by the officials of the Health Department in schools. 5. Pressure of friends during wedding ceremony and other social and family get togethers lead towards getting used to intoxication. 6. School teachers and parents should be taught about ARSH. 7. Some girls indulge in pre marital sex and often give birth to children. 8. They preferred private hospitals and clinics for sharing their health related problems. 9. Bidi smoking is a common problem. 10. An adolescent viewer of TV serials adopts easy virtues quickly and not the pious pleadings. 11. Bhang is commonly taken that boosts their appetite but not the opium. 12. Bidis and Cigerettes are sold to those below 18 in the villages. 13. Iron tablets should be made available, especially to adolescent girls, in schools. 14. If the students getting good position in a class smokes, others emulate him. 15. Gutka taking is common. 16. Private Doctors do MTPs of adolescent girls in Nerwa Block. 17. Some boys take drugs also. A pill costs Rs.1200 and a small portion of it mixed with water gives the required jolt. 18. Dirty socks boiled in water and then the water is taken – it gives a kick. 19. Smoking and taking alcohol is common. Some of the boys do indulge in sex too and do not always use condoms. Suggestions 1. The Tobacco Act should be implemented in letter and spirit. The authorized officers should include Principals and Headmasters of the schools. 2. The schools should appoint a male and a female teacher to liaison for ARSH problems with the nearest HI. 36
3. Haemoglobin test of adolescent girls in schools should be done and, if need be, IFA tablets should be given to them. 4. Adolescents indulge in substance abuse and IEC for that should be held. 5. Parent Teacher Association can be a platform from where ARSH can be checked.
FGD 8 SON PREFERENCE AND DOMESTIC VIOLENCE
Justification: Status of women in any country is one of the important indicators for its social development. In this context decreasing sex ratio and increasing discrimination against women in India is a major problem. In order to improve this challenging situation there is a need to understand and analyze the women’s perspective which will enable to assess the social status of women in the region and its effects on various development aspects, including health, of the society. This understanding would help development of appropriate strategies. Objective of the Programme: To improve the status of women and support activities of women empowerment Objective of FGD To bring out the issues and social dimensions of low social status of women in rural areas and to understand women’s perspectives to improve their status. Respondents: Married women in the age group of 20 to 30 years. Responses: 1. Son preference is undoubtedly there though girl’s opinion is considered in matters relating to her personal life. 2. There is a belief that if girl is highly educated, she would not get a match of her qualification, so she is withdrawn from an educational institution after she achieves a certain standard. 3. Elders also want to see the face of a boy in the family even if the couple has two daughters. 4. It is the moral duty of the female members to get up first in the morning and sleep last in the evening. 5. Domestic violence occurs in certain areas against elders and wives under the influence of liquor. 6. A committee under the Panchayat Pradhan should be there where the prayer of a harassed woman is heard. 7. Preference for son has yet another reason that with him a daughter in law would come to look after the household affairs. 8. A son is always sent to good school and a daughter to government school. 9. Three reasons for wife beating are: Jealousy, when husband is drunk and when she does less work than what was expected from her. 10. Girls are given tea whereas son is given milk. 11. Girls are not allowed to leave home after it is dark; there is no such restriction on boys. 12. Male child is pampered and the girl child is neglected. 13. Woman, if she speaks of her rights, is thrown out of the house. 14. If unable to bear a son, she is divorced. 15. A woman bearing a daughter is congratulated that her life was saved not that a daughter has come to their home. Suggestions: 1. It is an area where NGOs can play an important role. 2. Woman Empowerment needs to be preached and practiced. 3. Parents need to be educated on daughter’s standing and importance. 37
4. A committee should be formed at the Panchayat level to hear the grouses of the harassed women. 5. Orientation of elders towards status of girl child and importance of women is required.
FGD 9 ROLE OF PRIs
Justification: Devolution of funds, functionaries and programmes for health to PRIs has been done so that local level decisions are taken and there is greater involvement of grass root workers in all health related activities.
Objectives of the Programme: To empower local Governments to manage, control and be accountable for public health services at various levels. PARIKAS or Village Health, Water and Sanitation Committees at the Village level will be the standing committee of the Gram Panchayat providing peep into all NRHM activities at the village level and be responsible for developing village health plan. Block Panchayat Samitis will coordinate the works of various GPs and the Chairperson of Zila Parishad will play an important role in DHM, which will guide and manage all public health institutions in the district.
Objectives of the FGD: To ascertain the existing framework at the three levels, availability of funds for the health sector, including for the determinants of health and optimum utilization of funds after identifying ‘hot spots’ for convergent actions.
Repondents: Panchayati Raj elected persons 1. A remuneration may be fixed for attending the meetings of PARIKAS./ (VHWSC) 2. These bodies exist but are non functioning in most of the blocks 3. PARIKAS is not organizing Health Melas in the Panchayats. 4. Annual Health Plans be prepared for the Panchayat area. 5. All S/C should have blood testing facility; necessary equipments and the AHP should have priority for TSC and potable drinking water. 6. Cleansing of traditional water sources should be the job of PARIKAS. 7. Central Kanda Jail has increased pollution of water and surroundings, so the incidence of disease in the area has enhanced. 8. There should be provision of Health Workshop every month in the Panchayat area. 9. The composition of PARIKAS should be wide covering all the line departments, at least. 10. Disabled should get money for all illness from PARIKAS through NRHM. 11. Pradhan agreed that they would be not helpful if they are not trained in what NRHM is and also about the AHP. They simply sign the cheques presented to him/her by the MPW (F). 12. Emphasis was on cleanliness of sources of water and sanitation. Suggestions: 1. Members of PARIKAS should be trained and its composition be expanded so as to cover all the line departments responsible for the health of the people. 2. Guidelines for untied funds be modified so that a remuneration or expenditure on tea etc. be arranged for the attending members of PARIKAS meetings. 3. Training on the preparation of AHP or a module for that be arranged. 4. PARIKAS be made the primary convergence agency which tackles all the problems faced by the people due to laxity of health or other line departments. 5. Untied funds be utilized in best possible way so that the people of the area are benefited. Guidelines be prepared for it keeping in view the local conditions. 38
CHAPTER 6. GOALS and OBJECTIVES
Objectives of NRHM 1. Reduction in child and maternal mortality 2. Universal access to public services for food and nutrition, sanitation and hygiene and universal access to public health care services with emphasis on services addressing women’s and children’s health and universal immunization 3. Prevention and control of communicable and non communicable diseases, including locally endemic diseases. 4. Access to integrate comprehensive primary health care. 5. Population stabilization, gender and demographic balance. 6. Revitalize local health traditions & mainstream AYUSH. 7. Promotion of healthy life Table below depicts objectives to be achieved within one year(2008 09) and till the year 2O12.
Table. : Objectives to be achieved
Sr Objectives to be achieved Current level Level to be Level to be No DLHS 2004 attained in 2009 attained by 2011 10 12 1 Universal coverage of 71.6 % 90 % 100 % pregnant women 2 Safe deliveries 62.5% 80 % 100% Institutional deliveries 65. % 70 % 80 % 3 FRUs made functional 1 ZH + 3 CH 2 ( Nerwa and 5 Sunni ) 4 JSY coverage 886 100 % 100% beneficiaries 5 Exclusive Breast Feeding 43.5% 50 % 100% (EBF) 6 Fully immunized children 84.1% 100 % 100% 7 Vitamin A coverage 75 % 2 nd dose 80 % 100% 8 Severely malnourished 13+3 grade 3 Nil Nil children referred & 4 (ICDS data,2007 08) 9 Unmet need for Limiting 5.2 % Limiting 3 % Limiting O% contraception Spacing 3.5 % Spacing 2 % Spacing O% ..Number of Govt. Health Total 8.7 % Total 5 % Total O% Institutions providing male and female sterilization 1ZH+ 3CH 1 ZH+3 CH + 2 1ZH+3CH+5CHC services CHC ..Number of accredited nil 3 5 private institutions providing male and female sterilization 39
services Contraceptive Prevalence 49.39% 6O% 80% Rate
10 Number of institutions Nil 15 25 providing ARSH Services 11 Number of institutions 1 ZH +4 CH 1 ZH +4 CH +9 1+4+9 providing RTI /STD CHC /PHC Services 12 Performance indicators for API:0.08 API: < 1 API: <1 NVBDCP( Malaria) ABER:12.0 ABER: 15% ABER : 15% 13 Prevalence of HIV/AIDS 0.2% < 0.2% < 0.2% among Ante Natal women
14 Performance indicators for Detection Detection Rate Detection Rate RNTCP Rate:219/lac 85% 85% pop./yr Cure Rate:93% Cure Rate:95% Cure Rate:92.29% Conversion rate:96.41%
15 Mahila Panchayat Swasthya Nil 113 113 Sahayika in the district 15 RKS in the district 1+7+9 1+7+9+ 76 1+7+9+76 16 Number of health institutions HSC Nil HSC 116 HSC 75 % upgraded to IPHS PHC Nil PHC 25% PHC 5O % (HSC,PHC ,CHC) CHC Nil CHC 2 CHC 5
17 VHWSC/PARIKAS 25O 25O 25O constituted and Grants given 18 Number of HSCs Nil 25O 25O Strengthened 19 Number of PHCs Nil 12 35 Strengthened 24 x 7 2O National Blindness Control NA Blindness Blindness Programme Prevalence rate Prevalence rate < 0. 03 <0. 03 21 National Leprosy Eradication Prevalence rate Prevalence Prevalence rate Programme 0.35/10000 pop rate0.25/10000 pop 0.1/10000 pop 22 Integrated Disease Distt Lab estd No of Labs No of Labs Surveillance programme CHC Labs not upgraded upgraded up graded % of satisfactory % of satisfactory water samples water samples 23 Staff for mobile medical units Nil In position In position in place 24 Number of facilities to be Nil All All covered for facility survey 25 Number of Villages to be Nil All All covered for HH survey 40
26 District Training plan nil Plan developed Plan developed developed and implemented 27 District BCC plan developed Nil Communication Communication and implemented strategy and plan strategy and plan developed and developed and implemented implemented and evaluated 28 District Procurement and nil Warehouse Store rooms Logistics plan developed constructed in ZH added in all Shimla block headquarters 29 No. of PHCs/CHC s where Nil Depends on Govt Depends on AYUSH physicians posted policy Govt policy
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CHAPTER 7. TECHNICAL COMPONENTS
A. REPRODUCTIVE AND CHILD HEALTH (RCH II )
A 1. STRENGTHENING OF DISTRICT AND BLOCK MANAGEMENT
Situation Analysis
1. District Health Mission has been notified in the year 2005. A Cabinet Minister is the chairman. Chaiman Zila Parishad is the vice chairman. Deputy Commissioner is the Chairman of Executive Committee. DHM has met once. 2. District Health Society has been constituted under the Chairmanship of the Deputy Commissioner, thus integrating all vertical societies but due to reasons beyond control, functional integration among various vertical societies has not been achieved. 3. Behaviour Change Consultant appointed in 2OO6 and is still working. 4. Three Block project Managers, having MBA qualification, have been appointed and trained. They are based at Mashobra, Kotkhai and Kumarsain blocks. 5. Eight Block Accountants have been appointed and trained in accountancy and 1 posted at CMO office. 6. Computer Assistant under UIP strengthening scheme is vacant for want of permission from DHS.
There is a need for providing more support to the CMO office for better implementation especially in light of the increased volume of work in NRHM, monitoring and reporting especially in the areas of Maternal and Child Health, Civil works, Behaviour change and accounting right from the level of the Sub centre (suggestion for one MBA ,one CA and DEO with CMO office).
Objectives Effective management and implementation of various programmes under NRHM in the district.
Strategies 1. Strengthening the CMO’s office. 2. Strengthening the Block Management Units.
Activities 1. To appoint one District Project Manager, with MBA qualification in CMO’s office. 2. To appoint one Chartered Accountant, in CMO’s office. 3. To appoint one Data Entry Operator (DEO) at district level. 4. Regular meetings of DHM and Block health Committees.
5. To appoint Block Project Managers for all 9 blocks (currently only 3). 6. To appoint One Accountant for Sunni (Basantpur) block. 7. To form Block Health Committee (BHC) in all blocks on the pattern of DHM.
Timeline: All appointments in 2008 09; all BHCs to be constituted in 2008 09
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A 2. MATERNAL HEALTH
Situation Analysis
Ante Natal Care: In the year 2007 08, 21636 pregnant women were registered against the target of 15519, which is very high level of achievement. Out of these, 14776 received three check ups ( 66 %). This is less than the DLHS 2004 figure of 71.6% and not a good performance. While registration of antenatal cases is more than required, number of three checkups is not universal. Reasons for low number of three check ups are, lack of faith in sub centres, antenatal check up at higher level institutions, absence of follow up at their homes, and poor maintenance of records by service providers.
Iron Folic Acid: As per DLHS 2004, 46.5 % pregnant women received IFA tablets during pregnancy, while routine data for the district for the year 2007 08 reveals that 9655 women received IFA against the target of 16388, which is quite low ( 58.92%), though there is improvement over DLHS data. Possible reasons for low coverage of IFA are low acceptance due to side effects, irregular supply, poor follow up and motivation by the service providers. There is a need to provide adequate and better quality of Iron preparation, regularly to all Primary Health Care level institutions.
Detection of high risk cases 412 women were detected to be having high risk pregnancies and 399 cases were referred for complications during last year.
Tetanus Toxoid: Annual coverage for the year is 2007 08 is 15500 against the target of 16388( 94.5 %), which is good. DLHS 2004 report reveals that 11.1 % women did not receive TT injections. No case of tetanus has been reported in the district for many years.
Deliveries: As per DLHS 2004, institutional deliveries were 62.5%, out of which 60 % were conducted in government institutions and 3 % in private. 74% deliveries were safe. 26% deliveries were conducted at home by untrained dais. 24% experienced pregnancy related complications of which 72% sought treatment. 25% had delivery complications and 19% had after delivery complications and 58% sought treatment
2007 08 report reveals that 10379( 67%) women out of the target of 15519, delivered in health institutions. In addition, 105 women were delivered by trained health workers. 2438 deliveries were conducted by local dais. Above data shows that there is increasing trend towards institutional deliveries but the proportion of safe deliveries has declined. Information about deliveries being conducted by private practitioners is quite large but report is not collected from them. Out of 93 health institutions, only 22 (1 ZH + 7 CH + 5 CHC + 9 PHC) are conducting institutional deliveries in the district. Civil Hospitals at Rampur, Rohru, Theog, and Chopal are very popular with local population for conduct deliveries, while CHC and PHCs are not so popular. Many women prefer to visit KNH Hospital and DDU Hospital in Shimla for normal delivery, which costs them dearly. Out of 12, 24 x 7 PHCs, deliveries are taking place in 6 PHCs, only. Last year 670 deliveries were conducted in 24 x 7 delievry institutions.
43
Large number of deliveries are being conducted by private hospitals in Shimla but are not being reported.
FGD with women revealed that they had to go to Shimla even for normal deliveries and they had to spend a lot of money on delivery. The reasons for this are non availability of trained staff and poor facilities in institutions.
Post natal care Only 5007 women (32.3 %) had 3 post natal check ups during post natal period in the last year. It is far from satisfactory and attributed to lack of follow up by the field staff.
Referrals: 29 cases with obstetric complications were referred. 5FRUs have been notified but none is functional for want of manpower and inadequate facilities. But Civil Hospitals at Rampur, Rohru and Theog are performing emergency surgical procedures for pregnant women.
MATERNAL DEATHS District reported only 3 maternal deaths in the last year. MMR for the district is not known.
Pregnancy outcomes District reported 12542 live births and 162 still births in the last year. Order of birth was 6898 first, 4131 second and 1674 as 3 and 3+. This means that people are still having third child and not all have adopted two child norms. However, this figure could be influenced by births among migratory labour class.
MTP: 904 cases of MTPs have been reported during the last year. MTP is done only in 6 hospitals, namely DDU, MGM Rampur, CH Rohru, Nerwa, Chopal and CH Theog. Some cases with pregnancy also undergo MTP during sterilization operations which might not be reported.
Malnutrition: 1179 (11.7% ) newborns were less than 2.5 kgs weight. This is indicative of malnutrition problem among newborns. This has to be read with level of malnutrition among children being covered by ICDS Projects.
Janani Suraksha Yojana (JSY ): The JSY scheme is being implemented in the district satisfactorily. Number of beneficiaries upto 31 March 2008 is 886 and expenditure incurred is Rs 4, 46,650. The number of beneficiaries for “referral transport” is 153 and the amount utilized was, Rs. 57,314.
FGD Observation is that JSY beneficiaries present in the FGD got the money after two months and had to visit the health institution many a times. Benefit of the scheme was not understood by women.
Objectives • 100%pregnant women to consume 100 IFA tablets by 2010. • 70% Institutional deliveries by 2010 and 80% by 2012. 44
• 80% deliveries to be carried out by trained /Skilled Birth Attendants by 2010 and 100% by 2012. • 100% women to get improved postnatal care by 2012.
Strategies 1. Involving MPSS in conducting deliveries 2. Involvement of other agencies/ functionaries like ISM, AWWs, MPSS, PRIs in mobilization for institutional deliveries. 3. Micro planning for antenatal cases, detection of high risk cases and their timely referral. 4. Strengthening of facilities for emergency obstetric care in FRUs. 5. Strengthening of institutions for routine maternal care. 6. Ensuring safe deliveries in villages for disadvantaged beneficiaries through local trained dais. 7. Developing an effective IEC strategy. 8. Improving manpower status and capacity building of the staff. 9. Improving monitoring and supervision in the field.
Activities
• Appointment of Mahila Panchayat Swasthya Sahayika(MPSS) in Panchayats having no health institution. • Involvement of ISM functionaries i.e. ANMs and dais, and AWWs in mobilizing antenatal cases for institutional delivery. • Accreditation of private nursing homes for normal and high risk delivery. • Monitoring by Block Health Committee and field supervision. • Involvement of PRIs in ensuring safe deliveries by mobilizing community. • Increasing the Janani Suraksha Yojana coverage by actively identifying the beneficiaries and tracing them at regular intervals. • Intensive IEC campaign for maternal care and institutional deliveries. • Strengthening of all CHCs/ FRUs for Comprehensive Emergency Obstetric Care (CEmOC) in a phased manner in three years. • Recruitment of required health staff and training of skilled birth attendants. • Training of Traditional Birth Attendants in safe deliveries in very remote blocks of Chopal, Nankhari and Chirgaon block. • Provision of a ready made delivery kit during delivery (free of cost) to skilled birth attendants. • Collection of data about deliveries conducted in private clinics/nursing homes.
Support required 1. State government shall ensure availability of specialist manpower in CHCs. 2. Timely payment of incentives to beneficiaries of JSY. Making JSY guidelines more flexible. 3. Appointment of staff nurses in PHCs not having them. 4. Improving referral by providing ambulances to institutions. 5. Residential accommodation for staff.
Timeline
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A 3. CHILD HEALTH
Situation Analysis Infant Mortality Rate and Child Mortality Rate for the district are not known. DLHS 2004 estimated IMR for the district at 18.44 per 1000 live births. 1. Indicators
S Indicator Total DLHS 2004 No 2007 08 1 Live Births 12542 NA 2 Child Deaths (1 5 years) 21 NA 3 Still birth in the current year 162 NA 4 Low birth weight newborns (less than 2.5 kgs) 1179( 9.4%) NA 5 Complete Immunization 12 23 months age 8653 84.1%(!2 35)
6 ARI cases in last year 19677 NA 7 Deaths in the last year due to pneumonia in children 8 NA 8 Diarrhea cases in last year 8398 NA 9 Deaths in last year due to Diarrhoea in children Nil NA
2. Vaccine preventable diseases As per DLHS 2004 Survey, number of fully immunized children (age 12 35 months) is 84.1 %, 98.1 % BCG, 95.3 % DPT 3, 91.5 % OPV 3, and 91.0 % Measles. 1.9 % children did not receive immunization at all. District is one of the best performers in immunization in the state.
Annual report of the district for the year 2007 08 shows immunization coverage for BCG as 152O3(107.53%), DPT 3 and OPV 3 as 14132( 99.96%) and Measles as 14129 ( 99.94%). The number of fully immunized children is 14129 which is 98 % of the target. This shows that there is a continuous increase in coverage of children. District has achieved near universal immunization. No case of adverse reaction and no case of vaccine preventable disease was reported by the district.
3. Vitamin A Coverage In the year 2007 08, Coverage of Vitamin A administration to children was 99.94 % for first dose and 75.15 % for second dose. Achievement dropped to 58.92 % for 3 rd to 5 th doses.
4. Breastfeeding As per DLHS, 72% newborns were breastfed within 24 hours, 42% within 2 hours and 31% after two hours. 17% were breastfed within 1to 3 days. 7% were breastfed after three days and 2% were never breastfed. Exclusive Breast Feeding (EBF) for 4 months was 70% and for 6 months was only 9%. EBF requires a sustained campaign in the light of observations that breastfeeding is not popular with modern young mothers
5. ARI 46
19677 children suffered from ARI and all were treated with Cotrimoxazole. 124 children were referred for treatment. Only 8 deaths were reported. As per DLHS, 16% mothers were aware of danger signs of Pneumonia, which is one of the major killers of children and responsible for a large number of infant deaths.
6. Diarrhoea 8398 children suffering from Diarrhea were reported and all cases were treated with ORS. 23 cases were referred and no death was reported. As per DLHS, 80 % mothers were aware of diarrhea management and 70 % were aware of ORS. During the survey, 10.5 % children had diarrhea and 59% mothers gave ORS.
7. Malnutrition 1179 (11.7% ) newborns were less than 2.5 kgs weight as recorded by routine data during the year 2007 08. Among the ICDS beneficiaries, out of 37937 children weighed, 8821 had Grade 1 malnutrition, 1243 had Grade 2, 13 had Grade 3 and 3 had Grade 4 malnutrition. It indicates that approximately 25 % of children are suffering from malnutrition in the district
Infant and Child Deaths 202 infants and 21 children deaths were reported in the annual report but the cause of death has not been mentioned. Out of 202 deaths, 108 are neo natal deaths which constitute 53.5 %. This number indicates low infant mortality but authenticity of the information has to be ascertained. . Objectives 1. Reduction in IMR to 30 by 2012 2. Increased proportion of women breastfeeding exclusively for 6 months to 100% by 2012 3. 100% Complete Immunization by 2009 2010 4. Increased use of ORS in diarrhea to 100% by 2009 2010 5. Increase in the Treatment of 100% cases of Pneumonia in children by 2009 2010 6. Increase in the utilization of services to 100% by 2009 2010
Strategies 1. Improving feeding practices for the infants and children including breast feeding. 2. Promotion of health care seeking behaviour for sick children. 3. Community based management of Childhood illnesses. 4. Improving newborn care at the household level and availability of Newborn services in all CHCs & hospitals. 5. Capacity building of doctors and staff in counseling, nutrition and management of childhood diseases.
Activities 1. Education of the families for provision of proper breast feeding and weaning. 2. Education of mothers on early and exclusive breast feeding and also giving Colostrum. 3. IEC, BCC activities by MSS , AWW and ANM regarding the use of ORS and increased intake of fluids and the type of food to be given 4. Availability of ORS through ORS depots with MSS, AWW, and MPSS. 50 packets shall be provided to each AWW so that ORS is available in a village 24 hours. 5. Strengthening the neonatal services and Child care services in CHCs in a phased manner. 6. Availability of Pediatricians in CHCs, in a phased manner 47
7. Training of doctors and paramedics in management of Diarrhea, ARIs, nutrition counseling, emergency pediatric care etc.
Support required 1. Support from Govt. for availability of trained staff including Pediatricians. 2. Adequate medicines for management of childhood diseases.
Timeline
A 4. FAMILY PLANNING
Situation Analysis
1. Indicators The data from the Directorate of H & FW,HP( Health at a Glance 2007) reveals that as on March 2007, out of 133127 estimated eligible couples, 37.34% were protected by sterilization methods, 5.89% by IUDs,2.78% by OPs and 3.38% by CC. The couple protection rate is 49.39% while DLHS estimates it as 76.7%.
Indicators Coverage in 2007 08 DLHS 2004 Eligible Couple in the district 121174 Couple Protection Rate 49.39 % 76.7 % Female Sterilization operations 2917 (2798+119) Vasectomies in the year 285 Total Sterilizations 3202 Couples using temporary methods IUD 2931, OP 3207 , CC 10309
2. Performance In the year 2007 08, 2917 sterilization operations were conducted, out of which 285 were male acceptors and 2798 were female acceptors. This is a decrease over last year performance by 2.8 %. For spacing methods, 2931 IUDs were inserted, which is 8.81 % less than last years performance. There is a decrease in the coverage of oral pills by 12.06% but the condom coverage is up by 15.32%. All FHWs are inserting IUDs in sub centers but there is an inadequate follow up of beneficiaries.
As per DLHS 2004, 78.6% respondents knew about any modern FP method.51.0 % and 3.4% females and males, respectively, were covered by sterilization. Coverage through IUD, OP and CC was 3.4%, 7.0% and 11.9 % respectively. Overall, couple protection rate was 76.7%.
3. Unmet Needs Total unmet FP need was 8.7 %, 5.2 % for limiting methods and 3.5% for spacing methods.
4. Services Four institutions, DDU Hospital Shimla, MGM Rampur, CH Rohru, and CH Theog are performing sterilization operations. Teams from these hospitals conduct family planning camps in peripheral institutions. NSV is not popular in the district. 48
Objectives 1. Increase in Contraceptive Prevalence Rate to 80 % by 2012 2. Decrease in the Unmet need for modern Family Planning methods from 8.7 % to 0 % by 2012 3. Increase in the awareness levels of Emergency Contraception to 100% by 2010
Strategies 1. Decreasing the Unmet Need for Family Planning. 2. Improving availability of all spacing methods at all places, including emergency contraceptives 3. Increasing access to terminal methods of Family Planning. 4. Promotion of NSV. 5. Expanding the range of providers.
Activities 1. Wide advance publicity about the FP camps on sterilizations. 2. Organizing more number of FP camps and prepare advance annual action plan. 3. Training of GDOs in NSV and tubectomy. Each CHC and PHC will have one MO trained in NSV sterilization or tubectomy method so that each block has its own team and conducts the camps independently. 4. Equipments and supplies will be provided at CHCs and PHCs for conducting sterilization services. 5. Opening of depots for CC and OPs with AWWs, MPSS and Community Based Organizations. 6. Training of HWs, AWWs and MPSS in Spacing methods and Emergency Contraceptives. 7. Training of HWs in interpersonal communication for effective counseling and follow up of FP cases.
Support required 1. Availability of a team of master trainers and tutors. 2. Availability of training modules for NSV and IPC. 3. Adequate beds and linens for operated cases. 4. Provision of transport facility for operated cases.
Timeline 2008 to 2012
A 5. ADOLESCENTS RE PRODUCTIVE AND SEXUAL HEALTH (ARSH )
Situation Analysis ARSH Clinics are being made operational in all block headquarters. Rs. 1, 14,478 have been received and disbursed to BMOs. Counseling Rooms have been made ready in all the Block headquarters and CHs. However, Medical Officers and other staff are yet to be trained in ARSH.
Problems of adolescents have been recorded during FGDs conducted with boys and girls groups in the district and findings available in Chapter 4. Summary of main problems among adolescents are 1. Lack of awareness amongst adolescents regarding health issues. 49
2. High risk taking behaviour among male adolescents. 3. High prevalence of anemia among female adolescents as detected by ICDS projects.
In Zonal Hospital at Shimla, VCTC set up by State AIDS Control Society, now designated as ICTC, is providing counseling services on issues related to HIV / AIDS and STDs.
Objectives 1. To provide Adolescent Friendly Health Services (ARSH) at CHC /PHC level. 2. To reduce the prevalence Anemia among adolescent girls and boys. 3. To ensure counseling for high risk behavior and unsafe sex practices etc.
Strategies
1. Expanding coverage of ARSH services through health institutions and schools. 2. Generating awareness among adolescents about ARSH services. 3. Building capacity among health staff and school teachers in counseling skills 4. Coordinating with schools for health talks and ensuring referral of students.
Activities 1. Adolescent Reproductive and Sexual Health Clinics will be conducted at least once every week by the MO and Counselor to provide clinical services, nutrition advice, detection and treatment of anemia, easy and confidential access to medical termination of pregnancy, Antenatal care and advice regarding child birth, RTIs/STIs detection and treatment, HIV detection and counseling and specific problems of adolescents. 2. Opening of more counseling centers in in all PHC/AHCs. 3. Training of health staff, AMO, teachers, peer educators and NGOs in counseling of adolescents. 4. Educational activities among adolescents in villages for out of school and out of college adolescents 5. Providing detailed guidelines to health institutions regarding ARSH activities.
Support required 1. Training in ARSH for various category of trainees. 2. Providing training modules/manuals. 3. More funds for establishing counseling centers. 4. Posting of lady doctors and female staff in health institutions.
B. NEW NRHM INITIATIVES
B 1. MAHILA PANCHAYAT SWASTHYA SAHAYIKA ( MPSS )
Situation Analysis
This scheme, for which ground work had been done by the department, has been modified in place of ASHA scheme. It is decided to appoint a trained Female Health Worker in that Gram Panchayat which is without a sub centre. She shall be called as MAHILA PANCHAYAT SWASTHYA SAHAYIKA . She is to be appointed by local Gram Panchayat and she will be responsible and accountable to local Panchayat. She would be paid by the local Panchayat out of NRHM funds. 50
Out of 363 Gram Panchayats in the district, 113 Gram Panchayats are without sub centres. Hence 113 MPSS shall be appointed.
Objectives To appoint 113 MAHILA PANCHAYAT SWASTHYA SAHAYIKA (MPSS) in Gram Panchayats without Health sub centre
Strategies 1. Ensuring health care to people of those Gram Panchayats having no health institution by recruiting suitable local females. 2. Building capacity of MPSS to provide primary health care to local people.
Activities 1. Identification of Gram Panchayats without a sub centre. 2. Selecting a suitable female candidate for MPSS. 3. Contractual appointment of MPSS by local Gram Panchayat 4. Training of MPSS in providing primary health care to people. 5. Providing Untied Grants to MPSS and local Panchayats. 6. Arranging necessary accommodation for a health centre in the village.
Support required 1. Accommodation for health centre. 2. Training of MPSS. 3. Medicines, equipment and supplies to MPSS. 4. Untied grants to local Panchayat
Timeline
B 2. UNTIED GRANT FUNDS TO SUB CENTRES
Situation Analysis Grants to 250 sub centers amounting Rs 24.70 lakhs has been released, up to march 2007. Funds are being operated by PARIKAS,
FGDs conducted with PRIs revealed that there is need to train the members of PARIKAS about village health planning and utilization of untied grants for health purposes, since most of the expenditure has been incurred on infrastructure improvement only.
Objectives To provide Untied grants of Rs 10000/ each year to Sub centres ,at the disposal of the FHW and Panchayat Pradhan for local needs.
Strategies 1. Developing effective linkages with PRIs. 2. Strengthening of the Sub Centres through financial support under NRHM. 3. Utilization of funds to meet out local needs relating to health care.
Activities 51
1. Untied Funds along with guidelines will be provided to all 250 SCs, 2. Such funds will be used as per the local needs and guidelines. 3. Proper accounts will be maintained for such funds. 4. Timely submission of Utilization Certificate to MD NRHM through MO IC of PHC/ BMOs, will be ensured by the FHW concerned. 5. Training of HWs and PRIs on village health planning and accounting.
Support required 1. Timely release of funds from Mission Director NRHM. 2. Support from SHFWTC for training of HWs and PRIs on village health planning and accounting.
Timeline
B 3. Provision of Untied Funds and Annual Maintenance Grant to PHCs
Situation Analysis Rogi Kalyan Samitis (RKS) have been constituted in 43 out of 76 PHCs. Funds as untied grants and annual maintenance funds have been released to concerned BMOs. Utilization reports of the funds have not been received so far. None of the RKS has developed an annual action plan.
Objectives To provide Untied Funds of Rs.25000/ and Maintenance Grants of Rs. 50,000/ to each PHC each year.
Strategies 1. Strengthening of the PHC through financial support. 2. Utilization of funds as per guidelines by the RKS.
Activities
1. Rogi Kalyan Samitis shall be constituted and registered in remaining PHCs. Funds will be used as per the need and guidelines after the due approval of RKS. 2. Proper accounts will be maintained of such funds. 3. Timely submission of Utilization Certificate to DHS through BMOs will be ensured by the MO in Charge. 4. RKS members shall be trained in management of grant / funds.
Support required 1. Timely release of funds 2. Regular Meetings of the Rogi Kalyan Samitis. 3. Providing revised guidelines to get Minor Civil Works executed through a Pvt. Agency.
Timeline
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B 4. Provision of Untied Funds to CHCs
Situation Analysis All the 7 CHCs have constituted RKS but annual maintenance funds have not been released so far. As a result no action plans have been developed by CHCs
Objectives To provide Untied Funds of Rs. 50000/ and annual maintenance funds of Rs. One Lakh to each CHC per year.
Strategies 1. Strengthening of the CHC through financial support. 2. Utilization of funds as per guidelines by the RKS.
Activities
1. Provision of Untied funds maintenance grants and seed money each year to the CHCs, at the disposal of the Rogi Kalyan Samitis. 2. Such funds will be used as per needs and guidelines after due approval of RKS. 3. Proper accounts will be maintained of such funds. 4. Timely submission of Utilization Certificate to MD NRHM will be ensured by the BMO. 5. Training of BMOs/MOs and others in management grants/funds etc.
Support required 1. Timely release of funds 2. Regular Meetings of the Rogi Kalyan Samitis. 3. Providing revised guidelines to get Minor Civil Works executed through a Pvt. Agency.
B 5. MOBILE MEDICAL UNIT
Situation Analysis Various vulnerable areas have been identified in the district. These are remote, difficult, unserved or under served and snow covered areas. Population in these areas remains mostly devoid of preventive and promotive health care. However, immunization services are arranged by deputing health staff from nearby health institutions. Curative services not so easily accessible.
Vulnerable areas needing the services of MMU have been identified and enlisted in Chapter 1.
Objectives To increase the out reach of medical and diagnostic services through Mobile Medical Unit.
Strategies Operationalizing a Mobile Medical Unit (MMU )
Activities 1. One or two mobile vans shall be procured and equipped. 53
2. Staff shall be provided.( one Lady Medical Officer and staff nurse will be ensured ) 3. A Micro Plan will be developed for MMU. 4. Publicity of MMU will be done extensively. 5. MMU will provide the following services: o ANC, PNC, Delivery services o Diagnostic – Haemoglobin, Urine, Blood Sugar, Blood slide for Malaria, ultrasound, x rays etc; o Referral of cases needing specialist care o Provision of emergency services
Support required 1. Approval of Mobile Medical Unit by the state Government 2. Approval of staff for MMU.
Timeline
B 6. Upgrading CHCs to IPHS Standards
Situation Analysis Five health institutions namely CH Jubbal, CHC Nankhari, CHC Sunni, CH Nerwa and CHC Chirgaon have been notified to be upgraded as FRUs but none conforms to IPHS standards. CH Jubbal has 50 beds in position and CHC Chirgaon has 30 beds. Others do not have 30 beds. None of these institutions have specialists. It may not be possible to upgrade all CHCs to IPHS standards, in view of availability of manpower in the district and state.
Objectives 1. To strengthen CHC Sunni and CH Nerwa in current year as per Indian Public Health Standards. 2. To ensure that CH Jubbal, CHC Nankhari and Chirgaon are also upgraded as First Referral Unit for all curative services in next three years.
Strategies Strengthening of Health Institutions in terms of requisite manpower, infrastructure, equipment, drugs etc.as per IPHS.
Activities 1. Hiring of additional staff as per IPHS and filling of vacancies. 2. Repair of CHC buildings and expansion as per norms. 3. Procurement of equipment, drugs, supplies etc. as per IPHS norms. 4. Construction of staff qtrs.
Support required 1. Availability of all personnel as per IPHS 2. Proper buildings 3. Adequate Laboratory, Blood Storage Unit, Equipment and Drugs. 4. Allowing Contractual Personnel at Market Rates.
Timeline 54
B 7. Up gradation of PHCs for 24 hour Services as per IPHS requirements.
Situation Analysis Twelve PHCs, namely Mashobra, Tikker, Kupvi, Jeori, Ghanvi, Summerkot, Baragaon, Chhaila, Tharoch, Deudi, Kalbog, and Balag have been notified as 24 x 7 PHCs but only 6 are providing delivery services. Other six are not functional as 24 x 7 PHCs. None of the twelve conform to IPHS. Lack of staff nurses is the sole issue to make them fully functional.
31 PHCs are housed in Government buildings while 45 are in private or donated buildings and require new buildings. 18 PHCs require major repairs. 26 PHCs are without water supply and 21 are without electricity. 58 PHC are without Labour Rooms and 55 are without Operation Theatres. 41 PHCs are without separate toilets for patients. 52 PHCs do not have minimum 6 indoor beds. 66 PHCs are without vehicle.
Objectives 1. To upgrade 25 % of the PHCs as 24x7 PHCs by 2008 09. 2. To upgrade 50 % of the PHCs as 24x7 PHCs by 2010 12.
Strategies Strengthening of PHCs as per IPHS so as to ensure round the clock emergency and obstetric services.
Activities 1. Hiring of additional staff i.e Staff Nurses. 2. Construction of new buildings. for 3 PHCs. 3. Repairing of 18 PHCs. 4. Construction of staff quarters for the 2 PHCs. 5. Addition of OTs, labour rooms in PHCs as per facility survey report. 6. Upgrading the Laboratory for tests necessary for 24 hours x 7 PHCs. 7. Procurement of Furniture, Drugs and Equipment as per IPHS norms.
Support required 1. Ensuring availability of all personnel as per IPHS. 2. Allowing Contractual Personnel at Market Rates. 3. Proper buildings with staff quarters in all PHCs. 4. Adequate Laboratory, Equipment, Furniture and Drugs. 5. Adequate funds for construction and maintenance of buildings.
Timeline 2008 to 2012
8. Upgrading Sub Centres to IPHS standards
Situation Analysis The district has 250 Sub centres, out of which 137 are in properly constructed buildings, with residences for FHW. 113 Sub centres are in private or Panchayat buildings, which require new buildings. 132 sub centres require major repairs. 97 Sub centers are 55 without water supply and 123 are without electricity. 113 Sub centers are without toilet facilities for clients. Only 128 Sub centres have both the workers. 68 Sub centres are without FHWs and 33 without MHWs. 30 Sub centres are vacant and nonfunctional. 116 Sub centres can be upgraded to IPHS standards Objectives 1. Upgrading of all Sub centres as per IPHS standards. 2. Opening Additional Sub centres to cater to the entire population.
Strategies Strengthening of Sub centres as per IPHS.
Activities
1. Construction of buildings for new Sub centres and those housed in rented or private buildings. 2. Provide staff as per IPHS. 3. Repair of Sub centres. 4. Procurement of equipment, drugs, supplies, furniture etc.
Support required 1. State to sanction posts as per IPHS. 2. Adequate funds for construction and repair. 3. Required equipment, drugs, supplies, furniture etc.
C. IMMUNISATION
Situation Analysis
As per DLHS Survey, the number of fully immunized children is 84.1 %, O Polio at 39 %, BCG 98.1 % , 95.3 % DPT 3, 91.5 % OPV 3, and 91 % Measles. 1.9 % children did not receive immunization at all. District is one of the best performers in immunization in the state.
Annual report of the district for the year 2007 08 shows immunization coverage for BCG as 152O3(107 %), DPT 3 and OPV 3 as 14132 ( 99.96%) and Measles as 14129 (99.94%). The number of fully immunized children is 14129 which is 98 % of the target. This shows that there is a continuous increase in coverage of children. District has achieved near universal immunization. No case of adverse reaction and no case of vaccine preventable disease was reported by the district.
MNTE Validation Survey June 2OO8 (Maternal and Neonatal Tetanus Evaluation Validation Survey ) There is no available data regarding prevalence of Tetanus in the district. However, in June 2008, a survey on prevalence of Tetanus was conducted by WHO and Govt. of India, and Government of Himachal Pradesh jointly in all blocks of Chamba District. The total 188 villages were surveyed by 94 teams. 24 supervisors and 14 MOs completed this validation process. The whole activity was monitored and analysed by nine consultants from WHO, GOI and State Govt. 56 officers. Out of required sample size of 1350 live births, 23 neo natal deaths were detected in these villages. Out of 23 deaths, no death had occurred due to neo natal tetanus. Thus Chamba in particular and Himachal Pradesh in general has been declared as Neo natal tetanus free .
Objectives 100 % immunization of all infants and children by 2010.
Strategies 1. Enhancing the coverage of Immunization. 2. Alternative Vaccine delivery. 3. Effective Cold Chain Maintenance. 4. Zero Polio cases and quality surveillance for Polio cases. 5. Close Monitoring of the progress.
Activities 1. Ensuring alternative vaccine delivery system (mobility support to PHCs for vaccine delivery). 2. For Alternative vaccine delivery, Rs. 50 will be given to the FHW (2 sessions in a month) and Rs 25/ to AWW. 3. Mobility support (hiring of vehicle) for vaccine delivery from PHC to VH Days site where the immunization sessions are held for 8 days in a month. 4. IEC campaign and Community Mobilization. 5. Evaluation Survey of Immunization Programme to assess the coverage.
Support required
1. Evaluation of vaccination coverage 2. Funds for mobility to MOH Timeline
D. NATIONAL DISEASES CONTROL PROGRAMME
D 1. Revised National Tuberculosis Control Programme
Situation Analysis
TB Control Programme is running satisfactorily in the district with the help of 4 TUs at Shimla, Rampur, Rohru and Chopal and 2O microscopy centres at RH DTC, CHCs and some PHCs. 511 DOTS centres provide treatment near to the homes of patients. The ongoing activities under the programme include, IEC, training of doctors and lab. tech., management of cases as per DOTS strategy, regular monitoring, etc. Data for the year 2007 08 is as below:
New Sputum positive cases: 570 (74 per lakh pop. /yr) Total Annual Case Detection Rate: 1690 (219 per lakh pop./yr) Sputum Conversion Rate 96.41 % (Target 90%) Cure Rate 92.29 % (Target 85%) Defaulter rate 3.25%
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Detection rate is declining but the cure rate and conversion rates are more than the expected targets. Objectives
1. Detection rate of 260 Cases/ lac pop/yr. 2. 100% sputum conversion rate. 3. 85 % Cure rate in New Cases. 4. Reduction in the defaulter rate to less than 3%.
Strategies 1. Improvement in the quality of the intervention. 2. Increasing the outreach of the programme. 3. Increasing the awareness regarding Tuberculosis.
Activities 1. Increasing the outreach of the programme by increasing the DOTS providers through involvement of MPSS and AWWs. 2. Opening of more microscopic centres. 3. Increasing the awareness regarding the various issues of Tuberculosis through involvement of Community leaders, NGOs. 4. Screening of migrants through special caqmps. 5. DOTS regime to be strictly monitored through the VH WSC, the PRIs and the PHC M.
Support required Posting of the required staff i.e. Lab Tech.
Timeline
NATIONAL HIV/AIDS CONTROL PROGRAMME
Situation analysis The programme has entered Phase III (2007 12) now. The overall goal of the programme is to halt and reverse the epidemic over the next five years by integrating programmes for prevention, care, support and treatment.
The various activities being implemented under the programme are: Targetted Intervention for high risk groups and bridge population, IEC,RTI/STI control, Condom Promotion, access to safe blood, Integrated Counseling and Testing facilities, Post Exposure Prophylaxis(PEP),Prevention of Parent to Child Transmission(PPTCT), Care and support to People Living with HIV/AIDS, Antiretroviral Therapy, Monitoring & Evaluation and Surveillance. There are 14 RTI clinics, 4 blood banks and 4 ICTCs (IGMC, DDU Hosp., CH Rampur and Rohru) in the district.
As per HIV sentinel surveillance data for 2007 08, the prevalence among Antenatal cases was 0.25% and nil among STD patients. As of 31 st March2008, 374 cases of HIV/AIDS have been identified in district Shimla since 1987 which includes 130 AIDS cases. A total of 3595 RTI/STIs cases were reported to be treated during 2007 08 out of which 459 were referred for further management. DLHS 2004 survey estimated that 76.3% of women were aware about HIV/AIDS while only 21.2% of them knew about RTI/STIs. 23.8 % of women reported any one symptom of RTI/STIs 58 during the survey.This is indicative of the fact there is a strong need for educating women on RTI/STIs which are important risk factors for HIV/AIDS.
Objectives To reduce the prevalence of HIV among Antenatal women and STD patients below 0.2% by 2012.
Strategies 1. Prevent infections through saturation of coverage of high risk groups with targeted interventions and scaled up intervention among the general population. 2. Provide good care and support and treatment to People Living with HIV/AIDS. 3. Strengthening of infrastructure. 4. Capacity building of staff. 5. Improving monitoring and evaluation system
Activities 1. Mapping of areas with high risk groups and bridge population. 2. Implementation of targeted intervention projects. 3. Carrying out IEC activities. 4. Strengthening of RTI clinics. 5. Expansion of counseling and testing facilities up to CHC levels. 6. Establishing blood bank at CH Rohru. 7. Opening of more condom depots in AHCs, AWCs, and CBOs. 8. Expansion of PPTCT programme upto CHCs level. 9. Strengthening of HIV and STI surveillance mechanism 10. Ensuring quality care and support to PLHA. 11. Refresher training of doctors and paramedics. 12. Regular monitoring of activities at different levels.
Support required 1. Required manpower in blood banks ICTCs and RTI clinics. 2. Funds, drugs, equipments, furniture and supplies. 3. Good quality of condoms. 4. Training modules /manuals. 5. Standard Treatment Guidelines for RTI/STIs.
D 2. NATIONAL LEPROSY CONTROL PROGRAMME
Situation Analysis
Current Prevalence Rate as on 31 03 2008 is < 0.32 per 10,000 population. 31 New cases were detected in last year and 39 cases were deleted in 2OO7 O8. 28 cases are under treatment Out of 31 cases, 1O are from within the district and 21 are from outside. 6 cases are from Bihar, 9 from Nepal, 1 from Uttarakhand and 5 from UP. Maximum cases, 4 have been detected in Nankhari block. The prevalence rate of 0.32 per 10,000 is much below the elimination benchmark. 59
The various activities going on under the programme are IEC, Training of doctors and paramedics, sensitization of NGOs and Mahila Mandals, detection and treatment of cases, monitoring etc.The programme is now integrated with general health services. GLRA is supporting the state about rehabilitation of lepers in the state.
Objectives 1. Maintain the achievements gained so far. 2. Provide quality leprosy services with integrated health care system.
Strategies 1. Strengthening and Integration of Service Delivery Mechanism. 2. Institutional Development through integration of Leprosy services with the general health services. Merging of State and District Leprosy Societies under NRHM 3. Improved case detection, treatment and monitoring.
Activities 1. Comprehensive IEC activities. 2. Training of doctors, paramedics, MPSS, NGOs, ISM functionaries, AWWs and Community Based Organisations(CBO). 3. Involvement of Health Workers, MPSS, ISM functionaries, NGOs, AWWs and CBOs in education and screening of local population and migrant labour. 4. Regular follow up and monitoring.
Support required 1. Funds for IEC and trainings. 2. Drugs and supplies.
D 3. NATIONAL MALARIA CONTROL PROGRAMME
(VECTOR BORNE DISEASES CONTROL PROGRAMME )
Situation Analysis
District is almost free from Malaria like other districts of the state. In the year 2007, 17 cases suffering from malaria were found positive and were treated. Surveillance activities are going on routinely. 26358 blood slides were collected actively and 30092 blood slides were collected through passive surveillance. No insecticide spray has been undertaken since the API is less than 2 i.e. 0.08. For the last four years, number of Malaria cases have been, 27, 2O, 27 and 17 only.
Objectives 1. To sustain surveillance activities in local population and migrant labourers. 2. To undertake insecticide spray operations in areas more than 2 API, if required.
Strategies 1. To foster inter sectoral coordination with project authorities for ensuring timely collection of blood slides of all fever cases among project labourers 2. To ensure timely treatment of positive malaria cases
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Activities 1. Active and passive surveillance as per prescribed norm. 2. Monthly review of programme by MOH 3. Plan insecticide spray if the API is more than 2. 4. Procurement drugs and slides.
Support required Adequate Primaquine and slides.
D 4. OTHER VECTOR BORNE , LOCALLY ENDEMIC, DISEASES
Situation Analysis Locally endemic diseases in the district are Scrub Typhus, Cutaneous Leishmaniasis and Plague.
1. Cutaneous Leishmaniasis The number of cases suffering from Cut. Leishmaniasis was 176 in 2007, as reported from MGM Complex Rampur. However, this data includes cases from Shimla, Kullu and Kinnaur district.
2.Scrub Typhus Cases of Scrub Typhus were reported in the last year from Rampur block, mainly from area alongside river Satluj. Surveillance measures are being undertaken. This topic shall be discussed under IDSP
3.Plague District Shimla has an endemic focus of plague . The plague belt extends from Kharapathar and Mural forest range in Jubbal Kotkhai block to Tangnu village in Chirgaon block. Cases were reported for the first time in seventies and later in nineties. Some deaths were also reported. However, during second outbreak vigilance on the part of doctors in Civil Hospital Rohru, preventive measures were taken well in time and no time was wasted in diagnosing the outbreak. Now a plague surveillance unit has been set up in CH Rohru which conducts surveillance activities in this belt. Recently another focus has been found in adjoining area of UTTARKASHI in Uttarakhand State. This signifies the threat of plague outbreak in future in this belt.
Objectives 1. To ensure timely detection and treatment of cases suffering from Cutaneous Leishmaniasis 2. To undertake insecticide BHC spray operations in the affected area so as to contain the spread of the disease 3. To set up a Plague Surveillance Unit in endemic belt in the district and strengthen surveillance activities against Plague 4. To set up facilities in the district for timely diagnosis of Scrub Typhus
Activities 1. Surveillance by health, ISM, and project hospitals and prompt treatment of patients. 2. To start insecticide spray operations in the catchment area of river Satluj 61
3. To carry out entomological survey in the catchment area of Satluj 4. Monthly monitoring of situation by MOH and project medical authorities 5. Training of staff in surveillance of diseases 6. To operationalise Plague Surveillance Unit in Rohru
Support required 1. Funds for insecticides 2. Funds for wages for insecticide spray 3. Funds for drugs against CL 4. Training
D 5. BLINDNESS CONTROL PROGRAMME
Situation Analysis Last year, 43782 eye patients were examined, 25177 refractions were done. The number of Cataract operations done was 1959 against the target of 1800 (108 % ). 1838 IOL Implantations were done. Only 2 Eye camps were held. Children screened under SES were 28515. Eye surgery is carried out at DDU Shimla, MGM Rampur, CH Rohru and CH Theog, in addition to IGMC Shimla. There is no partnership with private sector under this national programme in the district. Prevalence Rate of blindness for the district is not known. Objectives
1. Reduction in the Prevalence Rate of blindness to 0.5 % by 2012. 2. Decrease in the Prevalence Rate of Childhood blindness to 0.6 % per 1000 children by 2010. 3. Usage of IOL in 95% of Cataract operations.
Activities 1. Increase in number of cataract camps by strengthening existing infrastructure 2. Ophthalmologist (surgeon) and ophthalmic assistant will be posted at all the CHCs 3. IEC activities 4. Collection of data about operations performed by private practitioners. 5. Partnership with Private sector (PPP) 6. Training of school teachers in screening of students for any defective vision and their referral.
Support required
1. Specialists to be posted in CHCs. 2. Adequate funds
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D 6. INTEGRATED DISEASES SURVEILLANCE PROGRAMME (IDSP)
Situation Analysis The project was launched in the district in 2005 06. IDSP includes surveillance of communicable diseases and other conditions (Malaria, Acute diarrhoeal diseases Cholera, Typhoid, Jaundice, Tuberculosis, Acute Respiratory Infections, Measles, Polio, Road Traffic Accidents, Plague, Yellow Fever, Meningo encephalitis etc., HIV, HCB and HCV). 5 state specific communicable diseases are, fever, Jaundice, diarhoea, AFP, and Cough more than 3 weeks. Cases of Scrub Typhus, Plague and Cutaneous Leishmaniasis have been reported in the district in the past.
Rapid response teams have been established in the district. One doctor has been identified as the Nodal Officer. So far renovation work of District Surveillance Unit (DSU) and District Public Health Lab. has been completed. Labs at CHCs have been renovated and upgraded. V– SAT is in the process of installing in DDU campus. Training has been imparted to some MOs, FHWs, MHWs, MHSs, And FHSs. Rest shall be trained in future. Equipments like Binocular microscopes, etc. have been procured. Surveillance for 6 diseases i.e. Fever, Cough more than 3 weeks, AFP , Diarrhoea, Jaundice has been started from September, 2OO6.
Water Monitoring Sample Report for 2007 08 is as below:
Total Water samples received; 165 Satisfactory samples: 102 Suspicious samples : 27 Unsatisfactory samples: 36 Prompt action is taken about unsatisfactory samples by intimating the reports to the concerned department. However, there is no single forum to discuss such issues.
Problems 1. District is facing shortage of funds, even for release of salaries of staff, procurement of logistics, reporting forms and reporting registers. 2. Rapid Response Teams are not properly active and functional as was evident during recent outbreak of Jaundice in Shimla town. 3. DSU is not fully manned and there is a lack of mobility. 4. Rapid testing kits are required in the field for testing water quality during outbreak. 5. Widal kits and Weil Felix Kits are also required. 6. There is a lack of coordination between various agencies in Shimla.
Objectives To fully establish the Integrated Disease Surveillance System for Communicable and Non Communicable diseases.
Strategies 1. Strengthening data quality, analysis and links to action. 2. Improving the laboratories. 3. Building capacities of all stakeholders. 4. Coordinating and decentralizing surveillance activities. 63
5. Intersectoral Coordination and involvement of communities and the private sector.
Activities 1. Identification of Laboratories for Upgradation. 2. Staff on contractual basis at state and district headquarters to be hired. 3. Preparation of annual IEC plan for specific diseases, which can be used every year. It will be reviewed each year based on analysis of surveillance data. 4. Training of all the stakeholders in disease surveillance and action 5. Inter sectoral collaboration with NGOs, local civic bodies, etc.
Support required 1. Adequate funds 2. Rapid Test kits for testing water sample. 3. Weil Felix test kits for diagnosis of Scrub Typhus. 4. Transport media for samples.
D 7. Iodine Deficiency Disorders (IDD)
Situation Analysis
Iodine Deficiency Disorders are not a problem in the district due to wide awareness among people, consumption of iodized salt and implementation of PFA Act. Actual magnitude of the problem is not known.
Objectives
1. Ensuring the sale of only iodized table salt in the district. 2. Keeping the prevalence of IDDs low.
Strategies 1. Building Awareness among people. 2. Monitoring the sale of iodized salt. 3. Effective implementation of PFA Act.
Activities 1. Continuing health education and publicity through print/electronic media about intake of iodized salt 2. Regular health talks in schools. 3. Screening of school children for detection of endemic goiter. 4. Procurement and distribution of salt testing kits. 5. Continuing Iodine estimation of salt samples by the field staff.
Support required
1. Supply of salt testing kits. 2. Strict implementation of PFA act. 3. Funds for IEC activities. 64
D 8. School Health Programme
Situation Analysis Health checkup of primary school children is carried out by Medical Officers of CHCs and PHCs. There are 2177 schools in the district. In the year 2007 08 1950 schools were covered, and 89977 students were examined. 46366 children were found to be suffering from various ailments. 2038 students were referred. Common problems found are worms, anaemia, dental diseases, eye diseases, ENT diseases and mental problems. Those children who require spectacles are given free of cost under NCPB Programme. The Department of ISM also carries out school health activities.
Objectives: To screen all elementary school children for different ailments and referring all those requiring specialist care.
Strategies and Activities: 1.Operationalization of Programme: The School Health Programme will be operationalised by four departments, Health, Ayush, Education and Social Welfare Department. The schools will be distributed among all the heath institutions, including ISM in the block for carrying out activities. Medical Officers of PHC, AHC, MHW, FHW of the concerned Sub centre and AWWs and School teachers will coordinate the school health programme. An annual action plan will be prepared.
2. Training: Teachers will be trained in counseling, first aid and will be oriented about the health problems commonly found among school children. They will also be trained in maintenance of health record of school children.
3. Health Check Up/ Referral The PHC Medical Officer and HWs will carry out the school health check up at the beginning of each annual session in all the schools in their area. Ailments detected will be adequately treated or referred for the same. The IEC material and medicines eg. IFA tab. Mebendazole etc shall be distributed after proper counseling. Health card of each student will be prepared. 4. Issuing School Health Cards: Each student will be provided school health card with all relevant details. 5. Monitoring: The programme will be regularly monitored and reviewed at PHC and Block level monthly meetings.
Support required 1. Government orders to different Departments to coordinate the programme. 2. Depatrtment‘s permission to doctors to use their own car if Govt. Vehicle is not available for field tours. 3. Training modules/ manuals. 4. Funds for training, IEC materials, stationery, medicines, TA/DA and POL.
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CHAPTER 8. INTERSECTORAL CONVERGENCE
As the indicators of health depend as much on quality of drinking water, nutrition, sanitation, female literacy, women’s empowerment as they do on functional health facilities, NRHM seeks to adopt a convergent approach for interventions under the umbrella of the District Health Plan. The plan seeks to integrate all the related initiatives at the village, block and district levels. While substantial spending in each of these sectors would be from the concerned departments, the Village Health Plan /District Health Plan would provide for some catalytic resources through Untied Grants for convergent action
Health is a social responsibility and is not the domain of the Health Department only. Unfortunately, the total responsibility has fallen on the Health Department. The various departments have been involved in the Pulse Polio Campaign which has led to the massive mobilization and success of the campaign.
7.1 Integration of Health and AYUSH
Situation Analysis:
Functional integration of Health and AYUSH There is a separate department for AYUSH, headed by the District Ayurvedic Officer at the District level with one Regional Ayurveda hospital at Shimla and two Ayurveda Hospitals at Rampur and Rohru. Besides, one Homeopathy Health Centre and one Unani Health Center are located in Shimla town and there is a wide network of 145 (138 in rural areas) Ayurvedic Health Centres in the district. Out of 145 AHCs, 38 are housed in Govt. buildings and 107 in rented buildings. The condition of 15 Govt. buildings of AHCs and Rampur hospital is not good and require major repairs. Overall, functioning of health institutions is hampered for want of funds. The quality of heath care is affected due to shortage of trained manpower, essential medicines and equipments, nonfunctioning laboratories, lack of minor OT, x ray and transport facilities at Rampur and Rohru hospitals. RKS constituted in both the hospitals is not functioning well due to shortage of funds (seed money). In spite of various deficiencies, the ISM Deptt. is providing good health care to people in the district especially in the remote and difficult areas. Though majority of population shows preference for Allopathic system yet Ayurveda is popular in major chunk of community in the district. The Deptt. is carrying out some of the activities under National Health Programmes like distribution of condoms, IFA tablets and ORS packets, surveillance in Malaria, acting as DOTS providers, health check up of school children, Pulse Polio Campaign etc. However, their involvement in community health education is not up to the desired level. Effective participation in health programmes is lacking for want of necessary instructions from higher authority and coordination with Health Department. 66
There is a need for ensuring regular supply mechanism and training of different category of personnel. The Ayurvedic Medical Officers are permitted to use allopathic medicines in case of emergencies. However, their participation in providing health care round the clock is negligible.
The AYUSH department also has a large force of frontline workers in the form of ANMs and Dais. However, the contribution of the AYUSH department in promoting institutional deliveries or facilitating emergency obstetric care is wanting.
Objectives Involvement of all Ayurvedic Health Centres in implementation of all National Health Programmes in the District. Monthly Joint meetings (Ayurveda and Allopathy) are held at Block level.
Strategies & Activities: 1. Expanding coverage by involving all Ayurvedic Health Centres in implementation of all National Health Programmes Government order by the Principal Secretary Health & Ayurveda to all AHCs to be responsible for implementation of National Health Programmes. Training of AMOs and AYUSH frontline workers on National Health Programmes. 2. Improved coordination with Allopathic Department • Map the locations of health sub centres and AYUSH health centres. Based on results of mapping exercise, convergence with AYUSH departments will be strengthened. Rationalisation of facilities can be undertaken to optimize health facility coverage in a phased manner. District IEC strategy for Allopathy and Ayurveda should be jointly prepared. The IEC materials should be shared and both the systems should participate in implementing the IEC strategy. Regular meetings at Block and District levels (once a month). Appropriate provisions for TA/DA for these meetings for AYUSH. Promotion of institutional deliveries – by sensitization of Dai’s on the importance of institutional deliveries & AN/PN care. 3. Rogi Kalyan Samities in Ayurvedic Hospitals These Samities will be formed in Ayurvedic Hospitals in the district and be governed by common guidelines issued by the State under NRHM. 4. Outreach camps For outreach and coverage of areas not covered by AHCs
Support required: Government order by the Principal Secretary Health & Ayurveda to all AHCs responsible for implementation of National Health Programmes. • Government order by the Principal Secretary Health & Ayurveda to selected AHCs for untied and maintenance funds; seed money for RKS. 67
Integration of Health and ICDS
Situation Analysis:
There are currently 1987 AWWs in the District Shimla, where there is effective convergence between Health Department and ICDS at the village level. A Village Health Day is held on the first Tuesday of each month where the AWW and Health functionaries mobilize women and children, provide health education and perform other routine RCH services. A clinic day is held at the sub centre on every Wednesday where the AWW and FHW are performing routine RCH services. An immunization day is held once every month in the sub centre where there is convergence in the functions of FHW and AWW. Sector levels meetings and joint reviews are not being held regularly. The monitoring of field level activities is not being undertaken jointly. The development of Village Health Plan is primarily undertaken by the health functionaries with inputs from AWW. Training under RCH II such as ISD etc. are done primarily for health worker; no joint trainings have been carried out by the State. AWWs are providing DOTS under RNTCP. In service delivery there is effective convergence, however, there is little or no convergence in planning, monitoring and reviews.
Objectives: • To improve accessibility and availability of health care for the community through better coordination. • Monthly Joint review meetings to be held at Block, Sectoral and Village level.
Strategies & Activities: Joint Common Communication Strategy to promote health and utilization of services. Training of AWWs to perform the role of link worker prescribed under NRHM. Depot holder for Nirodhs,IFA tab. and ORS. Joint review meetings at the block level to be initiated through a Government order. Capacity building for counseling & other activities of NRHM like: Identify malnutrition among children (0 5) and manage or refer to PHC Weigh and examine newborn as soon as possible after birth. Provide ORS to children with diarrhea Provide IFA Tab./Sol. to young children Provide Vitamin A solution to children Provide Immunization Provide Health Education Provide DOTS Diseases Surveillance: For Plague, Cutaneous Leishmaniasis, Scrub Typhus etc.
7.3 Integration of Health and IPH 68
Situation Analysis All the 2520 villages have the facilities of drinking water. According to 2003 survey conducted by IPH, there were 7703 habitations in Shimla, out of which by 2008, 4868 habitations were totally covered, 2312 were partially covered getting 11 to 40 liters of water per person per day and 523 were not covered. To supplement Piped water supply there are 1042 hand pumps only. There is one water testing laboratory in the District. As perceived by the community, quality of water is not satisfactory . There are standard reporting forms for monitoring of water quality.
Objectives:
Activate PARIKAS members’ roles and responsibilities subsequent to training
Strategies & Activities: Chlorination will be done by the IPH Deptt.and chlorine tablets will be provided by the Health Department and distributed by field functionaries to households Joint communication and review strategy
Information sharing Copy of water quality monitoring reports generated by IPH Department will be shared with the Health Department at block & district level.
Community organization Community based organizations formed under various programmes/sectors will be engaged by a team of frontline workers – Health, ICDS and IPH departments. Proper drains to be built & covering of all open drains and puddles of water. Notification of diseases in villages Diseases Surveillance: Water borne diseases Joint monitoring Joint review meetings to be held at the block level to be initiated through a Government order.
7.4 Integration of Health and Rural Development
Situation Analysis: School Sanitation and IEC are important components of Total Sanitation Campaign. The performance is relatively poor on sanitation as is evident from the figures available from the survey conducted by Rural Development Deptt. in 2005 06. Out of 2489 schools only 570 were covered. Only 9750 BPL families out of 23874 were covered whereas out of 53231 APL families, 27500 were covered.
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The Sanitation programme in the District has the strategies which would critically impact the health status. The important areas such as sanitary latrines at Anganwadis and schools would have direct bearing on the health outcomes; however on these fronts the performance is relatively poor.
Objectives: Sharing of information among frontline workers’ team through PARIKAS meetings. Initiate monthly reporting system after orientation of PARIKAS members.
Strategies & Activities: The frontline workers’ team should share information about the sectoral programmes and their operational strategies. The team will identify and prioritise the locations and thus jointly plan. This will be done after PARIKAS members in the State have been duly trained. A monthly report will be sent to PARIKAS on the sanitation and water supply situation in schools and Anganwadi centres. Disease surveillance eg. Water borne diseases
7.5 Integration of Health and Education Department
Situation analysis: Education Department has an important role in promoting health of school children in coordination with Health Department. But, there is a poor coordination between the two departments thanks to lack of proper official instructions to the Education Department.
Last year, out of total 2177 schools, 1950 were covered for health check up and immunization by the Health Department. Very few private schools have been covered. Various activities carried out in schools include health check up, immunization, vision testing, health talks, treatment of any defect. However, there is a lack of initiative on the part of Education Department to organize health activities in schools. Even sometimes the bona fide of local doctors and health staff is questioned by the Principal of the school to carry out any health activity. By and large, teachers cooperate whenever any health team visits school. No joint review meetings are held. Referral of children is rarely done by the teachers. Objectives: • To work out a better strategy and coordination for coverage of schools. • To hold joint review meetings at block level for assessing the progress and do better planning. Strategies and activities • Planning and organizing joint review meetings at block level to be initiated through a Govt. order. 70
• Developing effective coordination between the two Departments for adequate coverage of schools. • Health Department to distribute schools among various health institutions for providing health coverage. • To arrange training of teachers in counseling, screening and referral of students with defects. • Teachers to do regular follow up of students with defects. • Counseling of students to be done by school teachers. • Schools to maintain health records of each and every student.
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CHAPTER 9. COMMUNITY ACTION PLAN
Situation Analysis: District Health Mission Shimla has participation from the health and other concerned departments. The State Health Mission in its meeting held on 20.09.2005 approved that PARIKAS shall function as Village Health Water and Sanitation Committee as envisaged under NRHM. Training for PARIKAS was planned and basic training material was also developed. Presently, PARIKAS are non functional at Panchayat level . Given the scale, state wide presence of PARIKAS at all levels, and the intensity of the training that is required, an appropriate cost effective strategy for training PARIKAS in a reasonable timeframe needs to be developed. Currently, the functions and membership of PARIKAS at District level overlap with those of District Health Mission.
OBJECTIVES To ensure constitution of PARIKAS conforming to the provisions of the Amendment of the PRI Act (2005) across the District in 363 Panchyats. To develop appropriate training strategy and conduct the training of all PARIKAS in the District. More than 85% PARIKAS regularly meet as per prescribed periodicity i.e. once a month. All the PARIKAS lead the planning process for preparation of Integrated Village Health Improvement Plan. Six meetings of Block PARIKAS in a year (once in two months) Two meetings of District Health Mission in a year (once in six months)
STRATEGIES & ACTIVITIES
1. District Level Advocacy Workshop District level advocacy workshop is to be held with the various line departments to ensure commitment and agreement of all the concerned departments on the structure/roles/responsibilities of PARIKAS leading to guidelines binding on all departments and followed by a joint directive from all departments. 2. Operationalization of PARIKAS Government order is resent communicating decision on the District Health Mission. Government order is resent communicating involvement of MPSS in those Panchayats which do not have a Health Sub centre. Report by District Panchayat Officer on the compliance of Government order (operationalization of PARIKAS at all levels).
3. Training of PARIKAS Development and finalization of Training approach including training design, resource kit and training modules Training of facilitators at SIHFW. Training of PARIKAS members. Monitoring and evaluation of training. 72
Establishment of a Resource Centre for PARIKAS at district level for continued support to PARIKAS.
4. Community mobilization Mobilization of the BPL, SC, ST population for availing JSY and Referral Transport benefits under NRHM.
5. Meetings of PARIKAS The PARIKAS at Panchayat will meet every month. PARIKAS at block level will meet once in every two months & District Health Mission shall meet twice a year. 6. Monitoring PARIKAS Meetings Assign responsibility to Block Medical Officer to monitor activities of PARIKAS in his/her block. He will report to the Chief Medical Officer every month. Funds will be provided for attending meetings to PARIKAS representatives. Micro plans thus prepared by the PARIKAS are monitored, evaluated and supported (by attention and resources) by the higher levels within departments and Government.
SUPPORT REQUIRED: .
1. Development of relevant Training modules/IEC Material (including field testing) covering various aspects of PARIKAS: • Booklet on Structure/Roles/Responsibilities of PARIKAS with a copy of the relevant Government Notifications. • Booklet on step by step approach towards conducting CNA and preparing micro plans. • Training modules on specific health issues (like modules already developed by the project and module prepared by the government for Health Workers). The module should also include chapters on NRHM and micro planning • Technical Standards with regard to sanitation, harvesting of rain water, protection of water sources (with regard to water quality). • Manual/guidelines on Management of Funds.
2. Printing of the Training Modules and the IEC Material. 3. Conduct TOT on PARIKAS so that at least 3 4 master trainers available in the district. 4. Facilitate capacity building as well as preparation of micro plans by the PARIKAS Members. 5. Funds for advocacy workshop and trainings. 6. Sending Govt. Notification on PARIKAS to DC, CMO, and all the Gram Panchayats.
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CHAPTER 10. PUBLIC PRIVATE PARTNERSHIP (PPP)
Situational Analysis Private sector in health has developed well particularly in Shimla town and to a lesser extent in other towns of the district. There are a few nursing homes in Shimla and other towns, which provide specialist services. Besides, there are a large number of private practitioners. Rs. 1, 50,000 were received for implementation of PPP which are unutilized. No MOU has been signed so far.
MNGO and FNGOs
SNS Foundation at Parwanoo, is the Mother NGO for the district. It supports smaller NGOs in RCH programme in district Shimla namely Gramodyog Workers Welfare Association (GWWA) covering Nankahari and Kumarsain blocks, Manav Kalyan Sewa Samiti(MKSS) covering block Nerwa, SAHYOG covering Matiana block and Parivartan covering Chirgaon block.
The scheme is functioning satisfactorily in the district.
Objectives
To foster public private partnership in some of the towns to achieve the goals of NRHM in the district.
Strategy 1. Exploring various feasible options for PPP. 2. Conduct a feasibility study for PPP
Activities
1. Listing various agencies and assessing their strengths in providing services. 2. Selecting a few credible agencies and sign a MOU for RCH and other services . 3. Continuation of MNGO scheme on revised guidelines
Support required
• Approval of Government
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CHAPTER 11. GENDER AND EQUITY
Situational Analysis Total sex ratio in the district as per 2001 census is 896 per 1000. Juvenile Sex ratio in the age group of 0 to 6 is 929. Sex ratio at birth is being monitored with data available from annual report being published by DHS under RBD Act.
1. Implementation of PC and PNDT Act . Currently district is implementing PC and PNDT Act. Raids have been conducted on ultrasound clinics and one case has been registered for divulging information about the sex of foetus. All the ultra sound clinics are registered. Chief Medical Officer of the district is the Appropriate Authority for implementation of the PC and PNDT Act. Member Secretary of this committee is Medical Officer of Health and other members are gynaecologist and radiologist of RH, and representatives of two NGOs. Meetings of AA are held regularly . However the district is facing problems in implementation of the Act. District has no manpower to implement the Act. Implementation of the provisions of the Act relies very heavily on records and in the absence of manpower it is not possible. Also there are no funds available for logistics etc. There are 33 USG clinics in the district and all are registered
2. Monitoring of sex ratio . `Figures for sex ratio are available only after a decade. However figures for sex ratio at birth are routinely recorded by the health department under RBD Act 1968. (Civil Registration Scheme ). Annual report is brought out by the de partment. Fortunately the state has im plemented the Act well and has ensured hundred percent registration of births and near 95 % registration of deaths. Hence it is possible to monitor sex ratio at birth Gram Panchayat, block and district wise at the end of year. This could well give an idea of the current trend in sex ratio and this information could be utilized for further analysis
The annual CRS report shows year wise rising trend in sex ratio at birth in the district for three years as 876,896 and 920 from the year 2002 to 2004 respectively. For subsequent three years i.e. from 2005 to 2007 the sex ratio is fluctuating as 907,946 and 931 respectively.
3. Involvement of NGOs and CBOs Certain NGOs are taking lot of interest in this issue. These would be willing to act as decoys for conducting raids on USG clinics and work as watch dogs to detect violation of the Act. 4. Outcome of pregnancy Health workers routinely collect data about the outcome of pregnancy as live birth, still birth etc but no analysis is done by supervisors and MOs at any level. This information is available on forms 6,7, and 8 and is submitted to state on Form 9. BMOs and supervisory staff require training in analyzing this data, which is routinely available. Increasing number of missing pregnant women shall give an indication of something going wrong in the area and focus on preventive and promotive activities.
5. FGDs Findings FGDs conducted in the area revealed clear son preference and lot of domestic violence. Status of women as a whole is very low. Women are not taken in 75 confidence for any of reproductive issues and decision masking about it. Awareness about sex determination by USG clinics is well known to women though they deny ever visiting the clinics. Women are forced to undergo USG and abortion forcibly in some areas of the district
FGDs conducted in the area revealed clear son preference and some degree of domestic violence. Status of women as a whole is low. In certain areas, women are not taken in confidence and involved in decision making about reproductive issues. Awareness about sex determination by USG clinics is well known to women though they deny ever visiting such clinics. However, girls are generally consulted before finalizing their engagement. In some areas, women participate equally in decision making process in all family matters.
Objectives To create awareness on gender discrimination, equity and equality which would lead to better health and social status of women in the society.
Strategies 1. Orientation of personnel of Health Departments, ICDS, Education, PRIs, local self Government, on gender equity and equality, age at marriage, PC and PNDT Act, domestic and gender based violence. 2. Effective implementation of PC and PNDT Act.
Activities 1. Training of service providers (Doctors, FHSs, FHWs, Nurses) in gender so as to make them gender sensitive 2. IEC campaign against feticide as in required under the PC and PNDT Act.
Support required 1. Training support from SHFWTC 2. IEC support from DHS 3. Funds for training and IEC
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CHAPTER 12. CAPACITY BUILDING
Situational Analysis
District has two training schools for pre service training of Male Health Workers at Mashobra and Staff Nurses Training School at Rampur. These schools are understaffed. No training has been conducted at Mashobra in the past years since 2002. Staff nurses training is going on at Rampur. This is the first batch undergoing training in this school.
In service trainings are conducted by the in house faculty from local hospital and District Programme Officers. No training action plan is developed by the district. Various categories of staff undergo trainings either at SHFWTC Shimla or in DDU Hospital. Under NRHM, trainings for skilled birth attendants, IMNCI, short course in Anasthesia etc. are being carried out by IGMC Shimla.
Objectives To improve the availability and quality of health care by enhancing the knowledge and skill of various category of health personnel.
Strategies 1. Assessing the training needs of staff. 2. Organising the quality trainings.
Activities 1. To identify the broad areas of trainings like, counseling and communication skills, NSV, ARSH, Skilled birth attendants, Gender issues, RTI/STIs,IMNCI, RKS management etc. 2. To work out the training load of different category of staff. 3. To prepare training action plan. 4. To arrange training for Master Trainers. 5. To arrange funds, venue and training material ( Trg. Modules, manuals etc.) 6. To monitor and evaluate trainings.
Support required 1. Development of training material by SHFWTC Shimla 2. TOT by SHFWTC Shimla 3. IGMC Shimla to train doctors in minilap method of sterilization, anesthesia, skilled birth attendants, IMNCI etc. 4. Funds for trainings.
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CHAPTER 13. HUMAN RESOURCE PLAN
Situational Analysis
The situation of the Human Resources in district Shimla is inadequate. There are large scale vacancies and none of the institutions conforms to staffing pattern as per the IPHS Norms. HR gaps, staff category wise, are reflected in Facility survey.
Objectives To equip health system with adequate manpower especially as per IPHS to meet the NRHM goal.
Strategies & Activities
1. Rational placement of Specialists and trained staff. 2. Recruitment of staff on contract where vacancies exist. 3. Approval and recruitment of staff for new facilities
Support required
• Manpower deployment.
Requirement of Staff as per IPHS Norms Sub centres FHWs 7 9 in 2O12
PHC MO 7 Pharmacists 19 HE or BEE 21 Staff Nurse 19 LT 19 MHS 18 FHS 18 Fhw 13 Class IV 11
CHC General Surgeon 3 Physician 3 Obstetrician / Gynaecologist 3 Paediatricians 3 Anaesthetists 3 Public Health Programme Manager 3 Eye Surgeon 3 Public Health Nurse 3 78
ANM 3 Staff Nurses 7 21 Pharmacist 3 Lab. Technician 3 Radiographer 3 PMOA 3 Ward Boys 2 6 Sweepers 3 9 OPD Attendant 3 Data entry operator 3 Registration Clerk 3 OT Attendant 3 Chowkidar 3
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CHAPTER 14. PROCUREMENTS AND LOGISTICS
Situational Analysis
The office of the Chief Medical Officer does not have sufficient accommodation for storage of drugs, equipments etc. as there is no provision of warehouse or stores at district level. The same is the situation in CHCs (BMOs} also. Drugs, equipments etc are stacked in rooms scattered all over the hospital building and are managed by different staff belonging to vertical programmes.
70% of the budget for drugs is handled by the Civil Supply Corporation to which annual indent is sent by the CMO through the Directorate of Health. The remaining 30% of the budget provided to the CMO, is utilized to procure emergency drugs and other supplies.
Objectives To improve store and logistic management in the district.
Strategies 1. Improving storage facilities at district and at block levels. 2. Capacity building of staff in store and logistic management
Activities 1. Construction of a warehouse at Shimla, with computerized system of store management. 2. Providing storage facility at block level CHCs. 3. Training of Store In charge MO and Store keeper pharmacists in logistics and store management. 4. Developing Software for inventory management
Support required 1. Architectural design of Store Rooms duly approved by DHS. 2. Training support from SHFWTC or DHS.
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CHAPTER 1 5. DEMAND GENERATION (IEC ) Situational Analysis
Presently, there is no designated person in the rank of MEIO or Dy. MEIO for looking after the IEC activities in the district. However, there are only two Health Educators at block level and one BCC coordinator was appointed under RCH programme. Some IEC activities are being carried out by health staff under state guidelines but there is no evidence of any communication strategy or IEC plan of action in the district. Major focus is on HIV/ AIDS and Leprosy.
Issues for IEC Issues enlisted below were found during FGDs, planning process
1. Institutional deliveries not popular, role of TBAs 2. Spacing methods of contraception, low acceptance 3. Iron FA not taken regularly, no follow up 4. Importance of three ante natal check ups 5. Adolescents risk taking behaviour, counseling 6. Misconception about Tuberculosis 7. PC and PNDT Act , gender issues 8. Safe water, hygiene, environment sanitation 9. Reproductive Tract infections, STDs 10. Services available under NRHM and various schemes 11. Breast feeding, including Exclusive breast feeding, 12. Village Health Plans, coordination with PRIs 13. Mobile Medical Units 14. JSY scheme and Referral Transport 15. Counseling of beneficiaries on Family planning methods, RTI, special focus on partner treatment 16. Advance publicity of family planning and all service camps 17. Awareness camps for migrant labour 18. Health talks in schools
Objectives To improve the Health Care Seeking Behaviour of the community by raising the awareness among the people.
Strategies and Activities
1. A Technical Support Agency (TSA) will be hired for carrying out the IEC activities in a professional manner till vacancies are filled by department. 2. A comprehensive and district specific Behaviour Change Communication (BCC) strategy shall be developed by TSA. 3. A micro plan will be developed for implementing the IEC activities in the district on the basis of communication strategy. 4. Resources will be pooled from various programmes i.e. NDCP, RCH, NRHM, IDSP etc. 5. Mahila Swasthya Sanghs and other Community Based Organizations to be utilized for IEC activities in rural areas.
Support required
• Approval for hiring TSA 81
CHAPTER 16. FINANCING OF HEALTH CARE
Situation Analysis
1. Rogi Kalyan Samitis (RKS) have been formed in ZH i.e. DDU Hospital, all 8 CH and 7 CHCs and 61 PHCs. These are hospital based autonomous societies which are allowed to take user charges for services provided at the facilities. Formation of these RKS has improved the functioning and the quality of health care being provided by the institutions.
However, there is a lack of expertise in developing Improvement Plan for the institutions and management of funds, which requires strengthening. For efficient management and utilization of the funds, the members of RKS need to be trained.
2. During FGDs, it was revealed that poor patients who cannot afford the cost of treatment, are forced to raise loans.. In the light of this, it would be appropriate to launch a health insurance scheme, especially for BPL families. Or district could formulate a new scheme which would ensure free treatment to the needy patients.
Objectives To ensure the availability of sufficient funds with all PHCs, CHCs and CH for meeting the needs of the patients.
Strategies and Activities
1. Formation of Rogi Kalyan Samities in all PHCs. 2. Providing guidelines of RKS to PHCs. 3. Donations are to be generated from individuals. 4. Attainment of IPH Standards. 5. Training of RKS members in management of activities and funds. 6. Health Insurance for BPL families (Rashtriya Beema Yojna).
Support required 1. Training in RKS management with the support of SHFWTC 2. Implementation of RBY Timeline
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CHAPTER 17. MONITORING AND EVALUATION
Situational Analysis
Community Needs Assessment Approach is used to gather data at Sub centre level by Health workers. It is further integrated at PHC, CHC and District level to develop the District Action Plan. In general, the monitoring is done by superior officers through monthly meetings and reports and periodic field visits. State has developed a computerized HMIS under GTZ Project and the staff was trained to use computers and software. This HMIS covers RCH and other national programmes. Non Communicable diseases are not included in surveillance system even though the burden due to them is high. However, new software to meet the requirements of NRHM is being developed.
Objectives
To develop a comprehensive HMIS for better monitoring and evaluation of health services.
Strategies 1. Including NRHM indicators in monitoring. 2. Using HMIS for decision making on regular basis. 3. Developing linkages for decision making at district level. 4. Involving Gram Panchayats in health monitoring.
Activities
1. Training of staff in new NRHM softwar; till that time current HMIS to continue. 2. Training of health managers in analysis and utilization of data. 3. Training of Gram Panchayat members in monitoring of health activities. 4. Internet connectivity upto Block level for online transfer of data. 5. GIS for the district covering all the parameters. 6. AMC for all computers.
Support required
1. Training for different personnel. 2. New NRHM software. 3. Facilitation in internet connectivity and GIS. 4. Funds for AMC. 83
CHAPTER 18. BUDGET
Shimla BUDGET NRHM
A 1. Strengthening Of District Health Management
Budget in Lakhs Activity Unit Cost 2008 09 Salary of DPM Rs 12000 1.44 Salary of Project Accountant Rs. 8000 0.96 Salary of Data Entry Operator Rs. 6500 0.78 Salary of 6 BPMs Rs. 12,000 8.60 Expenses for DHM and BHC meetings 1.00 Total 12.78
A 2. Maternal Health
Activity Item Unit Cost 2008 09 Training of experienced 100 TBAs Rs. 2500 per TBA 2.5 6 Multi speciality Camps one camp in Rs. 8 Lakhs 8.00 Dodra Kwar 20000 Disposable delivery kits Rs. 300 per kit 60.0 JSY and Ref Transport 12000 Rs 1200 14.4 Total 84.9
A 3. Child Health
Activity Item Unit Cost 2008 – 09 50 ORS packets with all 1987 Rs. 2 per packet 1.99 anganwadis Rs.100 Per year per aww Total 1.99
A 4. Family Planning
Activity Item Unit Cost 2OO8 – O9 24 NSV camps Rs 5000 Per Camp 1. 20 Compensation money to 1000 acceptors Rs 1500 Per case 15.0 of NSV Compensation money t o 3000 Rs 1000 30.0 acceptors of Tubectomy Per case Emergency contraceptives 500 cases Lumpsum 1.5 NSV kits Lumpsum 1.5 Total 49.20
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A 5. Adolescent Reproductive and Sexual Health
Activity Item Unit Cost 2008 – 09 ARSH clinics in 9 Blocks Rs. 10, 000 0.90 pr ovision of drugs and su pplies Rs 2000 per clinic 0.18 Health camps for adolescents in all 363 Rs. 5000 per camp 18.15 Gram panchayats Training of peer educators, 363 peer Rs 500 per person 1.82 educators Total 21. 05
B. NEW NRHM INITIATIVES
B 1. Mahila Panchayat Swasthya Sahayika (MPSS)
Activity Item Unit Cost 2008 – 09 Compensation to 113 MPSS Rs. 2000 27.12 Drug kits for 113 MPSS Rs. 2500 2.83 Untied funds for 113 MPSS Rs.10,000 11.30 Total 41.25
B 2. Untied Grants for Sub Centres
Activity Item Unit Cost 2008 – 09 Untied funds to 250 sub centres Rs. 10,000 25. 00 Total 25.00
B3. Untied Grants and AMC for Primary Health Centres
Activity Item Unit Cost 2008 – 09 Untied funds and AMC grants for 76 Rs. 75, 000 57.00 PHCs Total 57. 00
B 4. Untied Grants and AMC for CHCs
Activity Item Unit Cost 2008 – 09 Untied funds for 7 CHCs Rs. 1 lakh 7.0 Total 7.0
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B 5. Mobile Medical Unit
Activity Item Unit Cost 2008 – 09 Medical Van Rs. 7 Lakhs 7. 0 Accessories Rs. 18 lakhs 18. 0 Recurring cost Rs. 15 Lakhs 15. 0 Total 40.00
B 6. Upgrading CHCs to IPHS Standards
Activity Item Unit Cost 2008 – 09 Construction of new staff Qtrs in 3 CHCs 100 lakhs 300.0 Equipment for 5 FRU 25. 00 Lakhs 125.0 Medicines Rs. 5 Lakhs 25. 0 Purchase of 5 generator sets Rs 2 Lakhs 10. 0 Total 460.00
B 7. Upgrading PHCs to 24 x 7 service IPHS Standards
Activity Item Unit Cost 2008 – 09 Construction of new buildings for 3 Rs. 50 Lakhs 150.0 PHCs Construction of staff quarters 2 PHCs Rs. 50 Lakhs 100.0 Addition of Labour rooms, in 58 PHCs Rs. 2 Lakhs 116.00 Addition of OT in 55 PHCs Rs. 5 lakh 275.00 Addition of water and electricity in 26 Rs. 4 Lakhs 84.00 PHCs Equipments, beds, medicines and Rs. 5 lakhs 60.00 furniture for 12 PHCs Total 785.00
B 8. Upgrading Sub Centres to IPHS Standards
Activity Item Unit Cost 2008 – 09 Construction of 50 sub centres Rs.10 lakhs 500.00 Repair of 50 sub centres Rs. 2 lakhs 100.00 Provision of water supply in 97 sub Rs. 1 lakh 97.00 centres Provision of electricity in 123 sub Rs. 50,000 61.50 centres Provision of toilets in 100 sub centres Rs. 25000 25.00 Total 783.50
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C 1. Immunisation
Activity Item Unit Cost 2008 – 09 Preparation of microplans in all villages, Rs. 1 Lakh Per block 9.00 after training in all 12 blocks Mobility to MOH for supervision Rs. 50000 0.50 Health days at 1987 AWCs Rs. 25 per AWC per month 5.97 Evaluation coverage survey of the Rs. 5 lakhs 5.00 district Total 20.47
National Disease Control Programmes
D 1. RNTCP
Activity Item Unit Cost 2OO8 – O9 2OO9 1O 2O1O 11 2O11 12 As per RNTCP programme norm
D 2. Leprosy
Activity Item Unit Cost 2OO8 – O9 2OO9 1O 2O1O 11 2O11 12 As per NLEP programme norm
D 3. National Anti Malaria Programme
Activity Item Unit Cost 2OO8 – O9 2OO9 1O 2O1O 11 2O11 12 As per programme norm
D 4. Other Vector Borne Diseases, Cutaneous Leishmaniasis
Activity Item Unit Cost 2OO8 – O9 Entomological survey by NICD Rs. 5 Lakhs 5.OO Delhi Drugs for treatment Rs. 3 lakhs per year 3.OO Cost of insecticides Rs. 1O Lakhs per year 1O.OO Spray cost of wages Rs. 1OO x 9O days x 6 persons O.54 Operationalisation of Plague Cost of staff, 3O.OO 87
Surveillance Unit at Rohru Cost of travel of field staff Cost of sampling Total 48.54
D 5. Blindness Control Programme Activity Item Unit Cost 2OO8 – O9 2OO9 1O 2O1O 11 2O11 12 As per NBCP programme norm
D 6. Integrated Disease Surveillance Programme
Activity Item Unit Cost 2008 – 09 Procurement of Rapid water test kits Rs.30 per kit 3.60 12000 Procurement of Transport media 1500 Rs. 50 per kit 0.75 100 Kit for Weil Felix test for Scrub Typhus Rs. 30 per kit 0.03 Total 4.38
D 7. Iodine Deficiency Disorders (IDD Activity Item Unit Cost 2OO8 – O9 IEC for IDDs Rs. 1 lakh 1. 00 Kit for salt testing Rs. 1 lakh 0.50 Total 1.50
D 8. School Health Service
Activity Item Unit Cost 2008 – 09 Cost of 1,00,000 health cards Rs. 10 10.00 Cost of drugs Rs. 1 lakh per 9.00 block Mobility POL Rs. 50000 per 4.50 block Cost of travel for visiting schools Rs. 2 lakhs per 18.00 block Total 41.50
INTERSECTORAL CONVERGENCE Activity Item Unit Cost 2008 – 09 Meetings of the Block Rs 1000 /meeting x 12 blocks 1.44 Committees x 12 months Untied funds for 145 ISM AHCs Rs.10000 14.50 Untied funds for 3 ISM hospitals Rs. 1 Lakh per institution 3.00 Total 18.94
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Community Action Plan
Activity Item Unit Cost 2008 – 09 District level PARIKAS meeting Rs. 2 lakhs 2. 00 once a year 12 Block PARIKAS Rs.10000 4.80 Meetings quarterly Per meeting 6.80
Public Private Partnership
Activity Item Unit Cost 2008 – 09 Feasibility Study Rs. 3 Lakhs 3.00 Implementation of PPP Rs. 5 Lakhs 5.00 MNGO Scheme Rs 5 lakhs per block 60.0 Total 68.00
Gender and Equity
Activity Item Unit Cost 2008 –09 IEC for PC and PNDT Rs. 1 Lakh Per year Per 12.00 Act block Support for District AA Rs. 3 Lakhs 3. 00 Total 15.00
Capacity Building
Activity Item Unit Cost 2008 –09 Training of PARIKAS Rs 5000 per training batch 20.00 members in NRHM 400 batches of 20 for 2 days ToT at SHFWTC Shimla Rs. 20,000 0.20 for 10 persons once Training material Rs. 10000 per training batch 20.0 Total 40.20
Human Resource Plan
Activity Item Unit Cost 2OO8 – O9 As per policy of State Government
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Procurement and Logistics
Activity Item Unit Cost 2008 – 09 Construction of ware house at ZH Rs.50 Lakhs 50.0 Dharamshala Development of computerized system Rs. 5 Lakhs 5.0 for warehouse Construction of central store rooms in Rs. 10 Lakhs 120.00 12 Blocks Per block Trainings in logistics and store Rs. 5 Lakhs 5.00 management Software for inventory management Rs. 5 Lakhs 5.00 Total 185.00
Demand generation (IEC)
Activity Item Unit Cost 2008 – 09 Hiring a TSA and IEC strategy Rs. 35 Lakhs 35. 00 implementation MSS in all 369 villages Rs. 1200 er annum 46.42 Total 81.42
Financing of Health Care
Activity Item Unit Cost 2008 – 09 Seed money to RKSs Rs. 0.5 Lakh per 38.5 77 PHCs, PHC 14.0 14 CHCs , Rs. 1 Lakh per 6. 00 1CH CHC and CH 5. 00 1 ZH Rs. 5 Lakhs per RH Total 63.50
HMIS, Monitoring and Evaluation
Activity Item Unit Cost 2008 – 09 Internet connectivity for 12 Block CHCs Rs. 25, 000 per 3.00 CHC AMC for computers Rs. 10, 000 Per 2.00 system Training of 35 managers in data utilization Rs. 2500 Per 0.90 person Training of PRIs in NRHM MIS Rs. 500 Per person 37.50 Total 43.40
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ANNEXURE 1 FACT SHEET DISTRICT SHIMLA
• Population ( As per 2001 Census ) :
Male 3,80,244 Female 3,41,501 Rural 5,54,912 Urban 1,66,833 Sex ratio 898 Density of population (per KM²) 141 Total Population 7,21,745
• People and Culture :
Major Religions Hindu Languages Spoken Hindi,Pahari Culture Pahari Traditions Pahari Economy Based upon Agriculture
• Literacy Rate Aggregate ( As per 2001 Census):
Male Literacy 87.72 % Female Literacy 70.68 %
• Geographical Area ( in KM²) : 5131 sq. km
Forest Area (by Village Paper 1999 2000) 119331 Hect. Cultivated Area (by Village Paper 1999 2000) 101160 Hect. Unusable Area (by Village Paper 1999 2000) 49051 Hect. Longitude East(76º59'22'' 78º18'40'') Latitude North (30º45'48'' 30º43'0'') Major Rivers Sutlej , Pabbar , Giri
• Climate:
Humidity (at Hqr.) 89%(Max.) 51%(Min.) Rainfall 1252.6 mm ( Average) Temperature 33.3ºC(Max.) 3.1ºC (Min.)
• Distances : 91
Nearest Railway Station Shimla (1 Km from Mall Road Shimla ) Jubbarhatti Airport ( 14 Kms from Bus Nearest Airport Stand Shimla .)
• Administrative Set up :
No. of Sub Divisions 7 No. of Tehsils 12 Tehsils,5 Sub Tehsils Development Blocks 9 Panchayats 331 Villages 2895 Patwar Circles 257 Kanungo Circles 32
• Education (As on 12 07 2001):
Primary Schools 1616 Middle Schools 264 High Schools 157 Sr. Secondary Schools 9 Engineering Colleges 0 Medical Colleges 1 Other Colleges (in Shimla Town) 4 University 1
• Animal Husbandry ( As on 12 07 2001) :
Hospitals 36 Dispensaries 194 Mobile Units 2 Others / Farms e.t.c. 25
• Cattle Population ( As per cattle census 1992 ) :
Cows 327690 Buffaloes 22450 Poultry 45050 Others 248474
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• General ( Per 1000 ) :
Telephone Connections per 2000) 74.5 Length of Pucca Roads 2048 Length of Kutcha Roads 1172 Number of Post Offices 348 Electrified Villages 100% Nationalized Bank Branches 122 Name of Lead Bank UCO Bank Cooperative Bank Branches 42 Major Crops ( Rabi ) Wheat , Potato Major Crops ( Kharif ) Maize,Rice,Potato
• Health Setup ( As on 12 07 2001 , CMO Office Shimla ) :
Regional Hospitals 1 Block Hospitals (Civil) 9 PHC s / Sub Centres 313 Subsidiary Health Centres 30 Dispensaries 30 Ayurvedic Hospitals (as on 31 12 2000) 2 Ayurvedic Dispensaries 147
• Welfare Pensioners :
(a) Pensioners :
Old Age 14872 Handicapped 1481 Widow 6154 Lepor 307 2434 NSAP
Total 25248
(b) Disability Card Holders :
Blindness 422 Low Vision 198 Hearing Impaired 589 Locomotor disability 3219 93
Mental illness 35 Mentally Retarded 194 Leprosy Cured 23
Total 4780
• Assembly Constituency details :
Name Male Female Total No. of electors Rampur(SC) 31970 29122 61092 Rohru 32396 30637 63033 Jubbal Kotkhai 26149 25860 52009 Chopal 25593 23953 49546 Kumarsein 28473 28121 56594 Theog 27335 26495 53830 Shimla 40900 27662 68562 Kasumpti(SC) 45473 38050 83523
Total 258289 229900 488189
District Rural Development Agency :
MAJOR SCHEMES BEING IMPLEMENTED BY DRDA
Swaranjayanti Gram Swarozgar Yojna
Date of launch of Programme : April, 1999
Salient Features:
Aims at establishing micro enterprises by building potential of rural poor into collective Groups & imbibing a spirit of entrepreneurship of the Individual.
Assistance upto Rs. 1.25 lacs provided to a Self Help Group against taking a key activity subject to maximum of 50% of the total project cost and for individuals 30% subject to maximum of Rs. 7,500/ . For ST / SC the limit is 50% subject to maximum of Rs. 10,000/ .
Allocation of funds:
(Rs. In lacs)
1999 2000 2000 2001 2001 2002 2002 2003 2003 2004
59.439 43.535 29.02 56.86 81.32 94
Progress:
Self Help Groups formed = 463
Groups taken up economic activity = 147
Total credit disbursed = 407.88 lacs
SWARANJAYANTI GRAM ROZGAR YOJANA (SGRY)
Date of launch of Programme: April, 1999
Salient features :
To provide additional wage employment in all rural areas and thereby provide food security and improve nutritional levels. The scheme also aims at the creation of durable community, social and economic assets and infrastructural development in rural areas.
SGRY I
Allocation of funds:
Funds released during 2003 2004 Rs. 81.17 lacs
Funds utilized Rs. 58.43 lacs
No. of works undertaken 1255 Nos.
Employment Generated 99330 Nos.
SGRY II
Funds released during 2003 2004 Rs. 83.80 lacs
Funds utilized Rs. 69.86 lacs
No. of works undertaken 958 Nos.
Employment Generated 160339 Nos.
Indira Awas Yojana (IAY) (Special Programme)
Salient features:
Aims at providing houses to the houseless rural poor by giving financial assistance. The programme has two components, viz, construction of new houses and up gradation of the existing houses by the rural poor. The quantum of assistance is Rs. 22,000/ for new construction and Rs. 10,000/ for upgradation. 95
Funds to be allocated Rs 51.56 lacs
Houses to be constructed 188 Nos.
RURAL SANITATION PROGRAMMES
A proposal under the total Sanitation Programme with a project outlay of Rs. 7.78 Crores has been sent to the Govt. of India. The project aims to improve the quality of sanitation in the rural areas by sensitizing the rural poor through education and inoculating sanitation habit among the school children and to provide cost effected and suitable technology in sanitation. The project on its execution would reduced the water and sanitation related problems.
INSTALLATION OF HYDRAMS
(Pilot Project)
(DEVELOPMENT OF WASTELAND & MARGINAL LAND BY USING APPROPRIATE TECHNOLOGY
• PROJECT COST Rs. 282.47 lacs • HYDRAMS TO BE INSTALLED 100 Nos. • PROJECT PERIOD 1999 2000 TO 2002 2003 • AMOUNT RELEASED
Total Rs. 207,88,750/
Total Expenditure
Total Rs. 192.67 lacs
HYDRAMS INSTALLED 51 Nos.
IN PROGRESS 24 Sites
The installation work of the Hydram is being taken up by HIMURJA.
INTEGRATED WASTELAND DEVELOPMENT PROJECT (IWDP I)
(1999 2000 04)
AREA TO BE COVERED 7386 h.a.
PROJECT COST Rs. 2.95 Crores
IMPLEMENTING BLOCKS Mashobra, Theog & Basantpur 96
NO. OF MICRO WATERSHEDS 14
(Mashobra 6, Theog 3 & Basantpur 5)
FUNDS RECEIVED (31.10.2003) Rs. 199.61 Lacs.
EXPENDITURE Rs. 135.20 Lacs.
BALANCE Rs. 64.41 Lacs
INTEGRATED WASTELAND DEVELOPMENT PROJECT (IWDP II)
(2001 2002 2003 2004)
AREA TO BE COVERED : 12420 h.a.
PROJECT COST : Rs. 4.97 Crores
IMPLEMENTING BLOCKS : Rampur and Chopal
NO. OF WATERSHEDS : 21
(Rampur 12 Chopal 9 )
FUNDS RECEIVED (31.10.2003) : Rs. 226.55 lacs
EXPENDITURE : Rs. 184.80 lacs
BALANCE : Rs. 41.75 lacs
INTEGRATED WASTELAND DEVELOPMENT PROJECT (IWDP III) (2003 2004 to 2007 2008)
AREA TO BE COVERED : 6000 h.a.
PROJECT COST : Rs. 3.60 Crores
IMPLEMENTING BLOCKS : Jubbal and Rohru
NO. OF WATERSHEDS : 12
(Jubbal 7; Rohru 5 )
FUNDS RECEIVED (31.10.2003) : Rs. 58.00 lacs
Proposal under Submission under IWDP for Development Block Chhohara
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ANNEXURE 2 FACILITY SURVEY ANALYSIS, DISTRICT SHIMLA
SUB CENTRE 25O 1. Condition of building Sub centres in Govt buildings 137 Sub centres in private buildings 113 Sub centres in donated or free buildings 1O1 Sub centres in rented buildings 12 Sub centres requiring major repairs 13O Sub centres without water supply 97 Sub centres without electricity supply 123 Sub centres without toilet facilities for clients 113 2. Manpower Sub centres with only FHW 68 Sub centres with only MHW 33 Sub centres with both 116 Sub centres without both (closed ) 39 Sub centre serving more than 3OOO population 6 ( Shingla, Baldeyan, Kohbag, Chanawag, Bainsh and Kansakoti, 3. Drugs Kits Sub centres without medicine or drug kits nil 4. Equipments Sub centres without adequate equipments nil 5. Furniture Sub centres without adequate furniture nil 6. Residential accommodation Sub centres without residential accommodation 113
PRIMARY HEALTH CENTRE 76 1. Condition of building (Mention Numbers ) PHCs in Govt buildings 35 PHCs in rented or private buildings 41 PHCs requiring major repairs 18 PHC without water supply 26 PHC without electricity 21 PHC without Labour Rooms 58 PHCs without Operation Theatres 55 PHCs without separate toilets for patients 41 PHCs without bio medical waste management system NIL PHCS without Laboratory 41 PHC without RKS 15 PHCs without vehicle 66 Any other deficiency
2. Manpower PHCs without a single MO 12 PHCs without Pharmacists 48 PHCs without HE or BEE 76 PHCs without Staff Nurse 49 98
PHCs without LT 64 PHCs without MHS 75 PHCs without FHS 76 PHCs without FHW 68 PHCs without Class IV 23
3. Equipments PHCs without equipments as per IPHS 76 4. Medicines PHCs without essential drugs as per IPHS
5. Beds PHCs without beds or less than 6 beds 52 6. Other facilities PHCs without telephone 75 PHCs without generator 76 PHCs without Computer 76 7. Residential Accommodation PHCs without residential accommodation 55
COMMUNITY HEALTH CENTRES 7
2. Condition of building CHCs in Govt buildings 7 CHCs in rented or private buildings nil CHCs requiring major repairs 7 CHC without water supply nil CHC without electricity nil CHC without Labour Rooms nil CHCs without Operation Theatres 3 ( Sunni, Chirgaon and Nerwa CHCs without separate toilets for patients nil CHCs without bio medical waste management system nil CHCS without Laboratory nil CHC without RKS nil CHCs without vehicle nil Any other deficiency
2. Manpower CHCs without a single MO 1 recently upgraded CHC Tikkar CHCs without Secialists 7 CHCs without Pharmacists 3 (Tikkar, Chirgaon and Nerwa CHCs without HE or BEE 6 CHCs without Staff Nurse nil CHCs without LT 2 CHCs without MHS 3 (Tikkar, Chirgaon and Nerwa CHCs without FHS 5 (Tikkar, Chirgaon, Nerwa, Kotkhai, Nankhari CHCs without FHW 5 CHCs without Class IV nil
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3. Equipments CHCs without equipments as per IPHS 7 4. Medicines CHCs without essential drugs as per IPHS nil
5. Beds CHCs without beds or less than 3Obeds 5 ( Sunni, Chirgaon, Kumarsain, Tikkar, and Nerwa 6. Other facilities CHCs without telephone 2 (Tikkar and Nankhari CHCs without generator 7 CHCs without Computer nil 7. Residential Accommodation CHCs without residential accommodation 7 (Accommodation only for MOs
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Annexure 3. Recommendations of Blocks
1. Block Sunni (Basantpur) 1. PHC Jalog and Ghaini should be upgraded as 24 x 7 PHCs. 2. Sub centre Karachi should be relocated to Poabo which is centre of the Panchayat. 3. Sub centre Jajehar should be relocated to Garkahan, which is the centre of GP Jajehar. 4. PHC Chabha should be shifted to block HQ Basantpur, which has only sub centre. 5. 5 Gram Panchayats without health sub centre may be provided a sub centre. 6. 2 Gram Panchayats are without any health institution. Some HI should be opened in these Panchayats.s
2. Block Matiana(Theog) 1. Block is without a CHC. PHC Matiana should be upgraded as CHC. 2. PHC Dharampur should be upgraded as 24 x 7 service delivery PHC. 3. 2 Gram Panchayats, Kelvi and Deorighat has two sub centres each. Shift one of the sub centres to Gram Panchayats Rauni and Jais. 4. Sub centres Aloti, Bajrolipul, Janahan, Chair, Keet and Joy Kasna should be relocated to the centre area of the concerned Panchayat. 5.7 Gram panchayats without any HI should be provided with a HI.
3. Block Mashobra 1. PHC Shoghi and Kufri should be upgraded as 24 x 7 service delivery PHCs. 2. Sub centre Kwara should be shifted to centre place at Mehli. Sub centre Shatlai should be shifted to Neen. 3. Sub centre Poabo in Gram Panchayats Poabo (2 sub centres) should be shifted to Gram Panchayat Dhamun, which is without a sub centre. 4. Four sub centres, namely Baldeian, Bainsh, Chanawag, and Kohbag cover more than 3000 population. Additional HW should be provided in these subcentres. 5. 8 Gram panchayats are without any HI, hence any HI may be opened. 6. One PHC should be opened at Dargi ,a difficult area.
4. Block Kumarsain (Narkanda) 1. CHC Kumarsain should be upgraded as FRU. 2. PHC Narkanda, Shamathala and Kotighat should be ugraded as 24 x 7 service delivery PHCs. 3. PHC Virgarh should be shifted to Khaneti Gram Panchayat. 4. One Panchayat, Mailan is without a HI. A sub centre should be opened here.
5. Block Nankhari (Rampur) 1. PHCs Kholighat and Taklech should be upgraded as 24 x 7 service delivery PHCs. 2. 3 Gram Panchayats (Shahdhar, Kool & Jhakhri) are without a HI. Some HI should be opened in these Panchayats.
6. Block Kotkhai 1. CHC Kotkhai should be upgraded as FRU. 2. PHCs Kiari, Himri, Giltari, Sawra and Mandhol may be upgraded as 24 x 7 service delivery PHCs. 3. 5 Gram Panchayats are without HIs. Some HI should be opened in these Panchayats.
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7. Block Nerwa (Chopal) 1. CH Nerwa is not properly equipped and staffed to serve as FRU. There are only 6 beds on the pattern of PHC. Infrastructure needs to be strengthened. 2. PHC Throach should be upgraded as 24 x 7 service delivery PHC. 3. PHC Rewalpul should be shifted to Jhiknipul and sub centre at Jhiknipul may be shifted to Reawalpul. There is no feeding population at Rewalpul. 4. Sub centre Kashan should be relocated to the centre of Gram panchayat Bamta. 4. 10 Gram panchayats are without any health institution. Some HI should be opened in these Panchayats. 5. A PHC may be opened at Dhar Chandna, a difficult area.
8. Block Chirgaon (Chhohara) 1. PHC Kwar and Ghoshali should be upgraded as 24 x 7 service delivery PHCs. 2. One Gram Panchayat is without any HI.A sub centre should be opened here.
9. Block Tikkar(Rohru) 1. PHC Pujarli 4 may be upgraded as 24 x 7 PHC. 2. PHC Dharada needs to be closed down. 3. Sub centre at Kansakoti has population more than 3000. Additional HW should be provided here. 4. 2 Gram Panchayats are without any health institution. Some HI should be opened in these Panchayats.
ANNEXURE 4 FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK: MASHOBRA Randomly Selected Panchayats: Meolbari, Ghachech, Dhamoon, Patgar, Mundaghat, Jabri, Bhaut, Kanda, Chailly, Saulaghat, Chamyana, Satlei, Cheri,Majthai, Kot, Okhru, Baldyan, Chanawag FGDs conducted in the third week of April Family Planning Nutrition RTI/STI TB and ARSH ORT/ARI Son preference Convergence Health MCH among mothers Diarrohea and New and Domestic Institutions and and children Born Violence Instituti onal Delivery Condom should Extra diet is Knowledge A patient is This is the age Knowledge Son preference is PARIKAS or Doctor should Doctors be available at required during of STI/RTI treated at when good and about ARI is there. VHWSC exists visit a S/C once atKNH more places. pregnancy and a was good. home for nutritious diet is adequate. but the a week. during lactating mother 10 to 12 required. members delivery should get more days, if he would not ask for of milk and green has cough attend without kit and vegetables. and cold. any medicin Taken to remuneration. e worth hospital Rs. after that 1500. It period. should be reduced. Though women AWs supply food Husbands People in We prefer to live Use of Girls opinion is Bleaching or People do not Home knew that to pregnant generally do not the villages in friends’ circle. colostrums considered when Chlorination of carry good delivery tubectomy is a ladies. take the medicine are not is common. marrying her. water should opinion about is much difficult even when the informed be in its government cheaper. operation but less doctor prescribes about TB. agenda. HIs. Even Class We give men come medicine for both The IV misbehave to forward for man and woman. medicine is with the midwife vasectomy. given to patients. accordin them but g to our nobody wish. explains about the effects of medicine.
SIHFW Parimahal, Shimla 9 103
Condom among Respondents Respondents DOTS Those found Some of the No domestic Health Mela Costly KNH men and oral pills knew the purpose admitted that medicine intoxicated mothers violence today. has not been medicines are does not among women for which IFA they go to should be should be heavily nourished organised. If generally pay any are popular tablets are given hospital only available at penalised. their arranged prescribed heed to spacing methods. and they use when the home the nearest children on community which are referenc these. remedies fail to place. mothers’ support would beyond the e made address the milk for be there. purchasing by S/C. disease. three years. powers of the It should One had to villagers. be use milk valued. bottle from the very beginning as she felt dry. Character of a Today’s children Bedding with Tap water Information Though Girls should not Annual Health S/C should be Generall female is at stake are more other than is taken about periods and ORS is be highly Plan (AHP) strengthened; y if after delicate. They husband is there direct. sexual health given, yet educated because should be doctors in the recomm vasectomy, she need more care but only in very Boiling of should be given there was equally educated prepared. Not hospitals endation gets pregnant. and nutritious few cases. water and in schools. not partners are being done at behave well of a food. then sufficient lesser present. with the patients high up drinking it knowledge. commodities. and medicines is is not IEC on ORS are available in required followed. is required. HIs. for getting admissio n in KNH. Generally, Calcium tablets IEC on these Go to Respondents Syrup PCM Son is the choice Three priorities Nurses in Ambula mother in law be made diseases shall be hospital preferred to and septrain of one and all. for AHP are: 1. hospital nce forces couples to available in HIs. beneficial when all discuss about is available Conducting misbehave. charges have more than A woman, after because there is domestic ARSH with in plenty for blood tests in should one child. 45, needs such mixed reaction remedies friends. ARI cases in S/C; 2. Buy be tablets. about the for cough HIs. certain reimburs knowledge of fail. It instruments for ed when these. takes about S/C and one goes a month. 3.Emphasis on for sanitation and institutio potable water. nal 104
delivery. Copper T is Pressures of Expectations of a Transmit There is no Each considered as friends during son remains even information privacy in village harbinger of marriage if there are two about government should diseases. Condom functions lead to daughters in the PARIKAS hospitals and so have a and Oral Pills are bad habits. family. Elders private clinics trained taken, though also force a are preferred. midwife. oral pills lead to couple to have a weight gain. son. Traditionally it is School teachers Female members Doctors in Felt need for a JSY the woman who and parents of the family AHC do not Refrigerator for should undergoes FP should be well should get up know how to S/C was be operation. informed about early in the diagnose the expressed. extended ARSH so that mornings, illness. to all they understand otherwise there is categori the problems of danger of words es of adolescents. exchange. women. It is common Both boys and There are no Behaviour of PHC saying that if girls suggested to toilets at the doctors need Dhami longer gap have Health homes. Elders to be improved. should between two Melas in the are opposed to have the children is villages. constructing facilities maintained, then toilets within of there is danger of the residential conducti not conceiving. premises. ng deliverie s. Mahila Mandals Adolescents Acute shortage S/C should be Preferen should also prefer private of drinking opened at or tial distribute doctors for their water. Taps run transferred to treatmen condoms. problems. Why? for 15 minutes central places. t in a day. Mundagahat is hospitals one such place should where a S/C be should be. checked. First come, first serve 105
should be the basis. 17% of girls Schools have There is huge Midwive indulge in pre toilets but no rush in s in the marital sex and water, so hospitals. It can villages give birth to closed. be reduced if are babies. There is doctors start untraine great need of visiting S/C d. counseling regularly. centres. Bidi smoking is Bawri water is Injections In common. used. It should prescribed by hospital, be cleaned the hospitals are during every month. not injected by delivery, S/C staff. They more should do it and medicin trained for the es are purpose. asked for and far less are consume d. Adopt ‘bad’ PARIKAS IRDP family quickly from TV functioning. should get free and not ‘good’. medicine. Training of Central Kanda Knowledge parents on ARSH Jail has about donating is essential. increased the eyes should be pollution. It given. has enhanced the incidence of diseases. AWs should No staff have available at immunization Sanjauli during 106
facilities. night. There should be a provision in NRHM for a Workshop every month on various health issues at the Panchayat level.
FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK: MATIANA Randomly Selected Panchayats: Ghar Bharana, Kot Shilaroo, Shari, Barog, Majhar, FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Condom These are Knowledge TB is a Bidi, Knowledge Under No Hospitals Deliveries in should be elders who of STI/RTI problem cigarette, about ARI intoxication, awareness should be Theog available at tell the is there but and people liquor and is there is about neat and Hospital. more places. pregnant details are die of this bhang are adequate. domestic PARIKAS or clean and 10% do ladies what not known. disease. commonly violence. It VHWSC. medicines deliveries at food has to A seminar taken by is on the be made homes Knowledge be taken or adolescents. wane now. available because about untied and what workshop there. there is more funds is has not to would help care and less there. be taken. people. expensive. Though Mother in Leucorrhea AW Opium is Use of Girls now No health Behaviour Midwife is women law forces a is not should be not used. colostrums go in for Mela has of S/C staff not trained knew that pregnant common, DOTS is love been is good but and once a tubectomy is lady not to but a few provider.. common. marriage. arranged in people do child died a difficult take the IFA women the not visit too. For high operation tablets. have it. Panchayat so S/Cs for risk but less men far. paucity of deliveries, 107
come medicines we go to forward for there. hospitals. vasectomy. Condom Multi TB patient Those who Domestic Son Untied funds Both Theog To have among men partner sex is kept in take bhang medicines preference should be and KNH deliveries in and oral pills is a story of isolation say that are tried is there and used for: are costly hospitals is a among the cities in villages. their before his birth is hospitals. costly affair. For nutrition women are and not of appetite has taking the celebrated Behaviour of pregnant popular the improved child to with pomp of staff women; spacing villages. since they HIs. and nurses is too methods. have started splendour. For arranging bad. In both taking it.. First Aid kit these hospitals, Cleansing urban traditional patients are water sources better For cleaning attended to. S/C and its surroundings. Men do not Easy to Though Arrange Bidi, Though Parents AHC has Theog Aftercare at enjoy the preach but women awareness cigarettes ORS is decide who ample hospital is home by a intercourse the reality is find no camps on etc are sold given, yet the medicines, dirty while midwife is using different. hesitation TB. to those there was bridegroom there is no KNH is much better. condom. It Sometimes talking to under 18 not would be. dearth of tolerable. She does sometimes we do not male also. There sufficient Girl’s these. massaging gets torn have doctors or is no check knowledge. opinion is and makes during the enough to MPW, yet on it. IEC on seldom and let use process and have two to discuss ORS is considered. ‘gaachi’. its disposal square such required. after use is a meals, so matters problem. tonics etc. with a lady be made doctor or available MPW (F) free of cost. is easier. Generally, Mother’s Not Diarrhea Adolescent Women, Three S/C should If the mother in milk is good satisfied is sex is there even priorities for have enough midwife is law forces for the with the common though not educated AHP are: 1. medicines. good, ladies couples to child, they treatment in villages in a bigger and older Conducting would prefer have more know it. But meted out during the ladies are blood tests in to have 108
than one what is bad to the rainy scale. beaten. S/C; 2. Buy deliveries at child. in bottle’s respondents season. certain home. milk is not in Matyana instruments known to or Theog for S/C and the hospitals. 3.Emphasis respondents. Doctors do on sanitation not give and potable patient water. hearing. Copper T is Weaning No privacy ORS and Bhang is There Transmit There were considered starts when in hospitals Jeevan made in the should be a information divided as harbinger Pandit give and Rakshak villages workshop about opinions of diseases. auspicious information Ghol is from the for women PARIKAS about PRIs Condom and time to start about the given to plants. It is on handling Oral Pills it. It could patient is the costly, if it Women’s S/Cs. are taken, be after four leaked out. patients. has to be rights and though oral months or purchased. various pills lead to could be other laws. weight gain. after eight months. Traditionally IFA tablets Medicines Nutritious The main Doctors in There JSY should it is the be kept in be made food is a cause for AHC do not should be be extended woman who AWs as available in necessity domestic know how to 24X7 Sub to all undergoes well as the during this violence is diagnose the centres too. categories of FP S/Cs. Locks hospitals period of intoxication. illness. women. operation. there are life. It needs to great be checked. dampers. It is Knowledge Organise Lecture by A There are no All minor PHC Dhami common about awareness doctors and committee toilets at tests be should have saying that if anaemia is or health be formed homes. conducted in the facilities longer gap needed. treatment educators in at Elders are S/Cs. of between two Elders ask camps in schools on Panchayat opposed to conducting children is the pregnant the ARSH level where constructing deliveries. maintained, ladies to hospitals. prayers of toilets within then there is cook food the harassed the danger of in iron woman be residential not vessels. heard. premises. conceiving. 109
Mahila S/C and Iron tablets Son is Acute Awareness Preferential Mandals AW should be available preferred shortage of Camps and treatment in should also act as the in schools. because drinking Swasthya hospitals distribute basic unit with him a water. Taps Melas be should be condoms. for health, daughter in run for 15 arranged in checked. well law would minutes a villages. First come, equipped also come day. first serve with staff who would should be and be looking the basis. medicine after the and household. knowledge. 17% of Schools have Not satisfied Midwives in girls toilets but no with the the villages indulge in water, so working of are pre marital closed. both the untrained. sex and PHCs and give birth S/Cs to babies. because There is these have great need no of medicines counseling other than centres. paracetamol. Bidi Bawri water Charges for In hospital, smoking is is used. It tests be during common. should be reduced. delivery, cleaned every more If a student month. medicines standing are asked for first or and far less second in are the class consumed. smokes, the others follow him. Adopt ‘bad’ PARIKAS S/Cs should quickly functioning. be from TV transferred and not to central 110
‘good’. places in the Panchayats. Training of Untied funds parents on are kept in ARSH is banks. essential. 50% boys AWs should smoke and have 20 % are immunization invoved in facilities. sex.
FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK: SUNNI Randomly Selected Panchayats: Chebri, Basntpur, Bhawan, Ogli, Himri, Domehar, Ghaini, Rewag FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Prefer to A pregnant Little Knowledge Gutka Respondents Domestic RDD is doing its best Faith on Preference go for woman knowledge of about taking is go to violence is to achieve ODF by Khaira S/C for home permanent was given RTI/STI diarrhea is common hospital or there to a 2010 but the help and deliveries. method IFA tablets there among HI little extent cooperation of other On after the for 15 days because adolescents. immediately. and is departments including cases go to second only. majority of resolved in health would quicken hospitals. child newborn Panchayats. the proceedings. have attacks of diarrhea. Copper T Knowledge IEC on S/C staff Health Knowledge Dowry, as Chlorine tablets are not Doctors are Biggest results in about RTI/STI was delivers check up is of ORS is such, is no made available. available in problem backache nutritious forcefully lectures on done in there. problem Bleaching powder is CHC Sunni during and food to be recommended. diarrhea. schools but but that being used. all the delivery is to excessive taken after Hb test of much times. carry the bleeding. delivery is girl students amount as pregnant 111
Still it si not known. should be required woman to the most done. under the main preferred traditions road from method. has to be the village. spent. Tubectomy We are People were Lack of Boiled water Domestic Awareness camp on Satisfied A death is the most told to eat aware of knowledge is not taken. violence to PARIKAS is required. with the during accepted green HIV/AIDS. about the extent health pregnancy mode of vegetables ARSH. of calling services had occurred FP. but words only. being in the village monkey provided. about four menace years back. does not allow us to eat these as they destroy the crops. Males are Meals There is Chlorine Elder at PARIKAS and not We have to Importance not should not easy tablets are home VHWSC is there. take money of post natal interested only be accessibility available in expect a on loan care is in NSV. nutritious to alcohol S/C and son child. when we understood but also be and AWs. have to go by all. hot and tobacco. It to a freshly needs to be hospital. prepared. checked. Most Lactating The composition of Not About JSY, women use mothers PARIKAS is limited to satisfied they knew Mala N should be AWs, PS, Pradhan, with the that some and men given Mahila Mandal and working of money is use dalia, MPW (F). HIs because given to the condoms. green of non pregnant vegetables, availability lady under sprouted of staff. the scheme. daals and seasonal fruits. IFA tablets No knowledge about Staff be JSY money give posted on should be 112
troubled NRHM. all HIs. given prior stomach. to the delivery and not after the delivery has taken place. Bio waste management In hospitals and Immunisation is in more its agenda. attention is paid to the persons who have wires to pull and not on the emergent treatment required by certain people. Besides beautification Non of S/C, it has given availability money for of transportation of pharmacist pregnant women. in certain HIs. Untied fund should be spent on : 1. Requirements of pregnant women and their check up; 2. their transportation facilities; 3. Part time employee for 113
cleaning the S/C Deputing S/C staff to other places be stopped Ayurveda is good for certain ailments. The powers of Panchayat over the S/C be enhanced.
FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK:NERWA Randomly Selected Panchayats: Khoond Neel, Gorli, Dewat, Judu,Chaijan, Gorli, Bamta,Mafal, Saraha,Baur,Nanhar, Sari, Bhallu,Thana, Dharthana, Bijmal and Dhar Chandana. FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son preference Convergence Health MCH and Planning among Diarrohea and New and Domestic Institutions Institutional mothers Born Violence Delivery and children Tubectomy Sweet No TB is very Friends’ Depend on Son’s birthday is AW is Government Free is the ‘khira’ knowledge common pressures domestic celebrated. partial, helps hospitals ambulance popular made of about because of lead to medicines, those who are ignore us; service for mode of wheat is RTI/STI. poverty. intoxication. like dahi influential. private carrying a FP. given to a podina; hospitals pregnant woman sugar salt attend to us. wom an to who has mixture. the nearest delivered. hospital. Sweet increases the quantity of milk and kills wind. Condoms No Leucorrhea DOTS Girls get No money to Son is sent to a Selection in Doctors in Home are knowledge is common card their MTPs take child to good school. If IRDP is government delivery is available about IFA and holders go done in hospital government helps totally hospitals very in plenty continues to Kupvi private us financially, we wrong. Poor common. 114
but not tablets. even after once a clinics. immediately. will send girls families have misbehave. Mothers used. treatment week. also to good not been law conduct at PHC schools. included. deliveries. Kupvi. Oral pills Colostrums Multi A TB A small pill We give Problem of dowry AHCs neither MPW (F) Institutional lead to is given partner sex patient is costs ‘kachoor’ is there. immunize does not deliveries giddiness. and bottle used to be isolated in Rs.1200. A when a child nor attend to visit the can increase is not used. common the small suffers from delivery villages. if there are which is village. portion of it diarrohea cases. Not at all ambulances now is mixed in satisfied in the declining. water and with her villages. taken. working. Condoms No Apply TV has Know about A woman goes on Roads in bad No doctor at Small height are knowledge toothpaste great ORS. delivering till the conditions. Tharoach. woman goes available of in vagina influence on son is born. Difficulty in for in Post nutritious to check adolescents. visiting HIs. Caesarean. Offices food. ‘garmi ki and AWs. bimari’. Benefits of Nutritious Leucorrhea Awareness Drunkards beat VHWSC Not Chopal adequate food is far is common camps on their wives. Those exists. Did satisfied hospital space cry when in Kupvi. ARSH are who want to not know its with the refers cases between simple food A Health essential. marry again also functions. services of to Shimla. two cannot be Camp is recourse to AW. children is afforded. required. beating their known to wives. all. Condom is Mother Polyandry Dirty socks Three reasons for The meat Doctors in Post natal a killjoy. takes is are boiled violence: sellers clean government care is done Khinda practiced. and then the meat in hospitals by the 1. Jealousy Ghee, take that water is the running misbehave family aajwain taken to get 2. When drunk water. The so we go to members. water and a jolt. feathers of private panchmewa 3. When she killed rooster hospitals. laddu. does less are thrown work there. Anaemia is Ladies 80 to 90 % When a Post Lady Cowshed is common. know less of students traditional doctors. considered about in Marawag source of pious for 115
RTI/STI. school take water is delivery so it intoxicants. cemented, it is done Generally gets dried up. there. 15 % do sex. The Husbands Only 10 % AW is Nerwa is Home newborn is refuse to of useless. poor in all delivery is taken out of take adolescents There is no kinds of preferr home only medicine if use need of it. services. the homes when the for condoms Even where the Pandit problems while headache is lady is finds a of ladies indulging in not treated alone. She ‘lagan’. they have sex. there. stays at to take it. home till late and delivers there. Iodex, A generator Elders prefer Corex are is required home to used as in Nerwa. hospital for substance deliveries. abuse. Even S/Cs should teachers stay under join the the control students in of the taking government. intoxicants. A health A S/C at camp once Dhar in a month Chandana. in the schools be held. Not ready to listen to any advice. FOCUS GROUP DISCUSSIONS Shimla 116
HEALTH BLOCK:TIKKAR Randomly Selected Panchayats:Bhallara,Kutara, Bashca,Jagotti FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Condom is Know No Knowledge One out of More Son is PARIKAS Medicines be JSY is acceptable, what knowledge about eight take knowledge essential. exists but is made unknown. IUD is nutritious of diarrohea intoxicants on non available in troublesome. food is and RTI/STI. is there. and breastfeeding functional. HIs. give it to indulge in is required. the pre marital pregnant sex. ladies. Inclination Iodised They know Adolescent Know about Domestic No Rohru No post towards Salt is about girls were ORS violence is chlorination hospital to natal care by NSV. used. DOTS and non after of drinking be health its regular committal. consuming water. strengthened. workers. intake. liquor. Government IFA tablets Smoking Steam is Elders Open air MPWs do More supply of lead to and given to want that defecation is not visit the medicines Nirodh is gastric drinking is check ARI. the couple common. villages. and Calcium useless. troubles common. should tablets be and are have a son. made generally available. stopped before completing the full course. Elders are Bottle AWs are Preferential consulted at feeding is on doing good treatment in the time of decrease. It job. hospitals. going in for is common FP saying that bottle 117
operation. feeding leads to tonsilitis. FP operation Non of men availability make them of doctors in impotent. HIs is a big problem. Tubectomy is easier than Vasectomy. Condoms be made available in Panchayats. FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK:KOTKHAI Randomly Selected Panchayats:Pandranu, Dhar, Badhal, Kot Kaina, Thana, Solang, Himri, Baghi, Darkoti, Gumma, Purag, Kiari, Kathasu, Giltari, Prali (Badruni) FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Mala D is first IFA tablets Man does Knowledge Gutka is Know about Son Telephone PHC at Deliveries at preference. are not accept about TB is very ORS but preference. facility Pandranu. home and available at the adequate. popular domestic should be hospital. S/C. medicine among mixture is there in cut when a boys. given. off villages. woman has a disease for which both have to take the 118
medicine. NSV is not No We feel Have to They copy When Girls are Females Medicines Hospital i popular knowledge shy of walk long their newborn given tea work harder not far off and is because a man about stinking for taking elders. falls ill, whereas to run the available in expensive. has to do nutrition water DOTS. immediate the boys household in HIs. heavy work. requirement flowing doctor help get milk. a better way. of women. from is taken. vagina. Spacing BPL We do Arrange Girls also Mothers Girls are IPH water is No Hospital injectables (as families pranayam. Health take found to not not drinkable arrangement delivery has in Nepal) cannot give Melas and intoxicants have certain allowed to during rainy of three risks: could be the nutritious give but very poisonous go out of season. informing Money, favourite of food. detailed few. toxins homes higher ups transportation the people information (Moch) alone. if a calamity and chances here. on TB. cannot give Boys can takes place. of being milk to the do so. referred to child. Only Shimla. after going to the Pandit who gives water purified through mantras and is taken by the mother, she milks the child. No knowledge Iron Lady Pre Delayed Not heard Open Hospitals Little that NSV is utensils doctors marital health care is that after Defecation is should have payment easier. should be for sex is because of sons, a common. clean under PPP used to diseases there. shortage of daughter is toilets. acceptable if cook the pertaining money in the wanted but doctor comes food. to ladies. families. the reverse to Rohru or is daily Jubbal. heard. FP Camps STI is De Child Male child PRIs/User’s Limit the When should be kept a addiction specialists be is Group have User’s delivered in regularly secret. Go centres be pampered, little say in private 119
arranged. late to started appointed. girl child is health system Charges. hosp ital, JSY hospital. here. neglected. so less benefits were accountable not given. health delivery. Transportation 10% of the For Control of Security in JSY b enefits problems. girls breastfeeding Panchayat the be given to smoke and , mothers over S/Cs. hospitals be all. 15% follow updated. drink. blindly what the elders say. IEC required. IEC for 80% boys Knowledge PRIs should PHC There should popularizing smoke; of neonatal be given building far be no delay NSV 80% take care is poor. training on away from in getting the gutka and NRHM the locality. pregnant 5% drink It will not woman be useful. registered. Pre Instruments Privacy of A delivery in marital be allotted the patient the hospital sex is for testing the has to be costs about there. drinking considered. Rs.2000/ water. Medicines Because of without distance, explaining many women anything have about them delivered on are given to the roads. the patients All PHCs 60% of the are locked total in the deliveries are evenings. conducted in Residences private for doctors hospitals. be 120
earmarked. No check Money for on Bengali referral doctors. transport is insufficient. It should be increased. Female Health Worker has not conducted even a single delivery. FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK:NANKHADI Randomly Selected Panchayats: Taklech, Nirath, Kaleda Majhiothi, Bhadawali, Tipper Majholi, Shali, Racholi, Jeoritywal, Koot 15/20, Sarpara Samej 15/20, Baglati, Khuni Panoli, Dolfa, Shinula, FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Interference Knowledge Leucorrhea Knowledge Friends Newborn Son The staff at Adequate Rampur of elders in of nutritious is taken about TB force an are well preference AHC Sholi staff in S/C. Hospital spacing food is there casually is very adolescents looked is there. misbehaves refers the methods. but not and HIs are little. to smoke or after. with the pregnant necessary visited drink. patients. ladies to that it is when the Shimla or taken. situation does goes out of Caesarean hand. immediately. This hampers the ladies to go to the hospital for 121
conducting deliveries. The IFA tablets RTI/STI – A TB To a non Domestic A few No Behaviour Home difficulties are IEC is patient is smoker, treatment respondents knowledge of staff is deliveries with available required. isolated in smokers as well as said that about very bad. are common. Nirodh is and taken. the say, ‘you ORS is they would PARIKAS or There is a that it has villages. will die given to like to have VHWSC. myth that if to be kept early’ and the child only one the first born under lock he starts whenever child is a girl, a and key and smoking. it fall sick. whatever midwife does not its sex may massages the satisfy be. stomach of when used the lady and and then it next child is has to be son. buried somewhere. Present Colostrums Knowledge Knowledge Relatives Domestic The top of Preferential Behaviour of generation is now of about ORS make an violence is the Tank of treatment in the staff in is ready to given to the HIV/AIDS is not adolescent little and water is all HIs. Rampur accept newborn. – Yes. much but drink in that too open. Hospital is NSV. About to a Melas or because of Animals and wanting. RTI/STI, diarrohea weddings. alcohol. humans take IEC is patient, water from required. mint water there only. or sugar salt water is given. One child For first six People are Health Improve X Ray and Even IRDP norm is months shy of Education sewerage. Lab women have being water is also hearing lectures in facilities be to purchase practiced in given to the about schools. made medicines certain child with AIDS. A available in from the households. mother’s few of PHCs. market. milk. them left the place when AIDS was being 122
talked about. Bari made Does Other Staff Full faith on of wheat polyandry at midwives. and ghee is lead to Kholighat They can immediately STD? is not there. bring a child given to the Blood to proper lady after testing is position with she has not done. massaging. given birth to a child. Knowledge Nirodhs are Rampur is Post natal of why IFA easily our check up is is taken is available destination not done. lacking. and used by for adolescents. everything. Smoking Health Every among boys Institutions village and girls should not should have starts from be under a trained eighth the control Nurse. class. of Panchayats. Girls enjoy NRHM bidi and should pay some take for the entire liquor too. expenses on delivery of a child including hospital charges. Lady Medical teachers Bills are avoid very heavy. teaching Medicines ARSH should be subjects in free in 123
classes. hospitals. FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK:CHIRGAON Randomly Selected Panchayats: Bamfad, Tikkari, Jiskoon, Kewar, FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional mothers Born and Delivery and Domestic children Violence Elders AW Women Not much Sex Immunisation Women have Water First Home decide the gives have no is known education is universal. to take cleanliness domestic deliveries spacing extra knowledge about TB. in schools No newborn permission and treatment is are preferred methods to food about is bad. The is left without of the sanitation depended because it is be used. required these. children it. husbands for should be upon. a costly by the are getting taking arranged by affair in the pregnant spoiled. treatment. the hospitals. ladies. Panchayats. Nirodh is There is a They use Patient is Organise Knowledge Women get No Emergency Permission generally myth that local kept in awareness of ORT/ARI beatings knowledge of medicines of the elders acceptable. women grown isolation. camps. was found when the PARIKAS be made is necessary are not to herbs for wanting. males are though untied available in for take milk the drunk. fund and its PHCs. institutional as per treatment use is known. deliveries. orders of of these local diseases. deity. Only men and children can take milk. Tubectomy Women Lady Water is If there is Woman No health People have Class IV is the only get that doctors not boiled no cannot take mela was faith in employee operation food that required. even when restrictions meals that organized in deities and gets the for FP is left there is from home she likes. the go for delivery practiced over after diarrohea. for Takes only Panchayat treatment done in the entire spending that that has only when hospitals. 124
here. family money, the the approval area. they allow Doctors and has eaten. adolescents of the family them to do Nurses keep takes to members. so. themselves intoxicants. away. Tubectomy Because Husband When a Smoking is If she speaks Annual Very bad The in camps. AW doubts the woman common. of awareness health plan is behaviour medicines gives wife if she gets ill at , she is prepared by of health and other food to develops home, she thrown out of S/C. staff. necessary children, such is given her house. requirements they are diseases. domestic for sent treatment conducting hungry to in the deliveries AW. No beginning are food is and purchased given to brought to from the the hospital if market. children. there is no recovery. All in this In certain Wife If ‘talu’ of If the woman Untied fund S/Cs Deliveries small places attends an a child is unable to should also remain are village are AWs HI alone drops after bear son, she be used for closed. conducted in relations, give food to get diarrohea, is divorced giving help to Question of a private If bahu is to the treatment we go to and the man BPL families satisfaction hospital at working in children for these local vaid marries when they does not Rohru. a AW, to carry diseases. and hakim again. fell ill. arise. how can the for lifting her Chacha packet it up. or Mausa home can go to where it her and ask is shared for by all the condoms. members of the family. IUD Polyandry Jeevan Husbands Pradhans Supervision Heard of insertion in the area Ghutti is give money know only of HIs be JSY but be done by also leads given to to wives for that they had with funds lady to these newborn. treatment. signed Panchayats. provide doctors in diseases. cheques and under it are 125
AHCs. no more. too little. Mothers in Pradhan said law are not that he had happy with no role in those who Health’s have meeting. daughters only. When a Pradhan said daughter is without born, mother training he is would be congratulated useless in for her life health was saved meetings. and not that a child was born to her. Birth of any Water during child boy or the rainy girl is season is celebrated dirty. equally. Very few houses have latrines. PARIKAS is there but not functioning properly. FOCUS GROUP DISCUSSIONS Shimla HEALTH BLOCK:KUMARSAIN Randomly Selected Panchayats:Kotighat, Narkanda, Bhutti, Jarol, Deeb, Krewathi, Zar, Baragaon, Glane Shalota FGDs conducted in the third week of April Family Nutrition RTI/STI TB and ARSH ORT/ARI Son Convergence Health MCH and Planning among Diarrohea and New preference Institutions Institutional 126
mothers Born and Deliver and Domestic children Violence Condon, Mala Black Leucorrhea is Night Discuss IEC on People have Priorities Deliveries at D are available. gram, common. services ARSH ORT/ARI no preference for HIs: KNH, DDU Quality of fruit, available related is required. for any Adequate and condoms in S/C soup, in Civil matters with ‘pathy’. They medicines Sanitarium, is not good. spinach Hospital, friends and like both for Shimla has to be Kotkhai. sisters. Allopathy children; taken. and Ayurveda. Transport facilities; Awareness Camps; Laboratory services; Delivery facilities; 24X7 facilities. IUD creates Multi sex DOTS We take Newborn PRIs should Fee for Normal problems. partners exist. facilities intoxicants care is be given Parchi is deliveries at are given. just for the there but control over being Kumarsain heck of it. shortage of the Health charged. and Rampur: money in Institutions. Emergency the deliveries at households Shimla and means Rampur. delay in regular health check up and care. NSV is linked Condoms are Only their Malnutrition Disabled Residence Money with a myth that used to check utensils results in should get of doctors under JSY it affects the RTI/STI. are slow growth money for all be with the be given genital of man. separate and medicines HIs. prior to 127
otherwise weakness. from actual there is no PARIKAS delivery. isolation. through NRHM. With Nirodh, Multi partner Diarrohea Blood Lady Refer ring to enjoyment is sex is there. during testing be doctors be Shimla is lessened. rainy done twice appointed. generally season. in a year in done. schools. Both husband Men suffering Health Long date MPWs and wife take from semen check up be for X should visit decision as to discharge leave done in Raying is homes for what mode of coffee, garam higher given. This post natal FP has to be masale and classes of furthers the check up. adopted. other schools. disease. X spices.Ayurveda Rays be is also helpful in done in all such cases. PHCs. Condoms Awareness Knowledge JSY benefits should be camps for of AIDS is should be available at RTI/STI. adequate. extended to S/C, with all pregnant MMs,Panchayat ladies. Ghars, Yuvak Mandals. Pre marital sex is there.
Annexure 5
SIHFW Parimahal, Shimla 9 129
Contents Sr Topic Page No 1. Block health Plan Chirgaon 3 2. Block health Plan Jubble-Kotkhai 40 3. Block health Plan Kumarsain 82 4. Block health Plan Matiana 111 5. Block health Plan Nankhari 153 6. Block health Plan Nerwa 185 7. Block health Plan Suni-Basantpur 221 8. Block health Plan Tikker 263 9. Block health Plan Mashobra 296
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BLOCK HEALTH PLAN : BLOCK: CHIRGAON, DISTRICT SHIMLA 131
Background Information:
Profile of the Block:
Chirgaon Block is one of the 9 blocks of District Shimla. The Block headquarter of Block Chirgaon is situated at Chirgaon but for health purposes it is covered by CHC Sandasu. It has population of 41090 which lives in 152 villages of 26 Gram Panchayats. It falls in Tehsil Chirgaon. There are 132 Primary schools, 24 Middle schools, 17 High schools, 8 Senior Secondary schools and one Sanskrit college in the Block. Note: The above information does not include data from Dodrakwar.
There is one unserved Panchayat (Dhandhanwarri ) where there is no Health Institution. 7 Panchayats are underserved where there is no Health Sub Centres but other Health Institutions like AHC or PHC’s are present (Names of the Panchayats are given below) Migrant labor from Nepal is the vulnerable population whose number varies from 3000 to 5000 in Block depending upon the working season. There are two Industrial Sites in the Block namely: Andhra Phase –II and Gumma Phase–II. There is no Sub Centre having population more than 3000 in the Block. Villages far away from Sub Centre are “Sheeladesh”, “Saribasa” and two Panchayats of “Dodrakwar”.
Health Institutions Number of Gram panchayats without any sub centre: 7 PANCHAYATS Names: “Tikarri”, “Rohal”, “Sheeladesh”, “Saribasa”,”Dhandhanwarri”, “Kwar” and “Dodra”.
Number of gram panchayats without any health institutions, allopathic and ISM : One Panchayat (Dhandharwarri) of Chirgaon. Any geographical area requiring special consideration : Panchayats namely,“Rohal”, “Jangalik”, “Deodi”, “Sheeladesh” and area of “Dodrakwar” need special consideration because the topography of the area is difficult and there is a poor communication and transport facilities. 132
MATERNAL CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Most of • Inadequate • Develop an • IEC 10 1 People are IEC. Action plan Material aware about for and Funds • Shortage of months Registration. female (8) and IEC • They did not male health (Information ANTENANTAL know about workers (13) Education CARE the Health Communication. • Pregnancy importance Educator (1) test kits. 2 • Preparation of of and 10 Health months proposal for REGISTRATION Registration Supervisors additional staff (5 Male and • Required and submit to 5 Female) 4 TARGET = 845 staff is not CMO. available. • Lack of months ACHIEVEMENT = • Orientation of testing kits for 828 (98%) • Danger field staff about early GAP (2%) signs in registration of detection of pregnancy Antenatal care. not fully pregnancy. 6 • Procurement and known. months distribution of • No services urine pregnancy for urine kits to PHC and pregnancy S/C. kit in sub centre for early detection of pregnancy.
133
MATERNAL CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Most of the • Poor IEC. • Develop an • IEC 10 ANTENANTAL females are • Shortage of Action plan Material 2 CARE busy in their for female and and months own male health IEC Funds. fieldwork workers (Information • Training 3 VISITS and do not (FHW, Education Material. come for MHW), Communicati 2 TARGET = 845 check ups. Health on) months ACHIEVEMENT = • Do not know Educator • Request for
428 (51%) the (1),Male additional
GAP = (49%) importance Supervisor staff and
of three and Female submit to visits. Supervisor CMO. 6 • Staff is not (10) and • Training of months available at Doctors (3) Health sub centre • Lack of Workers and all days in a transportation. Supervisors week. • Poor health in counseling. 2 • Pregnancy counseling by • Request to months test is not staff. provide the done at Sub • Inadequate required staff Centre and follow up, e.g. PHC level. tracking Radiologist • Prefer to go system in and to Specialist. place. Gynecologist. • Visits to Lack of Health Radiologist and Institution Gynecologist at are not done CHC Sandasu. due to less transportatio n facility.
134
MATERNAL CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY ANTENANTAL • Awareness • Lack of IEC. • Develop an • IEC, 10 3 CARE about TT • Shortage of Action plan Training for injections. staff at Material months • Specific “Janglikh”, IEC and TT benefits of “Pekha”, (Information Funds. IMMUNISATION TT are not “Kharshali”, Education known. “Amboi”, Communicati TARGETS= 845 • Health “Khashdhar” on) 2 ACHEIVEMENT = Institution is Sub Centers. • Request for months 845 (100%) far away • Cultural additional from their barriers. staff and home. • Inadequate submit to 6 • Not aware follow up, CMO. about tracking • Training of months disease system in Health (Tetanus) place. Workers in and its proper complication counseling of . patient. • Some people have false belief that injection is injurious to mother and child. • Some people go to CH Rohru because staff is always there. • There are less health workers at sub centre level.
135
MATERNAL CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY ANTENANTAL • Fully aware • Lack of IEC. • Develop an • Funds and 10 4 CARE of IFA • Inadequate Action Plan for IEC tablets. IEC in the Block. material. health months IFA COVERAGE • Get 100 counseling. • Request for • IFA tablets of • Irregular regular and Tablets. TARGETS = 845 iron and supply of IFA adequate supply 2 Achievement = 390 folic acid Tablets. of good quality (46%) for • Poor quality IFA tablets. months GAP = (54%) weakness of IFA • Orientations of and Anemia. Tablets. staff in meeting • Forget to • Lack of for regular follow take follow up of up. 4 complete beneficiaries. months course. • Inadequate supply of IFA Tablets. • Complain of bad taste and other side effects regarding tablets like, burning in stomach, nausea etc. DELIVERY • They know • Lack of IEC. • Develop an • IEC 10 5 SERVICES that • Lack of Action plan Material, months institutional skilled staff for Funds and delivery is like, Doctors, IEC Ambulanc SAFE AND the safe paramedical (Information e. INSTITUTIONAL delivery. and staff Education • Manpower DELIVERY. • Institutional nurse in Communication) • Equipment 2 services are PHC’s. for Labour months • Request for up very far (Shortage of 8 room. gradation of PHC away. Staff TARGETS = 845 for 24 x 7 • Lack of Nurses, 8 2 ACHIEVEMENT = (“Goshalh”) facilities in Female months 117 (14%) • Request for the Health GAP (86%) additional staff. Hospitals Workers and 2 and Lady 3 Medical • Request for months Doctors. Officers). Ambulance at PHC level. • Most of • Ill equipped them prefer labour room • Request for 2 to deliver at at CHC strengthen of months “Rohru”. Sandasu. Labour room.
• Staff is not • Lack of 24 x available at 7 hrs service all the time delivery in PHC. PHC. 136
• Less • Lack of transportatio transport n from facility. villages. • No facility for Caesarian section at CHC Chirgaon.
137
MATERNAL CARE S.N ISSU PROBLEM & NEEDS CONSTRA ACTION SUPP TIME ES OF THE INTS REQUIRED ORT LINE AND COMMUNITY REQUI SITU RED ATIO NAL ANA LYSI S • Most of the people • Lack of • Request of • IEC 10 DELIVER opting for home 24 x 7 proposal for Mat Y delivery are poor. erial facilities up gradation months 6 SERVICE • Non availability of for safe of PHC for s, S transportation at the deliveries 24 x 7. • time of delivery and in PHC’s. • Training of Trai odd hours. • Lack of the staff at ning 6 HOME • No proper delivery transport PHC level Mat months DELIVER services at PHC, ation. especially erial Y. and CHC level. • Inadequa lady doctors • (164) • Services provided te and female Fun OUT OF by traditional birth services health ds 6 845 attendant are at workers. and months cheaper and they are hospital. • Training of guid always available. • Untraine traditional eline 2 • In” Khashdhar” area d local Dai’s at CHC s. there is no Dai’s. “Sandasu”. • Upg months transportation • Lack of • Request to rade facility. counselin strengthening d • Non availability of g by the infra specialist Lady staff. infrastructure struc Doctor in CHC. • Inflexibl and ture. 2 • Hospital care e manpower. depends upon guideline • Request to months approach. s to provide
• Money for referral provide guidelines to
transport is not money provide
provided in for advance advance. referral money in transport. case of referral transport.
138
MATERNAL CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY DELIVERY • No • Poor • Develop an • IEC 10 SERVICES knowledge emphasis on action plan Materials. months about locally and for IEC in • Training essential culturally the block. Material 7 POST NATAL Post Natal appropriate • Preparation and Funds. 2 CARE Check up. health and of proposal • Manpower. months • Do not know communicatio for TARGETS = 828 proper n efforts. additional ACHIEVEMENT = technique of • Shortage of staff and 286 (35%) breast female and submit to 6 GAP (65%) feeding. male health CMO. months • Follow what workers, (8 & • Training of the elder 13) staff the staff at Through out the people say nurses (8) and PHC level regarding doctors (3). especially year weaning • Lack of female practices. systematic health • No skill up workers. knowledge gradation of • Counseling about the staff. services to quality and • Lack of focus the quantity of on migrant mothers by diet to be population female taken in Post (under health Natal period. privileged). workers. • Some go to AW where they take additional diet. • Go to the • Shortage of • Request a • Funds and 2 CHILD CARE nearest Sub staff like proposal IEC months Centre for female health for material 8 IMMUNISATION immunizatio worker (8), additional COVERAGE n. male health staff and 10 BCG = 753 • Know worker (15). submit to months DPT = 803 importance • Inadequate CMO. TT = 802 of IEC. • Develop an MEASLES = 843 immunizatio • Cultural action plan n of the barriers. for IEC in child. • Health care the block. • Some people facility is far have false away from belief that their homes immunizatio e.g. “Rohal”, 139
n weakens “Khashdhar”, child. “Mathala” • Some and beneficiaries “Dumrerra” have to etc. travel to a far off Health Institution for immunizatio n because the HSC is closed. • They are not in favor of having BCG, DPT, Hepatitis B and OPV Immunizatio n on the same day.
140
CHILD CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Majority are • Poor IEC. • Develop • IEC 10 unaware • Cultural an action Material months about the barriers. plan for and EXCLUSIVE importance IEC in the Funds 9 BREAST of exclusive block. Through FEEDING breast • Counseling out the feeding. services to year • They feed the baby within pregnant 1 2 hours and after birth. lactating
• They don’t mother’s know about during the proper antenatal technique of check up breast and feeding. immunizati • Some of on session. them believe that early start of breast feeding is dangerous to baby. • Some of them complain of inadequate breast milk and supplement feed with cow’s milk. 141
• Know about • Inadequate • Develop • IEC 10 ORT the salt and IEC. an Action Material months sugar • Lack of Plan for and 10 CASES OF solutions depots IEC in the Funds DIARRHOEA = (ORS). holders in the Block. 6 664 • ORS is area for ORS • Opening of months available in distribution. depots in health villages institutions and in but not in AWC.
odd hours. • Initially they take domestic treatment like home made solutions (Dal ka pani, sugar and salt solution) etc. • They are unaware about the signs and symptoms of Dehydration . • They rush to Hospital when the home made remedies are not effective.
142
CHILD CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Majority of • Lack of • Develop • IEC 10 them aware Health an Action Material months about signs education. Plan for and Funds. ARI and • Lack of child IEC in • Medicines. 11 symptoms of specialist the 2 (CASES = 884) ARI like (Doctor) in Block. months common the Block. • Request cold, fever, • Shortage of the
cough etc. medicines. Departm • Unaware ent for 2 about the Child months signs and Specialist symptoms of at FRU Pneumonia. level. • Initially they • Request prefer home for more remedies medicine like steam, s. saline gargles etc. • Medicines are available at every health Institution for their illness. • They prefer to go to Shimla as no Pediatrician is available in the Block. 143
• They know • Inadequate • Develop • IEC 10 RISK something IEC. an action Material months FACTOR but not • Cultural plan for and Funds AMONG NEW everything barriers. IEC for 12 BORN BABY about early essential treatment Through new born in out the care. neonatal year. • For first few care in days they the take home block. remedies. • Provide • They give Health Bal Jivan Educatio Ghuti and n to the Jai fal to the communi Child. ty. • They know that Mother’s milk is better than bottle feeding. • In emergency they prefer to go to Rohru and Shimla (to Pediatrician) .
144
CHILD CARE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Unaware • Lack of • Provide • Funds for Through about signs Health counseling training. out the and Nutrition services to • Training year MALNUTRITION symptoms of Education. the material. 13 IN CHILDREN malnutrition • Lack of pregnant UNDER THREE. in children. knowledge and • Some of among staff. lactating people are mothers 6 poor so they during months can not immunizati
afford on required services. quantity of • Training of nutrition. staff in • Unaware Nutrition. about proper diet of child. • Unaware that nutrition given in anganwari is supplementa ry to their normal diet. FAMILY PLANNING • Most of • Inadequate • Develop • IEC 10 PROGRAMME them know IEC. an Material. various Action plan • Lack of • Training months 14 spacing counseling for Material methods. SPACING METHOD skills among IEC. and
• Spacing the staff. • Counseling Funds
OP USERS = 3716 methods are • Cultural of couples
CONDOMS = 14717 used by both barriers. for spacing Through IUD USERS = 88 males and methods at out the females. every • Condoms Health year and Oral Institution. Pills are • Training of 6 easily Workers in months available at counseling all the techniques. Health Institutions. • They don’t prefer IUCD as they think 145
that it is harmful to female; it causes bleeding and backache. • Some feel shy to take Condoms from Health Institutions.
146
FAMILY PLANNING PROGRAMME S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Men have to • Poor IEC. • Develop • IEC 10 do heavy • Inadequate an Material. POOR MALE Action work and counseling of • Training months 15 PARTICIPATION feel couples as a plan for Materials IN ADOPTING weakness unit. IEC in and FAMILY after family • Cultural the Funds. Through PLANNING planning barriers. Block. out the METHODS. operation. • Lack of • Proper year • They are counseling counselin TOTAL scared of skills among g of 6 STERILIZATION failure of the staff. couples months = 92 operation. as a unit. MALE = 5 • Most of • Training FEMALE = them prefer of 87 Tubectomy. Workers • The head of for the family counselin takes g skills. decision. • Prevalent customs of polyandry and polygamy in certain area. • Mutual understandin g. • Male do not prefer operation because in case of mishap there remains scope for remarriage. 147
• Camps are • Lack of • Request • Funds 1 STERILISATION being transportation to 16 SERVICES organized at after providing month PROVIDED CH Rohru operation. additiona LOCALLY OR only. l POL BY CAMP • Local team budget. APPROACH provides FROM services. OUTSIDE. • Most of them prefer CAMPS HELD to go to CH VASECTOMY = Rohru. 1 • After TUBECTOMY = operation 12 less TOTAL transport STERILIZATION facilities. = 92
148
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF THE REQUIRED REQUIRED LINE ANALYSIS COMMUNITY • Majority • Inadequate • Develop • IEC 10 aware of the IEC. an Material, 17 TUBERCULOSIS signs and Action Funds, • Lack of months (RNTCP) symptoms of transportation plan for and staff. TB. facilities. IEC. • Inadequate • Lack of • Request to 2 SPUTUM knowledge of manpower. provide months EXAMINED = 450 disease. • Less number the CASES IDENTIFIED • Medicines are of additional = 29 provided at microscopic staff at UNDER Sub Centre but centers. Sub 2 TREATMENT = 29 some Sub • Lack of Centre. months Centers are health • Request very far away education of for from villages. Migrant opening Through • Medicines are population. more out the not provided microscopi year. at some Sub c centers. Centre, as they • Health are closed education since 5 6 of migrant years. population • Discrimination . among TB patients. • Unaware of • Inadequate • Develop • IEC 10 signs and IEC. an Material 18 DIARRHEA symptoms of • Inadequate Action , Funds months Dehydration. staff at Sub plan for and (CASES = 664) • Initially home Centre. IEC. staff. made • Lack of • Request to 2 remedies are knowledge provide months given i.e. regarding the sugar and salt dehydration. additional solution, Dal • Lack of staff and Through ka Pani etc. potable water. submit to out the • Quality of CMO. year drinking water • Coordinate is not good. with IPH • Health Departmen Institutions are t for far away from providing villages and safe water some are in regular closed. monthly 149
meetings
150
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • They have • Inadequate • Develop • IEC 10 heard about IEC. an Material LEPROSY the Leprosy. Action plan and • Social and months 19 • Some of the Cultural for Funds CASES signs and barriers. IEC. IDENTIFIED AND symptoms of • Shortage of • Request UNDER leprosy are staff. for 2 TREATMENT = 1 known to • Inadequate additional months them. health staff. • Facilities for education of • Health Through diagnosis migrant Education out the are far away population. and year. from home. screening • Do not know of the that migrant treatment is population available at by the field PHC level. staff. • Stigma is still there. • They know some of the complication s of leprosy. • Migrant population is more at risk.
• Unaware • Lack of • Develop • IEC 10 MALARIA about the Health an Action Material 20 disease as Education. Plan for and months there is no • Inadequate IEC. Funds 219 SLIDES problem of surveillance. • Orientation EXAMINED Malaria. of staff to 8 ACTIVE = 121 • No idea ensure months PASSIVE = 98 about regular POSIVE CASES = investigation surveillanc NIL at Sub e. Centre level.
151
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Know about • Poor IEC. • Develop • IEC 10 the Kala • Lack of an Material months BLINDNESS Motia and transport Action and 21 PROGRAMME Safaid facilities. plan for Funds Motia. • Eye camps IEC. 2 CAMPS = NIL • Unaware are not • Make an months CATARACT about early organized. Action OPERATION = signs and Plan for 35 (CH symptoms of eye ROHRU) disease. camps • Facility for and surgery at submit to
CH Rohru CMO. is far away for majority of the population. • Do not know about screening of schools children by teachers. • Go to CH “Rohru” for Cataract surgery and CHC “Kotkhai”. • Less transport facilities.
152
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Know about • Poor IEC. • Develop an • IEC 10 school • Lack of staff. Action plan Material, months SCHOOL programme • Lack of for Funds 22 HEALTH but not participation IEC. and staff. PROGRAMME being done by Ayurvedic • Prepare the 2 regularly. Department. proposal months TOTAL • Mid day • Lack of additional SCHOOLS = meal is transportation. staff at s/c 181 given IN level and NO. OF SCHOOL Primary submit to 2 COVERED = 160 Schools. CMO. months NO.OF • Quality of • Request to STUDENTS mid day provide EXAMINED = meal could transportatio 6613 be n to the staff Through improved. or funds for out the • Shortage of TA/DA. year. staff. • Coordination • Some with schools are Ayurvedic far away Department from the and Health distribution Institutions. of school • Ayurvedic among Department AHC’s. not participating in School Health Programme.
153
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • They know • Inadequate • Develop an • IEC 10 about HIV IEC. Action plan Material months HIV / AIDS and AIDS. • Lack of HIV for and Funds 23 PROGRAMME • Did not testing IEC know signs facility. (Information (CASES IN THE and Education BLOCK = NIL) symptoms of Communicati HIV and on) In the AIDS block. 2 • Don’t know • Request for months where opening diagnostic ICTC. facilities are available for HIV / AIDS • Only know it is non curable. • Don’t know all the modes of spread of HIV/AIDS. • They don’t • Lack of any • To establish a I D S P know about mechanism reporting 2 PROGRAMME I DSP. for reporting mechanism at months 24 at village village level. ______level.
154
DISEASE CONTROL PROGRAMMES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Hesitation • Poor IEC and • Develop • IEC 10 and shyness counseling. an Material, months RTI / STD in talking • Lack of lady Action plan Funds. 25 about doctors. for • Lady Through RTI/STD. • Cultural IEC. Doctors. out the CASES • Not fully practices. • Counseling year SYNDROMIC = 11 aware about • Partner’s for partner ETIOLOGICAL = all the signs treatment is treatment. 2 12 and difficult. • Request months TOTAL = 23 symptoms of for posting STD/RTI. of • Don’t know Specialist about the Doctors. importance of early diagnosis and treatment. • They don’t know of importance of Partner treatment. • Husband in general is indifferent about Seeking Health Care. • At some places, there is custom of Polyandry. • They Know • Inadequate • Develop • IEC 10 IDD CONTROL that iodine IEC. an action Material months 26 PROGRAMME deficiency • Lack of salt plan for and causes gillad testing kits. IEC in the Funds. Through (goiter) block. • Salt out the • Do not know • Testing of testing year other salt with kits. disorders of kits. iodine deficiency. • Use of iodized salts 155 prevents problems.
156
NEW NRHM INITIATIVES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Know about • Inflexible • Request • Training 2 UNTIED GRANTS the Untied guidelines. for Materials months 27 OF SUB CENTRE Grant for • Untrained modifyin and Sub Centre. members. g the Funds. 6 • Two guideline months s. TWO installments
INSTALMENTS have been • Training
RECEIVED received. of • Accounts PARIKA maintained S in local Members banks and . being operated by Health Worker and Panchayat Pradhan. • Funds are used mainly for purchase of medicines, minor repairs of Sub Centre and referral of poor patients. • Transparency is there in accounts. • Lack of specific guidelines for incurring expenditure. UNTIED GRANTS • Know about • Specific • Request • Funds 2 Of PHC’s the money guidelines not for and months (grant). available guideline Guidelin 28 • Works are • Funds were s. es. 2 ONE being done. received late. • Request months INSTALLMENTS • Proper for timely RECEIVED guidelines release of required. grant. • Transparency is there in 157
accounts.
• Grants not • Lack of • Request • Funds 2 UNTIED GRANTS receive funds. for early and months Of CHC’s d as release of Guidelin 29 yet. grants. es.
NEW NRHM INITIATIVES S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Maintenance • Lack of • Request • Guidelines, 2 funds proper for Doctors months 30 received. guidelines. guideline and Seed 2 RKS GRANTS • RKS is • Non s. Money. months constituted availability of • Request at CHC Doctors in PHC for 2 “Chirgaon”, “Goshali” and posting months PHC PHC “Deodi”. of “Badiara” • Seed money Doctors and PHC not received. in “Jangla”. PHC’s. • No proper • Request guidelines as to pointed out provide by medical seed officers. money. • Funds not utilized.
• Majority do • Poor IEC. • Develop • IEC 10 JSY not know • Administrative an Action Material months about the problem in Plan for and Funds. 31 NO. OF scheme. providing IEC and Through BENEFICIARIES • Money is money during education out the = 112 not provided Antenatal of year. during Period. communi pregnancy. ty about • Money JSY. 2 provided is • Request months 158
inadequate. to modify the guideline .
• There is no • Inflexible • Request • Proper 2 REFERRAL good guidelines. for guidelines months 32 TRANSPORT effective • Lack of change in and transport transport guideline Ambulanc NO. OF system. facility. s. e. 2 BENEFICIARIES • Money paid • Request months = 112 later and not for in the Ambulan beginning. ce at • No proper PHC guidelines level.
ISSUES OF CONVERGENCE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • All villages • Lack of • Coordination Through covered for coordination meetings out the supply of with IPH with IPH year IPH 33 water. Personnel. Department. • In some places there is a bad quality of water. • Chlorination of water is done once in a week by IPH personnel. • No member of IPH Department in PARIKAS. • No sharing 159
of information regarding quality of water with Health Department. • Bad taste of water during chlorination. • Improper maintenance of water tanks and pipes by IPH Department. • No water user association in villages. • No joint • Lack of • Participation • Necessary Through meetings coordination in instructions out the year. ISM (AYUSH) with with AYUSH coordination from AYUSH at personnel. meetings. Govt/Departm 34 Block level. • Lack of any • Request the ent. 2 • Only direction from department months participation higher to issue in Pulse authority to necessary Polio. Ayerveda. instructions • No role in to AYUSH. institutional delivery at Ayurvedic Hospital. • No member of PARIKAS from ISM. • No training given by Health Department to AYUSH Personnel. • Not participating in MCH Services.
160
ISSUE OF CONVERGENCE S.N ISSUES AND PROBLEM & NEEDS OF THE CONSTRAINTS ACTION SUPPORT SITUATIONAL COMMUNITY/CONVERGENCE REQUIRED REQUIRED ANALYSIS RURAL • Most people no sanitary toilets. • Inadequate • Coordination • Funds DEVELOPMENT • No public toilets in the Block. IEC. meetings and IEC NO. OF • No proper coordination with • Lack of with BDO. Material. 35 HOUSEHOLD= other staffs or departments. coordination • Health 13696 • No toilets in AWC. with BDO. education of NO. OF community. HOUSEHOLD HAVING ACCESS TO TOILETS= 3350 • No. of Aaganwari Centers = • Lack of • To participate • Govt. 155 coordination at in orders.
ICDS • AWW participate in formation Block level. coordination 36 of Village Health Plan. meeting at • AWW acting as DOTS Block level. providers. • AWW acting as Depots holder for ORS packets and CC. • Doctors and Health Workers attend Health Day in Aaganwari every Tuesday. • Aaganwari Workers attending Clinic Day and Immunization Day at Sub Centre. • AWW participating in Pulse Polio Campaign. • AWW are members of PARIKAS and RKS at PHC level. • AWW has been sensitized for JSY / Referral transport and Institutional Delivery.
ISSUES OF CONVERGENCE S.N ISSU PROBLEM & NEEDS OF CONSTR ACTION SUPP TIME ES THE COMMUNITY AINTS REQUIRED ORT LINE AND REQ SITU UIRE ATI D ONA L ANA LYSI S 161
• PARIKAS is formed • Lack • Arrange • Gui Throug and functioning. of coordinatio deli h out PRI’s • Minutes are not particip n meetings nes the year 37 prepared at the time of ation by with PRI’s. and PRI’s in Go meeting. • Providing • Untied funds being Village guidelines vt. 2 received and utilized. Health to ord months • No member of Plan. PARIKAS. ers. PARIKAS trained under • Lack NRHM and handling of of funds. coordin • Funds deposited in local ation banks and between operationalised by the Health signatures of Pradhan Depart and Health Worker. ment • NO proper guidelines to and spend Untied Funds at PRI’s. Sub Centre level. • Lack of • No role of PRI in local proper Health Mela’s. guidelin • They are maintaining es to traditional water spend resources. Untied • Willing to have control Funds. over health institutions for ensuring better services.
ISSUES OF CONVERGENCE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Aware of • Lack of • To motivate • Govt. Through ARSH (GIRLS) risky counseling for staff to orders. out the 38 RISK TAKING behaviors. adolescents. provide year BEHAVIOUR • They are • Lack of Lady counseling AMONG aware about Doctors. services. 2 ADOLESCENTS the • Lack of • Request the months (SMOKING, complication referral from department DRUGS, s of alcohol, schools. to post Lady ALCOHOL, SEX) drugs, • Lack of Doctors. Through smoking and counseling • Coordination out the premarital centres. with schools. year sex. • Request to 2 • They are not open more months indulging in counseling any such centers. activities. 162
• Not fully aware about the signs and symptoms of RTI/STI. • Aware of AIDS, fear of pregnancy and STD. • They want lady doctors to share their concerns. • Discuss about such problems with their friends and sisters. • Aware about • Lack of • Request the • Funds and 2 ARSH (BOYS) the hazards Health Department Training months RISK TAKING of smoking, education and for training materials. 39 BEHAVIOUR drugs or counseling for of Doctors • Counseling AMONG other risks. adolescents. and centers. ADOLESCENTS • Some of • Lack of Paramedics (SMOKING, them are counseling in 2 DRUGS, indulging in skills among counseling months ALCOHOL, SEX) smoking, Doctors and skills. drinking and Paramedics. • Request to 2 sex. • Lack of open more months • Not fully Health staff. counseling aware about • Lack of centers. RTI/STI. counseling • Coordination • They discuss centers. with schools. their • Less referral problems from schools. with their friends and brothers. • Know about the problems e.g. lung cancer caused by smoking. • They take risks because they have some 163
curiosity. • Pressurized by their friends.
GENDER RELATED ISSUE S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • A girl has to • Lack of • Awareness • Funds 10 look after education on camps about and IEC months WHY SON her in laws gender related Gender material 40 PREFRENCE? after issues. Issues. marriage. • Son will look after them in their old age. • Want boy child for their VANSH (family). • Girl child is a liability. • Religious factors are there like “Pind Daan”
164
• Domestic • Lack of • Coordination • Govt. Through DOMESTIC violence awareness with Social orders. out the VOILENCE occurs in among Justice and year 41 some of the women about Empowerme households. their legal nt • Husband rights. Department and in laws • Lack of for are mainly schemes implementati responsible. related to on of various • Violence is empowerment schemes. triggered of women. when the husband is drunk. • A woman is also victimized in case of she doesn’t give birth to son. • Poverty and frustration also lead to domestic violence. • Unequal • Lack of • Coordination • Govt. Through STATUS OF status of schemes with SJE orders. out the WOMEN IN men and related to Department year 42 RURAL women. empowerment for AREAS • Male of women. implementati dominant • Ineffective on of various society. implementatio schemes. • Totally n of schemes dependent on women on husband empowerment and in laws. . • She has to take permission from husband and in laws to go out of the home. • They don’t know about their legal rights. • Less 165
opportunity to women for higher education. • Some women have very less role in important decision making at home.
166
HEALTH CARE SEEKING BEHAVIOUR S. ISSU PROBLEM & CONSTRAINT ACTION SUPPOR TIME N ES NEEDS OF THE S REQUIRED T LINE AND COMMUNITY REQUIR SITU ED ATIO NAL ANA LYSI S • Delivery services • Lack of need • Request • Funds. 2 are available only based for • Staff months HEALTH at CHC Chirgaon. medicines. providing and CARE • Lack of • Lack of 24 X Ambulanc Ambul 4 SEEKIN transportation 7 hrs services e at PHC ance. 2 3 G facilities. at PHC level. level. • Equip months BEHAVI • First few days they • Lack of • Request ments. OUR take home Ambulance for • Medic remedies. services. additional ines. • Only few • Lack of staff staff and • Traini 2 medicines are and strengthen ng months available at infrastructure. ing of materi Hospital. • Cultural infrastruct al 2 • Delayed Health barriers in ure. (manu months Care Seeking seeking • Request al/mod Behavior. timely health for need ules). • Lack of counseling care. based after delivery and • Health staff medicines. family planning not trained in • Make a 6 operations. counseling. proposal months • Non availability of for up lady doctor at gradation CHC. of PHC to • Less health camps provide 24 are organized. x 7 hrs • 24 X 7 hrs services services are not available and except at CHC submit to Chirgaon. CMO. • Emergency • Training services are not of staff in available at PHC. counseling • For some people . PHC’s are far away from their home. • Non functional lab in PHC’s. No facility for urine pregnancy test at PHC and S/C. 167
168
BLOCK OR AREA SPECIFIC PROBLEMS NOT COVERED ABOVE. S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY (a) Under served • Health • Non • Request the • Vehicle, staff, 1 month areas: Institutions availability of Department equipments and 5 Panchayats of are far off. Sub Centers in for opening medicines. 44 the Block (except • 24 hours the area. of new Sub • Training 1 month Dodrakwar) emergency • Area covered Centers. Material and namely services and only for • Request to Funds. “Sheeledesh”, delivery immunization CMO to “Rohal”, services are services by provide the “Tikkari”, not provided deputing staff. additional Through “Saribasa” and by PHC’s. • Shortage of staff, out the “Dhandhanwarri” • PHC’s need manpower. equipments year are underserved to be up • Poor , vehicle 8 month because there is graded. infrastructure and supply • Funds for no Health Sub • They need and transport of TA/DA. Centre in them. awareness facility. Medicines. Through and Health • out the (b) Migrant check up Coordinatio year population camps. • Scattered n with local varying from population of NGO’s for 4000 5000 • Lack of migrant labor Health (Nepal, Bihar and awareness working in check up UP) is working in about Orchards. camps. • Epidemiologica orchards and two various • Underserved • Training of l surveillance projects namely among the population. Local unit. 1 month Andhra Phase 2 migrant Dai’s. • Orientation of and Gumma population. staff for Through Phase 2. • Need • Lack of carrying out out the (c) Plague – awareness surveillance • To organize surveillance year “Tikkari”, and Health unit in the awareness activities. “Sheeladesh”, check up Block. and Health “Pekha”, camps. • Inadequate check up “Deodi”, IEC and camps on “Tangnu” and • Danger of surveillance. immunizati “Janglik” are out break of on day at ENDEMIC Plague in PHC’s, S/C FOCUS FOR the area. and PLAGUE. Two Need of Hydroelectr outbreaks of constant watch ic Project Plague have and awareness Sites. already occurred among people. within last 3 decades. • Request the Departme nt to make 169
the surveillanc e unit at Rohru functional. • Disease surveillanc e through field staff • Awareness camps in the villages.
BLOCK OR AREA SPECIFIC PROBLEMS NOT COVERED ABOVE. S.N ISSUES AND PROBLEM & CONSTRAINTS ACTION SUPPORT TIME SITUATIONAL NEEDS OF REQUIRED REQUIRED LINE ANALYSIS THE COMMUNITY • Non • Request to • Staff, 1 (d) Dodrakwar. • Low availability of the equipment month • There are 5 awareness Sub Centers in Departmen s, vehicle 44 Panchayats level about three t for and covered by 1 various Panchayats. opening of medicines 1 PHC, 3 Sub health issues • Area covered new Sub . month Centers and 3 related to only for Centers. • Medical AHC’s. Maternal and immunization • Request to team from • Two Panchayats Child care. services by CMO to district (Dodra and • Generally deputing staff. provide the and Kwar) are Health care is • Shortage of additional medical without any Sub sought late manpower and staff, college. Centre. and people vehicle. equipment • Area remains mostly take • Poor s and Once inaccessible due home infrastructure. supply of in a to heavy snow remedies in • Shortage of medicines. year and poor case of medicine. • To organize communication illness. • Poor awareness for about 5 • Medicines accessibility. and months. especially for Cultural barrier Multipurpo mother and in seeking timely se children are health care. Specialty inadequate. Health • Most of the Camps. deliveries are conducted at home by untrained Dai’s.
170
171 SIHFW Parimahal, Shimla 9 173