Raisen District, Madhya Pradesh Field Visit Report By: Dr. Arpana Kullu, Consultant NRHM-I MoHFW Introduction For the Action based Monitoring of High Focused Districts, first visit was made to the district of Raisen in Madhya Pradesh from 26th April 2010 to 30th April 2010. The facilities visited and key persons visited for monitoring are enumerated in the Table 1 shown below. The monitoring visit, out of 7 blocks, visit was made to 4 blocks and it included interaction with the Health staff including the Medical Officers, Block Programme Managers , Nursing Staff and few ASHA’s , to gain a better understanding of the processes and difficulties in functioning. DATE DISTRICT/BLOCK PLACE VISITED PERSONS VISITED 27.04.10 Raisen SPMU, Bhopal SPM- Mr. Kumar Sourav District Health Office, ASO- Mr. Raikward Raisen IEC Consultant- Mr.Amit Sharma 28.04.10 1).Obdullaganj CHC Mandideep & Block BMO- Dr.K.P.Yadav 2).Bareilly PHC(Obdullaganj) BPM- Mr.Sunil & CHC Bareilly Mr.Soni BMO- Dr.B.D.Khare 29.04.10 Raisen (Sanchi) CHC Sanchi & PHC BMO- Dr.Das Salamatpur BPM- Ms. Rashmi District Hospital MO 30.04.10 Silwani CHC Silwani BMO-Dr. Manre SC Itkhedi BPM- Deepak Singh LHV- Sulochana Table 1: Showing the Blocks and Persons visited for monitoring. Methodology Secondary Data was collected for the structured format from the state and district HMIS data format that was already available at the respective Programme Management Unit. The primary data was collected for the qualitative responses in the format through interactions with the health staff during the visits to the health facilities. In addition to the State Program Management Unit, the District Program Management Unit and the Block Program Management Unit, facilities from all the three level were randomly selected to conduct the monitoring. From the tertiary level the District Hospital was covered, from the secondary level , CHC Mandideep, Block PHC(Obdullaganj), CHC Bareilly, CHC Sanchi and CHC Silwani and from the primary level PHC Salamatpur and SC Itkhedi. And during these community visits the frontline workers including the ASHA’s, LHV and ANM’s were also interviewed. District Profile: Raisen , Madhya Pradesh The district caters to a population of 14 lakhs. The neighbouring districts are Vidisha, Sehore and Hoshangabad. Besides Bhopal, Vidisha district provides medical care to the patients referred out from Raisen block. The terrain in the district is plain and it has a good connectivity by roadways as shown in the map below. The distict is divided into 7 blocks namely, Sanchi-Raisen, Obdullaganj- Gohaganj, Silwani, Bareilly, Udaipura, Gairatganj and Begamganj. Figure 1: Road Map of Raisen District showing boundaries and road routes. District, Raisen Madhya Pradesh is one of the closest districts to the state capital of Bhopal. According to the Ranking and Mapping of Districts done by IIPs in 2006 the rank given to Raisen was 359 out of the total of 593 districts. The further elaboration of the indicators of the district is given in Figure 2 shown below. Figure 2: Rank of Raisen District, Source: Jansankhya Sthirta Kosh District Programme Management unit The DPMU at Raisen is headed by Dr. Chaubey, CDHO. The DPMU is stationed approximately 60kms from the State Programme Management Unit in Bhopal. It mainly monitors and supervises the functioning of the whole district. But the lack of staff being one of the universal problems across districts, Raisen is no different. Currently the position of District Programme Manager lies vacant since last one year hence the currently staff in position mainly the ASO and the IEC Consultant who have been working in the DPMU manage the responsibilities of the DPM, which often results in multi tasking by them. More over the DPMU as well as BPMU’s also lack data entry operator staff hence the burden falls on the existing staff. In addition, due to the non-availability and incomplete data leaves very limited baseline information to plan further. Thus lack of skilled staff results in compromised state of available data for any monitoring and evaluation. Hence forth there was a lot of information in the format that was unavailable. Besides the existing difficulties what is commendable is that the district is still able to upload their data within its limited capacities. The deputation of Block Program Managers also requires due appreciation since they are contributing immensely in providing managerial support for tracking funds and monitoring activities under the mission at the block level. But to further utilise their skills and capacities more effectively they need even more clear and focused guidelines on their roles and responsibilities, as told by them . Health Facilities in the District Health Facility Number District Hospital 1 Community Health Centre 9 Primary Health Centre 19 Sub Health Centre 176 Currently the number of health facilities in the district is not sufficient to meet the needs the whole population of 14lakhs. And there hasn’t been any proposal in the district health plan within last year for construction of any PHC or CHC. Capacity Building Along with ensuring availability of the health staff in the facilities NRHM focuses on build on the capacities of the existing staff. For which there are provisions for trainings at all levels. As mentioned in the monitoring format the trainings for doctors in EmOC, LSAS, Abdominal Tubectomy (Minilap) and IMNCI in the last one year has been nil. Human Resource The problem of shortage of specialists in the districts is not any different to Raisen. Currently in the district, there are 40 regularly employed MBBS doctors and there are another 40 MBBS doctors who are deputed on contractual positions. For specialists there are 20 specialists available in the whole district. And even with the ones available the services provided are not adequate. For example, the number Of caesareans performed in 2009-2010 in the District hospital: 48. Moreover when combined with other problems of lack of supportive staff it becomes even more difficult to provide essential care also. The area under the field staff on average is 7-8 villages which in terms of population constitutes a population of up to 600 people. There has been a significant addition of ANM’s in the district. A total of 216 ANM’s were added in the year 2009-2010. The current state of vacant and filled positions of ASHA’s and AWW’s is given in the following table.( Source: State HMIS data, updated till Feb 2010) ASHA’s AWW Total No of Villages Filled Vacant Filled Vacant Bareilly 145 108 260 -7 253 Sanchi 173 24 197 53 262 Silwani 120 129 112 137 249 Obdullaganj 145 108 195 58 253 Udaipura 137 30 157 8 155 Gairatganj 85 77 98 64 162 Begumganj 118 78 116 80 196 Communitization Process: Community participation is an important component of NRHM for which many strategies have been incorporated in the programme so as to ensure that the health mission reaches the underserved communities and involve people in planning process also. Broadly these strategies include Selection of ASHA’s, Rogi Kalyan Samiti and Village Health and Sanitation Committee. Even after five years of NRHM the programme has not been able to reach completely up till the community level. (i). ASHA’s The observations and concerns regarding ASHAs’s that were found out in the district are as follows: There are a total of 940 ASHA’s in the district against the sanctioned positions of 1477. Hence a huge need of almost 537 ASHA’s still remains unmet. For which strategies like making the eligibility criterion more flexible needs to be adopted. On interactions with the DPMU staff it was told that 625 drug kits given to ASHA’s was supplied only once in the year 2007, hence the newly selected ASHA’s in the last couple year did not receive these drug kits. Whereas, the data shows that all the 940 ASHA’s have received drug kits. This information requires further probing at the PHC and Sub Centre levels. Moreover the ASHA’s when inducted in the system they were supposed to be the between the beneficiaries and the providers, and support the system to generate demand for the services amongst the people, hence they were chosen as voluntary workers and not regular employees. But now they have become a part of the system, this was substantiated when the ASHA’s who were interviewed and asked about their roles and responsibilities they would reply that they are expected to get all the pregnant women in their village to the health facility for delivery. (ii). RKS To upgrade facilities in the public health system and with a purpose to provide sustainable quality care with accountability and people’s participation along with total transparency. The RKS is in place in all the health facilities as per the guidelines in the framework. But their meetings do not happen regularly as told by one of the Block Medical Officers and thus utilization of funds for which the RKS was formed is very difficult to mobilise. Therefore currently the funds are not utilised with complete efficiency. (iii). Village and Health Sanitation Committee There are 664 VHSC’s in the district and the target for the next year is 736 which are still less when we equate them to the number of Gram Panchayats in the district. The committees are formed wherever there are ASHA’s thus places where an ASHA is not there VHSC’s are also absent. The VHSC’s that are already in place they have a joint bank account in the name of ASHA and the Women representative from the PRI. And the fund utilized only requires the signatory to produce a utilization certificate, there is no monitoring mechanism to ensure that the money is utilized for the purpose it is released.