N R H M COM M ON REVIEW M ISSION BIHAR REPORT 15TH - 20TH NOVEM BER 2007 THE TEAM The team m em bers of the Com m on Review Mission (CRM) to Bihar visited the State from 15th to 20th Novem ber 2007. The team onsisted of Dr.Thelm a Narayan, Publi Health Spe ialist, Dr. D. Tham m a Rao (Mission Dire tor, NRHM, Pudu herry), Dr.M.S.)ayalakshm i (DC, MOH,-. , /O0), Dr. Dileep 1um ar (Nursing Advisor, MOH,-. , /O0) and Shri Am ar4eet Sinha ()oint Se retary, Ministry of Health and -am ily . elfare (MOH,-. ), /overnm ent of 0ndia). The team assem bled in New Delhi on 15th Novem ber 2007 and attended the day long briefing at the National 6evel by all the Program m e Divisions and also had the benefit of som e State spe ifi briefing. THE SCHEDULE On 15th Novem ber 2007 the team rea hed Patna and parti ipated in a m eeting at the Bihar State Health So iety (BSHS) offi e. The Team was aware that it was visiting the State at the tim e of Chhatth festival whi h is one of the m ost im portant festivals of Bihar when every thing loses down for a few days. Detailed presentations were m ade by Ms. Mona /upta, Consultant, BSHS and State Program m e Managers Dr. D 1 Ram an, Dr. (Ma4) 1.N. Sahai, Dr. A. 1. Tewari, Dr. 7. N. Pathak, Dr. N 1 Bhim saria, Dr. /opalakrishna, Dr. Anil 1um ar, and Dr. 8arsha Singh. Sin e all the presentations ould not be om pleted that day, they ontinued on the 19th of Novem ber 2007. The Additional Dire tor from the Dire torate of Health, Dr. Ram an, was present during the presentations and also during the field visits on 16th Novem ber 2007. The State Program m e Managers presented the a tivities of their units, highlighting the NRHM a hievements in the im plementation of RCH and Disease Control program m es. The SHS data olle tion entre, whi h is outsourced, was also visited by the team . 0t was agreed that the team would visit Patna Medi al College Hospital, Nalanda Medi al College, Ra4endra Memorial Research 0nstitute of Medi al S ien es (RMR0) of 0CMR and its 1alaAzar ward at Patna, one PHC and one Sub- distri t Hospital in 8aishali distri t on 16th Nov 2007 and subsequently one CRM team would visit /aya, )ehanabad, Nalanda , Patna distri ts and the other team would visit 8aishali , Muzaffarpur distri ts. The Team – A visited Sub- entre (Moriara), six 25x7 PHCs/Referrral Hospitals at Dhanarua, Makhdumpur, Belagan4, Bodh/aya, Manpur, 8azirgan4, Harnaut, 6algan4, and Ra4gir. 0t also visited the Distri t Hospital at )ehanabad, Ha4ipur and the Pilgrim Hospital at /aya. The Team – B visited Sub- entre, Anganwadi Centre ay )ayanthigram , 25x7 PHCs at 6algan4, /oraul, Sarai, Paru , 8aishali, two Distri t Hospitals (Sarai ,Ha4ipur) as well as Patna Medi al College, Nalanda Medi al College and SN Medi al College, Muzaffarpur. Detailed wrap up m eetings were organized over the last two days of the Mission. Besides intera ting with the Health Minister of the State, the team intera ted with the Health Se retary, Mission Dire tor, Additional Dire tor Health Servi es, Program m e Coordinators, N/Os, et . OVERALL ASSESSM ENT After extensive visits to health facilities in six districts of Bihar and interactions with a wide cross section of people, the team places on record its appreciation for the tremendous work done in a strategic and innovative manner to translate the NRHM framework for implementation into reality. his is impressive given the neglect of the public health sector in the State over the past 15-20 years. Demand side financing, the ASHAs and other rural health initiatives have led to a large increase in utili)ation of health services. Increase in Block PH, OPDs from .9 per month 2 years0 ago to over 2500 per month now for many months, and from 1000 institutional deliveries in government institutions in October 2002 to over one lakh such deliveries in October 2001, confirms the significant increase in number of people accessing the public system. 3iven the low utili)ation of public services in Bihar as reported by NSSO 20th Round 2004-05 556 out patient and 11 per cent in patient treatment in 3overnment institutions7, this is indeed outstanding. here is a confidence that the public system shall deliver 8uality health care services and people are flocking the public system to utili)e services even on holidays and over weekends. here is still scope for improvement in the supply side and 8uality of services, which, hopefully, will receive priority attention in the months to come. The Bihar State Health So iety has steered the pro ess despite frequent hange of leadership with seven ADs over a two year period. The staffing of the BSHS has been sm all for the task entrusted to them. The appointm ent and fun tioning of PMBs at every level is m aking a differen e. Distri t and Blo k level Managers have added new energy to the system of health are delivery. 0nfrastru ture renovation and expansion has taken place in a remarkably short tim e and the setting up of a Constru tion Corporation for the health se tor is a good step to handle new onstru tions. The strengthening of Blo k PHCs has been a step to handle the in reased patient load. hile the ase load has tremendously in reased, there is room for further rationalization of do tor postings as there is under utilization of do tors in som e places, in luding Spe ialists. The thrust sh uld n w be t ensure surgeries and in patient care n a m uch larger scale. It needs a change f m ind set as well as m an. g vernment h spitals are still n t prepared t ta0e resp nsibilit. f r in patient cases. A l t f investment n up-gradati n f facilit. at Bl c0 PHCs have been c mpleted r are near c mpleti n. R1S res urces have reached H spitals. The challenge is t utilize untied res urces t give clean and well e3uipped wards and lab ur r ms, pri ritize 3ualit. health care, cleanliness and in patient care. -or the NRHM goal of ac ess to om prehensive prim ary health are, the Additional PHCs need to be m ade fun tional in a tim e based m anner. Human resour e development, espe ially Nursing, and m anagement needs to be the top priority over the next two years. The State /overnment plans to m ake all Additional PHCs and Sub Centres fully fun tional from )anuary 2008. This will really im prove the outreach and ac ess in diffi ult areas. THEM E W ISE ASSSESSM ENTS 1. L ad in Instituti ns (SHC, 25x7 PHC, Distri t Hospitals , Medi al Colleges)D There is learly a signifi ant in rease in the ase load in all Hospitals of Bihar. Aven at the tim e of Chhatth and on holidays, patients were om ing to the Hospitals and deliveries were taking pla e. The Blo k PHCs have be om e 25E7, even though 3 Staff Nurses are not in pla e as yet. Roster duty at Blo k PHCs ensures the availability of a m edi al personnel round the lo k. The health fa ilityGs load varied for different fa ilities of the sam e ategory depending upon the lo ation, availability of infrastru ture and a eptability. Avery Blo k PHC has witnessed in rease in ase load. Repair and onstru tion of new buildings in Blo k PHCs have prepared them for the higher work load. The outsourcing of /enerators and am bulan e at the PHCs is working very well and it has helped in m aking the Blo k PHC take the additional load. There is a long way to go in im proving the leanliness of 6abour Room s and provision of basi equipments. The dedi ation of staff at the Dhanarua, Makhdumpur and Ra4gir Hospitals refle ted the new m otivation with whi h health personnel have started working. The MO in- harge of Blo k PHCs need to have m ore powers to give servi e guarantees. The urrent system whereby they are dependent on the Civil Surgeon for m any outsourcing arrangements and leanliness needs to be reviewed. MOs should be given m ore powers with m ore responsibilities for ensuring quality and are standards. Resources provided under NRHM for upgradation of CHCs to 0ndian Publi Health Standards, at the rate of Rs. 20 lakhs per institution, as first advan e, needs to be utilized to fill up the m issing gaps in infrastru ture, equipment and m anpower in the Blo k PHCs (that are being upgraded as CHCs). The State /overnment has spent Rs. 23 lakhs per Blo k PHC from the -inan e Com m ission funds to im prove the physi al infrastru ture of Blo k PHCs. ith the unspent NRHM funds with the States for CHCs, it would be possible to over the m issing gaps in a very short period. The 0n-Patient load was very high in all the three Medi al Colleges. The quality of are is not adequate on a ount of a huge shortage of Nurses, so riti al for quality health servi es.