2014 CRM Bihar

7-14 Nov 2014

Dr Jyoti Joshi Jain

PHFI

Situational analysis: Bihar

• Team led by Dr Pradeep Haldar (DC(I))

• Visited districts Madhubani and Patna

• Health facilities visited range from: • District and Sub district Hospital • Block and Additional PHC • Subcentre • VHND • Othes including Blood Bank, ANM

training centre, Drug Warehouse

Type of institution

Population norm

Current Population covered

Actual no.

Subcentre 5,000 9,464 9,729

APHC 30,000 68,204 1,350

BPHC 1,20,000 1,72,749 533

Current status of health facilities. Bihar

IEC for Health

Soiled Delivery table

Que for OPD slip

Toilet facility in Hospital ward

Patient in ward JSSY records with photos of mother and child

Newborn with ANM Sub District Hospital

1. Service Delivery

Poor Infrastructure and patient facilities

• Increasing service utilization at health facilities but lack of 24X7 delivery services

• Lack of utilization of expensive equipment eg USG machines, radiant warmer & phototherapy units are present but not utilized appropriately.

• Erratic operationalization of Mobile Medical Unit (MMU)

• Absence of Annual Maintenance contract(AMC) equipment

• Infection control: Wards lack washing areas, waterlogging frequent, blocked drains and inadequate biowaste management and segregation,

• Biomedical waste management: rules and protocols should be followed strictly. Service terms of agency may need to be revisited

• Public Private Partnership used food, Laundry, cleaning and some investigations, Blood Bank, training of ANMs, Sanjeevini program, for running the NRC in SDH, Generator.

• Operation Theatre at SDH well equipped but not at DH, Autoclave/sterilizer needed for sterilizing instruments at delivery points are not available.

• Limited IEC display at DH, and peripheral units

2. Reproductive and Child Health

Reproductive Health

Establishment of RMNCH+A Technical Support Unit by the Development Partner Consortium

Supply chain & Inventory management needed for maintaining Family planning devices and MTP services

Training of ANMs on IUD insertions needed

Need for clearly defining the role of MAMTA volunteers for effective use.

Below standard cold chain infrastructure and equipment in Blood bank units of districts visited

Newborn and Child Health

• New born corner and Sick Newborn Care Unit (SNC)U)not appropriately located in hospital and lack HR

• Monitoring Plan needed for ensuring consistent utilization of Nutrition Rehabilitation centre run by NGOs

• Greater utilization of Newborn Stabilising Units(NBSU)

• Immunization : Vaccine logistics and cold chain need to be better planned, occasional stockouts of measles vaccines, reinforce open vial policy improved AEFI reporting needed.

• 5X5 matrix not seen

3. Disease Control Programs

• Integrated Disease Surveillance Program (IDSP) and National Vector Borne Disease Control Program (NVBDCP) need to coordinate better.

•Revised National Tuberculosis Control Program (RNTCP) :

•HR vacancies,

•poor notification rates,

•improved HIV-TB coordination for testing,

•increased private sector & medical college involvement required and

•need for block level entry to Nikshay,

•National Program for Control of Blindness (NPCB): no functioning ophthalmic ward in hospitals visited

•National Leprosy Elimination Program (NLEP): greater ASHA involvement needed

• Non Communicable Disease Control Program (NCDCP): Bihar ranks 6th in the nation for current tobacco user. State has announced banning of flavored chewing tobacco products on 7th Nov’14; Anti-tobacco laws needs to be enforced strictly

• National Programme for Prevention and Control of Cancer, Diabetes Cardiovascular disease and Stroke : Pilot screening program started

4. Human Resource and Training

• Manpower ( Medical, Para Medical, Management staff) has increased but there is serious shortfall of HR to manage programs under NHM. Wide gap Sanctioned Vs. existing staff; majority clinical staff is on deputation

• ANMs under-skilled and not supervised. At Madhubani DH 5 regular ANMs and 4 contractual ANMs are deputed in the maternity ward and all of them are trained SBA. All the contractual ANMs are on deputation in the district hospital from periphery facilities

• HR Rationalization – depending on functional requirements at different facilities

• No HR policy; No HR posting, transfer and placement policy;

• Requirement of Pre-service and In-service Skill development of nursing staff and Medical Officers; On the job mentoring

• High attrition rate of human resources

• Lack of specialists

• Delay in Payments of Staff for last 4-5 months.

• Need to link HRIS with Salary

5. Community Processes and Convergence

Village Health Sanitation and Nutrition Committee (VHSNC): VHSNCs formed at panchayat level, funds on the basis of revenue villages, leaving each VHSNC with large funds,

Restructuring of VHSNC as per new guidelines not done, ANM i s still member secretary, PRIs not active. ASHA plays virtually no role. Meetings irregular, Community level dialogue weak.

Community Action for Health programme piloted last year, but state decided for not taking it further,

ASHA: ASHAs, mainly playing role in immunization and institutional delivery. Role in distributing contraceptives, FP counselling and home based newborn care is weak

ASHA support structure in place at all levels, but needs strengthening, large no. of vacancies exist.

ASHA Facilitator is not effective in her support role, due to Poor knowledge, limited supervisory skills, and lack of role clarity. Their training on performance monitoring system and supervisory role is weak.

Big training infrastructure in collaboration with NGOs, problems of coordination and fund release observed

VHNDs are being held in integration with RI day, mostly at AWC. Weak Support and monitoring by health dept staff for quality of VHND, ASHA Facilitators’ involvement in VHND reported but not seen, (during the visit on VHND)

• Nutrition counselling is very weak, both ANM & ASHAs give only general advice for taking good food, healthy food and vegetables.

• Supplementary Nutrition distribution irregular in most places, cooked food not seen in most places

6. Information and Knowledge

• Adequate capacity, infrastructure, equipment, skill lab etc in place at SIHFW. • MCTS: Adequate awareness about MCTS but erratic use of due list . • Updation of service delivery data by DEO is very less • HMIS system is well established. Data is routinely used in review meetings by

health managers. • SAS application effectively used for analysis purpose. • Data entry for Long-Lat into web portal need to be expedite • USSD training done till block level but USSD is not used by ANM to update the

data. • Turnover of staff leads to delay in data uploading especially in periphery • Poor workplan generation and utilization by ANMs. Duty Charts for ASHAs

and ANMs not displayed at any facility

7. Health care financing

• Under new treasury route state transfers to SHS into one main NHM account and under this there are 4 major flexi pools (NRHM-RCH, NUHM, CD, and NCD) and 2nd layer of sub accounts under 15 major subheads. DHS also follows the same structure – receiving funds in one main account from SHS and allocating in 20 different accounts based on allocated funds.. Major Challenges

Budgetary allocation for the year 2014-15 is yet to be received by the districts. The State has not transferred the money to DHS as per approvals under different flexi pools, but only transferred for regular continued activity.

DHS has to maintain 20 accounts based on approved budget. Block level one account has to be maintained, but need to maintain 20 separate books.

Instructions on how to spend under each account have increased the workload for the same manpower.

7. Health care financing contd..

• HR issues: Position of Director Finance has been vacant for few years; Vacancy of 4 FRU accountants and 2 block accountants (Madhubani) and 1 FRU accountant (Patna)

• Increased workload and several vacancies has led to administrative challenges for accounting and administrative staff.

• Skills: Knowledge of Tally ERP.9 software important. Training to finance staff should be provided at the state and district level:, Operation Guidelines and Model Accounting Hand Book useful. Need orientation and training on Finance Management on regular basis.

• Implementation of Public Financial Management System (PFMS) is almost NIL in Patna

• Banks accounts has not been maintained as per the new banking guidelines. E.g in Madhubani 8 Accounts are inoperative, even though new account have been opened and 100% money has been transferred. Records maintained - In Madhubani Cash book complete till November 7, 2014; Pass book complete till October 14, 2014

• Re-appointment of concurrent auditor should be made by the district. Concurrent Audit for 2014-15 done till September and reports are available. State has yet to submit statutory audit report for the year 2014-15, though audit completed in September.

• Many facilities do not prepare Bank Reconciliation Statement (BRS) on monthly basis

7. Health care financing contd…2

• Cheque issue register is not being maintained properly like it does not have signature of the person/authority signing the cheque (Patna)

• Equal amount (Rs. 98,900 pm) is being paid for both type of ambulance (ALS & BLS), while agreement with service provider provides Rs. 89,900 for ALS and Rs. 79,900 for BLS.

• Utilisation of funds low on most accounts. In Madhubani major reasons were unspent balance on JSK drugs, and non availability of finance ; ASHA training not done; Asha incentives not paid due to poor documentation by ASHA, Delayed fund receipt – under NLEP, No activities took place under blindness, Kalaazar expenditure low. In 14 – 15 – Expenditures done only based on available funds not on approved funds under program.

• User charges are levied for various services – registration, referral transport, diagnosis, drugs. DH exempts those with BPL cards, however if the patient is not carrying the card at the time of admission, they had to pay. Also had to pay for medicines not available at the facility. User charges maintained under RKS funds to use for any emergency purposes. There is no separate accounting for User fees. No reporting to DAM or compilation at that level. Also no auditing reported to DAM. Untied funds under RKS are replenished based on performance and 80% utilisation.

8. Quality Assurance

• District Quality Assurance Committee (DQAC) has been established and meets periodically ; 46 facilities have been identified for ISO certification (SDH Jhanjharpur obtained ISO 9001 Certification in 2013, ISO Certification being sought for DH)

• Service quality: Current low quality of sterilization services (deficient space, privacy and asepsis in OT) and blood bank (non-functional refrigerators, inconsistent testing) Most peripheral institutions(PHCs and APHCs) infrastructure is below par

• Grievance redressal: Grievance Handling Mechanism- Complaint Box displayed prominently, no system of recording complaints from it, Complaint Register had two complaints recorded in June and August but no evidence of any action taken on them

• Patient Satisfaction Form -English Forms with patients writing one line signing in Hindi. No forms available since 2013. Appears as if formality done for ISO certification.

• SOPs for Asepsis and Facility Waste management processes needed.

• Sufficient signage for rights of the patients, complaint box, grievance redressal escalation matrix not found

• The existing initiatives under ISO & FFHI are being integrated with efforts under current NQAG

9. Drugs, Diagnostics, Procurement and Supply Chain management

• Bihar Medical Services and Infrastructure Corporation Limited procures and distributes drugs. State warehouse not adequate in numbers with respect to locational efficiency and requirement

• Set up with ERP, Quality Control cell in place though District drug warehouse not on ERP

• Drug testing Laboratories have been empanelled through a tender process

• RTGS payment system introduced for suppliers

• IT backed supply chain management up to state warehouse

• Dedicated transport vendors for drugs and vaccine empaneled through tender process

• Sanjeevani e system is in use at all facilities, used for OPD and drug distribution but there is multiple entry, no checking for duplication. Rationale for use and greater utilization of mobile no. database needed, E-system not being used for generating and updating computerized drug stock register

10. National Urban Health Mission

• Planning and Mapping of urban areas done

• Institutional arrangements started- Add. ED and small SPMU team

• Manpower and training has been approved in RoP

• 400 MAS and 392 ASHAs in place under donor supported urban health programme from before NUHM,

• A donors supported state level support team is supporting NUHM implementation actively

• Both ASHAs and MAS being planned in 15 cities

• U-PHCs planned, tender invited from NGOs and agencies

• Only OPD services being planned in U-PHCs as of now

• No involvement of Urban Local Bodies

• Need to expedite implementation

11. Governance and Management

• Policy articulation on HR recruitment so that the vacancies are filled at the earliest

• Adequate use of Rogi Kalyan Samiti (RKS) funds in case of drug stockouts

• RKS Meetings being held but focus almost entirely on spending untied funds and local appointments, weak role in monitoring of PPP contracts of cleaning, Bio-medical waste or diet.

• DPM has weekly meetings with BPMs – grievances, program running and performance reports across the blocks are discussed. Ranking of Blocks based on performance and non monetary incentives provided such as certificate of appreciation and felicitation.

• Good performing ANMs and ASHAs have been rewarded certificates on safe motherhood day

• Integration of 104 call centre for referral transport, Grievance redressal and health help line is under process

State response

• Major HR recruitment drive to take place next month addressing HR issues

• Quality Assurance trainings planned: Training for service providers and state programme officers planned in Dec 14

• ASHA supervision and training plan to be reviewed

• Plan for further utilization of Sanjeevani software in consultation with National level

THANK YOU

District visited: Madhubani • Dr Pradeep Haldar

• Dr Sharad Iyengar

• Dr Charu Garg

• Dr Jyoti Joshi

• Mr Pradeep Choudhary

• Mr Ratish

• Ms Pallavi Kumar

• Mr Amit Katewa

• Mr Ram Rattan (state representative)

District visited:Patna • Dr B K Pandey

• Mr Amal Pusp

• Dr R K Das Gupta

• Mr Kedar Nath Verma

• Mr Arun Shrivastav

• Mr Dharmendra Kumar

• Ms. Pinky Bulchandani

• Dr Sheenu Chaudhary

• Ms. Alia Kausar

• Dr Aniruddha Kadu

• Mr Gaurav Kumar (state representative)

Team members of Bihar 2014 CRM team

Facilities visited

Facility Type Patna Madhubani

Name Name

District Hospital - Madhubani

Sub Div Hospital Danapur, Guru Govind Singh Jhanjharpur

Block PHC Maner, Fatuha, Bakhtiyarpur, Phulwari sharif, Danapur, Sampatchak, Dhanarua

Rajnagar Laukahi Jhanjharpur

Additional PHC Sherpur Mahadev math

Sub centre Jethuli, Rukunpura, Pothahi, Tineri, Aurangpur

Sarv Seema AWW centre

Other PMCH, NRC Guru Govind Singh, Regional Drug Warehouse Fatuha, BMSICL

ANM training centre, Madhubani Blood Bank Madhubani Blood Storage Unit Jhanjharpur

VHND

Jethuli, Aurangpur, Tineri Madhya, Tineri Sarv Seema Paitghat AWW Lohan

Terms of Reference : 8th CRM 2014

1. Service delivery

2. Reproductive and child health

3. Disease control programmes

4. Human resources and training

5. Community processes and convergence

6. Health care financing

7. Quality Assurance

8. Drugs, Diagnostics and Procurement & Supply Chain Management

9. National Urban Health Mission

10. Governance and Management