RAJASTHAN 1.District Sirohi

Major observations of Regional Evaluation Team, Chennai and FSU Jaipur about the Evaluation work in of State in July, 2009.

I. Details of the visited Institutions: District Visited District HQ Hospital, PHCs aHSCs visited CHCs visited Sirohi District HQ Hospital:Sirohi HSCs: Oriya, Thelpet, Nayan CHCs: Seoganj, Mount Abu, Sanwara, Sivera, Taranju, Pindwada Pindwara and Kothada. PHC:Veervada, Bharja

II. Major Observations: The team also visited Arihant Sonography, Yadav Hospital & Scan Center, Ankita Hospital & Scan Centre and Sanjivani Hospital & Scan Centre in the District.

1. Human Resources: a. vital posts for providing health care delivery were laying vacant in the district. b. Out of the sanctioned posts of 45 MBBS MOs, 14 were not filled up. Out of the sanctioned strength of 217 ANMS 184 were in position. 10 posts of male field staff were vacant out of 30. AYUSH MOs were filled up only in 9 out of 22 PHCs. AYUSH doctors were not posted in any of the CHCs 2. Functions of Rogi Kalyan Samiti and VHSCs: A Rogi Kalyan Samiti were formed in all the 24 institutions in the district. It was functioning in all the centres visited . b. 473 VHSCs were formed in the district. c. It was observed that as many as 30 VHSCs in the area of Sheoganj CHC did not utilize their funds. d. It was also observed that in 12 VHSCs under PHC Veervada were not having ASHA as a Member.

3. ASHA Scheme: a. The district have selected 448 ASHAs and all were given 7 days training and provided with drug kit. b. Though the district requires more ASHAs but could not be filled up for lack of qualified persons. c. In the visited PHC at Veervada, only six ASHAs were selected against required.

4. Untied Fund: A The district received sufficient funds under the scheme. B The funds provided to the centres were almost spent as observed by the team during the visit. 5. Services of JSY: a. Janani Surakha Yojna Scheme is implemented in the district. b. No pending case of JSY beneficiaries was found in the district, but there is much scope for more coverage of eligible mothers. c. In CHC Sheoganj, it was observed that more funds are needed to meet the expenses of the pending cases.

6. 24 Hour Service: a. In the district, out of 22 PHCs only 10 are functioning as 24 hour delivery. b. This services can be introduced in more PHCs by providing adequate man power and infrastructure.

7. Physical infrastructure: (i) Sub Centres: a. ANM was not staying at the head quarter of HSC Nayansinwara. b. Water, electricity, labour room, ambubag, gloves, DDKs, EC Pills, Ampicillin, emergency contraceptive pills Gentamycine, anticeptic solution, oxytocin tablets, Cap Ampicillin, Gentamycin injection and Kits A & B were not available in most of the visited HSCs. c. Co-trimoxazole was not available at HSC Achpura.

(ii) CHCs/PHCs: a. In CHC Sheoganj there was no ultra sound machine and OT was also not functioning there. b. Blood Storage, X-Ray machine and Ultra sound were not available in CHC Mount Abu c. In PHC Veervada beds, ward, labor room, toilets etc. were found unhygienic. D In PHC Bharja, Jeep, Oxygen Cylinder and IFA tablet were not available. Residential quarters were also not provided to this PHC.

8. Maintenance of Records and Registers: a. Maintenance of registers and records needs lot of improvement in the district. b. No register for sterilization and IUD maintained in PHC Veervada. c. Service register for Sterilization, IUD, OP and CC not maintained in HSC Thelpur for the past 3 years. d. Sterilisation case cards also not maintained for any FW methods.

9.Sample verification of F.W. acceptors and Discrepancy in the reported figures. a. No performance reporting data of FW which is updated regularly was made available to the team at district office. b. During field verification, it was observed that there is no motivation for spacing methods and regular field contact by the concerned field staff at sub centre Thelpur. c. Similarly, IUD cases which were performed for previous year were also report during next year at sub centre, Pindwara. d. There is under- reporting of IUD performance during 2008-09 at PHC Bharja. The actual figure of the IUD acceptors was 277 but monthly progress report of the same shown as 177. e. It was also observed that Field staff is pressurized to fulfill the FW target and this leads to simply boosting the figures without providing services at the periphery level.

2.District Rajsamand

Major observations of Regional Evaluation Team, Chennai and FSU Jaipur about the Evaluation work in of Rajasthan State in September, 2009. I. Details of the visited Instituions: District Visited PHCs CHCs and GH visited HSCs visited Rajsamand GH:Nathdwara HSCs : Kakarmala, Vanai, CHCs: Khamnor and Amet Silwada, Binon, Jhor, Moracha PHC: Kunwaria, Sardargarh and and Badagaon Majhera

II. Major Observations: 1. Human Resources: In the district vital posts of health functionaries were not filled up. Out of 26 posts of specialists doctors, only 11 were in position. Out of total sanctioned post of 64 MBBS MOs, 15 were not filled up; ANMs were in position in 236 out of total 267 HSCs. Moreover, there were vacancies of 22 male health workers and 15 LHVs in the district. 2. Constitution of Rogi Kalyan Samiti and VHSC: a Rogi Kalyan Samitis have been set up in all the 44 institutions (PHCs/CHCs/GH) in the district. b. Out of total 1009 villages in the district, VHSCs formed in 969 villages. In the visited centre at Nathdwara, VHSCs were found constituted in most villages visited by the team. c. ASHA was included as a member in VHSC. 3. ASHA Scheme: a. The district has selected 785 ASHAs, out of them 739 were given with 7 days induction training and 735 ASHA were provided with drug kits. b. The required number of ASHAs was not there, in some of the places visited by the team in the district. 4. Untied Fund: a. It was reported to the team that expenditure of untied funds during 2008-09 was to the tune of Rs.82.27 lakhs . In the current year Rs. 44 lakhs were received out of which Rs.16.5 lakhs were spent. b. However, many of the centres visited in the district were observed to have not utilized the funds during 2008-09 i.e. PHC Sardargarh, CHC Khamnor, HSC Moracha, HSC Jhor and HSC Binon. c. For proper and effective use of Untied funds, district level authority needs to monitor the status regularly. 5. Services of JSY: a. Janani Surakha Yojna is implemented in the district. b The district has spent a total of Rs.2.62 crores for making payments to 16439 beneficiaries in 2008-09 and Rs. 1.30 crore to 8223 beneficiaries in the current year under JSY programme. c. Incentive to a few JSY beneficiaries was reported to be pending in the last year and the current year. d. JSY payment was given only to those mothers who were using accredited health facility for delivery in the district. e. 17 JSY beneficiaries contacted by the team inform that they received ANC check up, TT and IFA tablets. 6. 24 Hour delivery care Service: A In the district, out of 36 PHCs, only 9 were functioning as 24 hour delivery care centres. B In all the visited PHCs the team found that there was lack of sufficient number of doctors, Para medical staff and residential quarters to provide 24 hour service. C In PHC Kunwaria, the number of deliveries has come down to half in the current year compared to last year. 7. Physical infrastructure: (i) Sub Centres: a. Building of HSCs Badagaon and Silwada were not maintained properly for clinic purpose. Proper space and facility for conducting delivery was not found in HSC Badagaon. Building of HSCs at Badagaon and Kunwari was lacking cleanliness. b. ANM was not staying at the Head quarter of HSCs Binon and Vanai. c. Toilet facility was not found in HSC Badagaon. Labour room was not available in Jhor and Badagaon HSCs. d. Essential drugs like emergency contraceptive pills, Antiseptic solution, Cap Ampicillin and injection Gentamycin were not found available in most of the HSCs visited. e. Kits - A and B were also not available at any HSC visited. (ii) CHCs/PHCs: a. Ambulance facility in CHCs Amet and Khamnor and vehicle (jeep) at PHCs Sardargarh and Majhera were not available. b. In PHC Sardargarh, Oxygen cylinder, IFA syrup and Vitamin A syrup were not available. c. AYUSH MO were not available at PHCs Mejhera and Sardargarh. Post of lab technician was also vacant at PHC Sardargarh. d. In PHC Majhera OT facility was not available. Residential quarters for MO & staff were also not available. 8. Community Satisfaction/Opinion on Health Services : a. As many as 56 mothers having child upto one year old were interviewed to assess their opinion about the Health services rendered by the concerned ANMs in the sub centres area. b. 18(32.1%) of the contacted mothers informed that ANMs were not available when needed most. c. One fourth of the respondents were not aware of breast feeding practices and 21(37.5%) mothers were not aware of the use of ORS during diarrhea. d. ARI awareness was also not found in 49 (82.1%) mothers. 9. Maintenance of Records and Registers: a. Maintenance of register and records needs lots of improvement in the district. b. Except GH Nathdwara, Eligible Couple Register and Sterilization service register were maintained in all the visited centres. Sterilisation register were found incomplete in PHC Kunwaria. c. Age of Spouse and signature of the surgeon were not recorded properly in the register maintained at CHC Amet. d. IUD register was also not maintained properly in GH Nathdwara, CHC Amet and PHC Kunwaria. a. discrepencies in the performance of FW and MCH figures was observed between figures available at the district and those available at the facilities. 3.District Pali

Major observation of field survey Unit of CBHI, Jaipur about the Evaluation work in of Rajasthan State in the month of Oct.09 I Details of the visited Institutions

District PHCs/CHCs visited HSCs visited Pali CHC- Rohat Dhlaop, Dailana, Jhuntha and Sabalpur PHC –Nodal Pipalia kalan

II. Major Observations: 1. Human Resources:- 26 posts of specialists against sanctioned strength of 68 and 35 posts of Medical officer against 126 posts sanctioned under NRHM were lying vacant in the district. Two posts of Junior specialist at CHC Rohat, one post each of M.O. and ANM at PHC Nadol, one post of ANM & Lab Technician at PHC Pipalia Kalan were lying vacant. 2. Function of Rogi Kalyan samithee (RKS) :- a. 83 RKS in different institutions have been constituted in the district & all were reported to be functioning. b. In 2008-09 747 RKS meetings were held and in current year only 336 meetings were held up to Aug, 2009. c. The formal documentation of the RKS meetings was lacking at all the visited facilities. The meetings of RKS were not being held on the regular basis in the visited CHC and PHCs 3. Functioning of Janani Suraksha Yojana:- a. JSY has been implemented in the district since 2005 -06 . 19.8% of the total deliveries were covered under JSY in the year 2006-07 and this number increased to 62.8% during 2007-08, 69.2% during 2008-09 and 69.5% during 2009-10 (up to Aug. 09 ) respectively. b. The quantum of beneficiaries of JSY has gone up over time since the inception of NRHM both in govt. as well as private accredited hospitals. c. The centres were getting sufficient fund for proper functioning under the scheme. d. It was observed that institutional deliveries have increased in the visited CHC & PHC due to the implementation of JSY. e. However, it was observed that 292 beneficiaries were yet to get JSY payments in the current financial year under the scheme. 4. Functioning of ASHA:- a. As against target of 1073 ASHAs for serving 1014 villages in the district, 842 ASHAs have been selected so far and 769 of them were given training upto 3rd module. b. All the selected ASHAs were equipped with the drug kits. c . ASHAs were not in position in the visited CHC, PHCs Sub centres, as per requirements. performance of ASHAs on account of deliveries escorted was Very low, as only 6% of intuitional deliveries were escorted by ASHA in the year 2008-09 and 9.7% in the current year (up to Aug.,09). 98(21.1%) cases of sterilisation were also motivated by the ASHAs in the District.ASHA is also a DOTS provider and helps the villagers in obtaining BPL certificates f. In the Visited Sub centres at Dhalop, Sabalpura & Dailana Kalan SCs ASHAs were not yet selected. 5. 24 hour delivery care system a. All(15) the CHCs and 16 out of 68 PHCs were functioning as 24x7 delivery care centres in the district. out of the CHCs, 8 were also reported to be functioning as FRUs. b. Only 2 CHCs were having functional Blood storage unit and in rest of CHCs, Blood storage unit was not functional. c. There were 9,588 institutional deliveries conducted during April 09 to August 09, of which 4,337(45.4%) were reported to have been conducted in the prescribed night hours at 24x7 institutes. 6. Untied Funds:- a. There has been substantial increase in allotment of untied funds to the district Pali in the year 2007-08 as it was increased to Rs 2.05 crores in 2007-08 from Rs 43.0 Lakhs in 2005-06. Through it came down to Rs 1.88 crores in 2008-09 and further declined to Rs 1.23 crores in 2009-10. b. Due to non utilisation of untied funds, a substantial portion had been carried forward every year. Rs 1.31, 1.30 & 1.23 crores was carried forward in the years 2006-07, 2007-08 and 2008-09 respectively. C it was observed that the funds were not received at PHC Pipalia Kalan and the sub centres visited in the Districts. 7. Village Health & Sanitation Committees:- a. 964 village health sanitation committees have been set up in the district out of these 934 have also opened their bank accounts to handle funds . b. Number of meetings conducted by the VHSCs was very less. Documentation of the VHSC meetings was also very poor and at some of the visited Sub-centres, it was not even available. c. it was observed that some of the VHSC were having ASHA as a member. The funds provided to the sub-centre at Sabalpura for the year2007-08 & 2008-09 was not utilized and was unspent. 8. Maintenance of Records & Registers:- A Maintenance of registers like EC register, Sterilization, IUD, OP, CC Stock registers need improvement. b. Case cards for FW methods were not maintained at all the centre visited by the team. 9. Physical Infrastructure and Availability of Drugs a. CHC visited at Rohat was functioning in Govt Building with having regular water & electricity supply. None of the two Medical officer in the CHC was trained in Emergency Obstractic Care Services . All four specialist sanctioned at CHC were acant. b. There was no Blood Storage Unit and no Ultrasound facility. The Drug position was also not found satisfactory in the CHC. c. The Oxygen cylinder was not functional at PHC Pipalia Kalan. d. The cleanliness of sub-centre Sabalpura was very poor. The toilet was found to be chocked. e. Ambu bag, delivery kit, Emergency contraceptive pills and ORS were not available at sub- centre Sabalpura. f. Ambu bag, Steam sterilizer, Emergency contraceptive pills and Inj. Gentamycine were not available at sub-centre Dhalop & Jhutha. 10. Knowledge and opinion of health services (i) ANMs services a. The team had contacted 35 mothers having child up to one year old in the area of visited HSCs for evaluating their health awareness and the services being rendered ANMs. b. 32 respondents (91.4%) informed that ANMs were available when they needed. 33 (94.3%) mothers visited ANM / AWW to know about nutritional diet in 22 (62.9%) cases deliveries were conducted by the trained personnel. c. 22 (62.9%) followed breast feeding practices within half an hour their deliveries. d. ARI awareness was found in 10 (28.6%) mothers. 18 (51.4%) mothers were having the knowledge of use of ORS at the time of diarrhoea and 26 (74.2%) mothers were having contraceptive awareness. (ii)MPHW(M) Services The team also evaluated the work of one MPHW, who was working at Sub centre Jhuntha which comes under the PHC, Pipalia Kalan. Though the skill of the MPHW was good in handling Malaria and Chlorination activities, his technical knowledge relating to NSV motivation needs improvement. He was not able to identify the beneficiaries of OP, CC cases even though users were motivated by him. (iii) PHC services a. The team visited the PHCs at Nadol & Pipalia Kalan for evaluating the opinion of the public on their functioning. b. The people in the area of PHC Nadol were very much satisfied with the work of medical officer. He was alone managing OPD & IP, deliveries, Sterilization, follow up in the field and having good liaison with the public leaders. 11) Sample verification of F.W. acceptors. a. The team selected 146 cases of F.W. acceptors, out of them 119 (81.51%) could be contacted for verification. During sample verification of family welfare acceptors in the visited centres in the district, some discrepancies In the age of acceptors, number male children and age of last child were found b. 11 (7.5%) acceptors of spacing methods of family planning denied having received the services.

4. District Major observation of field Survey unit of Regional office for Health & family welfare, Jaipur carried out in Jhalawar Districts of Rajasthan state in November & December 2009. I Details of visited Institute District Visited PHCs/CHCs Visited HSCs Visited JHALAWAR PHC-Mishroli and hum Bhesani, Guradia joga, Shyampura CHC- Bhawani Mandi and Titarwasa.

II. Major Observations:

1. Human Resources -:

b) Against the sanctioned post, 25 (54.3%) junior Specialists, 10 (62.5%) Sr. Medical Officer 18 (24.7 %) MO in Rural areas and 3 (60%) Mos Dental were lying vacant in the District.

c) In visited CHC at Bhavani Mandi, 6 posts of Junior Specialists i.e. one post each of Junior medical officer of Medicine, Eye, Anesthesia, Gynecologist, Orthopedics and Pharmacist & 3 Mos. Of Dental were lying vacant. d) In the visited PHCs, post of Lab Technician was lying vacant.

d) No MPHW was posted at all the visited Sub –centres. 2) Functioning of Janani Suraksha Yojana-: a) JSY have been progressively increasing the district since -2005-06. The percentage of JSY beneficiaries has gone up over the period of the NRHM since its in Inception. The JSY beneficiaries in the year 2008-09 raised by 28% from the year 2007- 08. b) The district authority received Rs.1 000000/- in JSY head in the current year which was reported to be sufficient for the scheme. c) In the visited centres, sufficient funds were provided. In some of the sub-centre the scheme was not pick up due non- availability of labour room.

3) Functioning of Rogi Kalyan Samities (RKS).

a) 83 RKS are constituted in the district and all are functioning.

b) In 2008-09, 747 RKS meetings were held and in current year up to Aug, 09 336 meetings were head .

4) Functioning of ASHA

a) There are 1481 villages in the district and 1175 ASHAs were identified and have also been selected.

b) 937 ASHAs in the district received 3rd module training, all the ASHAs were equipped with the drug kit.

c) It was reported that 306 ASHAs are yet to be selected to cover the total villages in the district.

d) In the visited sub-centres, ASHAs were giving the services as per guidelines.

5) Village Health Sanitation Committees-:

a) In the district, 964 village health sanitation committees have been formed and out of these 934 have also opened bank account.

b) Meetings of VHSCs were being held.

6) Untied Fund -: a) An amount Rs 1.88 and 1.33 Crores was allotted to the district for the year 2008-2009 and 2009-2010 respectively. It was observed that a substantial portion of untied fund has been carried forward in last three consecutive years.

b) Annual maintenance grant and untied fund of Rs 1.0 lack each was allotted to the Bhawani Mendi CHC in the year 2008-2009 and total expenditure of Rs. 1,94,153/- was incurred by the CHC.

c) PHCs at Misharoli and Jumki have got prescribed maintenance grant and Untied funds in year 2008-2009 and in the current year.

d) The Untied fund of Rs 10,000/- was received by the Bhaisani & Titarwasa Sub-centre every year including the current year. The untied fund was not utilized by the Sub-centre in the last three years.

e) The Untied fund Rs 10,000/- was received by Guradiya Joga Sub-centre for the year 2008-09. Sub-centre is not running in its own building that’s why the fund is completely unutilized.

7) 24 Hours delivery care system:-

a) In the district there are 14 CHCs & 30 PHCs. All 14 CHCs functioning in the district were providing 24x7 services, out of which 9 were FRUs 8 PHCs were also functioning as 24x7.

b) In the district 9588 institutional deliveries conducted during April 09 to Aug.09 of which 4357 (45.4%) deliveries reported to be conducted in the prescribed night hours at 24x7 Institutions.

c) More than 50% of the total deliveries were reported to be conducted in night hour in the visited CHCs at Bhawani Mandi and PHC Mishroli.

d) Number of deliveries conducted at Jhumki PHCs is very low as only 6 deliveries were conducted, out of which 2 deliveries were conducted in the night in the year 2008-09, In current year up to Sep.-2009, a total 9 deliveries are conducted at this PHC.

8) Physical Infrastructure: a) CHC visited at Bhawanimandi was located in Govt. Building, having regular water & Electricity supply. There was no Blood storage unit. The residential quarters were available for MOs & other staff.

b) Anesthesia Equipments and Incinerator were not available at CHC.

c) Misharoli PHC was having adequate Infrastructure. AYUSH doctor of this PHC sits in Ayuervedic Hospital whereas In Jhumki PHC AYUSH doctor was not available.

d) Examination table, Benches for clients, Foot stool, Delivery table, McIntosh sheet, Ambu bag, DDK, AD syringes , Steam sterilizer ,Torch ,Gloves, Thermometer, Anteseptic solution, IFA tablets, IUD, E.C. Pills, Chlorine solution/bleaching, Chloroquine tablets etc. were not available more or less at the visited Sub-centre at Bhaisani, Guradiya Joga ,Titarwas and Shyampura.

e) The cleanliness of Sub-centre Bhaisani was found very poor. The toilet and the labour room were not available at Sub-centre Bhaisani, Guradiya joga & Shympura.+

9) Knowledge and opinion of health Services:-

(i) ANMs services a) The team contacted 40 mothers in the areas of the Sub-centres visited and 29 (72.5%) mothers informed that ANM was being available when they required the services.

b) On the post –natal care visit, only 9 (22.5%) mother were followed by the health personal within 24 hours of their delivery however 14 (35 %) mothers were visited within 3 days of the delivery.

c) Only 14 (35%) mothers had given breast feeding within half an hour of the delivery .

d) ARI awareness was found among 16 (40%) mothers. (ii) PHC services.

The team mentioned the opinion of the public on functioning of PHC Misharoli & Jhumki. The public of Misharoli were much satisfied with the work of medical officer. 10) Sample verification of family welfare acceptors. a) The team selected 104 family welfare cases, out of which 86 (82.69%) could be contacted. It is to be mentioned here that 17(19.77%) acceptors were found with the discrepancies of their age recorded in the service register.

b) 17 (19.77%) acceptors (12 CU-T, 2 OP, 3Nirodh users) also found to have been fake. In such reporting proper action needed to maintain the quality of services.

11) Maintainance of Records & Registers:-

a) The registers like EC register, Sterilization, IUD, OP, CC Stock register need improvement as many details were not recorded. Matching of FP with EC number was also not maintained in the registers.

b) Case card for family welfare acceptor especially in respect of sterilisation were not maintained at all the visited centres.

12) Observation & Suggestions:-

a) Monitoring and supervision at all levels needs to be strengthened. b) Citizen chart was not exhibited in some of the centres visited. It may be put on display in the institutions. c) Delivery load at some of 24x7 institutions is very low. Needful action should be taken to handle the deliveries in the area covered by these institutions. Immediate steps should be taken to create the infrastructure at the FRUs/24*7 institutions for optimal utilization of their services. d) The utilization of untied & VHSC funds is not up to mark, proper monitoring is required at the Block & District level for timely utilization of the fund. e) The DPM/ DAM should undertake more field visits for effective monitoring of the NRHM. f) Effective measures are required to improve service delivery of ASHA at grass root level. 5. District Pratapgarh

Major observation of field Survey unit of Regional office for Health & family welfare, Jaipur carried out in Pratapgarh Districts of Rajasthan state in November & December 2009. I Details of visited Institute PRATAPGARH PHC- Kulthana and Parasola Gandher, Asawata, Manpur and Ganera. CHC – Chhoti Sadari II. Major Observations: 1. Human resources:-

a) In the district there were 24 medical officers working against the sanctioned post of 35. Out of 11 sanctioned posts of specialists only 3 Surgeons were in position. b) In the Barisadari CHC, one post each of general duty medical officer, Ophthalomologist, Anesthesia, Gynecologist, Peoliatrieian, Malatria Inspector and staff nurse is lying vacant. c) MPHW (male) were not posted at any of the visited Sub-centres in the district. 2. Functioning of Janani Suraksha Yojna. (JSY) a) There were 1527 JSY beneficiaries during 2008-09 and 7186 in the current year, up to Sept. 09 in the district. Funds are sufficient for proper implementation the programme. b) Visited CHC and both PHCs were having sufficient funds under the schemes. c) There has been an increasing trend in number of institutional deliveries due to JSY at PHC level but the number of institutional deliveries at Kulthana PHC was very few as there were only 10 and 11 deliveries during last two years. This area need to be monitored closely to improve the situation. 3) Functioning of Rogi Kalyan samitees (RKS) a) In the district, 28 RKS are constituted and all are functioning. In the current year, a total 156 meetings were held up to Sep, 2009. b) In the meeting of Medical Relief Society (MRF), the formal documentation was lacking at the visited centres. 4) Untied Fund:- a) It was noted that untied fund and annual maintenance grants are being provided regularly every year at the CHCs, PHCs and HSCs level but the utilisation was poor. b) The Untied Fund , Rs 1,50000/- was received by the CHC at Chhoti Sadari in the year 2008-09 & 2009-10 respectively but only Rs 7364 were spent out of this . c) In the visited PHCs at kulthana and parosola, RS.50000/- as an annual maintenance grant and Rs 25000/- as an untied fund have been provided in each year 2007-08, 2008-09 & 2009-10 but in the current year, only PHC Kulthana spent Rs 85008/- and PHC Parasola spent Rs 28938/- from the untied fund. No money was spent from annual maintenance grant. d) The three instalments of untied fund each of Rs 10000/- was received by each Sub-centre at Gandher, Asawatha , Manpur,and Ghanera Sub-centre during last three years. It was observed that 50% funds by HSC Gandher, 33% funds by HSC Manpur and maximum amount by HSC Ganera have been spent. No record regarding expenditure of funds was presented at HSC Asawatha. 5) Functioning of ASHA:- a) Out of 921 villages in the district, 708 villages have been taken up for ASHA intervention and 798 ASHAs were presently working there. It is reported that around 18% of identified ASHSs have yet to be selected in the district. b) 657 ASHAs are reported to have been equipped with the drug kits. c) It was observed that ASHAs in the visited Sub-centres were providing the service to the Ante-natal mothers and also utilising the drugs in the kits. 6) Village Health Sanitation committees (VHSCs) a) In the district 872 village health sanitation committees have been formed and bank account opened for handling the funds. b) It was noticed that documentation of the VHSC meetings was poor and at some of visited sub-centre, it was not even available. The district authority can improve the activities by taking regular feedback from the sub- centres/PHC staff regarding active involvement of ASHA as a member of VHSC and utilisation of fund provision.

7) 24 Hours delivery care System:- a) Out of 22 PHCs existing in the district, 14 PHCs were identified as 24x 7. It is notable that more than 41%of the deliveries at these institutions are conducted in night hours during current year up to Sep. 09. 8) Physical Infrastructure:- a) There are 5 CHCs & 22 PHCs in the district out of which 3 CHCs are declared as FRU but the Infrastructure at these facilities is not up to the mark. No CHC is having the functional Blood storage unit. b) CHC Chhoti Sadare is located in Govt. Building, having regular water & electricity supply. The post of Anesthetic & Gynecologist, Pediateician was vacant. There is no blood storage unit. The residential quarters are available for MOs & other staff. Anesthesia equipments and Incinerator are not available at CHC. c) In Kulthana PHC, labour room was not available .The deliveries are conducted in one corner of the ward by the doctor. The toilet for staff was notavailable in the PHC. Curtain for privacy for the patients was not available. The labour room was under construction and it was not in the premises of the PHC. At PHC Parasola the curtain for privacy of the patient was not available in the doctor room. X-ray technician was not appointed at the PHC and patients are deprived of the available services in want of the technician. There is no separate toilet for staff. d) No labour room was available at visited sub-centres; electricity connection was not found at sub-centre Ganera . e) Equipments, Drugs and some essential suppliers were mostly available at the sub- centres but some of the items i.e. Cupboard for drug, mclntosh sheets, Ambu bag,Steam sterliser, Thermometer, Gloves, Oral Pills, E- Pills, condoms, Bleaching powder, Cap. Ampacillin, ing. Gentamycine,and supply of Kit-A and Kit-b. etc. were missing at the most sub-centres visited. 9) Community Knowledge and opinion on Health Services:- a) The team had contacted 39 mothers having Child of up to one year age to find out the awareness and knowledge about various health issues. b) Only 11 (28.2%) mothers were visited at their homes by the health personnel within 24 hours of delivery. C) Danger signs of ARI were known to only 18 (46.6%) mother and 28 (71.9%) mothers were aware of the use of ORS. d) The team visited the PHC of Kulthana & Parasola and evaluated the opinion of the public on their functioning. The public of Parasola was not satisfied with the work of Medical officer/Staff. People gave their opinion for improving public services at PHC Kulthana. 10) Summary Finding of sample verification of family welfare Acceptors:- a) The team selected 151 F.W cases in the district out of which 99 (65.6%) could be contacted. Out of 99 contacted cases , the discrepancies were found in the age of acceptors in 19 (19.2%) cases, in the age of spouse in 15 (15.2%) cases, in the number of total children in 2 (2.02%) cases and in the age of last child in 10 (10.10%) cases. b) All sterilization cases received full compensatory amount and follow up was also made to the contacted acceptors. c) The team selected 87 immunization cases and 72 were contacted, all of them were immunized as per schedule and no discrepancy was reported. d) Out of 74 users cases of IUD, OP and Nirodh users contacted for physical verification, as many as 25 (33.8 %) cases were found to be false. There is a need to eliminate such reporting and urgent step to improve the quality. 11) Maintenance of Records and Registers:- a) In the CHC Chhoti Sadari, PHC Kulthana and Parasola, the cash book was properly maintained in JSY scheme. b) The register like EC register, Sterilization , IUD, OP, CC stock register need improvement as many details were not recorded. c) Sterilization Register was not maintained at PHC Kulthana and Parasola. It was not made available to the team at the time of visit. d) Case cards of Sterilization were not maintained at PHC Kulthana and Parasola. 12) Miscellaneous observations and Suggestions:- a) Citizen charter not exhibited in some of the centers visited. It may be put on display in the institutions. b) Delivery load at some of the 24x7 institutions is very low. Necessary action should be taken to handle the deliveries in the area covered by these institutions. Immediate step should be taken to create the infrastructure at the FRUs and 24x7 Institutions for optimal utilization of their services. c) Member of the VHSC are not playing the proactive role in dealing with the health issues of the village. Documentation of the VHSC meetings need further improvement to assess the proper functioning. d) The payment of ASHA should be made in time. The Medical Officer should ensure that staff responsible for payment should not delay the payment to ASHA. e) Most of the JSY beneficiaries of PHC Parasola reported that at the time of delivery the MO/Staff charges the delivery fee from their attendant. Immediate action should be taken to stop such practice. IEC may further be strengthen. f) Effective measures are required to improve service delivery of ASHA at grass root level. g) The expenditure from the untied fund and AMC is very low. Concerned facilities should take up activities to optimally utilize this fund in the year of allotments. As observed, there is some apprehension in spending the AMC amount at all the facilities visited. Expenditure undertaken from the allotments in last three consecutive years was not up to the satisfactory leve at some of the facilities.