Rapid Appraisal of National Rural Health Mission (Nrhm) Implementation

RAPID APPRAISAL OF NATIONAL RURAL HEALTH MISSION (NRHM)

IMPLEMENTATION

DISTRICT: JORHAT

ASSAM

POPULATION RESEARCH CENTRE DEPARTMENT OF STATISTICS GAUHATI UNIVERSITY ASSAM

PREFACE

The Government of India, with the objective of meeting the basic requirement of Health for all, has launched the National Rural Health Mission (NRHM) to carry out necessary technical correction in the basic health care delivery system. The Mission aims at provision of comprehensive and integrated primary healthcare to the people, especially to the rural poor, women and children. The Mission covers the entire country including Assam. One of the most noted strategy of the Mission is decentralisation of programmes for district level management of health. The Mission adopts a synergistic approach by relating health with nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian system of medicine to facilitate health care. Realising the urgency the Ministry of Health and Family Welfare, Government of India has decided to conduct a study on Rapid Appraisal of NRHM Implementation in all the states of India where NRHM is in operation. Given the very wide scope of the Mission and diverse nature of its activities, the rapid appraisal of NRHM implementation is restricted to selected core components that directly associated with the health and family welfare needs of the people. As such the rapid appraisal is restricted to the following core components of the Mission: (i) Utilization of untied funds at SC, PHC and CHCs (ii) Janani Suraksha Yojona (JSY) (iii) Facility Upgradation under the NRHM and (iv) Assessment of Health and Family Welfare situation at the village level.

Government of India has launched the National Rural Health Mission (NRHM) on First April of 2005 and already passed four years of implementation, it is high time to evaluate the programme with a view to see the achievements and various lacunae in all stages of implementation. To be more effective in implementation of the health programmes the Mission felt needs of technical support from various organizations. The Ministry has selected different agencies to conduct the Rapid Appraisal Survey of NRHM implementation in all 18 states. The Population Research Centre, Gauhati University has been entrusted to survey in two districts of Assam namely Sonitpur and Jorhat and Bankura district in West Bengal and provided component wise various objectives to be studied under the Survey.

The present report confined only to the Jorhat district of Assam with inclusion of a state profile based on the state schedule. The report is based on the tabulation plan discussed and finalized at various workshops attended by representatives of all of the participating agencies including our centre. The report has been drafted by Dr. D.K.Kalita, Mr. G. Pathak, Research Investigators and Mr. M.M. Bora, Research Fellow of Population Research Centre, Gauhati University. The tabulation of the study has been done by Mr. Dipak Das Field Investigator of the Centre. The report contain ten chapters including the major findings, with invaluable information on utilization of untied funds at SC, PHC and CHC level, implementation of Janani Surakha Yojana, upgradation of health facilities under the NRHM and assessment of health and family welfare situation at the village level. It is hoped that the findings will help the administrators and policymakers in future implementation of the National Rural Health Mission in particular and family welfare programme of India in general.

L. Choudhury Hony. Director Population Research Centre

Gauhati University

COTETS

Pages

CHAPTER I: ITRODUCTIO AD STATE PROFIL 527

CHAPTERII: DISTRICT PROFILE 2841

CHAPTERIII: COMMUITY HEALTH CETRE 4275

CHAPTER IV: PRIMARY HEALTH CETRE 76112

CHAPTER V: SUBCETRE 113138

CHAPTER VI: HOUSEHOLD CHARACTERISTICS 139199

CHAPTER VII: ACCREDIATED SOCIAL HEALTH ACTIVISTS 200204

CHAPTER VIII: GRAM PACHAYATS 205208

CHAPTER IX: QUALITY OF CARE AD CLIET SATISFACTIO 209233

CHAPTERX: MAJOR FIDIGS AD SUGGESTIOS 234249

PHOTOGRAPH 250255

CHAPTER I

ITRODUCTIO AD STATE PROFILE

1.A.1. Introduction: Health care is one of the most important interventions in the process of economic and social development and improved quality of life of the citizens. The Government of India after experimentations of various programmes to improve the quality of health including improved nutrition, sanitation, and hygiene and safe drinking water has launched the National Rural Health Mission (NRHM) on First April of 2005. The main objective of the Mission is to carry out necessary architectural correction in the basic health care delivery system. It aims at provision of comprehensive and integrated primary health care to the people, especially to the rural poor, women and children. Also it aims at mainstreaming the Indian System of Medicine to facilitate health care. The plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalising Community Health Centres into functional hospitals meeting Indian Public Health Standards in each Block of the country. The National Rural Health Mission seeks to focus on 18 states, which have weak public health infrastructure and indicators. These states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal, Uttar Pradesh and West Bengal. The expected national outcomes from the Mission are (i) reduction of Infant Mortality Rate (IMR) to 30 per 1000 live births, (ii) reduction of Maternal Mortality Rate (MMR) to 100 per 100,000 live births, (iii) reduction of Total Fertility Rate (TFR) to 2.1 all by 2012,

(iv) reduction of Malaria Mortality Rate of 50 percent up to 2010, and additional 10 percent by 2012, (v) reduction of KalaAzar Mortality rate of 100 percent by 2010 and sustaining elimination until 2012, (vi) reduction of Filaria /Microfilaria Rate of 70 percent by 2010, 80 percent by 2012, and elimination by 2015, (vii)reduction of Dengue Mortality Rate 0f 50 percent by 2010 and sustaining that level until 2012, (viii) increase of Cataract operations to 46 lakhs until 2012, (ix) reduction of Leprosy Prevalence Rate from 1.8 per 10,000 in 2005 to less than 1 per 10,000 thereafter, (x) maintenance of Tuberculosis DOTS of an 85 percent cure rate through the entire mission period and sustaining the planned case detection rate, (xi) up gradation of all Community Health Centres to Indian Public Health Standard, (xii) increase of the Bed Occupancy Rate of First Referral units from less than 20 percent of referred cases to over 75 percent and (xiii) engagement of 400,000 female Accredited Social Health Activists (ASHA).

The Mission lists a set of core strategies to meet its goals like decentralised village and district level health planning and management, appointment of female ASHA to facilitate access to health services. The Mission attempts a major shift in the governance of public health by giving leadership to Panchayati Raj Institutions in matters related to health at district and subdistrict levels. One of the most noted strategies of the Mission is decentralisation of programmes for district level management of health. Under the scheme, all existing societies for health and family welfare programmes, Reproductive and Child Health and National Programmes for TB, Malaria, Blindness, Filaria, Kala Azar, Iodine deficiency and Integrated Disease Surveillance, integrate into a unified District Health Mission. Funding for all these programmes is eventually funnelled into the District Health Mission, which is empowered to formulate integrated health plan of the district. One of the core strategies of the Mission is to empower local governments to manage, control and be accountable for public health services at various levels. The Village Health and Sanitation Committee, the Standing Committee of the Gram Panchayat have provided oversight of

Mission’s all activities at the village level and been responsible for developing the Village Health Plan with the support of the Auxiliary Nurse Midwife, ASHA, Angawadi Worker and SelfHelp Groups. Block level Panchayat Samities coordinate the work of the Gram Panchayats in their jurisdiction and serve as link to the District Health Mission, which is led by Zila Parishad and control, guide and manage all public health institutions in the district. States are encouraged to devolve greater powers and funds to Panchayati Raj Institutions (PRI).

For successful implementation of the programmes, the Mission has taken various strategies. The core strategies are (i) to train and enhance capacity of PRI to own, control and manage public health services, (ii) to promote access to improved health care at household level through the female health activist (ASHA), (iii) to formulate health plan for each village through village health committee of the Panchayat, (iv) to strengthen sub centres through an untied fund to enable local planning and action and more Multi Purpose Health Workers (MPHW), (v) to strengthen existing PHCs and CHCs, and provision of 3050 bedded CHC per lakh population for improved curative care to a normative standard ( Indian Public Health Standards defining personnel, equipment and management standards), (vi) to prepare and implement an intersectoral District Health Plan prepared by the District Health Mission including drinking water, sanitation and hygiene and nutrition, (vii) to integrate vertical Health and Family Welfare programmes at National, State, District and Block levels, (viii) to provide technical support to National, State and District Health Mission , for Public Health Management, (ix) to strengthen capacities for data collection, assessment and review evidence based planning, monitoring and supervision, (x) to formulate transparent policies for deployment and career development of Human Resources for health, (xi) to develop capacities of preventive health care at all levels for promoting healthy life styles, reduction in consumption of tobacco and alcohol etc. and (xii) to promote nonprofit sector particularly in underserved areas.

In view of the above background and also the fact as the Mission is being implementing the programmes in its fifth year of existence, it has been pertinent to have stock of the operationalisation of the Mission at the state, district and local level in the context of the Plan of Action evolved at the national level. Realising the urgency the Government of India, Ministry of Health and Family Welfare has decided to conduct a study on Rapid Appraisal of NRHM Implementation in all 18 states including Jorhat district of Assam of India where NRHM is in operation. Given the very wide scope of the Mission and diverse nature of its activities, the rapid appraisal is restricted to selected core components that directly address the health and family welfare needs of the people. As such the rapid appraisal is restricted to the following core components of the Mission.

(A) Utilization of untied funds at SC, PHC and CHCs (B) Janani Suraksha Yojona (JSY) (C) Facility Upgradation under the NRHM (D) Assessment of health and family welfare situation at the village level. The Ministry has selected different agencies to conduct the Rapid Appraisal Survey and provided component wise various objectives to be studied under the Survey. A brief description of the components with its objectives to be studied is given bellow. (A) Utilisation of untied funds: NRHM has drawn a plan of action at all levels of health care to build up sustainable health care delivery system, where all citizens can access to affordable and appropriate quality healthcare. To achieve its goals, NRHM in its strategies, set up a platform for involving the Panchayati Raj Institutions in primary health programmes and infrastructure. The Mission also envisages the following roles for PRIs: States are required to commit for devolution of funds, functionaries and programmes for health to PRIs. At grassroots level, Village Health Committee has been formed to decentralize

the planning and monitoring of various programmes. For strengthening the health centres, all the health facilities are provided with untied funds. Untied funds can be used only for the common good and not for the individual needs, except in the case of referral and transport in emergency situations. Each subcentre receives an untied fund @ Rs. 10,000 per annum. Also, each PHC and CHC receives untied funds of Rs. 25,000 and RS 50,000 respectively per year for local health action. At subcentre level, the fund is deposited in a joint account of the ANM and the woman Sarpanch or the woman member of Panchayat, but the account is operated by ANM in consultation with village health committee and multipurpose health workers. At the PHC and CHC level, untied funds are kept in the bank account of the concerned Rogi Kalyan Samiti (RKS) / Hospital Management Committee. The funds are spent and monitored by RKS. As per Ministry’s directions the survey has been undertaken to analyze the actions under the following objectives of the study.

The survey objectives are (i) to examine the utilization of untied funds under different activities at subcentre, PHC and CHC levels, (ii) to highlight the problems faced by CHC and PHC Incharge and ANM in receiving and utilization of the funds, (iii) to seek the opinions of CHC and PHC Incharge and ANMs regarding the sufficiency of funds and

(iv) to study the role of village health committee particularly Lady Sarpanch /

Panch at subcentre level and Rogi Kalyan Samiti in the utilization of funds at

CHC and PHC level.

(B) Janani Suraksha Yojana (JSY) Janani Suraksha Yojona is an integral component for safe motherhood under NRHM having objective of reducing maternal and neo natal mortality. The scheme aims at promoting institutional deliveries amongst poor pregnant women in all States and Union Territories of the country with special focus in low performing states (LPS). It is a 100 percent centrally sponsored scheme linking with cash assistance for delivery and post delivery care. For this, clients are usually escorted, provided transport assistance to reach the institutions and for complicated cases provided referral services. These services are provided under the Reproductive and Child Health Programme interventions. Apart from this, states have been given flexibility to evolve publicprivate partnership (PPP) mechanism and accredit private health institutions for providing institutional delivery services. The special dispensation for LPS in both rural and urban areas has been made and linked to the ASHA intervention. In the States and Union Territories of High Performing States (HPS) category similar provisions have been made wherein Anganwadi worker or traditional birth attendant or ASHA like activist could be engaged and associated with the JSY scheme. The JSY focuses on (a) maternal care through microplanning of births, (b) cash assistance to all eligible mothers for delivery care, (c) cash assistance for referral transport, (d) cash assistance to institutions for hiring specialists for Caesarean Section or for the management of Obstetric complications and (e) cash benefit to ASHA for facilitating institutional delivery. The present survey is entrusted to study the following objectives. (i) To assess the role of ANM/ASHA in providing services to the beneficiaries of the JSY. (ii) To seek the opinions of ANMs/ ASHAs regarding sufficiency of funds and timely disbursement of funds. (iii) To study the role of other health officials in the implementation of the scheme at district.

(iv) Review engagement of private sector including accreditation and compensation. (v) To highlight the problems faced by beneficiaries in receiving the services/funds. (vi) To analyze nature and scope of IEC interventions for raising awareness of JSY. (C) Facility Up gradation Under the RHM: For meeting the health needs of the rural masses, one of the key strategies of the NRHM is to strengthen all the health facilities by upgrading them with necessary infrastructures according to the type of facility like CHC, PHC, SC etc. The main aim is to strengthen hospital care for areas, provide specialized care to the community and also to improve the standard of quality of care in order to enhance the level of patient satisfaction. Thus this evaluation study has been undertaken so as to examine as to what extent the SC, PHC and CHCs have been upgraded under NRHM. The study has examined the objectives under this component. (i) To assess the availability and adequacy of infrastructure, furniture, equipment. (ii) To observe the availability of medicine/drugs and vehicle in upgraded SCs, PHCs and CHCs. (iii) To examine the availability of manpower (medical, paramedical). (iv) To assess the type of services and investigate the availability of facilities. (v) To assess the client perception regarding quality of services through exit interviews and seek views of the community through FGD. (vi) To seek opinion of doctors and Para medics regarding the type and quality of services provided to the community.

(D) Assessment of Health and Family Welfare Situation at the Village level: It has been envisaged under NRHM that indicators of health depend upon drinking water, nutrition, sanitation, female literacy and women’s empowerment. NRHM seeks to adopt a convergent approach for interventions under the district plan, which seeks to integrate all the relative initiatives at the village, block and district levels. Wherever village committees have been effectively constituted for drinking water, sanitation, ICDS etc., NRHM attempts to move towards one common Village Health Committee covering all these activities. Panchayati Raj Institutions are being fully involved in this convergent approach so that the gains of integrated action can be reflected in district plans. Under NRHM, household surveys through ASHA, AWW has targeted availability of drinking water, firewood, livelihood, sanitation and other issues in order to allow a framework for effective convergent action in the Village Health Plans. This survey has assessed the health and family welfare situation in the village in terms of availability of drinking water, sanitation, functional health facilities, quality of services provided, nutritional status, women’s empowerment, maternal and child health, disease prevalence etc. 1.A.2. Survey Methodology and Design: The Rapid Appraisal has covered all tiers of public health care delivery system right from the village up to the state level. For the sake of objectivity, the rapid appraisal exercise has organised broadly in terms of policy formulation, programming and implementation for each of the four components of the Mission mentioned herein. At the state level the rapid appraisal exercise has focused primarily on policy formulation with respect to the conceived components. At the district and community health centre level the rapid appraisal exercise has focused primarily on programming necessary to translate policy into specific action while at the primary health care centre, subhealth centre and village levels, the rapid appraisal exercise has concentrated on the implementation aspects.

A mix of quantitative and qualitative tools has been developed for the rapid appraisal. At the village level, the community at large has carried out a household survey to assess the health and family welfare situation as well as to assess the use of public health facilities. At the institutions level, the rapid appraisal has reviewed and attempted analysis on the available records of public health institutions and indepth interviews and focus group discussions with the policy makers, programme managers and service providers at different tiers. The Ministry has also provided common Sampling Design for the survey conducted in the selected states of India. According to the Design one district is selected for every 15 districts. District within a State is selected randomly. In addition, for collection of information in regard to the survey the health facilities are selected in the following ways. (i) From each selected district the District Hospital (DH) is selected. In states where the Male and Female DH are separate, they are treated as one entity. They may be Subdivisional or District Head Quarter Hospital. (ii) Under the selected district, 2 Community Health Centres (CHC) are selected under the following conditions. (a) One CHC is the farthest from the district HQ. (b) If the first CHC selected is a First Referral Unit (FRU) then second CHC could be any CHC; else the second CHC should preferably be an FRU, if available. In case no CHC is available, the largest Block/ Addl. PHC should be selected. (iii) From each selected CHC 2 Primary Health Centres (PHCs) are selected. Each selected District has had 4 PHCs under the survey. One of the PHCs should preferably be 24x7, if available.

(iv) From each selected PHC 3 Subcentres are selected in the way that one SC be the farthest from the selected PHC. As a whole there are 12 Subcentres selected for the survey. (v) Also 2 villages from the catchments area of selected SC are selected and from each selected village 50 households are selected to know their perception on the programme. The villages are selected under the condition that one village to be where the subcente is located and the second village should be the farthest from the selected Subcentre. From each selected village 50 households are selected randomly. Thus in the selected district there are 1200 households in the 24 villages under 12 selected SubCentres. Apart from the above samples Indoor and Outdoor patients drawn from the District, CHC/Block and PHC are also interviewed in order to know their perception on the health service activities. ASHAs are also interviewed to have information on their performance. Questionnaires: In order to collect information from various Govt. Health facilities and other related beneficiaries, which are involved in implementation of NRHM activities 9 sets of questionnaires, are provided by the Health and F.W. Ministry. (i) State Level Questionnaire is mainly used to collect information on Demographic, Health and Family Welfare performance and infrastructure development of the States under NRHM. (ii) District Level Questionnaire has two parts: PartA covers to collect information related to performance and infrastructure development of the District. This is meant for District Administrative Office.

PartB covers to collect statistics on performance and infrastructure development of the District Hospital. (iii) The Questionnaire on CHC or BPHC (where CHC is not available) deals with identification of the centre, Framework and Structure related issues, Infrastructure Status, Human Resource, Operation Theatre, Labour Room and Diagnostic Facilities, availabilities of Equipment and Drugs and Services Availabilities and Outcome. (iv) Primary Health Centre is the key service centre, which provides immense health services to the rural people. So, to collect various information from the centre PHC Level Questionnaire is used. This PHC Questionnaire covers the sections of Identification Details of the centre, Framework and Structure Related Issues, Infrastructure Status, Availability of Equipment and Drugs, Human Resource and Training of Personnel etc. (v) The extension of Health SubCentre to the remote villages is an noble act of the Government for the rural poor. As such, the assessment of the performance and outcome is important for further development of the programme. With this view a SubCentre Level Questionnaire is also used. This questionnaire collects the information on Identification Details of the Centre, Availability of Human Resource, Infrastructure Status, Availability of Equipment and Drugs, Skills and Practices of ANM under RCH services, Maintenance of Records, Registers etc., Performance on the Janani Surksha Yojona and

Receipt and Maintenance of Untied Grants provided by the Mission. (vi) The Household Questionnaire collects information on various branches of the health services. Viz. Identification of the village and the Respondent of the Household, Household Details, Accredited Social Health Activist (ASHA), Janani Suraksha Yojona Scheme and Client Satisfaction (Quality of Care in Government Health Facilities). (vii) ASHA is a newly created Scheme under which the health activist extends services to the rural people in accessing to health services. A Questionnaire on ASHA is also prepared to interview them on the following parts. In addition to the Identification of the Respondent and their location of works, regarding Training, Role and Responsibilities, Janani Suraksha Yojona, ASHA’s performance and Awareness, and Cash Incentives are covered by this questionnaire. (viii) The Questionnaire on Sarpanch or any Member of the Gram Panchayat of selected village covers to collect information of the villages under the selected Gram Panchayat, regarding IEC, functioning of the Institutions like Village Health and Sanitation Committee (VHSC), ASHA/ JSY Scheme Implementation and about NRHM. (ix) Another two sets of Questionnaires on Outdoor and Indoor patients who undergo health services in District, CHC / BPHC and PHC are also used to collect information on having services and their satisfaction on the services. The Outdoor patient questionnaire deals with the Identification of the Respondent and the location, Waiting Time for getting services in

the centre, Centre Staff Behaviour, Maintenance of privacy in the centre on investigation of certain diseases, Communication between Doctors and Patients, Cleanliness in the centre and its other rooms of services, Crowding in the Centre and continuity of Treatment. Indoor Patient Questionnaire collects the information on Identification Details of the Patient and the Location of the health facility, Waiting Time for having services in the Centre, Behaviour of the staff towards the patients in the Centre, Maintenance of Privacy in treatment of certain diseases, Communication between Doctors and Patients, Cleanliness of the hospital, Crowding in the hospital, Amenities Provided by the Hospital and Continuity of Treatment. Survey Agency: The Ministry of Health and Family Welfare, Govt. of India has entrusted the survey assignments to all 18 Population Research Centres (PRCs) of India for their respective states. However, the Population Research Centre, Gauhati University of Assam has been assigned to conduct the survey in Jorhat and Sonitpur Districts of Assam and Bankura District of West Bengal. Team Composition: Each District was equipped with 9 Field Investigators, 3 Supervisors and 1 Coordinator (PRC Personnel) for correct and effective collection of field information. The Coordinator and Supervisors collected the institutional information in addition to supervision of the works of the Field Investigators. Field Investigators conducted the interviews with Household Personnel, ASHA and Outdoor and Indoor patients and collected required information in formatted questionnaires.

Time Schedule: The pre field work information was collected from the State Department of Health and Family Welfare, Govt. of Assam and from Joint Director, Health Service of Jorhat District where NRHM district unit is also located; in the last part of November, 2008 so as to prepare the details plans of field works. The main fieldwork was carried out during December, 2008 and February, 2009. The draft reports are expected to submit to the Ministry in the month of June 2009. Location of the Study: The study and its report is exclusively related to the Jorhat District of Assam. Some information relating to the sampling design of the Jorhat District is given here for ready reference.

State Assam, District Jorhat CHC/FRU Titabar FRU Kamalabari CHC MPHC/SD Mohimabari Borhola SD Karatipar Jengraimukh MPHC MPHC SD SC (1) Fulbari Gorajan Charpaikhowa Jengraimukh Village Balichapari 1)Tengajan 1)Gorajan 1)Charpaikhowa 1)Jengraimukh 2) Fulbari 2) Sildubi 2)Gondhuwa chapari G.P. Chapari 2)Mogua Chuk Tengajan 1)Borhola Karatipar Jengrai 2)Rajabahar SC (2) Mohimabari Bosa Molapindha phulani Village 1)Mohimabari 1) Bosa 1) Molapindha 1) Phulani No. 2) Bosabari 2)Kopahtoli Mishing 2 2) Bogoriguri 2) Noloni G.P. Turung 88No.Ikarani Sriluit 1) Phulani 2) Rangasahi SC (3) Bhagyalakhi Bojalkota Kardoiguri Bhakatidwar Village 1)Bhagyalakhi 1) Bojalkota 1) Kardoiguri 1) Bhakatidwar G.P. 2) Batiajan 2)AjoyNagar 2) Kargil 2) Nara Singha Saraipani Raidangjuri Sriluit Sriram

1.A.3. Geographic Features: Physical Setting: The study area Assam is located in the far northeast part of India within the longitude of 89○5’ E96○1’E and latitudes of 24○3’ N28○N. The area of the state is 78438 Sq. Km, representing 2.39 percent of the country’s total area. As per 2001 census the total population of the state is 2.66 crore. Assam is surrounded by seven Indian states and two foreign nations. There are only a few Indian states that have such a strategic location. The state can be divided into some physiographic divisions based on the land ford characteristics. They are 1) The Brahmaputra Valley, 2) The Barak Valley, 3) The Karbi Plateau and 4) The Barile and southern hills. The region is a land of rivers and tributaries. The dense network of two river systems, viz the Brahmaputra and the Barak systems, drains the whole state. The Brahmaputra River is one of the biggest rivers of the world. It forms complex river system characterised by very dynamic and unique water sediment transport pattern. The major north bank tributaries are Subansiri, Jia Bharali, Dhansiri, Puthimari, Pagladia, Manas and Champamati; while the principal south bank tributaries include the Burhidihing, Dishang, Dikhow, Dhansiri, Kapili and Krishnai. The state of Assam lies in the region of monsoon climate of subtropical belt. It enjoys heavy summer rainfall, winter drought, high humidity and relatively low temperature during a year. The state generally experiences four climatic seasons 1) Pre monsoon, ii) Monsoon iii) Retreating Monsoon iv) Dry winter. Under varying geological conditions and topographical characteristics and agro climatic conditions different types of soils are found to occur in hills, plateaus, piedmonts and plains. Therefore, the soils of Assam

can be divided into groups, viz. alluvialdistributed extensively over the Brahmaputra and Barak Plain, Piedmontconfined to the northern narrow zone along the piedmont zone of Himalayan foothills. Hill soilsfound in the southern hilly terrains of the State, Laterite Soilsmainly occurs in N.C. Hills and some parts of southern Karbi plateau. Of the total geographical area of the state, forests cover only 22 percent, which is much below the minimum norm of 33 percent prescribed by the National Forest Policy. The forests of Assam can be classified into four types; evergreen, semi evergreen, deciduous and degraded scrub. 1.A.4 Area and People: Area and Administrative Divisions: The total land area of Assam is 78,438 km2. It occupies about 2.4 percent of the land area of the country. Administratively, the state is divided into 3 divisions and 27 districts. People, Culture, Religion and Language: As per the 2001 Census, the population of Assam is 26655528, which constitute 2.6 percent of the total population of India. The density of population per km2 in 2001 in Assam was 340. The state has a large population belonging to tribes. The tribal include Bodos, Kacharies, Rabhas, Karbis, Misings, Deuries, Chutias, Dimasas, Hmars and Lalungs. Bihu is the major cultural festival of the state, which is observed by all the people irrespectively of caste and creed. Assamese is major language spoken in the state. It is the official language of the state except in the Bengali speaking districts of Cachar, Karimganj and Hailakandi where Bengali has been recognized as the official language. According to the 2001 Census, which is the latest Census, 64.9 percent of the population is Hindu, 30.9 percent Muslim, 3.7 percent Christian and 0.05 percent is from other religions (Office of the Registrar General and Census Commissioner, 2001).

1.A.5 Economy: The economy of Assam is predominantly based on agriculture. About 63 percent of the state’s labour force is engaged in agriculture and allied activities. The principal food crop is rice; and the cash crops include jute, tea, oil seeds, sugarcane, and potato. Industrially Assam is a backward state. There are no large scale industries in the state. The two oil refineries established by the Government of India, constitute the major industries of Assam. However, of the agriculturebased industries, tea occupies an important place in the state’s economy. There are more than 800 tea gardens in the state covering an area of about 225,000 hectares. Assam contributes about 15 percent of the world’s entire tea production (Ministry of Information and Broadcasting, 1993). The state also has cottage industries including sericulture, weaving, bamboo craft, cane, carpentry, brass and metal craft. The annual per capita income of the state estimated at current prices, although increased from Rs.1,200 in 198081 to Rs.2,756 in 198889, is lower than the allIndia per capita annual income of Rs.1,627 and Rs.3,835 for 198081 and 198889, respectively (Centre for Monitoring India Economy, 1991). 1.B.1. State Profile: This chapter presents a profile of population characteristics and status of NRHM Intervention along with list of facilities covered for the study based on the state schedule.

Table 1.1(A): Population Characteristics: Population of the State(As on 2001 as per Population Census Category Rural Urban Total

Male Female Male Female Male Female Schedule 802548 751143 141126 131132 943674 882275 Caste Schedule 1598267 1556279 79850 74174 1678117 1630453 Tribe Others 9539130 8968921 1616116 1396842 11155246 10365763 Total 11939945 11276343 1837092 1602148 13777037 12878491

The proportion of Schedule Caste population to the total population of Assam is 6.9 percent and the proportion Schedule Tribe population to the total population is 12.4 percent. The Rural population comprises 87.1 percent and urban population is 12.9 percent. The proportion SC Female (6.9%) population to the total female population is higher than SC male (6.8%) to the total male population in Assam. In case of ST population also the proportion of Female (12.7%) population is higher than the Male (12.2%). As per census 2001, the total number of villages in Assam is 26312 and out of which 25124 are inhabited. The total number of Gram Panchayat is 2489; total number of town in Assam is 125. The sex ratio is 935 females per 1000 males (Table1.1. (A)).

The state Health Department is unable to provide the population of Assam as on March, 2008 as per required format. However, the population of Assam projected by PRC, G.U. for 2008 is given below in the Table1.1 (B).

Table 1.1(B) Population of the State as on 2008. Population of the State As on 2008 Category Rural Urban Total

Male Female Male Female Male Female Scheduled 850635 796150 159416 148127 1010051 944277 Caste Scheduled 1744437 1698608 111632 103696 1856069 1802304 Tribe Others 10702624 10062863 2050981 1772704 12753605 11835567 Total 13297696 12557621 2178028 2024527 15619725 14582148

It can be calculated from the Table1.1(A) and Table 1.1(B) that the Scheduled caste population increases by 7.0 per cent, Scheduled Tribe population by 10.6 percent and other population by 14.3 per cent during the last eight years in Assam. The growth of total population during the period is 13.3 per cent in Assam.

Status of RHM Interventions: Table 1.2: Status of Health Infrastructure and Facility Upgradation under RHM: Public Health Total ew Buildings Total o. of Infrastructure Existing Under umber facilities (In os.) Construction where IPHS where IPHS (As on (In os.) (As facility Upgradation 30.6.2008) on 30.6.2008) Survey completed Completed (As on (As on 30.6.2008) 30.6.2008) Sub Centre 4592 750 0 0 PHC 844 50 0 0 24x 7 PHC 297 295 0 0 CHC 108 103 0 0 First Referral 36 14 0 0 Units(FRU) Mobile 10 medical unit Sub divisional 13 0 0 0 Hospital District 21 4 0 0 Hospital AYUSH 0 0 0 0

It is seen from the Table 1.2 that there are 4592 Sub Centre existing in the State and 750 new buildings for Sub Centres are under construction. It is reported that no any IPHS facility survey was done in any of the health facilities in Assam, as such there is no record of IPHS upgradation completed as on 30.6.2008. In Assam there are 844 PHC, 297 24x7 PHC, 108 CHC, 36 First Referral Units (FRU), 10 Mobile medical unit,

13 Sub Divisional Hospital and 21 District Hospitals. New buildings under construction as on 30.6.08 are in 50 PHCs, 295 Nos. in 24x7PHCs, 103 CHCs, 14 FRUs and 4 District Hospitals. There is no AYUSH existed in the state as per information received.

There are 178 Nos. of Private Health Infrastructure in the state of Assam but no separate record was found for Hospitals with more than 30 bedded and Nursing Homes with less than 30 bedded.

However, as per estimate of the Directorate of Economics and Statistics, Govt. of Assam the population of the State reached at about 2.97 crores as on 2008, with an increase of about 3.0 million people during 2001 to 2008.

1.B.2. Rogi Kalyan Samity (RKS) Information was also collected from the State Programme Manager in regard to Rogi Kalyan Samity relating to the health facilities from the District Hospital down to the PHC, Block and additional PHC. The Table–1.3 indicates the numbers of facility wise RKS in functioning and registered categories.

TABLE –1.3

umber of Functioning and Registered RKS in Assam: Total Functioning o. with Registered RKS District Hospital 21 21 Sub Divisional Hospital 3 3 CHC 103 103 PHC 844 844 Block PHC 149 149 Addl. PHC 0 0

The number of Rogi Kalyan Samities available in the localities of respective health facilities is mentioned in the Table –1.3. All the registered RKS are functioning at the time of Survey. But it is observed that 27 numbers of Districts of the State have only 21 district hospitals. There is no Additional PHC in Assam.

1.B.3. Janani Suraksha Yojona (JSY): State information is also collected regarding Janani Suraksha Yojona the most important and newly created woman health intervention that is developed under the NRHM. The State Programme Manager stated that Public Private Partnership (PPP) initiative has been undertaken in the State for implementation of Janani Suraksha Yojona Scheme. Accordingly, the Mission accredited only 7 numbers of Private Health Facilities for JSY scheme. Information was also sought for institutional deliveries held during 2007 08 as per various categories of population of the State. But the Programme Manager provided only grand total of institutional deliveries. For categories like Scheduled Caste, Scheduled Tribes, General, Bellow Poverty Line (BPL) and Above Poverty Line People, information is not available. The available information provided by the Department is given bellow for government facilities only and there is no information for private facilities existing in the state. umber of Institutional Deliveries (ID) reported during 200708 = 322557 umber of registered JSY during 200708 = 304741 Out of total registered JSY women, number of women Opting for institutional delivery during 200708 = 304741 It is seen that all the registered JSY women opted for institutional delivery during 200708. Out of the 322557 institutional deliveries reported during 200708, 304741 (95%) women are registered under JSY Scheme.

1.B.4. Financial Mechanism: According to the information reported by the State Health Department all the vertical health societies created under different programmes merged into State Health Society under NRHM. Out of 27 districts all the districts have merged in to registered health societies. The State Health Society has a common Bank Account for all programmes initiated under the Society. The State has prepared perspective State Health Plan for 200809 and also formulated 27 District Action Plans for the year 200809 and all these plans approved by the State Society. In regard to allocation of funds the States have been provided some norms

by the Mission. Under these norms Assam Govt. allocates the funds to the districts by activity wise. The other options like as flexi pool funds or based on a set formula like size of district etc or based on previous year’s expenditure etc. are not reported. The funds are usually transferred electronically to all 27 districts of the State. It is also reported that account payee Bank Draft has transferred some times the fund. In the State all the 4592 Sub Centres available in the state have Joint Bank Accounts, which are operated by ANM and Sarpanch of the ANM locality. During 200809 the Untied Funds are transferred to 108 CHCs 798 PHCs and 4560 Sub Centres. 1.B.5. Survey period for different categories of Schedules: The pre field work information was collected from the Directorate of Health and Family Welfare, Government of Assam and the District CMO office of Sonitpur District of the State in the first part of November, 2008 so as to prepare the details plans of field works. Also the State information regarding implementation of NRHM components are collected from the state Mission office situated at Guwahati during November, 2008. The training for Field Investigator was conducted during November, 2008. The main field work was carried out during December, 2008 and February, 2009.

1.B.6. Location of the Study:

The study and its report are exclusively related to the Jorhat District of Assam.

1.B.7. Households and Exit Interview Covered:

Information is collected by having interviews with the Head of the household or the senior member of the household where no head is available. From 24 selected villages 1200 households are interviewed and collected required information as per questionnaire with all possibilities. Apart from this, information also collected from the ANM of the 12 selected Sub Centres and 13 Gram Panchayat member of the concerned GP or from the Gram Pradhan. The exit interview for 47 Patients of OPD and 16 Patients of IPD were carried out from the concerned selected hospitals.

CHAPTER II

PART A

DISTRICT PROFILE

There are 27 districts in the State of Assam. Out of these districts, Jorhat has been selected for the Study. The study has two parts of questionnaires. Part A deals with the information of the Office of the Joint Director, Health Service, Jorhat, Assam and Part –B is Meant for District or SubDivisional hospital if District Hospital is not available. It is reported by the respondent from the NRHM office, Jorhat that the District has possessed 8 Blocks and 886 numbers of inhabited villages (2001 Census). The Population scenario of the District is depicted in the Table 2. (II) A1. 2.A.1 Population Scenario of Jorhat District : Table 2. (II) A1: Population Scenario of the District Jorhat as per 2001 Census

Category RURAL URBA TOTAL

Male Female Male Female Male Female Scheduled 34723 32853 5754 5333 40477 38186 Caste Scheduled 61264 59591 1201 1078 62465 60669 Tribe Others 329843 309627 84230 73724 414073 383351 Total 425830 402071 91185 80135 517015 482206 Sex Ratio 944 879 933 Source: Jorhat District NRHM Office The Table 2.(II)A1 shows the composition of population of various communities and overall SexRatio in the District which is computed as 933 females against 1000 male. This sex ratio is lower than the State SexRatio. Moreover, about 83 percent population of the district lives in rural areas while 17 percent are living in urban areas. This indicates lesser urbanisation in the district. The population Research Centre, G.U. has estimated the district population for the year 2008, and are shown in the Table – 2. (II) A2.

Table 2.(II) A2stimated Population of Jorhat District of Assam estimated as on March,2008

Category RURAL URBA TOTAL

Male Female Male Female Male Female Scheduled 38309 37203 6989 6551 45298 43754 Caste Scheduled 66712 67965 1821 1615 68533 69580 Tribe Others 351753 336877 102329 86779 454082 423656 Total 456774 442045 111139 94945 567913 536990 Sex Ratio 968 854 946

Population increase in the District under servey during 20012008 by 11 percent as a whole.

2.A.2 Status of Health Infrastructure, Facility Upgradation under RHM and availability of Human Resources: As a part of the evaluation study information are collected on health facilities available for general health service and child delivery. But the District NRHM Office has been able to provide some information on total existing Public Health Infrastructure and New buildings under construction. The Office has no details information sought for. However, in the Table2 (II). A3.i the collected information is presented as follows:

Table – 2(II). A3.i: umber of Public, Private infrastructure and Human Resource Available in the District Jorhat Public Health Total Existing ew Buildings under Infrastructure as on 30.6.08 construction as on 30.6.08. SubCentre 148 56 PHC (BPHC) 7 A 24X7 PHCs (BPHC) 7 A CHC 3 A First Referral Unit (FRU) 3 A Mobile Medical Units 1 A SubDivisional Hospital 2 A District Hospital 1 A Ayush 0 A Private Health Infrastructure existing as on 30.6.08 Hospitals (More than 30 bedded) 3 ursing Homes (Less than 30 bedded) 25

Table2(II).A3.ii Facilities Available in the District for Delivery :

Facility Total Existing Operational Providing Providing CeMOC With ew Born Care In the District (24X7) BeMOC (Having Blood storage,Unit (AS on 03.06.2008) Anaesthetist & Gynaecologist District Hospital 1 1 A 1 1 Subdivisional 2 2 A 1 1 Hospital CHC 3 3 A A A Contd…

Table2(II).A3.ii Facilities Available in the District for Delivery : Facility Total Existing Operational Providing Providing CeMOC With ew Born Care In the District (24X7) BeMOC (Having Blood storage,Unit (AS on 03.06.2008) Anaesthetist & Gynaecologist PHC 7 7 A A A Public Maternity 1 A A A A Homes Other Public 1 A A A A (ESI, Railways etc. Other Private A A A A A Private Accredited A A A A A For JSY

The Table–2(II). A3.i states the information on existing infrastructure and facilities, new buildings under construction and facilities operational 24x7. Jorhat has 1 district hospital, 2 subdivisional hospitals, 3 CHC and 7 PHC, which are reported to be operational for 24X 7 hrs. Regarding Human Resource availability in the District some information were collected from NRHM Office. The information is presented in the Table – 2(II). A4.

Table – 2(II) A.4: Number of Health Staff Available in the District Category o. sanctioned Regular in Contractual Total in Position Recruits Position Medical Officer 77 77 20 97 Gynaecologist 9 9 1 10 Anaesthetist 3 3 Nil 3 Paediatrician 4 4 Nil 4 Other specialists 31 31 3 34 Staff Nurses 62 62 133 195 ANM 117 117 162 279

The Table 2(II). A.4 shows that there are 97 Medical Officers in the district. Among them 77 are in sanctioned post and 20 are on contractual basis. On the other hand there are 10 Gynaecologists, 3 anaesthetists, 4 paediatricians, and 31 other specialists present in the district. Besides, the district has 195 numbers of Staff Nurses and 279 number of ANM in regular as well as in contractual basis. 2.A.3 Rogi Kalyan Samity (RKS): As per directives of the NRHM Implementation Authority, each Health Facility from District Hospital to PHC should have one Rogi Kalyan Samity through which the facilities are to be registered. The information regarding the Rogi Kalyan Samities of Jorhat district is shown in the table 2(II) A.5.

It is seen that there are 23 numbers of registered RKS in Jorhat district and all are functioning presently.

Table 2(II) A.5. Information on Rogi Kalyan Samity of Jorhat District

umber of Facilities having Rogi Kalyan Samities (RKS) Registered Total Functioning o. with Registered RKS District Hospital 1 Not yet registered Subdivisional Hospital 2 2 CHC 3 3 PHC 7 7

2.A.4 Janani Suraksha Yojona (JSY): For implementation of JSY schemes under NRHM initiative is being undertaken in the district. The information relating to JSY of Jorhat district is represented in table 2(II) A.6. It is found that PPP initiative being undertaken in the district Jorhat for the implementation of JSY scheme. In the district there are 9 private health facilities, which are accredited for JSY scheme. It is reported that a total of 12, 939 institutional deliveries have been taken place during 200708. Out of which, 1242 are scheduled caste, 1934 are scheduled tribe and 9763 are general caste beneficiaries. However, in the same period a total of 11,969 women have been registered under JSY scheme in the District. Of course, all of them have undergone for institutional delivery. Table 2(II). A6 Information in regards to the Institutional Deliveries under JSY Scheme.

Category Total Institutional Total number Out of total number of Deliveries Reportedof registered Registered JSY women, During 200708 JSY woman number of women opting during 2007 for Institutional Delivery 08 during 200708 AT GOVT. FACILITIES

Scheduled Caste 1242 1195 1195 Scheduled Tribe 1934 1494 1494 General 9763 9280 9280 APL BPL Total 12939 11969 11969 AT PRIVATE FACILITIES: IFORMATIO OT AVAILABLE

2. A.5 Financial Mechanism: In connection with the Financial Matters management some questions were asked to the District Programme Manager who stated the following responses. (i) The Vertical Health Societies created under different programmes are merged in to a District Health Society.

(ii) The merged Health Societies are registered.

(iii) There is no any common bank account for all programmes in District Health Society. Instead of this there are separate subaccount for different vertical programmes operated by concerned Nodal Officer and Jt. DHS.

(iv) The District has prepared District Action Plan for the current year and the District Health Society approves the Plans.

(v) It is reported that the District on the basis of the Annual Action Plans receives the Funds from the State. The funds are transferred electronically.

(vi) All total 146 SubCentres have operational Joint Bank Account.

(vii) Untied Grants for the current year have been transferred to 3 CHC, 7 PHC and 146 Sub Centre.

PART B DISTRICT HOSPITAL

2.B.1. Physical Infrastructure: The name of the Jorhat district hospital is JDS Civil Hospital. The hospital is located in a residential area at the heart of the Jorhat town, the head quarter of the district. The hospital is well accessible by different modes of transport from different parts of the district. The nearest ASTC Bus stop is located just 1 km away from the hospital. The hospital along with its staff quarters covers an area of about 2000 Sq. m. There are 241 indoor beds available in the hospital.

The hospital obtained essential environmental clearance from the Pollution Control Board.

2.B.2. Facilities available in the Administrative/ Main Block: Some of the facilities available in the administrative/ main block of the hospital are waiting space adjacent to each Consultation and Treatment room, Registration counter, Blood Bank/ Blood storage unit, Doctors duty room, Isolation room, Treatment room, Pharmacy, High dependency wards and Examination and preparation room. However, the hospital has no ICU and Critical Care area (emergency Services)

2.B.3. Hospital Services: The other services available in the Hospital are Hospital kitchen, Hospital Laundry, Medical and general stores, Ventilation in the wards, 24 hrs water supply, overhead water storage tank etc. On the other hand the hospital has no Central Sterile & Supply Dept. (CSSD), Engineering services backup, water coolers, Refrigerators, provision of fire fighting and proper drainage and sanitation system for waste water, surface water, subsoil water and sewage. Bio Medical Wastes are found to be buried in the Hospital and these wastes are segregated in three different bins.

2.B.4. Residential facilities: The hospital is facilitated by the residential quarters for medical and paramedical staff. It has parking place, Telephone etc. On the other hand the hospital is not provided by the medical record section, FAX equipments, computers and Internet services.

2.B.5. Obstetrics & Gynae Section: The hospital has a separate ward with 18 beds for female patients. The total OPD cases in last three calendar months record 12080. Total of1062 number deliveries have taken place in the hospital during last 3 calendar months. However, the hospital has a separate O.T. available for Gynaecology & Obstetrics. The hospital recorded 747 caesarean section deliveries during 200708. Out of

which, 86 were included under JSY Scheme. The hospital registered 2039 MTP and 2059 MidTrimester Abortion cases during 200708. The hospital also witnessed 10 Ectopic pregnancy during the same period. Of course 107 sterilization has taken place in the hospital during 200708. (Table 2(II) B.1)

Table 2(II).B.1 umber of Services conducted in the JDS Govt. Hospital Jorhat during 200708 Particulars o. of Services Conducted. Caesarean Section Deliveries 747 Caesarean Section for JSY 86 Assisted Delivery 4242 Forceps Delivery 25 MTP 2039 MidTrimester Abortion 2059 Ectopic Pregnancy 10 Retained Placenta Eclampsia PPH Sterilisation 107 Suturing cervical Tear Hysterectomy Infertility Treatment

2. B.6: Surgical Section: The hospital has recorded 3383 numbers OPD Surgical cases and 898 IPD surgical cases during last 3 months. However, no separate data for male and female have been provided in this regard. Some of the services available in the surgical section of the hospital are –Emergency (Accident and other emergency), Spleen and portal Hypertension surgery, Abdomen surgery, Breast surgery etc. However pancreas and Leprosy Reconstructive surgery facilities are not available there.

2.B.7 Medical Section: The hospital records 1843 medical OPD cases and 1312 medical IPD cases during last three months. The services available in the medical section areDermatology and Venerology, (skin and VD), RTI/STI, services under NLEP, Pleural Aspiration, lumber puncture, pericardial tapping, skin scarping for fungus/AFB psychiatry services etc. The hospital on the other hand has no facilities for Pleural Biopsy, Bronchoscopy, Bone marrow Biopsy and Endoscopic specialised procedures

2.B.8 Paediatric Section: The hospital records 14482 number pediatric OPD paediatric cases during 200708.But a total of 2335 numbers were admitted in the hospital during the same period. It is important to note that the hospital is lacking in some most essential services for paediatric patients like Asphyxia management, Management of severe malnourished children, management of Neonatal Sepsis, Management of dehydration and Diarrhoeal cases, Management of Respiratory Tract. Etc. Some equipment such as Radiant Heat Warmer, Phototherapy Unit, Oxygen Mask, Suction Machine, Thermometer etc. are available in the hospital. Whereas the section has no Incubator, Cradle, Bag with Mask, Laryngoscope etc. In case of availability of drugs, it is seen that the Paediatric section has ORS, VitaA, Solution, and Iron folic acid tablets and paediatric antibiotics etc. 2.B.9. Diagnostic Section: The diagnostic section of the JDS Civil Hospital has some essential services for patients like x ray, Ultrasound, ECG, etc. The hospital do not has Ultrasound guided Biopsy facility. 2.B.10: Laboratory services: The total number of person attended in last three months were 923, of which 506 were females and 417 males. Some available services on clinical pathology in the hospital are Haematology, Urine Analysis, and Stool Analysis etc. It is seen that 2968 Tests on haematology, 527 on Urine Analysis, and 32 on

Stool Analysis have been carried out in last three months. However, the lab has no facilities for Semen analysis, CSF analysis, and aspirated fluids. In the general pathology section only Biochemistry service is available. A total of 725 tests on Biochemistry have been done during last three months. Some most essential services like PAP smear, Split skin Smear, Exam for leprosy, sputum, Histopathology, Microbiology, serology and Physiology etc. are not available in the pathology section of the lab. 2.B.11: Human Resource: The medical, paramedical and administrative staffs are more or less available in the hospital. Except one contractual ECG technician all other staff are found regular in position. The details of staff pattern available in the hospital are given in the Table 2(II).B.2

Table 2(II). B2: Staff pattern available in the hospital

Category of Personal Regular in Position Hospital Superintendent. 1 Medical specialist 3 Surgery Specialist 3 Gynaecologist 2 Gynaecologist (Short term trained MO) NIL Contd…

Table 2(II). B2: Staff pattern available in the hospital

Category of Personal Regular in Position Paediatrician 4 Anaesthetist 3 Anaesthetist I(Short term trained MO) 1 Radiologist 1 General duty Doctors 1 Public Health Manager NIL Ayush Physician NIL Pathologist 1 Psychiatrist 1 Dermatologist/Venereologist 1 ENT surgeon 1 Ophthalmologist 5 Orthopaedician 1 Microbiologist NIL Dental Surgeon 1 Staff Nurse 29 Hospital worker(OP/ward+OT+ Blood 115 bank) Sanitary Worker 1 Ophthalmic Assistant/ Refractionist 1 Social worker/ Counsellor 3 ECG Technician NIL Audiometrician NIL Contd…

Table 2(II). B2: Staff pattern available in the hospital

Category of Personal Regular in Position Laboratory Technician 5 Laboratory Attendant NIL Dietician NIL ANM 22 LHV NIL PHN NIL Radiographer 1 Pharmacist 4 Matron 2 Physiotherapist 1 Medical Record Officer/ Technician NIL Manager NIL Junior Administrative Officer NIL Office Superintendent 1 Accounts Manager NIL Driver 5 Peon 42

2.B.12: Rogi Kalyan Samity: There is a Rogi kalyan Samity in JDS Civil Hospital, Jorhat, but the Samity is yet to be registered. The samity generates additional resources through users’ fees and it is used for samity work. However, the Samity do not use any board in the hospital premises showing their details.

Chapter III COMMUITY HEALTH CETRE

3.1 Availability of Infrastructure facilities: Community Health Centres (CHC) are the health facilities situated mainly in the Blocks rendering specialised health services to the people of the Blocks in particular and other people in general. The status of the CHC is next to that of District and SubDivisional Hospitals. The CHC is equipped with the Specialised Medical Staff, Patient Beds, Laboratories and Operation Theatres. Two CHC namely Titabar and Kamalabari (Majuli) were selected for the present study. The Titabar CHC is designated as FRU. The District Jorhat has 3 CHCs. However, in connection with the Appraisal Survey, Titabar and Kamalabari (Majuli) were selected for assessment. The tables attached in the chapter have described the characteristics like availability of infrastructure, distance from the CHCs to other related health facilities of the District, Human Resources, IPHS Status, FRU, RKS etc. of the selected CHC. Titabar and Kamalabari are the two selected CHCs of Jorhat district and the district hospital of Jorhat is located about 22 km away from the Titabar CHC and 22 km from the Kamalabari CHC. The Kamalabari CHC is situated in the Majuli, the largest riverine island of the world. The Titabar and Kamalabari CHC serve 44425 and 46763 numbers of populations respectively. The nearest PHC is situated 7 km away (25 minutes travel time) from the Titabar CHC, while, the farthest PHC is located 24 km away from it, and the temporal distance is 40 minutes. In case of Kamalabari CHC the nearest PHC is situated 6 km away and it required a time distance of 45 minutes, while the Farthest PHC is located 14 km away from the hospital, which require a travel time of 2 hrs. due to inconvenient road communication. .

In Titabar FRU there are total 37 beds consisting of 18 males and 19 females bed. On the other hand in the Kamalabari CHC there are 19 beds out of which 9 for males. Both the health centres are located in Govt. buildings. Both the centres have running Ambulance, laboratory facilities, X ray facilities, operation theatre, Labour rooms, separate areas for Septic and aseptic deliveries and pharmacy for drugs dispensing and storage. Where as, both the hospitals have no telephone as well as Internet connection. Of course Kamalabari CHC has not been provided computer, ECG facilities, Ultrasound facilities, and O.T. especially for gynaecology. In both the CHCs under study some necessary facilities like Separate Public Utilities (Toilet) for males and females, Suggestion/ Complain Box, OPD Rooms/Cubicles, Drinking Water in the waiting areas, Separate Wards for males and females, Emergency Rooms, Casualty and separate wards for males and. OPD of both the CHCs are found good. However, compound/premises of both the CHC are not good as it should be.

3.2 Medical and Paramedical Staff: This section deals with the human resource availability in the selected CHCs. The Table C2 describes the sanctioned and availability of Medical and Paramedical staff at Titabar and Kamalabari CHCs in the following paragraphs. It is found that Titabar CHC has one Regular General Surgeon, 2 Obstetricians/Gynaecologists, 1 paediatrician, 1 Anaesthetist, 4 general duty Medical Officer, and 1 Eye Surgeon. On the other hand, Kamalabari CHC has 2 General Duty Medical Officer out of 5 section posts, and 1 Eye surgeon only. Regarding Paramedical staff, it is seen that the Titabar CHC has 3 lady

health visitor, out of which 2 are in contractual basis, 1 BEE, 7 ANM, a 13 Staff

Nurse, out of which 7 are on contractual basis and 3 pharmacists. On the other

hand the Kamalabari CHC has 1 LHV, 1 BEE, 3 ANM, 6 Staff Nurse (2 on

contractual basis), 1 dresser, and 2 pharmacists.

Regarding Technical Staff, it is observed that the Titabar CHC has 1 laboratory Technician, 1 Radiographer, and1 Ophthalmic Assistant; while the Kamalabari CHC has 4 laboratory Assistant, out of which 2 are on contractual basis, 1 Radiographer, and 1 Ophthalmic Assistant. Of course both the CHC have no Statistical Assistant/ Data Entry Operator. It is reported that both The Titabar and Kamalabari CHCs have 1 OT Attendant. However the Titabar CHC has 2 ambulances driver against only 1 in Kamalabari CHC.

3.3 Availability of Specific Services: The TableC3 deals with the availability of Specific Services rendered by the selected CHCs. According to the information presented in the Table–C3 it is observed that both Titabar and Kamalabari CHC are functioning on 24x7 basis. Former is also functioning as First Referral Unit (FRU), but the later is not functioning so. Both the CHCs on the other hand, do not extend Emergency care for sick Children, full Range of Family Planning services to the people of its functional area and Cataract Surgery facility. However both the CHC have AYUSH and VCTC services as well as services for treatment of STI/RTI and Dots. 3.4 Specific Interventions: The Table C4 is prepared to describe the Status of Specific Interventions of both the selected CHCs. The Table C4 states that IPHS Facility Survey has been carried out only in Titabar CHC. It is observed that the funds are not electronically transferred from the District to both the CHCs. The norms of having registered Rogi Kalyan Samity (RKS) have been maintained in both Titabar and Kamalabari CHCs. It is reported that RKS in Titabar CHC does not generate any Resource of its own except Govt. money. Display board showing no. of meeting & members of RKS is found only in Kamalabari CHC. Feedback mechanism in place for grievances is not redressed by the RKS in Titabar CHC. Citizen Charter has been publicly displayed only in Kamalabari CHC. However All standard Treatment

Guidelines and Protocols are available in both the Titabar and Kamalabari CHC. 3.5 Residential Facility: Questions were asked the Hospital Authority regarding availability and occupancy of the residential facilities provided by the selected CHCs. The TableC5 shows that there are residences for doctors in the campus of the CHC and the doctors working therein duly occupy the residences. Residential facilities are also available there for some selected staffs that are urgently and immediately required for the hospital services. 3.6 Laboratory Facility: Availability of Laboratory Facilities in the hospitals is a most necessary infrastructure. With this view investigations were performed so as to know the existence of the Laboratory facilities in the selected CHCs. Results are presented in TableC6, which describes both positive and negative replies. In both the CHCs laboratory exists. It is important to note that, Titabar CHC regularly conducts testing on Blood Grouping, Haemoglobin, Bleeding Time/ Clotting Time, RTIs/STIs, Blood Sugar, Malaria Parasite, Urine Test, and Rapid Test for Pregnancy, RPR for Syphilis and Rapid Test for HIV and Blood Smear. While the Kamalabari CHC has been conducting almost all these Tests excepting the RTI/STI, Blood Sugar and RPR Test for Syphilis and Rapid Test for HIV. 3.7 umber of Laboratory Test done:

Hospital Authority could not provide the information due to non availability of records. 3.8 Surgeries performed during 200708

The Table C8 shows that the Titabar CHC performed 175 cases on Caesarean deliveries, 154 surgical cases, 13 cases on Tubectomy, 62 on Laparoscopic Sterilization, and 286 on MTP and 1 on Laprotomy. While, Kamalabari CHC was not conducted any surgical cases during 200708. It is reported in Kamalabari CHC that surgeries are not done in the CHC due to non availability of doctors, Anaesthetists and other related staff.

3.9 Performance of Labour Room: It is observed from the Table C10 that the Titabar CHC records 490 Institutional Deliveries during 200708. Out of which 200 deliveries were carried out from 8 PM to 8 AM and 480 are belongs to JSY card holders and 40 are the Neonates Resuscitated. On the other hand the Kamalabari CHC records 763 Institutional deliveries during the same period. In Kamalabari CHC deliveries carried out from 8 PM to 8 AM are notably higher (302) and for JSY cardholders are too much lower (150) as compared to Titabar CHC. As, both the CHCs have been carried out deliveries so the information on reasons for not conducting deliveries does not arise. 3.10 Availability of Equipments and Drugs: The availability of equipments and drugs in the hospital are two important elements for better performance of the hospital. With this view questions were asked the Hospital Authority regarding availability of equipments and medicines. Information collected is compiled in the Table C12 which describes the situation. Among the important equipments, Boyles Apparatus, ECG Machine, Cardiac Monitor OT., Gloves Dusting machine, Hydraulic operation Table, Resuscitation Trolley, MVA Syringes etc. are available in the Titabar CHC., whereas these equipments are not available in Kamalabari CHC. Both the CHC have Vertical High Pressure Sterilizer, Oxygen Cylinder, and Phototherapy unit. It is found that though, Vertical High Pressure Sterilizer and Oxygen Cylinder are available in Kamalabari CHC but these are not working at the time of Survey. Among the important drugs, stock out has been recorded in Titabar CHC for the drugs such as ORS with Zinc, Tab Fluconazole, Tab Nefidipine, injection Magnesium Sulphate, Tab Misoprostal, Tab Progestrone, Inj Pentazocine.Lactate, Inj. Adrenaline, Cap Doxycycline, Syp. Amoxycyclin and Syp. IFA due to irregular supply. Besides, all other drugs were available during last 6 months. On the other hand in Kamalabari CHC stock out has been recorded during last 6 months for the important drugs like Iron Folic Acid, Oral Pills, IUD 380 ORS, ORS with Zinc, Vita A, Tab Fluconazole, Tab Metronidazole, Tab Co Trimoxazole,

Tab Nefidipine, Injection Magnesium Sulphate, Inj. Oxytocin, Inj Gentamycin, Tab Progestrone, Inj. Lignocaine, Cap Doxycycline, Silver Sulphadiazine oint. IV Filuds, Inj. Prociane Penicillin, Injection Atropine, Syp. Amoxycyclin and Syp. IFA due to irregular supply.

3.11 Availability of Specific Services:

This section deals with the availability of Specific Services relating to the medical treatment in Titabar and Kamalabari CHC. The Table C13 states that the services facility of Surgery, Obstetric and Gynaecology, Paediatrics, Dots, Leprosy Diagnosis Management and Referral Services, Emergency Services (24 Hrs), Separate Neo Natal Care Unit, Safe abortion Services, Treatment of STI/RTI, Blood Storage facility, Counselling Facility on HIV/AIDS/STD etc., VCTC, AYUSH facility, Primary management of Wounds, Primary Management Fracture, Primary Management of Cases of Poisoning Snake Insect or Scorpion Bite, Primary Management of Dog Bite, Primary Management of Burns, and Management of RTI/STI are all available in the Titabar CHC while the Kamalabari CHC has possessed the facilities like Dots, 24 hours Emergency Services, Mobile Medical Unit, Safe Abortion Services, Treatment of STI/RTI Counselling Facility on HIV/AIDS/STD etc. Ayush facility, Primary Management of Wounds, Fracture, Poisoning Snake insect or Scorpio Bite, Dog Bite, Burns and management of RTI/STI etc. The Kamalabari CHC do not have availability of some important services like Medicine, Surgery, Obstetric Gynae, Paediatrics, Cataract Surgery, Emergency care for Sick Children, full range of Family Planning Services including laparoscopic Legation, Blood storage facility and VCTC etc. From the above information it is observed that the Kamalabari CHC in comparison to Titabar CHC is having shortcomings in case of possessing the modern facilities for rendering Quality Health Service to the people. This CHC needs attention for infrastructure, Human Resource development and provision of modern Equipment and Medicines. 3. 12. Service outcome:

The Table C14 discusses the average monthly service outcome of Titabar and Kamalabari CHCs under different category of people. It is observed from the table C 14 that Titabar and kamalabari CHCs recorded 299 and 22 ANC Registration cases respectively. On the other hand Total numbers of Registered JSY cases in Titabar and Kamalabari CHCs are 163 and 23 respectively. In case of ANC given 3 Checkups as per RCH schedule, it is seen that Titabar CHC (197) stands at better position than Kamalabari (38) CHC. The number of JSY beneficiaries is more in Titabar than in kamalabari CHC. There is no any record of number of pregnant women identified and attended with obstetric complications in Titabar CHC, but in Kamalabari CHC it is 9 numbers. In case of institutional deliveries Titabar CHC overcomes the kamalabari CHC, with 163 and 59 cases respectively. Again, a total of 287 numbers of infant given BCG in Titabar CHC, while in case of Kamalabari CHC it is found to be 40 in numbers. Besides the numbers of infants given Measles and Vitamin A first

doses were 320 for Titabar PHC, while for Kamalabari CHC it is 14 numbers. It is observed that 40 and 14 numbers of IUDs were inserted in the Titabar and Kamalabari PHC respectively. Again Titabar and Kamalabari PHC recorded 270 and 175 numbers of Indoor Patients respectively. The Titabar and Kamalabari PHCs register 2 and 1 numbers of Leprosy Cases under Treatment. Again the numbers of new TB cases enrolled for DOTs were found to be 17 for Titabar CHC and 5 for Kamalabari CHC. It is observed that bed occupancy rate is much higher in Titabar CHC (95) than that of Kamalabari CHC (26). It is reported that most of the patients in Kamalabari CHC are not willing to stay at hospital bed. Even after delivery the patients do not want to stay at hospital. Every implementation of the project is result oriented. NRHM is also implemented with different targets to be achieved within the project period. Targets were also fixed on the Immunization.

Table C1. Coverage and Availability of Infrastructure

Coverage CHC √ represents the corresponding response) ( TITABAR FRU KAMALABARI Population Served by the CHC Numbers 44,425 46,763 Nearest PHC Coverage Area Distance - 6 Nearest PHC Coverage Area: Time 45 Farthest PHC Coverage Area: Distance 24 14 Farthest PHC Coverage Area: Time 40 2 District Hospital Area: Distance 22 12 District Hospital Area: Time 30 2 No of Beds: Male 18 9 No of Beds: Female 19 10 Status of Building Own Government Building 1 1 Rented Premises Other Rent:Free Building Electricity in all parts: No Regular electricity supply Regular electricity supply in all parts 1 1 30 or more beds Yes √ No √ Generator Yes √ √ No Telephone Yes No √ √ Computer Yes √ No √ Internet Connection Yes No √ √ Running Vechicle/Ambulance Yes √ √ No Contd

Table C1. Coverage and Availability of Infrastructure Coverage CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Laboratory

Yes √ √ No ECG Facilities

Yes √ No √ X Ray Facilties Yes √ √ No Ultrasound Facilities

Yes √ No √ Operation Theatre

Yes √ √ No OT used for Gynaecology

Yes √ No √ Labour Room Available

Yes √ √ No Separate Areas for Septic and Aseptic Deliveries Yes √ √ No New Born Care Corner

Yes √ No √ JSY Benficiaries Maintained in Record Yes √ √ No Pharmacy for Drug Dispensing and Drug Storage Yes √ √ No Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines Yes √ √ No Separate Public Utilities (Toilets) for Males and Females Yes √ √ No Contd

Table C1. Coverage and Availability of Infrastructure Coverage CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Suggestion / Complaint Box Yes √ √ No OPD Rooms / Cubicles

Yes √ √ No Waiting Room for Patients

Yes √ √ No Waiting Room have Adequate Sitting Place Yes √ No √ Drinking Water Available in the Waiting Area Yes √ √ No Emergency Room / Casualty Yes √ √ No Separate Wards for Males and Females Yes √ √ No Type of Sewerage System Soak Pit √ Open Drain √ Connected to Municipal Sewerage Other Waste Material is Being Disposed Buried in a Pit √ √ Collected by an Agency Incernation Thrown in Open Status of Cleanliness of OPD Good √ √ Fair Poor Status of Cleanliness of Compound /Premises Good Fair √ √ Poor Contd

Table C1. Coverage and Availability of Infrastructure Coverage CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Status of Cleanliness of Room / Wards Good √ √ Fair Poor Prominent Display Boards Regarding Service Available in Local Language Yes √ No √ JSY Benficiaries Maintained in Record Yes √ √ No Pharmacy for Drug Dispensing and Drug Storage Yes √ √ No Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines Yes √ √ No

Table C2:Position of Medical Staff and Paramedical Staff

Type of Staff NUMBERS IN POSITION TITABAR FRU KAMALABARI General Surgeon:Sanctioned Numbers General Surgeon:Regular in Position Numbers 1 General Surgeon:Contractual Recruited Numbers General Surgeon:Total in Position Numbers 1 Physician:Sanctioned Numbers Physician:Regular in Position Numbers Physician:Contractual Recruited Numbers Physician:Total in Position Numbers Obstertrician / Gynaecologist:Sanctioned Numbers Obstertrician / Gynaecologist:Regular in Position Numbers 2 Contd

Table C2:Position of Medical Staff and Paramedical Staff

Type of Staff NUMBERS IN POSITION TITABAR FRU KAMALABARI Obstertrician / Gynaecologist:Contractual Recruited Numbers Obstertrician / Gynaecologist:Total in Position Numbers 2 Medical Officer Trained with Short Term Obstetrics Course:Sanctioned Numbers Medical Officer Trained with Short Term Obstetrics Course:Regular in Position Numbers Medical Officer Trained with Short Term Obstetrics Course:Contractual Recruited Numbers Medical Officer Trained with Short Term Obstetrics Course:Total in Position Numbers Paediatrician:Sanctioned Numbers Paediatrician:Regular in Position Numbers 1 Paediatrician:Contractual Recruited Numbers Paediatrician:Total in Position Numbers 1 Anaesthetist:Sanctioned Numbers Anaesthetist:Regular in Position Numbers 1 Anaesthetist:Contractual Recruited Numbers Anaesthetist:Total in Position Numbers 1 Medical Officer Trained with Short Term Anesthesia Course:Sanctioned Numbers Medical Officer Trained with Short Term Anesthesia Course:Regular in Position Numbers Medical Officer Trained with Short Term Anesthesia Course:Contractual Recruited Numbers Medical Officer Trained with Short Term Anesthesia Course:Total in Position Numbers General Duty Medical Officer:Sanctioned Numbers 4 5 Contd

Table C2:Position of Medical Staff and Paramedical Staff

Type of Staff NUMBERS IN POSITION TITABAR FRU KAMALABARI General Duty Medical Officer:Regular in Position Numbers 4 2 General Duty Medical Officer:Contractual Recruited Numbers General Duty Medical Officer:Total in Position Numbers 4 2 Eye Surgeon:Sanctioned Numbers 1 Eye Surgeon:Regular in Position Numbers 1 1 Eye Surgeon:Contractual Recruited Numbers Eye Surgeon:Total in Position Numbers 1 1 Public Health Nurse:Sanctioned Numbers Public Health Nurse:Regular in Position Numbers Public Health Nurse:Contractual Recruited Numbers Public Health Nurse:Total in Position Numbers Lady Health Visitor (LHV):Sanctioned Numbers 1 1 Lady Health Visitor (LHV):Regular in Position Numbers 1 1 Lady Health Visitor (LHV):Contractual Recruited Numbers 2 Lady Health Visitor (LHV):Total in Position Numbers 3 1 Block Extension Educator (BEE):Sanctioned Numbers 1 1 Block Extension Educator (BEE):Regular in Position Numbers 1 1 Block Extension Educator (BEE):Contractual Recruited Numbers Block Extension Educator (BEE):Total in Position Numbers 1 1 ANM:Sanctioned Numbers 7 3 Contd

Table C2:Position of Medical Staff and Paramedical Staff

Type of Staff NUMBERS IN POSITION TITABAR FRU KAMALABARI ANM:Regular in Position Numbers 7 3 ANM:Contractual Recruited Numbers ANM:Total in Position Numbers 7 3 Staff Nurse:Sanctioned Numbers 6 4 Staff Nurse:Regular in Position Numbers 6 4 Staff Nurse:Contractual Recruited Numbers 7 2 Staff Nurse:Total in Position Numbers 13 6 Dresser:Sanctioned Numbers 1 Dresser:Regular in Position Numbers Dresser:Contractual Recruited Numbers Dresser:Total in Position Numbers 1 Pharmacist / Compounder:Sanctioned Numbers 3 1 Pharmacist / Compounder:Regular in Position Numbers 2 1 Pharmacist / Compounder:Contractual Recruited Numbers 1 1 Pharmacist / Compounder:Total in Position Numbers 3 2 Lab_Technician:Sanctioned Numbers 1 2 Lab_Technician:Regular in Position Numbers 1 2 Lab_Technician:Contractual Recruited Numbers 2 Lab_Technician:Total in Position Numbers 1 4 Radiographer:Sanctioned Numbers 1 1 Radiographer:Regular in Position Numbers 1 1 Radiographer:Contractual Recruited Numbers Radiographer:Total in Position Numbers 1 1 Contd

Table C2:Position of Medical Staff and Paramedical Staff

Type of Staff NUMBERS IN POSITION TITABAR FRU KAMALABARI Ophthalmic Assistant:Sanctioned Numbers 1 1 Ophthalmic Assistant:Regular in Position Numbers 1 1 Ophthalmic Assistant:Contractual Recruited Numbers Ophthalmic Assistant:Total in Position Numbers 1 1 Statistical Assistant / Data Entry Operator:Sanctioned Numbers Statistical Assistant / Data Entry Operator:Regular in Position Numbers Statistical Assistant / Data Entry Operator:Contractual Recruited Numbers Statistical Assistant / Data Entry Operator:Total in Position Numbers OT Attendant:Sanctioned Numbers 1 1 OT Attendant:Regular in Position Numbers OT Attendant:Contractual Recruited Numbers OT Attendant:Total in Position Numbers 1 1 Ambulance Driver:Sanctioned Numbers 1 1 Ambulance Driver:Regular in Position Numbers 1 Ambulance Driver:Contractual Recruited Numbers 1 Ambulance Driver:Total in Position Numbers 2 1 Registration Clerk:Sanctioned Numbers Registration Clerk:Regular in Position Numbers Registration Clerk:Contractual Recruited Numbers Registration Clerk:Total in Position Numbers

Table C3. Availability of Specific Services in CHC

Availability of Specific Services CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Functioning on 24 x 7 Basis Yes √ √ No Functioning as FRU Yes √ No √ Emergency Care for Sick Children Yes No √ √ Full Range of Family Planning Services Yes No √ √ AYUSH Services Yes √ √ No VCTC Yes √ No √ Catatact Surgery Yes No √ √ Treatment of STI/RTI Yes √ √ No Dots Yes √ √ No

Table C4. Status of Specific Interventions

Status of Specific Intervantions CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI IPHS Facility Survey been Carried out Yes √ No √ Funds Being Electronically Transferred from District Yes No √ √ Registered Rogi Kalyan Samiti Yes √ √ No RKS Generate Resources:User Fees Yes √ No √ Money generated by RKS being used Yes √ √ No Display board showing no. of meetings & members of RKS Yes √ No √ Feedback mechanism in place for grievances redressed by RKS Yes √ No √ Citizen Charter Been Publically Displayed Yes √ No √ All Standard Treatment Guidelines and Protocols Available Yes √ √ No

Table C5: Status of Residential Facilities for Doctors and Other Staff

Residential Facilities CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Residential Facility for Doctors Yes √ √ No NonOccupied Residential Quaters Yes No √ √ Main Reasons for Non:Occupancy:Dilapidated Condition Yes No Main Reasons for Non:Occupancy:Insecurity Yes No Main Reasons for Non:Occupancy:Lack of Electricity and Water Supply Yes No Residential Facility for other staff Yes √ √ No NonOccupied Residential Quarters Yes No √ √

Table C6. Availability of Laboratory Facilities

Laboratory Testing CHC (√ represents the corresponding response) TITABAR FRU KAMALABARI Blood Grouping Yes √ √ No Haemoglobin Yes √ √ No Bleeding Time Clotting Time Yes √ √ No RTI/STIs Yes √ No √ Blood Sugar Yes √ No √ Malaria Parasite Yes √ √ No Urine Test Yes √ √ No Rapid Test for Pregnancy Yes √ √ No RPR Test for Syphilis Yes √ No √ Rapid Test for HIV Yes √ No √ Blood Smear: Yes √ √ No

Table C7: umber of Lab. tests done in CHC in last 3 calendar months

Type of tests done CHC TITABAR FRU KAMALABARI Haemoglobin Numbers Blood Sugar Numbers Blood Grouping Numbers Blood Smear Numbers Bleeding Time Clotting Time Numbers RTI/STIs Numbers Malaria Parasite Numbers Rapid Test for Pregnancy Numbers RPR Test for Syphilis Numbers Rapid Test for HIV Numbers Urine Test Numbers

Table C8: umber of surgeries performed during 20072008

Type of surgeries CHC TITABAR FRU KAMALABARI Caesarean Sections Numbers 175 No of C Section Deliveries for JSY Numbers 175 Surgical Cases Numbers 154 Cataract Numbers Tubectomy Numbers 13 Laproscopic Sterlisation Numbers 62 NSV Numbers Conventional Vasectomy Numbers MTP Numbers 286 Laprotomy Numbers 1

Table C9: Reasons for not conducting surgeries

Reasons for not conducting CHC deliveries (√ represents the corresponding response) TITABAR FRU KAMALABARI

Non availability of doctor/anaesthetist/staff Yes √ No Lack of equipment/poor physical state of the operation theatre Yes No √ No power supply in the OT Yes No √ Other Yes No √

Table C10. Status of performance of Labour Room during 20072008

CHC Number of deliveries TITABAR FRU KAMALABARI Total Institutional Deliveries Numbers 490 763 Deliveries Carried Out from 8.PM to 8 AM Numbers 200 302 Institutional Deliveries for JSY Card Holders Numbers 480 150 No of Neonates Resuscitated Numbers 40 40

Table C11: Reasons for not conducting deliveries

Reasons for not conducting CHC deliveries TITABAR FRU KAMALABARI

Non availability of doctor / anaesthetist/staff Yes No Poor condition of the labour room Yes No No power supply in the labour room Yes No