Situational Analysis of Caesarian-section services for deliveries in Chhattisgarh Based on Analysis of HMIS report 2015-16 Compiled By: State Health Resource Centre, Chhattisgarh Table of Contents S.N. Content Page No. 1 Introduction & Objectives 3 2 Methodology 3 3 Findings 4 4 Annexure 12-16 2 Introduction and Objectives: Availability of Caesarian-section (c-section) services is a critical component of Emergency Obstetric Care the health facilities are expected to provide as First Referral Units (FRUs). Chhattisgarh has made some progress in making FRUs operational over the last decade. The Directorate of Health Services, Chhattisgarh as well as NHM have been analyzing the performance of FRUs regularly. It is also an aspect on which information is easily available as part of HMIS. Though the reports in HMIS are expected to be accurate, it was felt that it may be useful to seek feedback from community to verify overall functionality. This report is an attempt to analyze the functionality of FRUs in Chhattisgarh based on the number of c-sections conducted. It also looks at role of private sector in providing c-section services (based on HMIS reports). Methodology: This study involved the following steps: From HMIS website of GoI, HMIS data on c-sections and deliveries of 2015-16 was downloaded – district-wise and facility-wise for government facilities as well as private facilities. The data was sent to field to get community feedback on functionality of each Government FRU through Meetings with Mitanin Trainers and VHSNC members. FRUs with at least one c-section done in last year, were called ‘operational FRUs’. The geographical distribution of above classification was shown on map of Chhattisgarh. An operational Government FRU was classified as ‘Functional’ if it conducted more than 24 c-sections in 2015-16 i.e. average of at least 2 c-sections per month. The rest of operational FRUs were categorized as ‘Poorly Functional FRUs’. The estimated deliveries were calculated for each district based on projected population for 2015 and district-wise birth rates reported by AHS 2012-13. Districts were classified into 4 categories of ‘Availability of c-section services in Government facilities’ based on percentage of expected deliveries conducted as c- sections in Government facilities. Districts were classified into 4 categories of ‘Availability of c-section services in all facilities’ based on combined percentage of expected deliveries conducted as c-sections in Government and Private Facilities put together. The geographical distribution of above classification was shown district-wise on map of Chhattisgarh. 3 Findings: a) Number of operational and ‘functional’ FRUs: In HMIS (April 2015 to March 2016), 54 Government health facilities have been reported as having conducted one or more c-section cases. On verification from local community sources (Mitanins and VHSNCs), it was found that 11 of them have not conducted any c-sections in 2015-16. Presumably, these centres might have been reported as doing c-sections in HMIS due to data-entry mistakes. The list of the above 11 centres is provided in Annexure 1. The remaining 43 facilities were found to be operational (i.e. conducted at least one c-section in 2015-16) as per HMIS as well as according to community. The functionality of these facilities was judged into two categories: Functional If the FRU conducts average of 2 c-sections per month or more (>=24) Poorly If the FRU conducts less than average of 2 c-sections per month, i.e. Functional conducted less than 24 c-sections in 2015-16 (<24) Based on the above criteria, 29 out of the 43 FRUs were found to be ‘functional’ i.e. conducted 24 or more c-sections in 2015-16. The following Table 1 summarizes the findings: Table 1: Functionality of Government FRUs in Chhattisgarh Type of Facility Functional FRU Poorly Functional FRU Medical College Hospital 5 0 District Hospital 13 6 CHC/Civil Hospital 11 8 Total 29 14 The list of above 43 facilities and their ‘functionality’ status is given in Annexure 2. The above 43 facilities and their status of functionality are shown in the following maps. The first map (Map1) shows the location of facilities and their functionality status. The second map (Map 2) shows the area that the 29 functional FRUs can serve well. It is assumed that each FRU can serve a radius of 40km (as the crow flies). This radius of 40km can mean actual distance to be travelled by road, is around 60-100 kilometers. The map shows that around half of geographical area of the state cannot be covered well by existing functional FRUs. 4 Map 1 : Functionality of FRUs in Chhattisgarh 5 Map 2 : Catchment area (40km) of FRUs in Chhattisgarh 6 b) How many c-sections are taking place in Chhattisgarh? As a thumb rule of rational practice in obstetric-care, around 10% of all deliveries should be through c-sections. In Chhattisgarh, according to HMIS reports, 8.1% of total deliveries took place through c-sections. However, the proportion of c-sections in government-sector remained very low as the following Table 2 shows. Table 2: C-sections out of total expected deliveries: Relative contribution of Government and Private sector % out of total estimated HMIS reported no. Parameter 6.49 lakh deliveries in of c-sections state in 2015-16 Total C-section in Government 13795 2.1% Facilities Total C-section in Private Facility 38805 6.0% Total C-section conducted 52600 8.1% The following table further shows the contrast. While Government sector carried out c-section in 4% of the institutional deliveries conducted by it, the figure for private sector was as high as 46%. Table 3: What proportions of deliveries are through c-section - Comparison of Government and Private sector C-sections Total institutional Parameter done deliveries % conducted By Government facilities 13795 317763 4.3% By Private facilities 38805 83386 46.5% Total 401149 13.1% c) District-wise availability of c-section services in Government facilities: As stated above, as a thumb rule around 10% of all deliveries should be through c-sections. In order to judge the relative district-wise availability of c-section services in Government facilities, a much lower rate was taken as criteria. The analysis is summarized in Table 4 below: 7 Table 4: District-wise Availability of functional c-section services in Government facilities Criterion - % of c- section done in Government facilities No.of Category Names of districts out of total expected Districts deliveries in the district District with No c- section services in Balrampur, Jashpur, Nil 4 Government Sukma Bijapur facilities District with poorly Kawardha, Dantewada, functional c- Gariyaband, Kondagaon, section services in 0.01% to 0.3% 8 Balodabazar, Bemetara, Government Balod, Mungeli facilities District with moderately Koriya, Narayanpur, functional c- Korba, Janjgir, Kanker, 0.3% to 2% 8 section services in Dhamtari, Mahasamund, Government Surajpur facilities District with fully functional c- Raipur, Raigarh, Bastar, section services in >2% 7 Bilaspur, Rajnandgaon, Government Sarguja, Durg facilities The District-wise information is given in Annexure-3. The map of above analysis shows the following picture (Map 3): 8 Map3: Availability of c-section services in Government facilities:- 9 d) Availability of c-section facilities (Government and Private sector Combined): Government of Chhattisgarh has extended health insurance with entire population being eligible for coverage under RSBY or MSBY. Though actual coverage is in progress, it can be useful to look at availability of c-section services in different districts, irrespective of whether provided by private or government sector. The district wise number of c-sections conducted and its percentage out of total expected deliveries in given in Annexure 4. Table 5 below lists the districts according to combined availability. Table 5: District-wise availability of c-section facilities (Government and Private sector Combined) No.of Category Name of District District District with Bastar, Rajnandgaon, Korba, Raigarh, functional C-section 9 Koria, Bilaspur, Dhamtari, Raipur, facility Durg District with Mungeli, Balod, Balodabazar, moderately 9 Sarguja, Mahasamund, Dantewada, functional C-section Janjgir, Kanker, Jashpur facility District with poorly Bemetara, Surajpur, Kondagaon, functional C-section 6 Narayanpur, Gariyaband, Kawardha facility District with No C- 3 Balrampur, Bijapur, Sukma section facility Map-4 shows the districts with varying level of overall availability of c-section services. 10 Map 4: District-wise availability of c-section facilities (Government and Private sector Combined) 11 Annexure 1: List of Facilities incorrectly reported in HMIS as conducting c-sections in 2015-16 No. of C-section Number of c-sections Health S.N. District reported in 2015-16 as per community Facility/FRU as per HMIS reports 1 Sukma District Hospital 44 0 2 Sukma Chhindgarh CHC 29 0 3 Surajpur Bhaiyathan CHC 55 0 4 Bilaspur Takhatpur CHC 9 0 5 Durg Nikum CHC 31 0 0 6 Janjgir-Champa Navagarh CHC 13 7 Baloda Bazar Bhatapara CHC 2 0 8 BIJAPUR District Hospital 1 0 9 Jashpur District Hospital 2 0 10 Kawardha Kawardha CHC 1 0 11 Rajnandgaon Dongargarh CHC 1 0 Total 188 0 12 Annexure 2: Operational FRUs and Functionality Status: No. of C-section S.N. District FRU conducted at public Functionality facilities in 2015-16 1 Raipur Medical College Hospital 3,503 Functional 2 Bastar Medical College Hospital 771 Functional 3 Bilaspur Medical College Hospital 1,430 Functional 4 RAIGARH