2013 National Health Systems Resource Centre [7TH COMMON REVIEW MISSION ODISHA] 0 Table of Contents: SECTION I A. Executive Summary ………………………………………………………………..………………..………………… 2 B. Introduction …………………………………………………………………………………………………………….… 5 C. Objectives of the VII CRM …………………………………………………………………………………………. 6 D. Methodology ……………………………………………………………………………………………………………… 7 E. Observations a. State profile …………………………………………………………………………………………………… 8 b. Compliance actions taken against VI CRM recommendations ……….…………….. 10 c. TOR wise observations ……………..…………………………………………………………………… 11 F. Recommendations …..……………………………………………………………..………………………………………. G. Positives and Challenges ………………………………………………………………………………………………… 1 Executive Summary The CRM visit to Odisha revealed numerous good practices and innovations adopted by State for health system strengthening as well as gaps that still exist and need to be plugged to achieve the goals of NRHM. The wide geographical disparity in the State is a major challenge and a cause of many areas that remain underserved. The State has however, taken appropriate steps in the direction to improve service delivery in these areas, primarily by classifying these hard to reach areas on the basis of grade of difficulty. State realizes the inappropriateness of the population norms for and has recruited more ASHAs against the population norms in these designated difficult areas. Mobile Health Units and utilization of NGO capacity in the underserved areas have been taken up and are promising interventions with their effectiveness yet to be established. Shortage of subcenters and PHCs, many of which are running through rented facility in a dilapidated condition along-with limited package of services as against required of the respective level of health facility results in underutilization and lack of faith in services delivered and the entitlements amongst the community. There is an urgent need to facelift the existing subcenters and health facilities and brand them to ensure a complete package of services commensurate with their designated level to improve their utilization, to cater to large unmet need for health services and to induce faith of the community in public health system. Shortage of staff quarters is a major concern and a cause of grave dissatisfaction amongst the Healthcare providers, which affects the availability of the doctors, ANMs and other staff at health facilities including DH and SDH. This is needs to be addressed on an urgent basis. A meager proportion of health facilities in State are delivery points with very few PHCs (11%) conducting deliveries. The non-functionality and underutilization of peripheral facilities leads to overcrowding at DH. There is a need to operationalize all the designated FRUs to ensure that majority of complicated pregnancies are managed round the clock at FRUs and not unnecessarily referred to DH. ANMs at some Sub-centres were found to be allocated with too larger areas that it was daunting for them to manage field visits along with their routine Sub-centre activities. Time to care analysis should be done to calculate the actual ANM requirements considering the vast geographical areas. 2 State has introduced numerous IT initiatives for efficient administration and monitoring of Human resource, Infrastructure construction, service delivery and drug management in form of HRMIS, e-Swasthya Nirman, e-Blood bank, ODIMS respectively. These are very innovative steps to reduce the administrative hurdles and to ensure there is a clear and short line of communication between the health facilities and the SPMU. Still, there is a scope of better use for planning and improvement in the IT interventions being used in the State. The community processes in the State are remarkably strong and efficient. ASHAs in the State are confident, motivated and respected in the community and have a symbiotic association with Anganwadi workers and ANMs. The inter-sectoral convergence at the ground level is commendable. The VHNDs and VHSNC meetings are held regularly and village health plans are formulated. Support structure for ASHA is good and they have been provided with cycle, uniforms, and benefits under Swalamban pension scheme and ASHA Ghar amongst other benefits. The disbursement of incentive to ASHA is directly into their bank accounts and no delays were reported by ASHAs except for delay in receiving payment for motivating for spacing in Jajpur. ASHA SATHIs are recruited to mentor and support ASHAs, the number of SATHIs needs to be increased so that one ASHA SATHI mentors not more than 20 ASHAs. The VHNDs are conducted separately from immunization days to ensure that VHNDs are merely not immunization days and other package of services is provided on the day. The Drug and equipment availability in the State is good and no drug shortages were reported in any of the facilities visited. The introduction of the ODMIS that provides real time indenting of stock requirement and availability from Block CHC level is a good step to prevent stock outs, re-appropriation of drugs within facilities and districts to minimize wastage. The drug warehouses are present in all districts and a mechanism has been put in place for drug quality testing that is functional. The State Equipment Maintenance Unit was reported to respond to the requests for repair of equipment in the health facilities with a team of engineers. The HRMIS, which is basically instituted with the intent to serve as a tool to ease administration in respect of contractual staff may include the place of posting of the regular staff so as to guide policy decisions and bring about rational deployment which is warranted urgently. The implementation of JSSK in the State is good at higher facilities with no out of pocket expenditure reported by postnatal women on drugs and diagnostics during pregnancy and stay in hospital. The provision of free diet however, needs attention as the mothers are being given one dry meal a day due to non-availability of kitchen in SDH and lower facilities. This can be a deterrent to 48 hours stay in facility after delivery. The JSY implementation in the State has been streamlined and Account payee cheques are issued to mothers after delivery, however, there has been reporting of inability of beneficiary to avail the incentive usually because of severe administrative hurdles in opening account with SBI bank. Awareness of free referral 3 transport for sick infants is low and the Janani Express in the State is underutilized despite the fact that the awareness of the 108 service is good in community in both the districts. District maternal death review team needs to be re-oriented on concept, protocols and processes of MDR as the review being conducted has not been able to tap the major causes and does not provide actionable information with a large proportion of maternal death still being attributed to ‘others’ in causes. Unnecessary referrals were also observed at some facilities equipped with adequate HR and infrastructure which may possibly be the reason for considerable share of maternal deaths occurring during the transit. Further, AYUSH doctors do not have pharmacists. The AYUSH drugs may be included in DIMS and pharmacist may be entrusted the responsibility of dispensing AYUSH drugs as well. All the delivery points have New born care corners, SNCU is functioning well at Koraput and have good bed occupancy. There is however no SNCU at Jajpur. There is a need to institute NBSUs at CHC level to act as referral center prior to SNCU. The staff in SNCU is trained and dedicated. There is very low uptake of PPIUCD in both the districts, despite availability of trained providers. Interval IUCD uptake is also poor with only MOs inserting IUCDs. ASHAs are involved in home delivery of contraceptives. There is no focus on NSV and there are very few trained providers for NSV. There is, however, a considerable network of YASHODAs who accompany women to institutions for delivery and also stay with women for the post-partum period but still counselling on Family Planning was not provided to the women at the facilities or at VHNDs. Monitoring of trained PPIUCD providers to track service delivery is important. Skill improvement of health care providers for few identified areas such as SBA, Hb estimation, AEFI reporting, Anaphylaxis management, F-IMNCI training for Pneumonia management, NSSK resuscitation protocol, IUCD training for ANM is essential. Consistent decline in API for Malaria noted from year 2010 (9.3 to 6.2). The no. of total Malaria cases reduced from 4 lakhs to 2.5 lakhs per year. “MO-MOSHARI” initiative for pregnant women and tribal residential school for LLIN distribution is a good example of convergence. Cluster approach to LLIN, case treatment, strong BCC, ASHA involvement and ownership of the Health Dept. at all levels appears to be the success factor for the Malaria reduction. Under RNTCP, there are 93 vacant Lab Technician at Microscopic centres and less than 2% referral of chest symptomatic from health facilities leading to less detection. TB-HIV coordination is satisfactory. ASHA participation in case detection and as DOT provider with ANM involvement to ensure treatment compliance seen during the field visits. State Leprosy prevalence rate is 1.2 per 10,000 population against the target <1 even after Nationwide declaration of Leprosy elimination in 2005. 3 districts have more than 3 leprosy prevalence rate. 10 position of Epidemiologist of IDSP lying vacant at district level and these positions are crucial for State 4 prone to natural calamity for early detection and management of outbreaks. Need to recruit vacant position for Disease Control Program on a priority basis. All the Districts in the State are reporting facility-wise data on HMIS portal. The registration of pregnant women and children on MCTS portal is around 74% and 64% respectively on pro-rata basis. Phone numbers of only 3% ASHAs have been validated on MCTS portal and personnel handling HMIS and MCTS have been entrusted other responsibilities which increase their workload. There are large vacant positions under Financial Management that need to be filled up on a priority basis.