Program Monitoring Report of Chattisgarh District Narayanpur First Quarter 2013-14 (April – June 2013) By National Health Systems Resource Center Executive Summary The report is based on monitoring visit to Narayanpur district of Chhattisgarh in June 2013. A) Introduction: The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district. Narayanpur is one of the least developed district of India and of Chattisgarh. The district borders Chattisgarh and Maharashtra. In the past, Narayanpur was part of the larger Bastar district of erstwhile Madhya Pradesh and later Chattisgarh. Almost 5 / 6 th of the district is the Abujhmarh, which is an extremely densely forested, hilly area. It remain the only unsurveyed area of India. Currently, Abujhmarh is the stronghold of the Left Wing Extremist groups. Narayanpur is tribal dominated, with Gond, Madia and Bada Madia being the scheduled and primitive tribe. Abujhmarh is almost a sanctuary of the Madia tribe without any access to roads, schools and health services. Parts of Abujhmarh are accessible by roads, but invariably after a certain point roads disappear. The only way of commuting is on foot, or vehicle like Tractor. It is crucial to note that Narayanpur being one of the most heavily affected districts due to LWE. Health, ICDS and school education are probably the only 3 programs signifying the existence of Government in the district, especially, in the affected area (which is the majority of the district). B) Analysis of overall indicators of Narayanpur: 1) Availability of data: Lack of reliable data in general, and especially from the Abujhmarh part of the district is a key problem. Any data needs to be evaluated in this context, with significant underreporting possibly the norm. This may be a reason why Narayanpur could not figure in the list of 183 High Priority Districts. Interestingly (and as a pointer to the significant underreporting), the NMR, IMR and CMR of the district are lower than the State as a whole. 2) High Priority district: The exclusion of Narayanpur from the list of High Priority District should be reconsidered as 5/6 th part of Narayanpur is Abujhmarh, which is probably the most backward and inaccessible part of India. The planning of health system and priority should be local with flexibility. Narayanpur should be included in the list of districts for the ‘Annual Health Survey’. This is crucial to get the baseline data for the district. C) Status of Facilities: Narayanpur has total 68 public health facilities out of these 30 are designated delivery points. Private health care providers are few and public health care providers are the only source of modern health care. The public health centers and personnel are concentrated in mostly the north – east corner of the district. The area which is the primary Abujhmarh, has negligible residential and functional health facility. D) Human Resources: 1) Overall HR: The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant. 2) Rural Medical Assistant (RMA): The RMA cadre was the backbone of health services in Narayanpur. Considering the remoteness, the difficulty in mobility and the conflict nature of the district, it is crucial that this cadre is encouraged and strengthened. 3) MPW: Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant as there was only 1 MPW training institute in the entire division, which is in the adjoining district of Kanker (Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate considering the total requirement of MPW (44 vacancies in only 1 district). A combination of MPW and ANM is an optimum combination in areas like Narayanpur, where instead of 2 nd ANM, a MPW can be considered. The MPW can provide the necessary support to the ANM including mobility and security in difficult areas during difficult times, provide curative services and work for National Disease Control Programs. 4) AYUSH: The involvement of AYUSH doctors in disease control programs as well as other NRHM activities is minimal. 5) ANM: The ANM are involved in several other works other than primary health work, for example preparing ration cards, which affected immunization coverage in the recent past and several immunization sessions did not happen. 6) HR Supervisory cadre and Supervision: The nodal officers for various programs in Narayanpur are appointed without any specific criteria with existing staff being given additional charges. For example, the BMO of Orcha block is also the District Malaria Officer. For nursing staff, there are only 2 LHV in the district. The reasons for significantly less number of LHV is due to absence of promotions of ANM to LHV, which was not happening due to the inability of the interested ANM to receive the 2 year training to become LHV as as there is not a single training institution for LHV in Chhattisgarh. 7) Specialist training: The selection of HR to be trained and the subsequent utilization of the training by appropriate posting was severely lacking in the district. E) Institutional Delivery The district could report 84% of the expected deliveries, of which majority (52%) were home deliveries. 1) C - Section and Complicated Deliveries: The C-Section rate is 2.3%, which is very low, and would mean that several needy women are unable to reach emergency obstetric care center of not receiving after reaching. This would also mean higher maternal mortality. Similarly, the proportion of complicated pregnancies attended is also extremely low. This could be improved by better training of ANM, RMA and PHC MO. 2) Stay in facility after delivery: Majority of the women were leaving the facility within 48 hours after delivery. 3) Management of Obstetric complications: The identification and management of obstetric complications such as Eclampsia was negligible (0%) in Narayanpur. The detection of maternal anemia is severely lacking. For ANC care there is lack of standard protocols and urine testing for Albumin, nitrite, leukocyte esterase and blood was lacking, which would miss cases of pre Eclampsia and UTI. The use of obstetric interventions as antibiotics, oxytocics was also severely lacking in Narayanpur. F) Janani Shishu Suraksha Karyakram (JSSK): 1) OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum women and newborns in all the facilities visited. 2) Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to pregnant women if the medicines are available. The system is centralized purchasing but the supply was not regular and timely for several medicines. System of maintaining inventory including regular watch of expiry date and timely replenishment is lacking. ANM and Supervisors were not replenishing the drugs or proactively getting demands from the ASHA. EDL was absent in the facilities visited and the records and stock were not computerized. 3) Diagnostics: Free Lab/diagnostics services were available at CHCs and DH. Exemptions for diagnostic services are available for PW and Sick new born. What is missing is the overall plan of maintenance including AMC, calibration of equipments, provisioning of diagnostics reagents and regular laboratory technician. 4) Diet: Free diet was provided to pregnant and postpartum women. The food was generally according to standard menu. 5) Referral transport: 4 Government and 3 Private Vehicles are available for JSSK transport. If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or using their own vehicle when the regular ambulances are not available on call or it is not possible to connect with the facility due to lack of cellular connectivity. Drop back facility was available in all the facilities visited though limited due to distances, limited number of Ambulances with respect to the size of the district and extremely difficult terrain. The referral transport mechanism was especially poor in case of newborns and (as per the data provided by the district authorities) not a single newborn had received any referral transport in the entire month of May. 6) Display of entitlement and awareness of community JSSK Entitlements were displayed in only 1 of the all facilities visited (PHC Chotedongar). Boards in Local language (Gondi) would be needed in the facilities in the tribal areas of the district. 7) Grievance Redressal / Nodal officer: No specific mechanism for redressal of grievances exists in facilities visited. The district does not have a separate JSSK nodal officer for solving grievances. There was lack of clarity on who is the specific point person for such is. There is no specific accountability or responsibility for following up on complaints received has been instituted. 8) Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the ASHA expressed the inability, finally the mother was delivered in the DH itself. 9) Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free referral transport but the cellular connectivity is almost absent especially in the Orchha block of the district. This creates a major bottleneck in the optimum implementation of JSSK in the district. 10) Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to pregnant anemic women is very few. The blood bank has most of the infrastructure and is waiting to get the License for operationalization. G) JSY: The implementation of JSY in Narayanpur is significantly below mark, especially in the case of home deliveries where only 15.56 % had received the payment. The key bottlenecks are lack of banking network and unwillingness of Bankers to open ‘0’ balance account.