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Draft Report

Rapid Appraisal of NRHM Implementation (Supported by Ministry of Health & Family Welfare

Government of India, New Delhi)

K. S. James

T. S. Syamala

R. Mutharayappa

Lekha Subaiya

Dhananjay W. Bansod

M. Lingaraju

P. Prabhuswamy

C. Yogananda

Population Research Centre Institute for Social and Economic Change

Dr. V.K.R.V. Rao Road, Nagarabhavi Bangalore - 560072

2009

1

Chapters Contents Page No.

Acknowledgement……………………………………………………..... i

Executive Summary……………………………………………………... 2

Chapter 1: Karnataka State Profile: An NRHM Front……………………... 7

Chapter 2 District Profile………………………………………………….. 18

Chapter 3 Community Health Centres…………………………………….. 49

Chapter 4 Primary Health Centres……………………………………….... 83

Chapter 5 Sub Centres……………………………………………………... 114

Chapter 6 Household Characteristics…………………………………….... 140

Chapter 7 Role, Awareness and Involvement of Gram Panchayats……….. 184

Chapter 8 Quality of Care and Client Satisfaction……………………….... 189

Chapter 9 Insights from the field: A Qualitative Enquiry…………………. 213

References…………………………………………………….................. 220

Appendix………………………………………………………………… 221

2

Executive Summary

The Government of India launched the National Rural Health Mission in April, 2005 to

carry out necessary architectural corrections in the primary health care delivery system.

The Mission aims to provide comprehensive and integrated primary healthcare to the

people, especially to the rural poor, women and children. It adopts a synergic approach

by relating health to determinants of good health viz of nutrition, sanitation, hygiene and

safe drinking water. It also aims to mainstream the Indian system of medicine to facilitate

comprehensive health care.

The Mission tries to achieve these goals through a set of core strategies including

decentralized planning and management, appointment of female Accredited Social Health

Activists (ASHA) to facilitate access to health services, upgradation of the public health

facilities to Indian Public Health Standards (IPHS), reduction of infant and maternal

mortality through Janani Suraksha Yogana (JSY) etc.

This study aims to conduct a rapid evaluation on some of the critical components of

NRHM in the district of Hassan in Karnataka state to gauge the effectivness of various

components of the programme. The following tools are used to carry out the evalution of

the different components. Altogether ten schedules are administered as part of the survey.

They are state schedule, district schedule, Community Health Centre (CHC) schedule,

Primary Health Centre (PHC) schedule, subcentre schedule, exit interview schedule for

inpatients, exit interview schedule for out-patients, schedule for Panchayati Raj members,

ASHA schedule and household schedule. The schedule on District Hospital, CHCs, PHCs

and SCs is used to understand the status of facility upgradation under IPHS, status of

utilization of untied funds and functioning of Janani Suraksha Yojana (JSY). The level

of client satisfaction measured through household survey and through exit interviews on

inpatients and outpatients of different health facilties. The Gram Panchayat schedule

elicits information on the integration of the community into the public health system.

Since the ASHA programme is yet to take off in Hassan district, this schedule is not

administred. To answer the utilisation of specific srvices by the beneficiaries, a

household survey is carried out in the sampled hoseuholds.

3

The following are the major findings of the study.

• In Karnataka all the Community Health Centres (CHCs) have registered ‘Arogya

Raksha Samitis’ (ARS). Out of the 29 district hospitals in the state Aarogya

Raksha Samitis are functioning in 24 district hospitals. However, none of the

‘Arogya Raksha Samitis’ has been is registered so far in PHCs.

• The state has initiated the Public Private Partnership (PPP) to implement the JSY

scheme. About 430 private health facilities in the state are accredited under the

JSY scheme.

• Untied Funds are allocated to all districts by activity as well as by a flexi pool

fund method.

• All CHCs, PHCs, and Sub centres have received Untied Grants from the state

government for the current year.

• All the sub centres have an operational joint bank account with Gram Panchayat

President or other members for the use of an Untied Grant of Rs. 10,000 per year.

• Hassan district has a good network of public health facilities. However, there are

many posts of Medical Officers and other specialists vacant in the district

• The construction of new buildings is in progress for a few health facilities. It is

found that none of the health facilities is upgraded as per the IPHS standard

• Altogether 25 private health facilities are accredited under the JSY scheme in the

district.

• The district hospital has all the required infrastructural facilities and equipments.

However, facilities like isolation rooms, high dependency wards, pleural biopsy

and endoscopic specialized procedures are not available in the district hospital.

• At the district hospital there are a number of vacant positions of paramedical staff

at the time of the survey.

• The district hospital has registered ‘Arogya Raksha Samithi’ (ARS) which

generate additional resources by charging user fees and outsourcing the services.

• Management Information Systems (MIS) seem to be poor in the district hospital

as various types of like sex and caste wise data are not available for many

indicators.

4

• The available infrastructure is reasonably good in CHCs of Hassan District and in

majority of the areas it is in compliance with the IPHS.

• The service utilisation data also show that most of the required services have been

provided in the CHCs

• Manpower position statistics indicate a shortage of support staff in CHCs.

• AYUSH services are yet to be introduced in the CHCs

• PHCs in Hassan district require improvement in various areas in order to be in

compliance with the IPHS.

• Although the availability of physical infrastructure in PHCs is relatively better,

the availability of man power, equipment and drugs require improvement.

• Another area which needs strengthening in PHCs is the functioning of Arogya

Raksha Samitis for the overall hospital management which is a core activity under

NRHM.

• Only one of the four selected PHCs had formed an Arogya Raksha Samiti.

Forming of ARS in all the PHCs might take care of the infrastructure shortfall as

the ARS are empowered to buy the required items.

• Only four out of twelve sub centres operate in a designated government building

in Hassan district. The rest operate in rented buildings or in PHCs, and in one

case, the construction of a building is being planned.

• Most specific equipment, medicines and miscellaneous medical items are

unavailable at most of the sub centres possibly due to the absence of a proper sub

centre building. However, basic equipment like thermometers and scales are

available and in good condition.

• Awareness and knowledge of JSY scheme among ANMs is high in Hassan.

• There is under-utilisation of Untied Funds at the sub centre level due to lack of

coordination between health functionaries and elected panchayat members.

• The survey of 1,200 households in Hassan district shows that about 98 percent of

the respondents are aware of JSY scheme. Majority of the pregnant women are

JSY beneficiaries. It is also observed that JSY beneficiaries are drawn from all

caste groups in the society.

5

• Although payment of funds was delayed, JSY beneficiaries received money in

one visit and in general are satisfied with the procedure.

• Nearly 85 percent of the deliveries have taken place at the health institutions.

• Utilization of government health services and knowledge of family planning,

particularly spacing methods, is relatively high.

• The satisfaction level of the public health facility is significantly high with only 4

percent reporting dissatisfaction with the facility.

• Awareness of AIDS, correct knowledge of its mode of transmission and location

of AIDS counseling centers is high.

• The survey among 23 Gram Panchayat members shows that they are, in general,

aware of the NRHM programme. Gram Panchayats are making progressive

changes in integrating the community into the public health system.

• However, the implementation of NRHM related activities are lagging due to poor

coordination between health functionaries and Panchayat members. VHSC

meetings are rare and the preparation of village health plans are not taking place

in the district.

• The exit interviews found that the time spent by patients for different services is

appropriate and that a majority of the inpatients and outpatients are satisfied with

the time spent for receiving services.

• The behaviour of staff in different health facilities is found to be reasonably good.

Privacy is also ensured in places of examination. However in the case inpatients

there are complaints about the behaviour of the supporting staff.

• Doctor-patient communication is found to be good in the district hospital, but

moderate in PHCs.

• Overall cleanliness is maintained in public health facilities but inpatients

complained about uniforms and bed sheets not being changed regularly.

• The overall satisfaction level of inpatients is high in the selected health facilities.

• In-depth discussions with various functionaries and the public reveal that in

general NRHM is successful in reducing maternal and child mortality by way of

increasing institutional deliveries.

• The JSY scheme is rated to be a huge success in reducing home deliveries.

6

• There were procedural delays in the disbursement of money under the JSY

scheme.

• ASHA workers have not been appointed yet in the district.

• Although Untied Funds are generally felt to be of benefit to health facilities, the

funds themselves are underutilized due to a number of bottlenecks.

• The involvement of Panchayati Raj members in the health system is not

successful in the district. This component of the NRHM requires strengthening

through the raising of awareness of the role of the community in the health

delivery system by imparting training to the PRI members.

Suggestions

• Up gradation of facilities as per the IPHS, especially at lower level facilities like

PHC and sub centre, is an immediate requirement. The utilization of the public

health facility is directly linked to the infrastructure facility. The CHCs in Hassan

district (Taluka level hospitals) are better utilised due to good facilities available

in the hospital.

• Training of the health functionaries has not been undertaken in Hassan district. It

should be done not only for technical guidance on the NRHM but also to bring

about better awareness of the importance of integrating the community into the

public health system.

• As envisaged by the NRHM, the integration of community with the public health

system remained incomplete. It appears that the Panchayati Raj members lack full

awareness of the NRHM programme resulting in non-cooperation from their part

in the NRHM activities. Increase of awareness through orientation and training

programme would contribute to better understanding of the programme, its phases

of implementation as well as the long term benefits to the community.

• It is also observed there is a need to provide simple and transparent guidelines for

utilizing untied funds as well as VHSC funds. Both these funds remain

underutilized in most places at this time.

• Appointment of ASHAs is likely to further enhance institutional delivery which is

relatively high in Hassan district at present.

7

Chapter 1

Karnataka State Profile: An NRHM Front

Introduction

The state of ‘Karnataka’ is located in the southern part of India and is the eighth largest

state in terms of total geographical area and ninth largest in terms of population in India.

Karnataka state was formed on November 1, 1956 by merging the districts of Belgaum,

Bijapur, Dharwad, and Uttara Kannada of Bombay Presidency; Bidar, Gulbarga and

Raichur of Hyderabad state; and Bellary and Dakshina Kannada of Madras Presidency

with the princely state of Mysore. As such, glaring disparities persist across these regions

in socio-economic and health achievements. The district of Hassan which is part of

erstwhile princely state of Mysore is ahead of other regions in development.

Population Characteristics

In Karnataka, at present, there are 29 districts, 176 blocks and 29,406 villages. Out of

these villages, 1925 are uninhabited villages. According to 2001 Census, Karnataka has a

total geographical area of 191,791 square kilometers with a population of 52,850,562 (53

million). Out of which, 26,898,918 (50.9 per cent) are male and 25,951,644 (49.1 per

cent) are female with a population density of 275 per sq. km. (as against the national

average of 312). The sex ratio of the state is 965 per 1,000 males (as against the national

average of 933). Nearly 34.0 per cent of the people lived in urban areas. The percentage

share of Scheduled Castes and Scheduled Tribes population to the total population in the

state is 8,563,930 (16.2 per cent) and 3,463,986 (6.6 per cent ) respectively.

Table 1 also reveals that the percentage of SC/ST living in urban area is far less

than the other groups. On the other hand, the sex ratio is more favourable to females

among SC/ST than other caste groups.

8

Table 1: Population of the State (as per 2001 Census)

TOTAL CATEGORY

Male

Female

Total %

Total Sex

Ratio Scheduled Caste 4339745 4224185 8563930 100.0 973 Scheduled Tribe 1756238 1707748 3463986 100.0 972 Others 20802935 20019711 40822646 100.0 962 Karnataka State 26898918 25951644 52850562 100.0 965 All - India 532156772 496453556 1028610328 100.0 933

RURAL CATEGORY

Male

Female

Total %

Rural Sex


URBAN CATEGORY

Male

Female

Total %

Urban Sex


Status of Health Infrastructure and Facility Upgradation under NRHM

Karnataka has a good network of health care infrastructure. About thirty per cent of

villages have some health facility. It is having a better record of health care and child care

compared to other states in India. There are six government hospitals which have

received ISO-9002 certification in Karnataka.

According to the data gathered from the Directorate of Health and Family Welfare

Services, Government of Karnataka - 2007-08, there are 8,143 ANM sub-centres, 2,193

Primary Health Centres (PHCs), 974 24X7 concept’s Primary Health Centres, 5 Mobile

medical units (KHSDRP), 192 First Referral Units (FRUs), 325 Community Health

Centres (CHCs), 762 AYUSH (103 Hospitals and 659 Dispensaries) in the state. In

addition, there are 29 district level and 149 taluk level hospitals.

9

In Karnataka, as on June 30, 2008, 142 Community Health Centres and 2 district

hospitals are currently under construction. The Indian Public Health Standard (IPHS)

facility survey was completed in 143 CHCs as on 30.06.2008 in the state (Pl. see State

Schedule).

Rogi Kalyan Samities (RKS)

The `Rogi Kalyan Samiti (RKS)’ is known as ‘Aarogya Raksha Samiti (ARS)’ in

Karnataka. According to the data, out of 29 district hospitals in the state, the ‘Aarogya

Raksha Samiti (ARS)’ is functioning only in 24 district hospitals and they are registered

under the `Karnataka Societies Registration Act, 1960 (Karnataka Act 17 of 1960)’.

Similarly, 325 Community Health Centres and 2,193 Primary Health Centres have

‘Aarogya Raksha Samities (ARS)’. Out of 325 CHCs, about 250 CHCs have registered

under the same Act. But, none of the ‘Aarogya Raksha Samiti (ARS)’ in 2,193 PHCs in

the state has been registered so far (Pl. see State Schedule).

Janani Suraksha Yojana (JSY)

The ‘Janani Suraksha Jojana (JSY)’ is one of the most important and also highly

progressive programme to promote institutional deliveries in the state as well as in the

country. This programme was launched in 2005. The package of JSY, includes early

registration of pregnancy (within the first trimester), delivery care through micro birth

plan, Referral Transport (Home to Health Institution) and incentive for institutional

births, post delivery visit and reporting, family planning and counseling. As far as Public

Private Partnership (PPP) is concerned, the state has initiated the Public Private

Partnership (PPP) to implement the JSY scheme. In this system, about 430 private health

facilities have been accredited so far for JSY scheme in the state.

Table 2 presents data on the status of JSY in the state. According to the data from

public health facilities, there were 474,546 institutional deliveries in the state during

2007-08. Among them, about 189,208 (39.9 per cent) women have registered under JSY

scheme. Out of 189,208 women, about 116,472 (61.6 per cent) women opted for

institutional delivery. With regard to caste-wise break-up, the data show that the

10

scheduled caste women have slightly lower percentage of institutional deliveries

compared to ST or general women. There is no data available from private health

facilities in these aspects.

Table 2: Status of Janani Suraksha Yojana in the state - 2007-08

Sl. No.

Particulars Number

1. Public Private Partnership (PPP) initiative undertaken for the implementation of JSY and number of private health facilities accredited for JSY in the state

430

At Government Facilities:

Social Groups

Total Institutional Deliveries Reported

during 2007-08

Total number of Registered JSY women during

2007-08

Out of total number of

Registered JSY women, Number of women opting for Institutional Delivery during

2007-08 No. % No. % No. %

1. Scheduled Caste NA NA 41797 NA 23649 56.6 2. Scheduled Tribe NA NA 21867 NA 14348 65.6 3. General NA NA 119244 NA 78475 65.8 4. Total 474546 NA 189208 39.9 116472 61.6

At Private Facilities: Not Available

NA = Data is Not Available Financial Mechanism at the State Including Transfer of Untied Funds

With regard to financial mechanism, all the vertical health societies in 29 districts are

merged to create a registered Health Society under NRHM scheme in Karnataka. Also,

they are having a common bank account for all the programmes in the state. Apart from

that, the state has prepared a `Perspective State Health Plan’ for the year 2008-09. All the

districts have prepared `District Action Plans’ which have been approved by the State

Society for the year 2008 - 09. The funds are allocated for all the districts normally by

activity wise as well as by a flexi pool fund. At present, all funds are being transferred

electronically from the state to the respective districts.

11

In Karnataka, there are 8,143 sub centres having operational joint bank account

with Gram Panchayat Presidents or other members (Sarpanchs) for using the Untied

Grant of Rs. 10,000 per year. The state government has transferred the Untied Grant to all

the 325 CHCs, 2,193 PHCs and 8,143 Sub Centres under NRHM scheme for the year

2008-09 (Pl. see State Schedule).

The Study Area and Data Collection

Table 3 presents data on the selected CHCs, PHCs, Sub-centres and villages for the

study. ‘Hassan’ is one of the districts in Karnataka, selected for the concurrent evaluation

of National Rural Health Mission (NRHM). Based on the distance and performance of

the activities, we selected two taluks, namely, Sakleshpur and Arsikere for the NRHM

evaluation. In each taluk, two Primary Health Centres (PHCs) are selected. Under each

PHCs, three sub centres (SCs) are selected and finally, in each sub centre, two villages

are selected for the study. The villages are selected on the basis of nearest and farthest

distance from the Sub-centre.

In Sakleshpur taluk, Ballupet and Uchangy PHCs are selected for the study.

Under Ballupet PHC, three sub centres viz., Heggavi, Bage and Hebbanahally are

selected. The selected villages are Kuniganahally and Vadoor selected from Heggavi sub

centre, Kendanamane and Aluvalli from Bage sub centre, and Kesaguli and Maasavalli

from Hebbanahally sub centre. The same procedure is adopted for Uchangy PHC also.

The selected sub centres of Uchangy PHC are Hosur, Goddu and Vanagur Koodu Rasthe

respectively. From Uchangy PHC, the selected villages are Hosur and Kawkodi from

Hosur sub centre, Tambalagere and Banagere from Goddu sub centre, and Koodu Rasthe

and Kongahally from Koodu Rasthe sub centre.

In the same way, Harnahally and Hiresadarahally PHCs are selected for the study

in Arsikere taluk. Under Harnahally PHC, three sub centres are selected viz. Harnahally

(B), Karagunda and Kerekodihally. The selected villages are Belavathahally and

Boranakoppalu from Harnahally (B) sub centre, Karagunda and Vrundavanahally from

Karagunda sub centre, and Bommenahally and Karehally from Kerekodihally sub centre.

12

Similarly, three sub centres are selected from Hiresadarahally PHC, namely,

Hiresadarahally (B), Kyatanahally and J C Pur. The selected villages are Narasipura and

Nagavedi from Hiresadarahally (B) sub centre, Byrapur and Chikkahalkur from

Kyatanahally sub centre, and Tumbapura and Melenahally from J C Pur sub centre.

A sample of 1,200 households are covered in the district at the rate of 50

households from each village. Apart from that there are 30 in-patients (IPD) and 44 out-

patients (OPD) are interviewed from the District Hospital, Hassan, two Community

Health Centres and four Primary Health Centres to assess the quality of services provided

to the people. The data collection was conducted in a month’s time starting from 26th

November, 2008.

Six Female Investigators and three Field Supervisors are appointed for data

collection. The supervisors are selected from the PRC staff. All the filled-in schedules

were duly edited for about a week and kept ready for data entry. The data entry was

carried out between 4th February and 25th February, 2009 (Table 3).

Table 3: Households and Exit Interviews Covered

Sl. No.

Name of the Place HH Covered

IPD Covered

OPD Covered

Hassan District Hospital - 5 5 I. Sakleshpur Community Health Centre - 15 12 1. Ballupet Primary Health Centre - - 5 I. Heggavi Sub Centre - - - 1. Kuniganahally 50 - - 2. Vadoor 50 - - II. Bage Sub Centre - - - 1. Kendanamane 50 - - 2. Aluvalli 50 - - III.Hebbanahally Sub Centre - - - 1. Kesaguli 50 - - 2. Maasavalli 50 - - 2. Uchangy Primary Health Centre - - 6 I. Hosur Sub Centre - - - 1. Hosur 50 - - 2. Kawkodi 50 - -

13

II. Goddu Sub Centre - - - 1. Tambalagere 50 - - 2. Banagere 50 - - III.Vanagur Koodu Rasthe Sub Centre - - - 1. Koodu Rasthe 50 - - 2. Kongahally 50 - - II. Arsikere Community Health Centre - 10 5 3. Harnahally Primary Health Centre - - 5 I. Harnahally (B) Sub Centre - - - 1. Belavathahally 50 - - 2. Boranakoppalu 50 - - II. Karagunda Sub Centre - - - 1. Karagunda 50 - - 2. Vrundavanahally 50 - - III.Kerekodihally Sub Centre - - - 1. Bommenahally 50 - - 2. Karehally 50 - - 4. Hiresadarahally Primary Health Centre - - 6 I. Hiresadarahally (B) Sub Centre - - - 1. Narasipura 50 - - 2. Nagavedi 50 - - II. Kyatanahally Sub Centre - - - 1. Byrapur 50 - - 2. Chikkahalkur 50 - - III.J C Pur Sub Centre - - - 1. Tumbapur 50 - - 2. Melenahally 50 - - Total 1200 30 44

Summary

The study reveals that the NRHM programme is implemented in most of the districts of

the state. The Rogi Kalyan Samities are found in 24 districts out of 29 districts. However,

no Rogi Kalyan Samities in PHCs are registered so far. In the case of Public Private

Partnership (PPP), the state has made some progress and around 430 private health

facilities have been accredited so far. The Untied Grant has been released for CHCs,

PHCs and Sub-Centres during the year 2007-08.

14

SCHEDULE (S): STATE SCHEDULE

Block A. Identification Details (Information to be collected from State Health Department)

Q. No. Questions

S101. Name of the State Karnataka

S102. Total Number of Districts 29 (27)

S103. Total Number of Census Villages (2001 Census) 27481 (Inhabited)

S104. Name of the Respondent Mr. K. P. Bhat

S105. Designation of the Respondent Monitoring & Evaluation Consultant

Block B. (I)

Population of the State (As on 2001 as per Population Census)

Rural Urban Total Q. No. Category

Male Female Male Female Male Female

S106. Scheduled Caste

3245315 3171928 1094430 1052257 4339745 4224185 8563930

S107. Scheduled Tribe

1486073 1448457 270165 259291 1756238 1707748 3463986

S108. Others 12917570 12619690 7885365 7400021 20802935 20019711 40822646

S109. Total 17648958 17240075 9249960 8711569 26898918 25951644 52850562

Block B. (II)

Population of the State (As on March, 2008) (Information to be collected from State Health Department)

Rural Urban Total

Q. No. Category Male Female Male Female Male Female

Source Code (Population Projection – 1; State Estimate – 2; Not Available – (3)



S112. Others

S113. Total

15

Block C. Infrastructure (Information to be collected from Programme Manager in State Programme Management Unit (SPMU))

Q. No.

S114. Name of the Respondent Mr. Ramaseshan

S115. Designation of the Respondent Buauro of Health Statistician

Public Health

Infrastructure

Total

Existing (In Nos.) (As on

30.6.2008)

New Buildings

Under Construction

(In Nos.) (As on

30.6.2008)

Total Number where

IPHS facility survey

completed (As on

30.6.2008)

No. of facilities

where IPHS Upgradation completed

(As on 30.6.2008)

S116. Sub Centre 8143 - - -

S117. PHC 2193 - - -

S118. 24x7 PHC 974 - - -

S119. CHC 325* 142 143 53

S120. First Referral Units(FRU)

192 - - -

S121. Mobile medical unit 5

S122. Sub Divisional Hospital

149 -

S123. District Hospital 17 2

S124. AYUSH 762** Not Available

Private Health

Infrastructure

Total Existing (In Nos.) (As on 30.6.2008)

S125. Hospitals (More than 30 bedded)

Not Available

S126. Nursing Homes (Less than 30 bedded)

Not Available

Block D.

Rogi Kalyan Samities (RKS) (Information to be collected from Programme Manager in State Programme

Management Unit (SPMU)) Q. No. How many facilities have Rogi Kalyan Samities (RKS) Registered?

Total Functioning No. with Registered RKS

S127. District Hospital 24 24

S128. Sub Divisional Hospital

- -

S129. CHC 325 250

S130. PHC 2193 Not registered so far

S131. Block PHC - -

S132. Addl. PHC - -

16

*325 CHCs Taluk Head Quarter CHCs are 147 with 100 beds capacity, and Below Taluk Head Quarter CHCs are 178 with 30 beds capacity **762 AYUSH 103 Hospitals , and 659 Dispensaries

Block E.

Janani Suraksha Yojana (JSY) (Information to be collected from Programme Manager in State Programme

Management Unit (SPMU))

Q. No. Response Category Skip

S133. Whether any PPP initiative undertaken in the state for the implementation of JSY Scheme?

Yes…………………….…….(1) No…………………………...2

> Q. S135

S134. If yes, number of private health facilities accredited for JSY scheme

430

Q. No.

Total Institutional Deliveries Reported

during 2007-08

Total number of Registered JSY

Women during 2007-08

Out of total number of Registered JSY

Women, number of women opting for

Institutional Delivery during 2007-08

At Govt. Facilities


Not Available 41797 23649


Not Available 21867 14349

S137. General Not Available 119244 78475

S138. BPL Not Available Not Available for BPL, It is included

Not Available for BPL, It is included

S139. APL Not Available - -

S140. Total 474546 189208 116472

At Private Facilities (Wherever accredited for services)


Not Available Not Available Not Available


Not Available Not Available Not Available

S143. General Not Available Not Available Not Available

S144. BPL Not Available Not Available Not Available

S145. APL Not Available Not Available Not Available

S146. Total Not Available Not Available Not Available

17

Block F.

Financial Mechanisms (Information to be collected from Finance Manager in State Programme Management

Unit (SPMU))

Q. No. Response Category Skip

S147. Name of the Respondent Mr. K. P. Bhat

S148. Designation of the Respondent Monitoring & Evaluation Consultant

S149. Have all the vertical health societies created under different programmes merged in to State Health Society under NRHM?

Yes…………………….….….(1) No………………………….….2

> Q. S152

S150. How many districts have merged registered health societies?

29

S151. Is there a common bank account for all programmes in State Health Society

Yes……………………. …….(1) No……………………………..2

S152. Has the perspective State Health Plan been prepared for 2008-09?

Yes……………… …….…….(1) No……………………….…….2

> Q. S155

S153. How many districts have District Action Plans for the current year (2008-09)?

29

S154. Have these plans been approved by the state society?

Yes……………… …….…….(1) No……………………….…….2

S155. How are the funds being allocated to the districts (Encircle all applicable options)

Activity wise……………....…(A) As flexi pool funds…………..(B) Based on a set formula like size of district etc……………….…C Based on previous year’s expenditure…………………...D Others (please specify)…..… E

S156. Are the funds being transferred electronically by the State to the district?

Yes……………… …….…….(1) No……………………….…….2

>Q S158

S157. If yes, then to how many districts is it being transferred electronically?

29

S158. How many Sub Centres have Operational Joint Bank Account of ANM and Sarpanch?

8143

No. of centres for which Untied Grant for the current year transferred?

S159. CHC 325

S160. PHC 2193

S161. Sub Centre 8143

18

Chapter 2

District Profile

Introduction

The district of Hassan is selected to evaluate the NRHM intervention in the Karnataka

state. The district has 8 taluks and 2, 400 revenue villages. The total geographical area of

the district is about 6, 845 Square kilometers with a total population of 17.22 lakhs. The

overall literacy rate of the district is about 69 per cent with male literacy of 78 per cent

and female literacy of 59 per cent. The district has a better position in terms of sex ratio

i.e., 1,004 females per 1,000 males than the state (965). The density of the population is

about 251 persons per Square Kilometers (Census, 2001).

Table D-1: Total Population by Caste and Place of Residence, Hassan, 2001

Total Category Male Female Total Sex Ratio Scheduled Caste 155409 156317 311726 1006 Scheduled Tribes 13297 13154 26451 989 Others 690410 693082 1383492 1004 District 859116 862553 1721669 1004 Karnataka 26898918 25951644 52850562 965

Rural Category Male Female Total Sex Ratio Scheduled Caste 136971 138455 275426 1011 Scheduled Tribes 12107 12095 24202 999 Others 558005 559363 1117368 1002 District 707083 709913 1416996 1004 Karnataka 17648958 17240075 34889033 977

Urban

Category Male Female Total Percentage of Urban

Sex Ratio

Scheduled Caste 18438 17862 36300 11.6 969 Scheduled Tribes 1190 1059 2249 8.5 890 Others 132405 133719 266124 19.2 1010 District 152033 152640 304673 17.7 1004 Karnataka 9249960 8711569 17961529 34.0 942

Source: Census of India, 2001

19

Part A

Population Characteristics

As per the 2001 census, the district has a population of 1,721, 669. About 82 per cent of

them are living in rural areas and the rest is in urban (17.7 per cent) areas. Among the

SC/ST population, around 11.6 per cent scheduled caste and 8.5 per cent of the

Scheduled Tribes are living in urban areas. The highest sex ratio is found among SCs in

rural areas (1,011) and Non-SC/ST in urban areas (1,010) compared to district average

(1004). (Table D-1). As on March 2008, the estimated population of the district is 18.37

lakhs. A total of 1.15 lakh population has been added since the 2001 census population

(Table D-2).

Table D-2: Total Population by Caste and Place of Residence, Hassan, as on March,

2008 (Estimated)

Total Category Male Female Total Sex Ratio Scheduled Caste 165140 166118 331258 1006 Scheduled Tribes 14131 13978 28109 989 Others 736303 741230 1477533 1007 District 915574 921326 1836900 1006

Rural Category Male Female Total Sex Ratio Scheduled Caste 145559 147136 292695 1011 Scheduled Tribes 12866 12853 25719 999 Others 595596 597440 1193036 1003 District 754021 757429 1511450 1005

Urban

Category Male Female Total Percentage of Urban

Sex Ratio

Scheduled Caste 19581 18982 38563 11.6 969 Scheduled Tribes 1265 1125 2390 8.5 889 Others 140707 143790 284497 19.3 1022 District 161553 163897 325450 17.7 1015

Source: NRHM Office, Hassan District, Hassan

20

Status of NRHM Interventions

Status of Health Infrastructure

As on June 30, 2008, there were 453 sub-centres (SCs) and 149 Primary Health Centres

(PHCs) (37 of them are 24 X 7) are functioning in the district. Besides this, there are 37

Community Health Centres (CHCs), 6 First Referral Units (FRUs), 7 Sub-Divisional

Hospitals and 62 AYUSH centres providing necessary health care services to the people

of the district. The district Hospital is located in the district headquarter. Besides, there

are 25 Private hospitals with more than 30 bedded and 31 Nursing Homes with less than

30 bedded facilities available for the people. In the district, the construction of a new

building is also in progress for a PHC, two CHC, one FRU, one sub-divisional hospital

and one AYUSH hospital. The IPHS facility survey is completed in most of the health

facilities. In the district hospital and 75 PHCs, the IPHS survey is yet to take place.

Facility Up-gradation under NRHM

As on the date specified, none of the health facilities have completed IPHS up-gradation

in the district.

Facilities Available in the District for Delivery

One of the important aspects of NRHM intervention is to promote hospital delivery and

ensure that all the deliveries are conducted in health facilities. At the district level,

district hospital is working on 24 X 7 basis, providing BeMOC and CeMOC services

with new born care facilities. Though there are 7 Sub Divisional Hospital functioning on

24 X 7 basis, only 5 Sub Divisional Hospital are having BeMoc and CeMOC with New

Born Care unit facilities. There are only 4 CHCs (out of 13 CHCs) providing New Born

Care facilities. In the district, 37 PHCs (out of 74 PHCs) are functioning on 24 X 7 basis,

providing delivery services for the pregnant women. Thirteen Public Maternity Homes

are also functioning to provide delivery care, of which 3 are working on 24 X 7 basis.

Besides, there are 2 other public health facilities (ESI, Railways etc). There are also 56

private facilities providing all required delivery care services, of which 25 are accredited

21

for the JSY purpose. Thus, in general, the district has a good network of public health

facilities.

Availability of Human Resources for delivery

In the district, there are 237 sanctioned Medical Officers’ (MO) posts. Out of that only

164 medical officers are in position, in which 120 MOs are in regular position and 44 are

working on contract basis. As such, 73 Medical Officer Posts are vacant in the district.

In Hassan district, Seven Gynaecologists are in position, in which 4 are regular and the

remaining 3 are working on contract basis. Three Gynaecologist posts are vacant out of

11 sanctioned posts. Only three Anesthetists are regular in position out of 6 sanctioned

posts. There are 5 sanctioned posts for Paediatrician and all are in position. There are

forty other specialists available in the district as against 64 sanctioned posts. But, in the

case of staff nurse, there are 205 staff nurse working as against 179 sanctioned posts.

Similarly, there are 481 sanctioned posts of ANMs and most of them (476 ANM) are in

position. Hence, the shortage is mainly observed in the case of specialists.

Arogya Raksha Samities (ARS)

The District Hospital, 7 sub divisional hospitals, 9 CHCs and 123 PHCs have registered

ARS.


For the implementation of JSY, 25 private health facilities have been accredited in the

district. These Public-Private Partnership (PPP) includes Lab services, Diagnostics like

Ultrasound and X-Ray, Bio Medical waste disposal, Sanitation, Hiring of specialist

services, procurement of Drugs and Equipment, transportation facilities for delivery and

referral cases.

During 2007-08, there are 19, 121 institutional deliveries reported in the district

from both public and private (accredited for services) facilities. During the period, 14,

684 women registered for JSY and about 88 per cent of the JSY women have opted for

institutional deliveries. Unfortunately, the public and private facility-wise data are not

22

available either for caste segments (SC, ST and General Population) or for economic

groups like APL and BPL families.

Financial Mechanism

In the district, all vertical health societies created under the different programmes have

been merged into a registered district Health Society. There is a common bank account

for all the programmes under the district health society. As per the data available, the

district action plan has been prepared for the year 2008-09 and it has been approved by

the district health society. The district is receiving funds from the state based, on activity

and Annual Action Plan. The funds are transferred electronically from the state to the

district.

There are about 420 sub centres have operational joint account of ANMs with

Panchayat Presidents receiving the Untied fund for the current financial year. Like-wise,

there are 13 CHCs, 121 PHCs in the district which received untied fund for the current

financial year.

Part B

Health Facilities at the District Hospital

Location of the Hospital and Status of IPHS

The district hospital is located in the heart of the Hassan main city near to the (less than

half km) General bus stand. The district hospital is located around 32 kms away from the

nearest sub-divisional Hospital (Sakaleshpur). It takes hardly 60 minutes by public

transport to reach the place from CHC. Similarly, the farthest sub-divisional Hospital

(Arasikere) is about 43 Kms away from the district hospital and it takes about 90 minutes

to reach the place by public transport. The administration procedure in Karnataka is from

district to Sub-divisional hospital (Taluk Hospital) to PHC. The CHCs are mainly

working as up-graded PHCs in the district. According to the information available, the

IPHS facility survey is yet to take place in the district hospital.

23

Physical Infrastructure

The total area of the hospital is about 25 acres, and the indoor bed available for the

patients in the hospital is 350. The hospital is mainly located in the commercial area of

the town. Necessary environmental clearance certificate has been obtained from the

Pollution Control Board. The hospital building is disabled friendly as per the provisions

of the Disability Act (Ramp, Lift, Wheel chair movement etc.).

Facilities Available in the Administrative/Main Block

In the hospital, waiting space are available for each consultation rooms, registration

counter, Blood Bank, doctors’ duty room, treatment room, Dispensary, ICU, emergency

services, examination and preparation rooms for the patients. However, the Hospital

does not have the facility of Isolation room and High Dependency wards.

Hospital Services

The district hospital has good ventilation in all the wards and has proper drainage and

sanitation system. Other services include kitchen, Laundry services, Central Sterile and

Supply Department, medical and general stores, engineering services, Water coolers,

water supply for 24 hours through overhead water storage tank with pumping

arrangements and provision of fire fighting in case of accidental fire. The Bio Medical

Wastes disposal work is out-sourced to an agency and the waste has been segregated into

three different bins.

Only two quarters are available for medical staff and both are currently occupied.

Twenty four quarters are available for Staff Nurses and most of them are occupied.

Protocols have followed in the classification of Diseases. The facility such as medical

record section, telephone, Fax, computers and internet etc., are available in the hospital.

Besides, the Hospital has convenient parking facility.

Medical Section

As per the information gathered from the respective departments, there are 16, 859 OPD

and 1,938 IPD cases registered in the last three months (September, October and

November 2008). No sex-wise break-up have been maintained in the department. Most

24

departments have admitted patients during the last three months indicating that all these

facilities are functioning in the district hospital. There are no facilities for Pleural Biopsy

and Endoscopic Specialized Procedures in the hospital.

Obstetrics and Gynae Cases

In this department, there is a separate ward for female patients with a capacity of 24 beds.

In the last four months, 1,987 patients have been admitted. In addition, there are 8, 050

OPD cases registered in the last 3 calendar months. The department has a separate OT for

Gynaecoloy and Obstetrics cases. About 1, 493 deliveries conducted in the department

during the last three months and about 5, 525 delivery cases handled by the department

during the year 2007-08 in which about 1, 923 are caesarean deliveries. The data show

that there are 83 cases of caesarean section of JSY beneficiaries, 51cases coming under

assisted delivery, 34 cases of forceps delivery, 11 MTP and 8 eclampsia. There are 364

sterilzation cases. There are also 10 Suturing Cervical Tear (not based on record), 113 are

Hysterectomy and only one case each from PPH, and Ectopic Pregnancy. There are 6

infertility cases (not based on record) treated in the department. No cases are found in

Retained Placenta.

Surgical

In this department, about 8, 822 OPD and 371 IPD cases are treated during the last three

months. There are about 6, 252 emergency (Accident and other emergency) cases

attended by the surgical department. About 28 and 27 cases have been registered in

abdomen and breast surgery respectively in the IPD section. No surgery cases belonged

to Leprosy reconstructive.

Pediatric

About 30, 306 OPD cases reported for the year 2007-08 and sex-wise details are not

available in the department. There are 24 beds available for newborn care and 3, 365

cases have been admitted during the year 2007-08. Seven hundred and seventy-two

neonates have been admitted during the year. In the department, services are available for

cases of Asphyxia, severe malnourished, Neonatal Sepsis, Dehydration and Diarrhoeal

25

and Respiratory Tract/Pnuemonia. There are equipments like, Incubator, Radiant Heat

Warmer, Phototherapy Unit, Bag with Mask, Laryngoscope, Oxygen Mask, Suction

Machine and Thermometer in the hospital to provide the required services to the people

and all the equipments are in working condition. It is reported that the equipment of

Cradle is not available and one radiant heat-warmer (out of two numbers) is not in

working condition. It is said that ORS, Vitamin A solution, Iron folic Acid Syrup and

Paediatric Antibiotics drugs are available in the department.

Diagnostic and Laboratory Facilities

This information is obtained from the Radiographer and Lab Technician in the hospital.

The total OPD records are not available in the diagnostic section. On an average, about

2,265 X-Ray has been carried out per month in the hospital. A total of 1, 940 Ultrasound

is also carried out during the last two months. Similarly there are about 2, 243 ECG

carried out during the last three months. The cases are registered for diagnostic and

laboratory services in the hospital indicating that the facilities are functioning.

Human Resources

Medical

In the hospital, 56 medical personal are in position (including 2 contract staff) out of 58

sanctioned posts. There is no shortage of specialists in the district hospital except two

specialists one each from Medical Specialist and Anesthetist falling vacant (Table D-3).

Table D-3: Details of Staff Position under the Medical Category in the District

Hospital, Hassan

Category Sanctioned Regular in Position

Contractual in Position

Total

District Surgeon 1 1 - 1 Deputy Chief MO 3 3 - 3 Hospital Superintendent - - - - Medical Specialist 29 27 1 28 Surgery Specialist 2 2 - 2 Gynaecologist 3 3 - 3 Gynaecologist (short term trained MO) - - - - General Physician 2 2 - 2 T B Specialist 1 1 - 1

26

Blood Bank MO 1 1 - 1 Forensic Specialist 1 1 - 1 Pediatrician 2 2 - 2 Anesthetist 2 1 - 1 Anesthetist (short term trained MO) - - - - Radiologist 1 1 - 1 General Duty Doctor - - - - Public Health Manager - - - - AYUSH Physician - - - - Pathologist 1 1 - 1 Psychiatrists 1 1 - 1 Dermatologist/Venerelogist 1 1 - 1 ENT Surgeon 1 1 - 1 Opthalmologist 2 2 - 2 Orthopaedician 1 1 - 1 Microbiologist 1 1 - 1 Dental Surgeon 2 1 1 2 Total 58 54 2 56 Source: District Hospital, Hassan District, Hassan

Table D-4: Details of Staff Position under the Para-Medical Category in the District

Hospital, Hassan.

Category Sanctioned Regular in Position


Total

Sr. Staff Nurse 8 5 - 5 Staff Nurse 64 56 - 56 Ophthalmic Assistant/Refractionist 2 2 - 2 Social Worker 1 1 - 1 ECG Technician - - - - Audiometerician - - - - Laboratory Technician 8 7 - 7 Dietician - - - - ANM 4 4 - 4 LHV 3 3 - 3 PHN - - - - Radiographer 1 1 - 1 Pharmacist 9 5 - 5 Matron 1 - - - Physiotherapist 1 - - - Medical Records Officer/Technician

- - - -

Hospital Worker (All Group D) 130 71 - 71 Total 232 155 0 155 Source: District Hospital, Hassan District, Hassan

27

Paramedical Staff

Table D-4 reveals that 155 para-medical staffs are in position as against 232 sanctioned

posts. In the Hospital, there are 77 vacant posts as against the sanctioned post. For

example, posts of three Sr. Staff Nurses, 8 Staff Nurses, one laboratory technician, 4

pharmacists, one Matron and Physiotherapist, One Junior Administrative Officer, two

drivers and 59 D group posts have fallen vacant. It is found that there is no sanctioned

post of ECG technician, Audiometricain, Dietician, PHN, and Medical Record Officer in

the hospital.

Administrative Staff

Table D-5 shows the details of Administrative staff position in detail. In this category, 9

posts are in position as against 12 sanctioned posts. It is found that there is no Manager’s

post sanctioned in the Accounts and Administration section.

Table D-5: Details of staff position Under the Administrative staff Category in the District Hospital, Hassan

Category Sanctioned Regular

in Position


Total

Manager (Administration) - - - - Junior Administrative Officer

2 1 - 1

Officer Superintendent 2 2 - 2 Accounts Manager - - - - Driver 8 6 - 6 Total 12 9 - 9 Source: NRHM Office, Hassan District, Hassan

Other Framework and Structural Issues

The district hospital has registered an Arogya Raksh Samithi (ARS) under the Karnataka

Societies Registered Act, 1960 (Karnataka Act 17 of 1960). An users fee has been

introduced in the hospital according to Government norm which is become a resource for

the ARS. There are procedures adopted to provide exemption for those families

belonging to SC/ST and BPL categories. The ARS is generating additional funds by

28

outsourcing services. The generated money is used within the facility for the

improvement of hospital facility. In the hospital, there is no display board put up

showing the number of ARS and number of meetings held so far. The ARS gets the

feedback on grievance redressal through social auditing.

Summary

The district has a good network of public health facilities. However, there are many

posts of MOs and other specialists vacant in the district. The construction of new

building is in progress for few health facilities. It is found that none of the health

facilities has upgraded as per the IPHS standard. Altogether 25 private health facilities

have accredited for JSY cases. The district hospital has all required infrastructural

facilities and equipments however, few facilities like Isolation room, high dependency

wards, Pleural Biopshy and Endoscopic Specialized procedures are found not available in

the district hospital. At the district hospital there are many vacancies of paramedical staff

and a few vacancies of specialists. The district hospital has registered Arogya Raksha

Samithi (ARS) which is generating additional resources by user fee and outsourcing the

services. The MIS seems to be poor in the district hospital as many information like sex

and caste wise are not available.

29

SCHEDULE (D): DISTRICT SCHEDULE

The interviewer is expected to interact with District NRHM society (Part A) member for collection of district level information and follow this up with a visit to the district hospital (Part B)

Part A

Block A. Identification Details (Information to be collected from District NRHM Society)

Q. No. Questions

D101. Name of the District Hassan

D102. Total Number of Blocks in the District 8

D103. Total Number of Census Villages (2001 census) in the District

2400

D104. Name of the Respondent D Vnkatesh

D105. Designation of the Respondent DPM

Block B. (I) Population of the District (As on 2001 as per Population Census)

Rural Urban Total Q. No. Category

Male Female Male Female Male Female

D106. Scheduled Caste 136971 138455 18438 17862 155409 156317

D107. Scheduled Tribe 12107 12095 1190 1059 13297 13154

D108. Others 558005 559363 132405 133719 690410 693082

D109. Total 707083 709913 152033 152640 859116 862553

Block B. (II)

Population of the District (As on March, 2008) (Information to be collected from State Health Department)

Rural Urban Total

Q. No. Category Male Female Male Female Male Female

Source Code (Population Projection – 1; State Estimate – 2; Not Available-3)

D110. Scheduled Caste 145559 147136 19581 18982 165140 166118

D111. Scheduled Tribe 12866 12853 1265 1125 14131 13978

D112. Others 595596 597440 140707 143790 736303 741230

D113. Total 754021 757429 161553 163897 915574 921326 2

30

Block C. Infrastructure [Information to be collected from Chief Medical Officer (CMO) Office]

Q. No.


D115. Designation of the Respondent DPM Public Health

Infrastructure Total

Existing (In Nos.)

(As on 30.6.2008)

New Buildings

Under Construction

(In Nos.) (As on 30.6.2008)

Total Number where IPHS

facility survey completed

(As on 30.6.2008)

No. of facilities where IPHS Upgradation

completed (As on 30.6.2008)

D116. Sub Centre 453 - 453 -

D117. PHC 149 1 74 -

D118. 24x7 PHCs 37 - 37 -

D119. CHC 13 2 13 -

D120. First Referral Units (FRUs)

6 1 6 -

D121. Mobile medical units

D122. Sub Divisional Hospitals 7 1 7 -

D123. District Hospitals 1 - 0 -

D124. AYUSH 62 1 - -

Private Health Infrastructure Total Existing (In Nos.) (As on 30.6.2008)

D125. Hospitals (More than 30 bedded) 25

D126. Nursing Homes (Less than 30 bedded) 31

Facilities available in the district for delivery Facility Number of Facilities

Total existing in the District

(As on 30.6.2008)

Operational 24x7

Providing BeMOC

Providing CeMOC

(Having Blood Storage,

Anesthetist and Gynecologist)

With New Born Care Unit

D127. District Hospital

1 1 1 1 1

D128. Sub Divisional Hospital

7 7 5 5 5

D129. CHC 13 - - - 4

D130. PHC 74 37 - - -

31

D131. Public Maternity Homes

13 3 - - -

D132. Others Public (ESI, Railways etc.)

2 2 2 2 2

D133. Others Private 56 56 35 35 35

D134. Private accredited for JSY

25 25 25 25 25

Block D. Human Resources Available in the District (Information to be collected from Chief Medical Officer (CMO) Office)

Q. No. Category No.

sanctioned Regular in Position

Contractual Recruits

Total in Position

D135. Medical Officer 237 120 44 164

D136. Gynaecologist 11 4 3 7

D137. Anaesthetist 6 3 - 3

D138. Paediatrician 5 5 - 5

D139. Other Specialists 64 27 13 40

D140. Staff Nurses 179 97 108 205

D141. ANM 481 371 105 476

Block E. Rogi Kalyan Samities (RKS) Information to be collected from District Programme Management Unit (DPMU)

Q. No.

D142. Name of the Respondent

D Vnkatesh

D143. Designation of the Respondent

DPM

Number of facilities having Rogi Kalyan Samities (RKS) Registered? Total functioning No. with Registered

RKS

D144. District Hospital 1 1

D145. Sub Divisional Hospital

7 7

D146. CHC 13 9

D147. PHC 123 123

32

Block F.

Janani Suraksha Yojana(JSY) (Information to be collected from District Programme Management Unit (DPMU))

Q. No.

Response Category Skip

D148. Whether any PPP initiative being undertaken in the district for the implementation of JSY Scheme?

Yes………………….1 v No………………….2

> Q D151

D149. If yes, number of private health facilities accredited for JSY scheme

25

D150. Which of the following areas are covered under PPP initiatives (Encircle all applicable options)

Lab services…………….…..A v Diagnostics like Ultrasound & X-Rays………………….…..B v Bio Medical waste Disposal..C v Sanitation……………..……D v Security……………………..E v Hiring of specialist services….F v Procurement of Drugs/ Equipment…………………...G v Providing transportation facility for delivery & referral cases……………...H v Other.......................................I

Q. No.

Total Institutional Deliveries Reported during 2007-08

Total number of Registered JSY Women during 2007-08

Out of total number of Registered JSY Women, number of women opting for Institutional Delivery during 2007-08

At Govt. Facilities

D151. Scheduled Caste

D152. Scheduled Tribe

D153. General

33

Block F.

Janani Suraksha Yojana(JSY) (Information to be collected from District Programme Management Unit (DPMU))

D154. APL

D155. BPL

D156. Total

At Private Facilities (Wherever accredited for services)

D157. Scheduled Caste

D158. Scheduled Tribe

D159. General

D160. APL

D161. BPL

D162. Total

Both Government and Private facilities

19121 14 684 12 883

Block G. Financial Mechanisms (Information to be collected from Finance Manager in District Programme Management Unit (DPMU))

Q. No.


D164. Designation of the Respondent

DPM


D165. Have all the vertical health societies created under different programmes merged in to a District Health Society?

Yes………………….1 v No………………….2

>Q D168

D166. Whether the merged district health society is registered?

Yes………………….1 v No…………………..2

D167. Is there a common bank account for all programmes in District Health Society

Yes………………….1 v No………………….2

34

D168. Whether the distric t has prepared District Action Plan for the current year?

Yes………………….1 v No………………….2

>Q D170

D169. If yes, has the plan been approved by the district society?

Yes………………….1 v No………………….2

D170. How are the funds being received from the State in the district (Encircle all applicable options)

Activity wise…….……………A v As flexi pool funds……..……..B v Based on a set formula like size of district etc…………….………C Based on previous year’s expenditure …………………....D Based on Annual Action Plan ...E v Others (pl Specify) ……………F Not aware...................................G

D171. Are the funds received were transferred electronically by the State

Yes………………….1 v No………………….2

D172. How many Sub Centres have Operational Joint Bank Account of ANM and Sarpanch?

420

No. of centres for which Untied Grant for the current year transferred?

420

D173. CHC 13

D174. PHC 121

D175. Sub Centre 420

35

DISTRICT SCHEDULE Part B District Hospital The infrastructure details to be supported by digital photographs of the facility and other areas like operation Theater, wards, pharmacy, lab etc

Block A. Identification Details (Information to be collected from the Office Of Medical Superintendent of the Hospital)

Q. No. Questions (for both Male/Female)

D176. Name of District Hospital Sri Chamarajendra Hospital

D177. Name of the Respondent M Ileyger

D178. Designation of the Respondent Pharmacist

Distance & Time Taken to travel to District Hospital in public transport from

Distance

(in Kms.)

Time

(in Hrs.)

D179. Nearest Sub-divisional Hospital in the coverage area 32 60

D180. Farthest Sub-divisional Hospital in the coverage area 43 90

D181. Distance of District Hospital from the nearest bus stop (in Kms.)

< 0.5 Km.………….A v 0.5 – 1 Km…………B >1 Km......................C

D182. Has the IPHS facility survey been carried out in the District Hospital

Yes………………….1 No………………….2 v

Block B. Physical Infrastructure (Information to be collected from the Office Of Medical Superintendant of the Hospital and supplemented by observation)

Q. No. Questions Response Category

D183. Area of the Hospital (in Sq. mtrs.) 25 Acres

D184. Number of indoor beds available 350

D185. Is the hospital located near residential area? Yes……………….1 No……………….2 v

D186. Is necessary environmental clearance obtained from Pollution Control Board by the Hospital?

Yes……………….1 v No……………….2

D187. Whether hospital building is disable friendly as per provisions of Disability Act? (Ramp, Lift, wheel chair movement etc.)

Yes……………….1 v No……………….2

Administrative/ Main Block (Availability of following)

D188. Waiting Space adjacent to each consultation and treatment room

Yes- in all ……….1 v No……………….2 Yes – in some……3

D189. Registration Counter Yes……………….1 v No……………….2

36

D190. Blood Bank/ Blood storage Unit Yes……………….1 v No……………….2

D191. Doctors' Duty Room Yes……………….1 v No……………….2

D192. Isolation Room Yes……………….1 No……………….2 v

D193. Treatment Room Yes……………….1 v No……………….2

D194. Pharmacy (Dispensary) Yes……………….1 v No……………….2

D195. Intensive Care Unit (ICU) Yes……………….1 v No……………….2

D196. High Dependency Wards Yes……………….1 No……………….2 v

D197. Critical Care Area (Emergency Services) Yes……………….1 v No……………….2

D198. Examination and Preparation Room Yes……………….1 v No……………….2

Hospital Services

D199. Hospital Kitchen (Dietary Service) Yes……………….1 v No……………….2

D200. Central Sterile and Supply Department (CSSD) Yes……………….1 v No……………….2

D201. Hospital Laundry Yes……………….1 v No……………….2

D202. Medical and General Stores Yes……………….1 v No……………….2

D203. Engineering Services Backup Yes……………….1 v No……………….2

D204. Ventilation (Natural or mechanical exhaust) in the wards

Yes…………….....1 v No…………….....2

D205. Water coolers / Refrigerators Yes…………….....1 v No…………….....2

D206. Round the clock water supply Yes……………….1 v No……………….2

D207. Overhead water storage tank with Pumping and boosting arrangements

Yes……………….1 v No……………….2

D208. Provision for fire fighting Yes……………….1 v No……………….2

D209. Proper drainage and sanitation system for waste water, surface water, sub soil water and sewerage

Yes……………….1 v No……………….2

37

D210. How is the Bio Medical Waste disposed? (Encircle all applicable options)

Buried ……………….A Incernation………..….B Outsourced to agency .C v Thrown in open……....D

D211. Is Bio Medical Waste segregated in three different bins?

Yes……………….1 v No……………….2

Number of Residential Quarters available for all medical and Para medical staff

No. Available

No. Occupied

D212. Medical Staff 2 2

D213. Staff Nurse 24 23

D214. Parking place Yes……………….1 v No……………….2

D215. Medical Records Section Yes……………….1 v No……………….2

D216. Is the disease classification being carried out as per protocols

Yes……………….1 v No……………….2

D217. Availability of telephone Yes……………….1 v No……………….2

D218. Availability of Fax equipment Yes……………….1 v No……………….2

D219. Availability of Computers Yes……………….1 v No……………….2

D220. Availability of Internet services * Yes……………….1 v No……………….2

* Available in 2-3 places

Obstetrics & Gynae Section (Information to be collected from the Sister In charge of Gynae ward & supplemented by Observation from records)

D221. Name of the Respondent Ms Chandrakala

D222. Designation of the Respondent Staff Nurse Response Category Skip

D223. Is there a separate Ward for Female Patients?

Yes………………….1 v No………………….2

>Q D226

D224. If Yes, the number of beds 24

D225. Bed Occupancy Rate in the last 12 months (As on March 31, 2008)

16 patents per day (Based on last 4 months data)

38

D226. Total OPD in last 3 calendar months

8050

D227. Total deliveries in last 3 calendar months

1493

D228. Is there a separate OT available for Gynaecology & Obstetrics

Yes………………..1 v No………………..2

Procedures Carried Out Particulars Availability of Services If Yes,

Numbers in 2007-2008

D229. Total deliveries conducted 5525

D230. Caesarean section deliveries Yes………….……….1 v No……………………..2

1923

If yes, no. done in 2007-08

D231. Caesarean section for JSY Yes………………….1 v No…………………..2

83

D232. Assisted Delivery Yes………………….1 v No…………………..2

51

D233. Forceps delivery Yes………………….1 v No…………………..2

34

D234. MTP Yes………………….1 v No…………………..2

11

D235. Mid trimester Abortion Yes………………….1 v No…………………..2

Not available

D236. Ectopic Pregnancy Yes………………….1 v No…………………..2

1

D237. Retained Placenta Yes………………….1 v No…………………..2

No cases

D238. Eclampsia Yes………………….1 v No…………………..2

8

D239. PPH Yes………………….1 v No…………………..2

1

D240. Sterlisation Yes………………….1 v No…………………..2

364

D241. Suturing Cervical Tear Yes………………….1 v No…………………..2

10 (Not based on records)

D242. Hysterectomy Yes………………….1 v No…………………..2

113

39

D243. Infertility Treatment Yes………………….1 v No…………………..2


Surgical Section (Information to be collected from the Sister In charge of Surgical ward & supplemented by Observation)

D244. Name of the Respondent Ms Saroja S Bangerea

D245. Designation of the Respondent Staff Nurse II No. of Surgical OPD in last

three months 8822

D246. Female Not available

D247. Male Not available No. of Surgical IPD in last

three months 371


D249. Male Not available

Availability of Services Response Category If Yes, Numbers in last 3 months

D250. Emergency (Accident & other emergency) (Casualty)

Yes……………….….1 v No…………………..2

6252

D251. Pancreas Surgery

Yes……………….….1 v No…………………..2

1

D252. Spleen and Portal Hypertension Surgery

Yes……………….….1 v No…………………..2

1

D253. Abdomen Surgery

Yes……………….….1 v No…………………..2

28

D254. Breast Surgery

Yes……………….….1 v No…………………..2

27

D255. Leprosy Reconstructive surgery

Yes…………….…….1 No…………………..2 v

40

Medical Section (Information to be collected from the Sister In charge of Medical ward & supplemented by Observation)

D256. Name of the Respondent Dr. Nagaiah

D257. Designation of the Respondent HoD Medical OPD in last three months 16, 859


D259. Male Not available Medical IPD in last three months 1938


D261. Male Not available Availability of Services Response Category If Yes, Numbers in last

3 months

D262. Dermatology and Venerology (Skin & VD) RTI / STI

Yes……………….….1 v No…………………..2

14

D263. Services under NLEP

Yes……………….….1 v No…………………..2

6

D264. Pleural Aspiration

Yes……………….….1 v No…………………..2

83

D265. Pleural Biopsy

Yes…………….…….1 No…………………..2 v

D266. Bronchoscopy

Yes…………….…….1 v No…………………..2

No cases

D267. Lumbar Puncture

Yes………….……….1 v No…………………..2


D268. Pericardial tapping

Yes…………….…….1 v No…………………..2

Nil

D269. Skin scraping for fungus / AFB

Yes…………….…….1 v No…………………..2

Nil

D270. Bone Marrow Biopsy

Yes…………….…….1 v No…………………..2

Nil

D271. Endoscopic Specialized Procedures

Yes……………….….1 No…………………..2 v

D272. Psychiatry Services

Yes……………….….1 v No…………………..2

19

41

Pediatric Section (Information to be collected from the Sister In charge of Pediatric ward & supplemented by Observation)

D273. Name of the Respondent Ms. Manjula

D274. Designation of the Respondent SDA Pediatric OPD in 2007-2008 Numbers

D275. Female

D276. Male Total 30, 306

D277. Designated/identified Beds for

newborns available? Yes -------------------1 v No --------------------2

>Q D279

D278. If yes, no. of beds 24 Pediatric Patients admitted in

2007-2008 Numbers

D279. Total Admitted 3365

D280. Neonates admitted 772 (From June 2007 to March 2008)

D281. Other Infants (0-1 years) admitted Not available

D282. Children under 5 yrs admitted Not available Services Available

D283. Asphyxia Management Yes………………….1 v No………………….2

D284. Management of severe malnourished children

Yes………….……….1 v No…………………..2

D285. Management of Neo Natal Sepsis

Yes…………….…….1 v No…………………..2

D286. Management of Dehydration and Diarrhoeal Cases

Yes……………….….1 v No…………………..2

D287. Management of Respiratory Tract / Pnuemonia Cases

Yes………….……….1 v No…………………..2

Equipment Available Available? If available, whether

working?

D288. Cradle

Yes…………….…….1 No…………………..2 v

Yes……………….1 No……………….2

D289. Incubator

Yes…………….…….1 v No…………………..2

Yes……………….1 v No……………….2

42

D290. Radiant Heat Warmer

Yes………….……….1 v No…………………..2

Yes……………….1 v No……………….2

D291. Phototherapy Unit

Yes…………….…….1 v No…………………..2

Yes……………….1 v No……………….2

D292. Bag with Mask

Yes…………….…….1 v No…………………..2

D293. Laryngoscope

Yes…………….…….1 v No…………………..2

Yes……………….1 v No……………….2

D294. Oxygen Mask

Yes…………….…….1v No…………………..2

D295. Suction Machine

Yes………….……….1 v No…………………..2

Yes……………….1 v No……………….2

D296. Thermometer

Yes…………….…….1 v No…………………..2

Yes……………….1 v No……………….2

Availability of drugs

D297. ORS (WHO new formula)

Yes…………….…….1 v No…………………..2

D298. Vitamin A Solution

Yes…………….…….1 v No…………………..2

D299. Iron folic Acid Syrup

Yes…………….…….1 v No…………………..2

D300. Paediatric Antibiotics

Yes…………….…….1 v No…………………..2

Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation)

D301. Name of the Respondent Dr. Mallikarjunappa

D302. Designation of the Respondent Radiographer Diagnostic OPD in last 3 months Not available


D304. Male Not available Availability of services Response Category If Yes, Number

carried out in last 3 months

43

Diagnostic Section (Information to be collected from Radiology Section & supplemented by Observation)

D305. X-Ray Yes……………….….1 v No…………………..2

6795

D306. Ultrasound

Yes……………….….1 v No…………………..2

1940

D307. Ultrasound guided Biopsy

Yes…………….…….1 No…………………..2 v

D308. ECG

Yes……………….….1 v No…………………..2

2,243

Lab Services (Information to be collected from the Lab Technician & supplemented by Observation)

D309. Name of the Respondent Mr. Shivakumar

D310. Designation of the Respondent Lab. Technician Number attended in last 3 months 9, 255


D312. Male Not available Availability of services Response Category If Yes, Number

carried out in last 3 months

CLINICAL PATHOLOGY

D313. Haematology

Yes…………….…….1 v No…………………..2

23, 850

D314. Urine Analysis

Yes…………….…….1 v No…………………..2

5,144

D315. Stool Analysis

Yes…………….…….1 v No…………………..2

28

D316. Semen Analysis (morphology, count)

Yes…………….…….1 v No…………………..2

32

D317. CSF Analysis (Cell count, culture sensitivity etc., gram staining)

Yes……………….….1 No………………….2

-

D318. Aspirated fluids (cell count cytology)

Yes…………….…….1 v No…………………..2

18

PATHOLOGY

44

Lab Services (Information to be collected from the Lab Technician & supplemented by Observation)

D319. PAP smear

Yes…………….…….1 v No…………………..2

64

D320. Split Skin Smear Examination for leprosy

Yes…………….….….1 No…………………..2 v

D321. Sputum

Yes…………….…….1 v No…………………..2

742

D322. Histopathology

Yes……………….….1 v No…………………..2

179

D323. Microbiology Yes……………….….1 v No…………………..2

390

D324. Serology

Yes……………….….1 v No…………………..2

2,778

D325. Biochemistry (Pulmonary Medicine)

Yes…………….…….1 v No…………………..2

11, 769

D326. Physiology (Pulmonary function test)

Yes…………….…….1 v No…………………..2

6

Block C. Human Resource (Information to be collected from the Statistics Section of the Office of Medical

Superintendent of the Hospital)

D327. Name of the Respondent Mrs. Muthamma

D328. Designation of the Respondent SDA Category of Personnel Sanctioned Regular

In Position

Contractual In Position

Total

D329. Hospital Superintendent - - - -

D330. Medical Specialist 29 27 1 28

D331. Surgery Specialist 2 2 - 2

D332. Gynaecologist 3 3 - 3

D333. Gynaecologist (short term trained MO)

- - - -

D334. Pediatrician 2 2 - 2

D335. Anesthetist 2 1 - 1

D336. Anesthetist (short term trained MO)

- - - -

45



D337. Radiologist 1 1 - 1

D338. General Duty Doctor - - - -

D339. Public Health Manager - - - -

D340. AYUSH Physician - - - -

D341. Pathologists 1 1 - 1

D342. Psychiatrist 1 1 - 1

D343. Dermatologist / Venereologist 1 1 - 1

D344. ENT Surgeon 1 1 - 1

D345. Ophthalmologist 2 2 - 2

D346. Orthopaedician 1 1 - 1

D347. Microbiologist 1 1 - 1

D348. Dental Surgeon 2 1 1 2 General Physician 2 2 - 2 T B Specialist 1 1 - 1 Blood Bank MO 1 1 - 1 Forensic Specialist 1 1 - 1 Deputy Chief MO 3 3 - 3 District Surgeon 1 1 - 1

Para-Medicals Sanctioned Regular

In Position

Contractual In Position

Total

D349. Staff Nurse 64 56 - 56

D350. Hospital worker (OP/ward +OT+ blood bank)

130 71 - 71

D351. Sanitary Worker - - - Included in Q 350

D352. Ophthalmic Assistant / Refractionist

2 2 - 2

D353. Social Worker / Counselor 1 1 - 1

D354. ECG Technician - - - -

D355. Audiometrician - - - -

46



D356. Laboratory Technician ( Lab + Blood Bank)

8 7 - 7

D357. Laboratory Attendant (Hospital Worker)

Included in q 350

D358. Dietician - - - -

D359. ANM 4 4 - 4

D360. LHV 3 3 - 3

D361. PHN - - - -

D362. Radiographer 1 1 - 1

D363. Pharmacist 9 5 - 5

D364. Matron 1 - - 0

D365. Physiotherapist 1 - - 0

D366. Medical Records Officer / Technician

- - - -

Sr. Staff Nurse 8 5 - 5 Administrative Staff

D367. Manager (Administration) - - - -

D368. Junior Administrative Officer 2 1 - 1

D369. Office Superintendent 2 2 - 2

D370. Accounts Manager - - - -

D371. Driver 8 6 - 6

D372. Peon

- - - Included in Q 350

Block D. Other Framework and Structure Related Issues (Information to be collected from the

Office of Medical Superintendent of the Hospital)


D373. Whether the Rogi Kalyan Samiti established for the Hospital

Yes……………….….1 v No…………………..2

>Q D382

D374. If Yes, whether Rogi Kalyan Samiti Registered for the Hospital?

Yes…………….…….1v No…………………..2

47

Block D. Other Framework and Structure Related Issues (Information to be collected from the

Office of Medical Superintendent of the Hospital)

D375. Are there any official charges for consultation/ procedures?

Yes…………….…….1v No…………………..2

>Q D378

D376. If yes, are people belonging to BPL/ SC/ ST exempted/ subsidized?

Yes………….……….1v No…………………..2

>Q D378

D377. If yes, what is the procedure for granting exemption (Encircle all applicable options)

Based on BPL Ration Card……………………A v Based on Certification by hospital authorities/ Govt.……………………...B v Based on recommendation of RKS………………………C Based on Financial compensation by RKS……………..…..……D Others (please specify) based on treating doctor recommendation.…..…… E v

D378. How do RKS generate additional

resources other than govt. grants? (Encircle all applicable options)

Donation…………….……A User fees…………..……..B v Other innovative means (through arrangements like PPP, outsourcing of services etc.) (Private nurse Collage)……………………C v

D379. How is the money generated used? (Encircle all applicable options)

Retained within the facility for local use…..……..…A v Retained but not used….....B Transferred to district Accounts………….…….C Other …………….……..D

D380. Is display board put up in Hospital showing number of members, number of meetings of RKS etc?

Yes……………….….1 No…………………..2 v

D381. How feedback is taken for grievance

redressal by RKS (ARS)?

Social Audit………..…..A v Public Scrutiny of action taken …………………...………..B No feedback mechanism .....C Others (please specify)…....D

D382. Any Other Special Ward/ Procedures not covered above Nil

D383. Any other remarks by MS of the hospital/ Other members which have not been captured in the questions above but are relevant

48

Nil

D384. Any other remarks or suggestions for improvement of services by Observer which have not been captured in the questions above but are relevant

• Some of the data are not available (as per the requirement) or poorly maintained in each departments

• The hospital should be equipped with computer facilities for information management

• The importance must be given to ma intain and update the statistics in each department.

If the patient has availed service either in (OPD or IPD) the observer to go to Exit

Interview Schedule D D M M Y Y

1 7 1 2 0 8 P Prabhuswamy C Yogananda

Date Name of the Investigator Signature of the Investigator

49

Chapter 3

Community Health Centre

Introduction

Health care delivery in India operates at three levels, namely, primary, secondary and

tertiary. The primary level of healthcare includes Primary Health Centres (PHCs) and

Sub-Centres (SCs), the secondary level includes Community Health Centres (CHCs) and

district hospitals. CHCs are designed to provide referral health services for cases from the

primary level and for cases in need of specialist care. According to the norm, there should

be one CHC for four PHCs and a CHC catering approximately 1, 20, 000 population in

plain areas and 80, 000 population in tribal/hilly areas. CHC, in general is a 30 bedded

hospital providing specialist care in Medicine, Obstetrics, Gynaecology, Paediatrics and

Surgery.

Since the provision of quality round the clock referral care at CHC level is an

important strategic intervention under NRH, the NRHM envisages bringing up CHC

services to the level of Indian Public Health Standards (IPHS). Not only the system

requires up-gradation to handle higher patients load, but also the emphasis needs to be

given for quality of care to increase the level of patients’ satisfaction. IPHS is a novel

concept to fix bench marks in infrastructure including building, man power, equipments,

drugs and quality assurance through the introduction of treatment protocols. The IPHS

will also provide a yard- stick to measure the services being provided.

The Objectives of the Indian Public Health Standards for CHCs are

• to provide optimal expert care to the community;

• to achieve and maintain an acceptable standard of quality of care; and

• to make services more responsive and sensitive to the needs of the community

CHC versus Taluka Hospitals

This chapter of the study aims to look at the compliance of CHCs to the IPHS standards.

In Karnataka all the districts do not have CHCs but the Taluka hospitals which are

located at the taluka headquarters which are considered equivalent to CHCs as each

50

Taluka hospital has a Taluka Health Officer who looks after the functioning of PHCs in

their jurisdiction. Taluka hospital serves a smaller population and has good infrastructure

created earlier with the World Bank assistance. A survey was conducted in two such

Taluka Hospitals (CHCs) in Hassan district of Karnataka to evaluate the facilities

available at the CHCs in order to understand how far these CHCs have adhered to the

IPHS. Certain minimum requirements have been prescribed by NRHM to CHCs in order

to be in compliance with the IPHS standards. In this chapter, an attempt has been made

to evaluate the existing facilities at the CHCs vis-à-vis the prescribed norms. Two

selected CHCs are Arsikere which is farthest from the district head quarters and

Sakleshpur which is nearer to the District Headquarters.


Coverage of Population and the Location of the Centre

According to the NRHM guidelines, a CHC should have 30 indoor beds with one

operation theatre, labour room, x ray facility and laboratory facility. In order to provide

these facilities, certain guidelines have been indicated on various infrastructural facilities

available at the CHCs such as location of the centre, outpatient department, treatment

room, wards, patient area, operation theatre/labour rooms and infrastructure for support

services (Ministry of Health and Family Welfare, 2007). We have compared the existing

facilities with the prescribed standards in each of these two CHCs to understand whether

these CHCs are able to adhere to the IPHS standards.

Table C-1 presents the data on coverage and availability of infrastructure which

includes the details of coverage of population and distance from PHCs, entrance zone,

service availability and information on outpatient department. This data indicate that the

coverage of population is much lower than the expected population 120, 000 to be

covered by a CHC. That may be mainly because these two surveyed CHCs are basically

Taluka level hospitals and therefore, not strictly adhering to the population norm kept for

a conventional CHC. The first CHC covers a population of only 25,200 and the second

one covers a population of 46, 188. The details of the location of the CHC indicate that

both the CHCs are centrally located with a minimum of 15 minutes to reach to the closest

PHC and a maximum of 75 to 120 minutes to reach the farthest PHC. Since these CHCs

51

are Taluka level hospitals, they are supposed to be located at the Taluka headquarters.

Both the CHCs have nearly 100 to 150 beds for both male and female occupancy.

Entrance Zone

As per the IPHS, the entrance zone of the CHC should have registration counters,

pharmacy, clean public utilities for both males and females and suggestion and complaint

boxes for the patients and visitors. The data on these indicators show that at both the

CHCs there are the following items: registration counter, public utilities for males and

females and a complaint/suggestion box, indicating that these CHCs have adhered to the

basic requirements as suggested by the IPHS (Table C-1).

Table C-1: Coverage and Availability of Infrastructure

Availability of Infrastructure

Coverage CHC1 Sakleshpur

CHC2 Arsikere

Population Served by the CHC Numbers 25,200 46,188 Nearest PHC Coverage Area Distance 10 8 Nearest PHC Coverage Area: Time 15 15 Farthest PHC Coverage Area: Distance 40 45 Farthest PHC Coverage Area: Time 120 75 District Hospital Area: Distance 39 50 District Hospital Area: Time 75 90 No of Beds: Male 54 50 No of Beds: Female 96 50 Status of Building Own Government Building 1 1 Rented Premises - - Other Rent:Free Building - - Electricity in all parts: No Regular electricity supply - - Regular electricity supply in all parts 1 1 30 or more beds Yes 1 1 No - - Generator Yes 1 1 No - -

Cont...

52


Coverage CHC1

Sakleshpur CHC2

Arsikere Telephone Yes 1 1 No - - Computer Yes 1 1 No - - Internet Connection Yes - 1 No 1 - Running Vechicle/Ambulance Yes 1 1 No - - Laboratory Yes 1 1 No - - ECG Facilities Yes - 1 No 1 - X Ray Facilties Yes 1 1 No - - Ultrasound Facilities Yes 1 1 No - - Operation Theatre Yes 1 1 No - - OT used for Gynaecology Yes 1 1 No - - Labour Room Available Yes 1 1 No - - Separate Areas for Septic and Aseptic Deliveries Yes 1 1 No - - New Born Care Corner Yes 1 1 No - - JSY Benficiaries Maintained in Record Yes 1 1 No - - Pharmacy for Drug Dispensing and Drug Storage Yes 1 1 No - -

Cont..

53


CHC1

Sakleshpur CHC2

Arsikere Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines Yes 1 1 No - - Separate Public Utilities (Toilets) for Males and Females Yes 1 1 No - - Suggestion / Complaint Box Yes 1 1 No - - OPD Rooms / Cubicles Yes 1 1 No - - Waiting Room for Patients Yes 1 1 No - - Waiting Room have Adequate Sitting Place Yes 1 1 No - - Drinking Water Available in the Waiting Area Yes - 1 No 1 - Emergency Room / Casualty Yes 1 1 No - - Separate Wards for Males and Females Yes 1 1 No - - Type of Sewerage System Soak Pit - - Open Drain - - Connected to Municipal Sewerage 1 1 Other - - Waste Material is Being Disposed Buried in a Pit - - Collected by an Agency 1 1 Incernation - - Thrown in Open - -

Cont…

54


CHC

CHC1 Sakleshpur

CHC2 Arsikere

Status of Cleanliness of OPD Good - - Fair 1 1 Poor - - Status of Cleanliness of Compound /Premises Good - - Fair 1 1 Poor - - Status of Cleanliness of Room / Wards Good - - Fair 1 1 Poor - - Prominent Display Boards Regarding Service Available in Local Language Yes 1 1 No - - JSY Benficiaries Maintained in Record Yes 1 1 No - - Pharmacy for Drug Dispensing and Drug Storage Yes 1 1 No - - Counter Near Entrance of CHC to Obtain Contraceptives, ORS Packets, Vitamin A and Medicines Yes 1 1 No - -

Service Availability

In general, the service availability data show that certain services are available in both the

CHCs like laboratory, X-ray and Ultrasound facilities, operation theatre, labour room

with separate areas of aseptic and septic deliveries, new born care corner and a pharmacy.

There are certain other facilities like ECG which is available in Arsikere but not in

Sakleshpur. The CHCs also has other amenities like ambulance, telephone, and computer.

Internet connection is also available in Arsikere CHC but not in Sakleshpura CHC. On

the whole, the data on service availability show that both the CHCs had nearly adhered to

the minimum requirement laid out in the IPHS standards.

55

Out -Patient Department

As per the IPHS guidelines, OPD should have the following items

• Clinics for various medical disciplines like general medicine, surgery, dental

obstetrics and gynecology. Separate cubicles for general medicine, surgery

and internal examination. The cubicles should have the required furniture like

doctors table, chair, patients stool, wash basin, equipment for examination etc,

• Rooms should be adequately ventilated with fans and lights.

• There should be a family welfare clinic

• Waiting room for patients

• Drug dispensary

• Emergency room and casualty

The data on the details of the out-patients department in these two CHCs indicate that

most of the required facilities mentioned above are present in the CHCs surveyed except

that one of the CHCs does not have drinking water facility near the waiting area.

Manpower Position

Table C2 presents the data on the position of medical, paramedical and support staff. As

per the IPHS guidelines, a CHC should have a general surgeon, physician, obstetritian

and gynaecologist, paediatrician, anaesthetist, public health programme manager and an

eye surgeon. Apart from these, the support manpower like nurse/midwife, dresser,

pharmacist, lab technicians, radiographer, ophthalmic assistant, ward boys, sweepers,

chawkidar, OPD attendant, data entry operator, OT attendant and a registration clerk are

required for the effective delivery of services.

Data on the position of medical staff in these two CHCs show (Table C2) that in

both the CHCs, surgeons, physicians, obstetricians/gynecologists and pediatricians are

sectioned and are in position. However, anesthetists and eye surgeons are available only

in Arsikere CHC but not in Sakleshpura CHC. Therefore, there is an urgent need to fill

these posts in Sakleshpura CHC to develop that CHC up to the standards set by IPHS.

56

Table C-2: Position of Medical Staff and Paramedical Staff

Numbers in Position Type of Staff CHC1

Sakleshpur CHC2

Arsikere General Surgeon:Sanctioned Numbers 1 1 General Surgeon:Regular in Position Numbers 1 1 General Surgeon:Contractual Recruited Numbers - - General Surgeon:Total in Position Numbers 1 1 Physician:Sanctioned Numbers 1 1 Physician:Regular in Position Numbers 1 1 Physician:Contractual Recruited Numbers - - Physician:Total in Position Numbers 1 1 Obstertrician / Gynaecologist:Sanctioned Numbers 1 2 Obstertrician / Gynaecologist:Regular in Position Numbers 1 2 Obstertrician / Gynaecologist:Contractual Recruited Numbers - - Obstertrician / Gynaecologist:Total in Position Numbers 1 2

Numbers in Position

Type of Staff

CHC1 Sakleshpur

CHC2 Arsikere

Medical Officer Trained with Short Term Obstetrics Course: Sanctioned Numbers 1 - Medical Officer Trained with Short Term Obstetrics Course: Regular in Position Numbers 1 - Medical Officer Trained with Short Term Obstetrics Course: Contractual Recruited Numbers - - Medical Officer Trained with Short Term Obstetrics Course: Total in Position Numbers 1 - Paediatrician: Sanctioned Numbers 1 1 Paediatrician: Regular in Position Numbers 1 1 Paediatrician: Contractual Recruited Numbers - - Paediatrician: Total in Position

57

Numbers 1 1 Anaesthetist:Sanctioned Numbers - 1 Anaesthetist: Regular in Position Numbers - 1 Anaesthetist: Contractual Recruited Numbers - - Anaesthetist: Total in Position Numbers - 1 Medical Officer Trained with Short Term Anesthesia Course: Sanctioned Numbers - - Medical Officer Trained with Short Term Anesthesia Course: Regular in Position Numbers - - Medical Officer Trained with Short Term Anesthesia Course: Contractual Recruited Numbers - - Medical Officer Trained with Short Term Anesthesia Course: Total in Position Numbers - - General Duty Medical Officer: Sanctioned Numbers 1 - General Duty Medical Officer:Regular in Position Numbers - - General Duty Medical Officer:Contractual Recruited Numbers 1 - General Duty Medical Officer:Total in Position Numbers 1 -

Eye Surgeon:Sanctioned Numbers 1 1 Eye Surgeon:Regular in Position Numbers - 1 Eye Surgeon:Contractual Recruited Numbers - - Eye Surgeon:Total in Position Numbers - 1 Public Health Nurse:Sanctioned Numbers - - Public Health Nurse:Regular in Position Numbers - - Public Health Nurse:Contractual Recruited Numbers - - Public Health Nurse:Total in Position Numbers - -

58


Type of Staff CHC1

Sakleshpur CHC2

Arsikere Lady Health Visitor (LHV):Sanctioned Numbers - - Lady Health Visitor (LHV):Regular in Position Numbers - - Lady Health Visitor (LHV):Contractual Recruited Numbers - - Lady Health Visitor (LHV):Total in Position Numbers - - Block Extension Educator (BEE):Sanctioned Numbers - - Block Extension Educator (BEE):Regular in Position Numbers - - Block Extension Educator (BEE):Contractual Recruited Numbers - - Block Extension Educator (BEE):Total in Position Numbers - - ANM:Sanctioned Numbers 3 3 ANM:Regular in Position Numbers 3 3 ANM:Contractual Recruited Numbers - - ANM:Total in Position Numbers 3 3 Staff Nurse:Sanctioned Numbers 12 20 Staff Nurse:Regular in Position Numbers 12 10 Staff Nurse:Contractual Recruited Numbers - 3 Staff Nurse:Total in Position Numbers 12 13 Dresser:Sanctioned Numbers 33 - Dresser:Regular in Position Numbers 26 - Dresser:Contractual Recruited Numbers - - Dresser:Total in Position Numbers 26 - Pharmacist / Compounder:Sanctioned Numbers 3 3 Pharmacist / Compounder:Regular in Position Numbers 2 2 Pharmacist / Compounder:Contractual Recruited Numbers - - Pharmacist / Compounder:Total in Position Numbers 1 2

59

Lab Technician: Sanctioned Numbers 2 2 Lab_ Technician: Regular in Position Numbers 2 1 Lab_Technician: Contractual Recruited Numbers - - Lab_Technician: Total in Position Numbers 2 1 Radiographer: Sanctioned Numbers - 1 Radiographer: Regular in Position Numbers - 1 Radiographer: Contractual Recruited Numbers - - Radiographer: Total in Position Numbers - 1 Ophthalmic Assistant: Sanctioned Numbers - - Ophthalmic Assistant: Regular in Position Numbers - - Ophthalmic Assistant: Contractual Recruited Numbers - - Ophthalmic Assistant: Total in Position Numbers - - Statistical Assistant / Data Entry Operator: Sanctioned Numbers - - Statistical Assistant / Data Entry Operator: Regular in Position Numbers - - Statistical Assistant / Data Entry Operator: Contractual Recruited Numbers - - Statistical Assistant / Data Entry Operator: Total in Position Numbers - -

60


CHC

CHC1 Sakleshpur

CHC2 Arsikere

OT Attendant:Sanctioned Numbers - - OT Attendant:Regular in Position Numbers - - OT Attendant:Contractual Recruited Numbers - - OT Attendant:Total in Position Numbers - - Ambulance Driver:Sanctioned Numbers 2 1 Ambulance Driver:Regular in Position Numbers 2 - Ambulance Driver:Contractual Recruited Numbers 2 2 Ambulance Driver:Total in Position Numbers 4 2 Registration Clerk:Sanctioned Numbers - - Registration Clerk:Regular in Position Numbers - - Registration Clerk:Contractual Recruited Numbers - - Registration Clerk:Total in Position Numbers - -

The position of different paramedical staff sanctioned and in position indicates

that, in general, there is a shortage of paramedical staff in both the CHCs (Table C-2).

The different categories of staff who are not in position in these two CHCs are lady

health visitor, Block Extension educator, radiographer, ophthalmic assistant, data entry

operator, OT attendant, ambulance driver and registration clerk. All these categories of

staff are neither sanctioned nor in position. ANMs and Staff nurses are in position in both

the CHCs. However, Arsikere CHC had a vacancy of nearly 50 percent of the post of

staff nurses. Further, both CHCs did not have dressers.

61

Availability and Use of Specific Services at CHC

Tables C-3 and C-13 provide information on the availability of specific services at

the CHCs. While strengthening the community health centres for the first referral care,

NRHM ensured certain specific services to be provided through CHCs. The data on the

availability of these specific services (Table C-3) indicate that both the CHCs have been

able to provide most of the specialized services. Services that are not available in both the

CHCs are AYUSH services and blood storage facility. Although revitalising local health

traditions through mainstreaming AYUSH was one of the main strategies under NRHM,

both the CHCs have not been provided with AYUSH services.

Table C-3: Availability of Specific Services in CHC

Availability of Specific Services CHC1

Sakleshpur CHC2

Arsikere Functioning on 24 x 7 Basis Yes 1 1 No - - Functioning as FRU Yes 1 1 No - - Emergency Care for Sick Children Yes 1 1 No - - Full Range of Family Planning Services Yes 1 1 No - - AYUSH Services Yes - - No 1 1 VCTC Yes 1 1 No - - Catatact Surgery Yes - 1 No 1 - Treatment of STI/RTI Yes 1 1 No - - Dots Yes 1 1 No - -

62

Data on other specific services (Table C-13) indicate that most of the specific services are

available in both the CHCs. The services which are not available in both the CHCs are

mobile medical unit and blood storage facility. Cataract surgery is not available in CHC 1

but it is available in CHC 2. Similarly, neonatal care unit was available in CHC1 but not

in CHC 2. Overall, CHCs surveyed have been ensured with the provision of specific

services.

The major criticisms on the utility of public health services have been the non use

of the available facilities in spite of ensuring the service availability. Table C-13 provides

data on the usage of services mainly on ANC care, details of JSY beneficiaries,

institutional deliveries and child immunization details. The table shows that most of these

services have been utilized by the beneficiaries. The CHC records have shown large

number of ANC cases registered and various ANC services have also provided to

women. Cases are also registered under Janani Suraksha Yogana. The data on

institutional deliveries show that a majority of the institutional delivery cases were JSY

cases. The data on children’s immunization also show that child care services have also

been used by the beneficiaries. The data on bed occupancy rate and OPD attendance rate

also support that the facilities at the CHC are utilized by the people.

Status of Specific Interventions

Table C-4 provides information on the status of specific interventions in these two

surveyed CHCs. The table shows that most of the specific interventions such as

transferring of funds electronically from the district, formation of Aarogya Raksh Samitis

(ARS) etc have been implemented in both the CHCs. However, a facility survey was not

conducted in either the CHCs to understand whether the CHCs are in compliance with the

IPHS standards or not. Further, feed back mechanisms are also not in place for grievances

redressed by ARSs.

63

Table C-4: Status of Specific Interventions

CHC1

Sakleshpur CHC2

Arsikere IPHS Facility Survey been Carried out Yes - - No 1 1 Funds Being Electronically Transferred from District Yes 1 1 No - - Registered Rogi Kalyan Samiti Yes 1 1 No - - RKS Generate Resources: User Fees Yes 1 1 No - - Money generated by RKS being used Yes 1 1 No - - Display board showing no. of meetings & members of RKS Yes 1 1 No - - Feedback mechanism in place for grievances redressed by RKS Yes - - No 1 1 Citizen Charter Been Publically Displayed Yes 1 1 No - - All Standard Treatment Guidelines and Protocols Available Yes 1 1 No - -

Residential Facilities for Doctors and Other Staff

Functioning of any government health facility depends mainly on the availability of

doctors and other staff. In order to make the staff available, the hospitals are supposed to

provide residential facility to their staff so that the CHC can function on 24X7 basis.

Provision of facility alone may not make the doctor available in the hospital for 24 hours

service because most of the studies conducted earlier have reported that a majority of the

64

staff quarters remain vacant because the staffs are not interested in occupying the

residential quarters provided to them. The data on the status of residential facilities for

doctors and other staff have been presented in Table C-5. This table shows that not only

both the CHCs have residential facilities for doctors and other staff but the quarters

provided have also been occupied by them.

Table C-5: Status of Residential Facilities for Doctors and Other Staff

CHC1

Sakleshpur CHC2

Arsikere Residential Facility for Doctors Yes 1 1 No - - Non-Occupied Residential Quaters Yes - - No 1 1 Main Reasons for Non: Occupancy: Dilapidated Condition Yes - - No - - Main Reasons for Non: Occupancy: Insecurity Yes - - No - - Main Reasons for Non: Occupancy: Lack of Electricity and Water Supply Yes - - No - - Residential Facility for other staff Yes 1 1 No - - Non-Occupied Residential Quarters Yes - - No 1 1

Availability and Usage of Laboratory Facilities

Data on the availability and usage of laboratory facilities have been presented in Tables

C-6 and C-7. The Table shows that laboratory facilities available at the CHCs are for

testing blood grouping, hemoglobin, bleeding and clotting time, blood sugar, malaria

parasite, urine test, rapid test for pregnancy and rapid test for HIV. The tests for RTI/STIs

and RPR test for Syphilis are not available in these two CHCs.

Data on usage of these facilities indicate that the laboratory facilities available at

the CHCs have also been utilized by the beneficiaries. Table C-7 presents the data on the

65

number of different lab tests done during the last 3 calendar months in these two CHCs.

The data show that a large number of different types of tests have been carried out in

these two CHCs indicating the maximum usage of the facilities provided.

Data on the number of surgeries (Table C-8) carried out during 2007-08 also

show that the different surgical facilities available at the CHCs had been used by the

people. The maximum number of surgeries performed in these two CHCs is laparoscopic

sterilization. Since surgeries were carried out in both the CHCs, the reasons for not

conducting surgeries given in Table C-9 are not applicable.

Table C-6: Availability of Laboratory Facilities

Laboratory Testing CHC1

Sakleshpur CHC2

Arsikere Blood Grouping Yes 1 1 No - - Hemoglobin Yes 1 1 No - - Bleeding Time Clotting Time Yes 1 1 No - - RTI/STIs Yes 1 - No - 1 Blood Sugar Yes 1 1 No - - Malaria Parasite Yes 1 1 No - - Urine Test Yes 1 1 No - - Rapid Test for Pregnancy Yes 1 1 No - - RPR Test for Syphilis Yes - - No 1 1 Rapid Test for HIV Yes 1 1 No - - Blood Smear: Yes 1 1 No - -

66

Table C7: Number of Lab. tests done in CHC in last 3 calendar months

Type of tests done CHC1

Sakleshpur CHC2

Arsikere Hemoglobin Numbers 1,300 634 Blood Sugar Numbers 540 524 Blood Grouping Numbers 489 217 Blood Smear Numbers 419 776 Bleeding Time Clotting Time Numbers 516 322 RTI/STIs Numbers 566 - Malaria Parasite Numbers 1,500 776 Rapid Test for Pregnancy Numbers 440 245 RPR Test for Syphilis Numbers - - Rapid Test for HIV Numbers 1,662 718 Urine Test Numbers 1,240 2,027

Table C-8: Number of surgeries performed during 2007-2008

Type of surgeries CHC1

Sakleshpur CHC2

Arsikere Caesarean Sections Numbers 12 205 No of C Section Deliveries for JSY Numbers 17 194 Surgical Cases Numbers 47 193 Cataract Numbers 5 95 Tubectomy Numbers 13 27 Laproscopic Sterlisation Numbers 683 849 NSV Numbers 7 8 Conventional Vasectomy Numbers - - MTP Numbers - 51 Laprotomy Numbers - -

67

Table C-9: Reasons for not conducting surgeries

CHC1

Sakleshpur CHC2

Arsikere Non availability of doctor/anaesthetist/staff

Yes - - No 1 - Lack of equipment/poor physical state of the operation theatre Yes - - No 1 - No power supply in the OT Yes - - No 1 - Other Yes - - No 1 -

Usage of Labour Room

Data on the usage of labour room during 2007-2008 has been presented in Table C-10.

This table shows that deliveries were conducted in both the CHCs during 2007-08. The

data on deliveries carried out between 8 pm and 8 am also indicate the usage of 24X7

services at the CHCs.

A large number of deliveries for JSY card holders were also carried out in these two

CHCs. Since deliveries were carried out in both the CHCs the reasons for not conducting

deliveries given in Table C-11 is not applicable

Table C-10: Status of performance of Labour Room during 2007-2008

CHC1

Sakleshpur CHC2

Arsikere Total Institutional Deliveries Numbers 738 1,383 Deliveries Carried Out from 8.PM to 8 AM Numbers 372 423 Institutional Deliveries for JSY Card Holders Numbers 116 1,314 No of Neonates Resuscitated Numbers 12 412

68

Table C-11: Reasons for not conducting deliveries

CHC1

Sakleshpur CHC2

Arsikere Non availability of doctor / anaesthetist/staff Yes - - No - - Poor condition of the labour room Yes - - No - - No power supply in the labour room Yes - - No - -

Status of Availability of Equipments and Drugs

In order to understand the status of availability of equipments at the CHCs, questions

were posed to each of the CHC representatives that whether a particular instrument is

available in the CHC and if available is it in a working condition. Many facility surveys

conducted earlier have pointed out that merely providing an equipment does not

necessarily ensure the usage. It is also essential to know whether the equipment supplied

is in working condition or not. Table C-12 presents the details of availability of

equipments and drugs in these two CHCs.

Table C-12: Status of Availability of Equipments & Drags

CHC1

Sakleshpur CHC2

Arsikere Boyles Apparatus : Available Yes 1 1 No - - Boyles Apparatus : Working Yes 1 1 No - - ECG Machine : Available Yes 1 1 No - - ECG Machine : Working Yes - 1 No 1 - Cardiac Monitor for OT : Available Yes - - No 1 1 Cardiac Monitor for OT : Working Yes - - No - -

Cont…

69

Defibrillator for OT : Available Yes - - No 1 1 Defibrillator for OT : Working Yes - - No - - Ventilator for OT : Available Yes - - No 1 1 Ventilator for OT : Working Yes - - No - - Horizontal High Pressure Sterilizer : Available Yes 1 1 No - - Horizontal High Pressure Sterilizer : Working Yes - 1 No 1 - Vertical High Pressure Sterilzer : Available Yes 1 1 No - - Vertical High Pressure Sterilzer: Working Yes 1 1 No - - OT Care Fumigation Apparatus : Available Yes 1 1 No - - OT Care Fumigation Apparatus: Working Yes 1 1 No - - Gloves Dusting Machines : Available Yes 1 1 No - - Gloves Dusting Machines: Working Yes 1 1 No - - Oxygen Cylinder : Available Yes 1 1 No - - Oxygen Cylinder: Working Yes 1 1 No - -

Cont..

70

Table C-12: Status of availability of Equipments & Drags

CHC1

Sakleshpur CHC2

Arsikere Hydraulic Operation Table : Available Yes 1 1 No - - Hydraulic Operation Table: Working Yes 1 1 No - - Resuscitation Trolley : Available Yes - - No 1 1 Resuscitation Trolley: Working Yes - - No - - Phototherpy Unit : Available Yes 1 1 No - - Phototherpy Unit: Working Yes 1 1 No - - MVA Syringe : Available Yes - - No 1 1 MVA Syringe: Working Yes - - No - - Baby Incubator : Available Yes 1 - No - 1 Baby Incubator: Working Yes 1 - No - -

Cont..

71

Table C-12: Status of Availability of Equipments & Drags

CHC1

Sakleshpur CHC2

Arsikere Iron Folic Acid :Stock Out Yes 1 1 No - - Iron Folic Acid: Irregular Supply Yes 1 - No - 1 Oral Pills : Stock Out Yes 1 1 No - - Oral Pills: Irregular Supply Yes - - No 1 1 IUD 380 : Stock Out Yes 1 1 No - - IUD 380: Irregular Supply Yes - - No 1 1 ORS : Stock Out Yes - 1 No 1 - ORS : Irregular Supply Yes 1 - No - 1 ORS with Zinc Adjutant as Per Policy : Stock Out Yes 1 - No - 1 ORS with Zinc Adjutant as Per Policy : Irregular Supply Yes - 1 No 1 - Vitamin A : Stock Out Yes - 1 No 1 - Vitamin A : Irregular Supply Yes 1 - No - 1 Tab Fluconazole : Stock Out Yes - - No 1 1 Tab Fluconazole : Irregular Supply Yes 1 1 No - - Tab Metronidazole : Stock Out Yes 1 1 No - - Tab Metronidazole : Irregular Supply Yes - - No 1 1

72

Cont… Tab Co Trimoxazole : Stock Out Yes 1 1 No - - Tab Co Trimoxazole : Irregular Supply Yes - - No 1 1 Tab Nefidipine : Stock Out Yes - - No 1 1 Tab Nefidipine : Irregular Supply Yes 1 1 No - -

Table C-12: Status of availability of Equipments & drags

CHC1

Sakleshpur CHC2

Arsikere Inj Oxytocin : Stock Out Yes - 1 No 1 - Inj Oxytocin : Irregular Supply Yes 1 - No - 1 Inj Gentamycin : Stock Out Yes 1 1 No - - Inj Gentamycin : Irregular Supply Yes - - No 1 1 Inj Magnesium Sulphate : Stock Out Yes - - No 1 1 Inj Magnesium Sulphate : Irregular Supply Yes 1 1 No - - Tab Misoprostal : Stock Out Yes - - No 1 1 Tab Misoprostal : Irregular Supply Yes 1 1 No - - Tab Progestrone : Stock Out Yes - 1 No 1 - Tab Progestrone : Irregular Supply Yes 1 - No - 1 Inj Lignocaine Hydrochloride : Stock Out Yes 1 1 No - -

Cont...

73

Inj Lignocaine Hydrochloride : Irregular Supply Yes - - No 1 1 Inj Pentazocine Lactate : Stock Out Yes 1 1 No - - Inj Pentazocine Lactate : Irregular Supply Yes - - No 1 1 Inj Adrenaline : Stock Out Yes - 1 No 1 - Inj Adrenaline : Irregular Supply Yes 1 - No - 1 Cap Doxycycline : Stock Out Yes 1 1 No - - Cap Doxycycline : Irruegular Supply Yes - - No 1 1 Silver Sulphadiazine Oint :Stock Out Yes 1 1 No - - Silver Sulphadiazine Oint : Irregular Supply Yes - - No 1 1 IV Fluids : Stock Out Yes 1 1 No - - IV Fluids : Irregular Supply Yes - - No 1 1 Inj Prociane Penicillin : Stock Out Yes 1 1 No - - Inj Prociane Penicillin : Irregular Supply Yes - - No 1 1

Cont....

74

Table C-12: Status of availability of Equipments & drags

CHC1

Sakleshpur CHC2

Arsikere Inj Atropine : Stock Out Yes - 1 No 1 - Inj Atropine : Irregular Supply Yes 1 - No - 1 Syp Amoxycyclin : Stock Out Yes - - No 1 1 Syp Amoxycyclin : Irregular Supply Yes 1 1 No - - IFA Syrup : Irregular Supply Yes - - No 1 1 IFA Syrup : Stock Out Yes 1 1 No - -

The data show that most of the equipments listed are available and functioning in these

two CHCs. Certain equipments like cardiac monitor, defibrillator and ventilator for OT,

resuscitation trolley and MVA syringes are not available in both the CHCs. The baby

incubator is not available in CHC2 but is available in CHC1. Certain other equipment

like ECG monitor is available in both the CHCs but it is not in a working condition in

CHC1. Overall, the data show that majority of the equipments listed are present and in

working condition. However, efforts are needed to ensure that all the required equipments

are provided to the CHCs and all are in good working condition.

Supply of drugs in each of the CHCs were ensured by asking whether any of the

drugs were out of stock in the last 6 months and whether there was irregular supply in the

last 6 months. Data on the supply of drugs have been presented in Table C12. Overall, the

table indicates that there is a problem with the supply of drugs. Most of the prophylactic

and preventive drugs like IFA, ORS, Vit A etc were either out of stock or had irregular

supply. The supply was also not satisfactory for family planning items like IUD and oral

pills. The supply was also poor in other general drugs like magnesium sulphate, in

75

Lingnocaine Hydrochloride etc. Hence there is an urgent need to improve the supply of

drugs in the CHCs so that necessary drugs are available for the treatment.

Table C-13: Availability of Specific Services

CHC1 Sakleshpur

CHC2 Arsikere

Medicine Yes 1 1 No - - Surgery Yes 1 1 No - - Obstetric Gynae Yes 1 1 No - - Pediatrics Yes 1 1 No - - Dots Yes 1 1 No - - Catatact Surgery Yes - 1 No 1 - Leprosy Diagnosis Management and Referral Services Yes 1 1 No - - Emergency Services (24 Hrs) Yes 1 1 No - - Mobile Medical Unit Yes - - No 1 1 Separate Neo Natal Care Unit Available Yes 1 - No - 1 Emergency Care for Sick Children Yes 1 1 No - - Full Range of Family Planning Services Including Laprosopic Ligation Yes 1 1 No - - Safe Abortion Services Yes 1 1 No - -

Cont…

76

Treatment of STI/RTI Yes 1 1 No - - Blood Storage Facility Yes - - No 1 1 Counseling Facility on HIV / AIDS / STD etc Yes 1 1 No - - Voluntary Counselling and Testing Centre Yes 1 1 No - - AYUSH Facility Yes - - No 1 1 Primary Management of Wounds Yes 1 1 No - - Primary Management Feacture Yes 1 1 No - - Primary Management of Cases of Posioning Snake Insect or Scorpion Bite Yes 1 1 No - - Primary Management of Dog Bite Yes 1 1 No - - Primary Management of Burns Yes 1 1 No - - Management of RTI/STI Yes 1 1 No - -

Service Outcome

The service outcome data pertaining to the maternal and child health indicators have been

presented in Table C-14. Overall, the data show that the people are making use of the

available facilities. Antenatal registration has been carried out in both the CHCs and

majority of the ANC cases are JSY cases. Data on other components of antenatal

checkups like women receiving TT, IFA etc also indicate the usage of these facilities.

The data on child care services also show that children received different vaccines and

Vitamin A drops. Both the CHCs also had any indoor patients.

77

Table C-14: Service out come

CHC1

Sakleshpur CHC2

Arsikere Total ANC Registration:SC Numbers 3 6 Total ANC Registration:ST Numbers 1 1 Total ANC Registration:Others Numbers 24 18 Total ANC Registration:Total Numbers 27 26 Total JSY Cases Registration:SC Numbers 2 6 Total JSY Cases Registration:ST Numbers 1 1 Total JSY Cases Registration:Others Numbers 12 18 Total JSY Cases Registration:Total Numbers 15 26 1st Trimester Registration:SC Numbers 1 3 1st Trimester Registration:ST Numbers 1 * 1st Trimester Registration:Others Numbers 10 8 1st Trimester Registration:Total Numbers 11 12 ANC Given 3 Checkups as Per RCH Schedule:SC Numbers 1 4 ANC Given 3 Checkups as Per RCH Schedule:ST Numbers 1 1 ANC Given 3 Checkups as Per RCH Schedule:Others Numbers 21 12 ANC Given 3 Checkups as Per RCH Schedule:Total Numbers 23 16 Out of Above the No of JSY Beneficiaries:SC Numbers 1 4 Out of Above the No of JSY Beneficiaries:ST Numbers 1 1 Out of Above the No of JSY Beneficiaries:Others Numbers 8 12 Out of Above the No of JSY Beneficiaries:Total Numbers 10 16

78

ANC Given TT :SC Numbers 3 5 ANC Given TT:ST Numbers 2 1 ANC Given TT:Others Numbers 24 13 ANC Given TT:Total Numbers 29 19

Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which values is :Not avilable/Not applicable


CHC1

Sakleshpur CHC2

Arsikere No of JSY Beneficiaries :SC Numbers 1 5 No of JSY Beneficiaries:ST Numbers 2 1 No of JSY Beneficiaries:Others Numbers 12 13 No of JSY Beneficiaries:Total Numbers 15 19 ANC Completed IFA Prophylaxis :SC Numbers - - ANC Completed IFA Prophylaxis:ST Numbers - - ANC Completed IFA Prophylaxis:Others Numbers - - ANC Completed IFA Prophylaxis:Total Numbers - - Out of No of JSY Beneficiaries :SC Numbers - - Out of No of JSY Beneficiaries:ST Numbers - - Out of No of JSY Beneficiaries:Others Numbers - - Out of No of JSY Beneficiaries:Total Numbers - - No of Pregnant Women Identified and Attended with Obstetric Complications :SC Numbers * 2 No of Pregnant Women Identified and Attended with Obstetric Complications:ST Numbers - 1 No of Pregnant Women Identified and Attended with Obstetric Complications:Others Numbers 3 10 No of Pregnant Women Identified and Attended with Obstetric Complications:Total Numbers 3 13

79

How Many have Been Referred from PHC / SHC :SC Numbers - - How Many have Been Referred from PHC / SHC:ST Numbers - - How Many have Been Referred from PHC / SHC:Others Numbers - - How Many have Been Referred from PHC / SHC:Total Numbers - - Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which

values is :Not avilable/Not applicable


CHC1

Sakleshpur CHC2

Arsikere Total Institutional Deliveries:SC Numbers 14 10 Total Institutional Deliveries:ST Numbers 2 3 Total Institutional Deliveries:Others Numbers 55 107 Total Institutional Deliveries:Total Numbers 71 120 No of JSY Cases (Out of Total Institutional Deliveries):SC Numbers - 10 No of JSY Cases (Out of Total Institutional Deliveries):ST Numbers - 3 No of JSY Cases (Out of Total Institutional Deliveries):Others Numbers - 101 No of JSY Cases (Out of Total Institutional Deliveries):Total Numbers - 115 No of Infants Given BCG:SC Numbers 5 7 No of Infants Given BCG:ST Numbers 3 2 No of Infants Given BCG:Others Numbers 25 29 No of Infants Given BCG:Total Numbers 34 37 No of Infants Given DPT3:SC Numbers 4 4 No of Infants Given DPT3:ST Numbers 1 *

80

No of Infants Given DPT3:Others Numbers 25 14 No of Infants Given DPT3:Total Numbers 30 18 No of Infants Given Measles:SC Numbers 5 6 No of Infants Given Measles:ST Numbers 2 1 No of Infants Given Measles:Others Numbers 27 19 No of Infants Given Measles:Total Numbers 34 26 No of Infants Given Vit A First Dose:SC Numbers 4 6 No of Infants Given Vit A First Dose:ST Numbers 1 1 No of Infants Given Vit A First Dose:Others Numbers 25 19 No of Infants Given Vit A First Dose:Total Numbers 30 26 Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which



CHC1

Sakleshpur CHC2

Arsikere Children Given IFA Syp:SC Numbers 7 - Children Given IFA Syp:ST Numbers 2 - Children Given IFA Syp:Others Numbers 12 - Children Given IFA Syp:Total Numbers 21 - IUD Inserted:SC Numbers 1 2 IUD Inserted:ST Numbers - 1 IUD Inserted:Others Numbers 12 13 IUD Inserted:Total Numbers 12 16 Total Indoor Patients:SC Numbers 127 103 Total Indoor Patients:ST Numbers 15 30 Total Indoor Patients:Others Numbers 212 427 Total Indoor Patients:Total

81

Numbers 353 559 No of Cases Referred Beyond CHC:SC Numbers 28 - No of Cases Referred Beyond CHC:ST Numbers 3 - No of Cases Referred Beyond CHC:Others Numbers 38 - No of Cases Referred Beyond CHC:Total Numbers 70 33,333 No of Leprosy Cases Currently Under Treatment CHC:SC Numbers - - No of Leprosy Cases Currently Under Treatment:ST Numbers - - No of Leprosy Cases Currently Under Treatment:Others Numbers - - No of Leprosy Cases Currently Under Treatment:Total Numbers - - No of New TB Cases Enrolled For Dots:SC Numbers 1 - No of New TB Cases Enrolled For Dots:ST Numbers - - No of New TB Cases Enrolled For Dots:Others Numbers 3 3 No of New TB Cases Enrolled For Dots:Total Numbers 3 3 Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which


Table C14. Service Outcome

CHC1

Sakleshpur CHC2

Arsikere No of Cases Given Blood Transfusion in Last 3 Months Numbers - - Bed Occupancy Rate in the Last 12 Months Rate 17 19 OPD Attendance Male Average 43 32 OPD Attendance Female Average 48 34 OPD Attendance Children Average 18 19 Out of the Total OPD Attendance Specify the Referred Cases from PHC / SHC Average 8 3,333 Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which values is :Not avilable/Not applicable

82

Summary

Overall, the survey shows that in terms of infrastructure and service availability, the

CHCs are mostly in compliance with the IPHS standards. However, the manpower

position statistics indicate a short fall of support staff. The supply of drugs also needs to

be improved in CHCs. Although revitalising local health traditions through

mainstreaming AYUSH was one of the main strategies under NRHM, the AYUSH

services were totally absent in the CHCs

83

Chapter 4

Primary Health Centre

Introduction

Primary health care is universally recognized as the most effective intervention to achieve

significant improvements in health status of the population. Subsequent to the National

Health Policy, which was adopted in 1983, the health infrastructure was reorganised to

universalise primary health care. The progress in establishing the three-tier system of

primary health care in terms of establishing sub centres, primary health centres and

community health centres are expected to help the rural mass in availing the required

services in health. The Primary Health Centres (PHC) are the cornerstone of rural health

service system. A typical primary health centre covers a population of 30,000 in plain

areas and 20,000 in hilly or tribal areas with 4-6 indoor/observation beds. It acts as a

referral unit for 6 sub-centres and it also refers cases to CHCs and other tertiary care

public hospitals located in the district.

In order to provide optimal level of quality health care, under NRHM, a set of

standards have been recommended for primary health centres to be called as Indian

Public Health Standards (IPHS) for PHCs. The IPHS for primary health centres has been

prepared keeping in view the resources available with respect to functional requirement

for PHCs with minimum standards such as building, manpower, instruments and

equipments, drugs and other facilities. The major aim of these standards is to underpin

the delivery of quality services that are fair and responsive to client’s needs and to

provided equitably and which deliver improvements in the health and wellbeing of the

population. These standards will be used for monitoring the progress of health care

delivery in PHCs.

The objectives of the Indian Public Health Standards for PHCs are:

• to provide comprehensive primary health care to the community through primary

health centres;

• to achieve and maintain an acceptable standard of quality of care; and

84

• to make the services more responsive and sensitive to the needs of the

community.

This chapter aims to look at the compliance of PHCs to the Indian Public Health

standards. Certain minimum requirements have been prescribed under NRHM for PHCs

in compliance with the IPHS standards. In this chapter is aimed at evaluating the existing

facilities at the PHCs vis-à-vis the prescribed norms. The survey was conducted in two

PHCs from each of the CHCs: one located near the main road and the other one located at

the interior, thus the total PHC covered is four. Out of the four selected PHCs two belong

to Malnad, that is, Ballupet (PHC 1 of CHC I) and Uchangy PHC (PHC2 of CHC 1) and

the other two belong to plain, that is, Haranahally (PHC 1of CHC 2) and Hiresadarahally

PHC (PHC 2 of CHC 2)


Coverage of Population and the Location of the Centre

The IPHS for PHCs specifies certain guidelines for the location of the PHC. As per the

guideline the PHC should be located in an easily accessible area (Ministry of Health and

Family Welfare, 2007). The building should have a prominent board displaying the name

of the Centre in the local language. The area chosen should have the facility for

electricity, all weather road communication, adequate water supply and telephone.

Table P-1 provides the details of coverage and facilities of the PHC. The number

of Sub-centres attached to each of these four PHCc varie between 5-9. The population

covered in these four PHCs also varie with a wide range of 9,000 to 37,000. The nearest

sub-centre in these four PHCs lie in the range of 2-7 Kilometres and the farthest sub

centre lie in a range of 8-16 Kilometres. Out of the four PHCs selected 2 PHCs

functioning as 24X7(PHC Ballupet and Harnahally). Three out of four PHCs have been

provided with 4-10 indoor beds.

85

Table P-1: Coverage and facilities of Primary Health Centre

CHC1 CHC2 Coverage and facilities PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Number of SC Under the PHC Numbers 6 5 9 5 Population Covered Numbers 18,862 9,098 37,132 12,400 Nearest SC in the Coverage Area: Distance 5 7 6 2 Nearest SC in the Coverage Area: Time 10 20 15 10 Farthest SC in the Coverage Area: Distance 16 18 16 8 Farthest SC in the Coverage Area: Time 60 40 45 25 Nearest CHC : Distance 12 43 10 28 Nearest CHC: Time 30 120 15 75 No of Beds : Male 2 5 2 - No of Beds : Female 2 5 4 - PHC Functioning on 24 x 7 Basis Yes 1 - 1 - No - 1 - 1 PHC Equipped to Provide Basic Obstetric Services Yes 1 1 1 - No - - - 1 PHC with 4-6 Beds Yes 1 - 1 - No - - - -

86

Table P-2: Primary Health Centres by Infrastructure

CHC1 CHC2 Infrastructure PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally PHC functioning in Designated govt Building Yes 1 1 1 1 No - - - - Labour Room Yes 1 1 1 - No - - - 1 Prominent Display Boards Regarding Service Availability in Local Language Yes - 1 1 1 No 1 - - - Names of JSY Beneficiaries Maintained in Record Yes 1 1 1 1 No - - - - Pharmacy for Drug Dispensing and Drug Storage Yes 1 1 1 1 No - - - - Separate Public Utilities for Males and Females Yes - - 1 1 No 1 1 - - Suggestion / Complaint Box Yes - 1 - 1 No 1 - 1 - OPD Rooms / Cubicles Yes 1 1 1 1 No - - - - Piped water supply Yes - 1 1 - No 1 - - 1 No Regular electricity Yes 1 - - - No - 1 1 1 Regular Electric Supply in all Parts Yes - 1 1 1 No 1 - - - Telephone Yes 1 1 1 1 No - - - - Computer Yes - - - - No 1 1 1 1 Internet Yes - - - - No 1 1 - 1

87

Availability of Infrastructure

Table P-2, which provides data on the infrastructure at the PHCs., shows that all the

selected PHCs are functioning in the designated government building. All the PHCs had

maintained records of JSY beneficiaries, had pharmacy, cubicles for OPD room,

telephone and computer. Although distance was not a reason for the presence of labour

room, Hiresadarahalli PHCs which is the farthest PHC of CHC 2 did not have labour

room. In spite of being 24X7 PHC, PHC Ballupet did not have display boards regarding

service availability in local language and piped water supply. Separate public utilities for

males and females were not present in both the PHCs of CHC1. Facilities like suggestion

and complaint box, piped water supply, regular electricity supply and internet

connections were also not available in all the four PHCs. Overall, the data on

infrastructural facilities indicate the need for improvement of the facilities at the PHCs to

be in compliance with the IPHS standards.

The data on the type of existing sewage system in the PHCs show that, in general,

PHCs in Hassan district have a poor sewage system. Except in Haranahally PHC, all

other PHCs have an open drain system. In all the PHCs waste material is buried in a pit.

Cleanliness of various facilities like OPD, compound premises and room/wards are rated

as either good or fair.

Table P-2: Primary Health Centres by Infrastructure

CHC1 CHC2 Infrastructure PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Type of Sewerage System Soak Pit - - 1 - Connected to Municipal Sewerage - - - - Open Drain 1 1 - 1 Other - - - - How Waste Material is Being Disposed Buried in a Pit 1 1 1 1 Collected by an Agency - - - - Incernation - - - - Thrown in Open - - - - Standby Facility Available Yes - - 1 - No 1 1 - 1

88

Separate Areas for Septic and Aseptic Deliveries Available Yes - 1 - - No 1 - 1 - New Born Care Available Yes - - - - No 1 1 1 - Status of Cleanliness of OPD Good - 1 1 - Fair 1 - - 1 Poor - - - - Status of Cleanliness of Compound / Premises Good - 1 1 - Fair 1 - - 1 Poor - - - - Status of Cleanliness of Room / Wards Good - - 1 - Fair 1 1 - 1 Poor - - - - Manpower Position

As per the IPHS guidelines for the PHCs, provisions have been made for about 24-25

staff on various categories at each PHCs. The data on the staff position in Table P-3

indicate that, in general, the availability of clinical staff is much better than the

availability of support staff in all the four PHCs. Although mainstreaming AYUSH was

one of the strategic interventions under NRHM, all the four PHCs did not have an

AYUSH medical Office. There are shortages in nearly all categories of support staff like

staff nurse, lady health visitor, lab assistant, block education and information officer and

statistical assistant. Surprisingly the staff shortage is felt even in 24X7 PHCs. Hence

there is an urgent need fill the required posts in PHCs so that they can function efficiently

under NRHM.

89

Table P-3: Staff Position of in Primary Health Centre

CHC1 CHC2 Type of Staff PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Medical Officer : Sanctioned 1 1 2 1 Medical Officer : Regular in Position - 1 1 - Medical Officer : Contractual Recruited - - - 1 Medical Officer : Total in Position 1 1 1 1 Pharmacist : Sanctioned 1 1 1 1 Pharmacist : Regular in Position 1 - 1 1 Pharmacist : Contractual Recruited - - - - Pharmacist : Total in Position 1 - 1 1 Nurses : Sanctioned - - 3 - Nurses : Regular in Position - - - - Nurses : Contractual Recruited - - 3 - Nurses : Total in Position - - 3 - ANM : Sanctioned 6 5 9 5 ANM : Regular in Position 3 1 8 5 ANM : Contractual Recruited 3 4 1 - ANM : Total in Position 6 5 9 5 Lab Technician : Sanctioned 1 1 1 1 Lab Technician : Regular in Position 1 1 1 1 Lab Technician : Contractual Recruited - - - - Lab Technician : Total in Position 1 1 1 1 Driver : Sanctioned 1 - 1 - Driver : Regular in Position 1 - - - Driver : Contractual Recruited - - - - Driver : Total in Position 1 - - -

90

Table P-3: Staff Position of in Primary Health Centre

CHC1 CHC2 Type of Staff PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Medical Officer AYUSH : Sanctioned - - - - Medical Officer AYUSH : Regular in Position - - - - Medical Officer AYUSH : Contractual Recruited - - - - Medical Officer AYUSH : Total in Position - - - - Staff Nurse : Sanctioned 3 1 - - Staff Nurse : Regular in Position 1 1 - - Staff Nurse : Contractual Recruited 2 - - - Staff Nurse: Total in Position 3 1 - - Lady Health Visitor : Sanctioned 1 - 1 - Lady Health Visitor : Regular in Position - - 1 - Lady Health Visitor : Contractual Recruited - - - - Lady Health Visitor: Total in Position - - 1 - Lab Assistant : Sanctioned - - - - Lab Assistant : Regular in Position - - - - Lab Assistant : Contractual Recruited - - - - Lab Assistant: Total in Position - - - - Block Health Education and Information Officer : Sanctioned - - 1 - Block Health Education and Information Officer : Regular in Position - - 1 - Block Health Education and Information Officer : Contractual Recruited - - - - Block Health Education and Information Officer: Total in Position - - 1 -

Cont…

91

Statistical Assistant : Sanctioned - - - - Statistical Assistant : Regular in Position - - - - Statistical Assistant : Contractual Recruited - - - - Statistical Assistant: Total in Position - - - -

Manpower Training

Training is an integral component under the NRHM guidelines. In order to ensure

quality, the provision of periodic skill development training to the staff of the PHC in

their various job responsibilities is envisaged. Table P-4 provides the status of training of

personnel in the PHCs. The data show that none of the PHC personnel had undergone the

required skill up-gradation training. Unless the existing personnel are trained they will

not be able to deliver quality services. Hence, there is a necessity to impart training

urgently in view of the changes taking place in the public health system with the

implementation of NRHM.

Table P- 4: Status of training of personnel at Primary Health Centre

PHC having personnel trained CHC1 CHC2 Training

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally

PHC2 Hirisadarahally

Pre Service IMNCI Yes - - - - No 1 1 1 1 Safe Abortion Methods Yes - - - - No 1 1 1 1 Skill Birth Attendant Training Yes 1 - - - No - 1 1 1 New Born Care Yes - - - - No 1 1 1 1 Availability and Usage of of Labour Rooms

Provision of labour room in PHCs is an important step towards increasing institutional

deliveries. Table P-5 provides the data on the availability of labour rooms in the selected

92

Primary Health Centres. Out of the four PHCs selected, 3 PHCs had labour rooms. The

labour room in one of the PHCs is not in use mainly because of the non availability of

lady medical officer doctor or female staff nurse. Functioning labour rooms are present

only in Ballupet and Haranahally which are 24X7 PHCs. Data on various components of

delivery related indicators presented in Table P6 confirm the usage of labour rooms in

both Ballupet and Harenahally PHCs. This finding indicates that one of the strategies to

improve the institutional deliveries could be the provision of labour rooms in all the

PHCs with a lady medical officer. The table also show that a large number of deliveries

are conducted between 8pm and 8am in those 24X7 PHCs indicating the need for round

the clock services. The proportion of institutional deliveries for JSY card holders are also

substantial in these two PHCs.

Table P-5: Availability of Labour Room in Primary Health Centre

CHC1 CHC2

Labour Room PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Availability of Labour Room Yes 1 1 1 - No - - - 1 Labour Room Currently in Use Yes 1 - 1 - No - 1 - - Reasons for Deliveries Not Conducting in Labour Room: Non Availability of Doctors / Staff Yes - 1 - - No - - - - Poor Condition of the Labour Room Yes - - - - No - 1 - - No Power Supply in the Labour Room Yes - - - - No - 1 - - Other Yes - - - - No - 1 - -

93

Table P- 6: Status of performance of Labour Room during 2007-2008

Number of deliveries performed in PHC CHC1 CHC2 Number of Deliveries

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Total Institutional Deliveries Numbers 50 - 181 - Deliveries Carried Out from 8 Pm to 8 Am Numbers 28 - 58 - Institutional Deliveries for JSY Card Holders Numbers 36 - 181 - No of Neonates Resuscitated Numbers - - 13 - Availability and Use of Laboratory Services

Provision of essential laboratory services is also an integral component under NRHM.

According to IPHS guidelines the essential laboratory services required at the PHCs are

i. routine urine, stool and blood tests;

ii. bleeding time, clotting time;

iii. diagnosis of RTI/ STDs with wet mounting, Grams stain, etc.;

iv. sputum testing for tuberculosis (if designated as a microscopy center under RNTCP);

v. blood smear examination for malarial parasite;

vi. rapid tests for pregnancy / malaria;

vii. RPR test for Syphilis/YAWS surveillance;

viii. rapid diagnostic tests for Typhoid (Typhi Dot);

ix. rapid test kit for fecal contamination of water;

x. estimation of chlorine level of water using ortho-toludine reagent;

Table P-7 provides the data on availability of laboratory testing in the PHCs. Facilities

for haemoglobin testing and blood smear examination for malaria parasites are the only

available facilities in all the four PHCs. None of the PHCs had facilities for bleeding

time/clotting time, diagnosis for RTI/STI s, RPR test for Syphilis and Rapid test for HIV.

The data on the usage of these facilities (Table P-8) indicate that wherever the facility is

available people made use of it.

94

Table P-7: Availability of Laboratory Testing in PHC

CHC1 CHC2

Availability Laboratory Testing PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Haemoglobin Yes 1 1 1 1 No - - - - Urine RE Yes 1 1 - 1 No - - 1 - Blood Sugar Yes 1 - - - No - 1 1 1 Blood Grouping Yes 1 1 - - No - - 1 1 Blood Smear Yes - 1 1 - No 1 - - 1 Bleeding Time, Clotting Time Yes - - - - No 1 1 1 1 Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc Yes - - - - No 1 1 1 1 Blood Smear Examination for Malaria Parasite Yes 1 1 1 1 No - - - - Rapid Test for Pregnancy Yes - 1 1 - No 1 - - 1 RPR Test for Syphilis Yes - - - - No 1 1 1 1 Rapid Test for HIV Yes - - - - No 1 1 1 1

95

Table P- 8: Number of tests done in PHC in last three calendar months

Number of tests done in last 3 calendar months CHC1 CHC2 Type of Test

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Haemoglobin Number 25 47 22 15 Urine RE Number 41 40 - 30 Blood Sugar Number 7 - - - Blood Grouping Number 8 23 - - Blood Smear Number - 498 641 - Bleeding Time, Clotting Time Number - - - - Diagnosis of RTI / STIs with Wet Mounting, Grams Stain Etc Number - - - - Blood Smear Examination for Malaria Parasite Number 922 - - 1,416 Rapid Test for Pregnancy Number - 43 - - RPR Test for Syphilis Number - - - - Rapid Test for HIV Number - - - - Status of Specific Interventions

Several specific interventions have been introduced under NRHM to promote better

health delivery system through public health facilities. The major interventions are the

promotion of 24X7 PHC to provide round the clock services to people, formation of Rogi

Kalyan Samiti’s for hospital management within the overall Panchayati Raj framework

and mainstreaming AYUSH for revitalizing local health traditions. Further, to make the

system more transparent, a charter of citizens health rights should be prominently

displayed outside the health facility. This charter should include services to be given to

the citizens and their rights in that regard, information regarding grants received,

medicines and vaccines in stock etc. will also be exhibited. This transparency will help

the community to better monitor the health services.

96

Table P-9 provides data on the specific interventions in these four selected PHCs. The

table shows that in all the four PHCs the IPHS facility survey has not been conducted.

Out of the four PHCs, Ballupet and Haranahalli are 24X7 PHCs. Although

mainstreaming AYUSH is one of the core strategies under NRHM, services of AYUSH

doctor has not been provided in any of the four selected PHCs. Except in one, Aarogya

Raksha Samiti’s are not yet formed in other PHCs. Although the role of Rogi Kalyan

Samitis are very important in decentralizing the ehalth system, it is yet to get activated in

Hassan district. Furthe,r the display of Citizens Charter is also not followed up in two of

the selected PHCs. However, the standard guidelines and protocols are available in all the

four PHCs.

Other specific interventions such as facility for primary management of wounds,

dog bites and burns are available in all the four PHCs. But other services such as

management of fracture, management of malnourished children, management of

snakebites are not available in all the four PHCs. Facility for MPT is available only in

one of the four selected PHCs. Overall, the data show that as on the day of the survey,

most of the specific interventions are not put in place. Hence, there is a need to introduce

these specific interventions in all the PHCs so that the PHCs are able to provide quality

services as visualized in the NRHM.

Table P-9: Status of specific Interventions

CHC1 CHC2

Status of Specific Interventions PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally IPHS Facility Survey done Yes - - - - No 1 1 1 1 PHC Functioning on 24 x 7 Basis Yes 1 - 1 - No - 1 - 1 AYUSH Doctor Providing Services Yes - - - - No 1 1 1 1 Registered Rogi Kalyan Samiti Yes 1 - - - No - - - 1

Cont…

97

RKS generating resources through user fees Yes - - - - No 1 - - 1 Money generated by RKS being used Yes 1 - - 1 No - - - - Display board showing no.of meetings & members of RKS Yes - - - - No 1 - - 1 Citizen Charter Publically Displayed Yes 1 - 1 - No - 1 - 1 All Standard Treatment Guidelines and Protocols Available Yes 1 1 1 - No - - - 1 Feedback mechansim in place for grievances redressed by RKS Yes 1 - - - No - 1 1 1

Cont…

Table P-9: Status of specific Intervention

CHC1 CHC2 Status of Specific Interventions PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Primary Management of Wounds Yes 1 1 1 1 No - - - - Primary Management Fracture Yes - - - 1 No 1 1 1 - Management of Neonatal Asphyxia,sepsis Yes - - - - No 1 1 1 1 Management of Malnourished Children Yes 1 1 - - No - - 1 1 Minor Surgeries Like Draining of Abscess etc Yes 1 1 - 1 No - - 1 -

Cont…

98

Primary Management of Cases of Poisoning / Snake Insect or Scorpion Bite

Yes 1 - 1 1 No - 1 - - Primary Management of Dog Bite Cases

Yes 1 1 1 1 No - - - - Primary Management of Burns Yes 1 1 1 1 No - - - - Facility for MTP Available Yes - - 1 - No 1 1 - 1 Management of RTI/STI Yes 1 - 1 1 No - 1 - - AYUSH Services Yes - - - - No 1 1 1 1 Availability of Specific Equipments and Drugs

Out of the 23 equipments listed only 5 are available and in working condition in all the

four PHCs. These are the basic equipment like examination table, delivery table,

thermometer, haoemoglobinometre and microscope. Other equipment such as patient

trolley, autoclave, suction apparatus, bag and mask and suction mask are available in

three out of four PHCs. Certain other equipment such as infant warmer, radiant warmer,

cradle, oxygen mask, and auto analyzer are not available in any of the four PHCs. In

general Table P-10 shows that there is a shortfall in the supply of equipment which needs

to be rectified.

The status of availability of drugs has been shown in Table P-11. This table

provides two indicators on the availability of drugs; whether any drug at any time is out

of stock in the last six months and whether the supply of drug is irregular in the last six

months. Out of the 24 drugs listed nearly 50 per cent of the drugs are out of stock some

time in the last 6 months in all the four selected PHCs indicating a huge gap in the supply

of essential drugs to the PHCs. A majority of the drugs which are sometime out of stock

in the last 6 months are related to maternal and child health programmes like the IFA

99

tablets, Oral Pills, vitamin A, measles vaccine, ORS and IUDs. Since the primary

objective of the NRHM is to improve the maternal and child health conditions, the

programme has to ensure the supply of necessary drugs. The other types of drugs which

were out of stock are antibiotics, drugs relating to treatment of TB etc. Many of these

drugs are also irregular in supply in most of the PHCs. Overall the tables show that the

supply of equipments and drugs needs a thorough revamping at the PHC level.

Table P-10: Availability of selected equipments in PHC

CHC1 CHC2 Equipments available/ working

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Patient Trolley:Available Yes 1 1 1 - No - - - 1 Patient Trolley:Working Yes 1 1 1 - No - - - - Exaimination Table:Available Yes 1 1 1 1 No - - - - Exaimination Table:Working Yes 1 1 1 1 No - - - - Delivery Table:Available Yes 1 1 1 1 No - - - - Delivery Table:Working Yes 1 1 1 1 No - - - - Wheel Chair:Available Yes - 1 1 - No 1 - - 1 Wheel Chair:Working Yes - 1 1 - No - - - - Stretcher / Trolley:Available Yes - 1 - - No 1 - 1 1 Stretcher / Trolley:Working Yes - 1 - - No - - - - Oxygen Cylinder:Available Yes - - - - No 1 1 1 1 Oxygen Cylinder:Working Yes - - - - No - - - -

Cont.....

100

Table P-10: Availability of selected equipments in PHC

CHC1 CHC2 Equipments available/ working PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Suction Apparatus:Available Yes 1 1 1 - No - - - 1 Suction Apparatus:Working Yes 1 1 1 - No - - - - Infant Warmer:Available Yes - - - - No 1 1 1 1 Infant Warmer:Working Yes - - - - No - - - - Radiant Warmer:Available Yes - - - - No 1 1 1 1 Radiant Warmer:Working Yes - - - - No - - - - Cradle:Available Yes - - - - No 1 1 1 1 Cradle:Working Yes - - - - No - - - - Autoclave:Available Yes 1 1 1 - No - - - 1 Autoclave:Working Yes 1 1 - - No - - 1 - Sterlisation Equipment:Available Yes - 1 1 - No 1 - - 1 Sterlisation Equipment:Working Yes - 1 - - No - - 1 - Bag and Mask:Available Yes 1 1 1 - No - - - 1 Bag and Mask:Working Yes 1 1 1 - No - - - - Laryngoscope:Available Yes - 1 - - No 1 - 1 1 Laryngoscope:Working Yes - 1 - - No - - - -

Cont…

101

Oxygen Mask:Available Yes - - - - No 1 1 1 1 Oxygen Mask:Working Yes - - - - No - - - - Thermometer:Available Yes 1 1 1 1 No - - - - Thermometer:Working Yes 1 1 1 1 No - - - - Suction Machine:Available Yes 1 1 1 - No - - - 1 Suction Machine:Working Yes 1 1 - - No - - 1 - Water Purifier:Available Yes - 1 - - No 1 - 1 1 Water Purifier:Working Yes - 1 - - No - - - - Microscope:Available Yes 1 1 1 1 No - - - - Microscope:Working Yes 1 1 1 1 No - - - - Haemoglobinometer:Available Yes 1 1 1 1 No - - - - Haemoglobinometer:Working Yes 1 1 1 1 No - - - - Auto Analyser:Available Yes - - - - No 1 1 1 1 Auto Analyser:Working Yes - - - - No - - - - Autoclave:Available Yes 1 1 1 - No - - - 1 Autoclave:Working Yes 1 1 - - No - - 1 - Resucitation Equipment:Available Yes - 1 - - No 1 - 1 1 Resucitation Equipment:Working Yes - 1 - - No - - - -

102

Table P-11: Status of Availability of Drugs

Type of Drugs PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


IFA Tablets:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - IFA Tablets:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Iron Syrup:Stock Out in Last 6 Months Yes - - - - No 1 1 1 1 Iron Syrup:Irregular in Last 6 Months Yes 1 1 - 1 No - - - - Oral Pills:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Oral Pills:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Vitamin A:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Vitamin A:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Measles Vaccine:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Measles Vaccine:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 ORS:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - ORS:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Tab Maethergin:Stock Out in Last 6 Months Yes - 1 - 1 No 1 - 1 -

103

Tab Maethergin:Irregular in Last 6 Months Yes 1 - - - No - 1 - 1 Tab Albendazole / Mabendazole:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Tab Albendazole / Mabendazole:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 IUDs:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - IUDs:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Inj Oxytocin:Stock Out in Last 6 Months Yes - 1 1 1 No 1 - - - Inj Oxytocin:Irregular in Last 6 Months Yes 1 - - - No - 1 1 1 Magnesium Sulphate:Stock Out in Last 6 Months Yes - 1 - - No 1 - 1 1 Magnesium Sulphate:Irregular in Last 6 Months Yes 1 - - 1 No - 1 - -

Cont........

104


CHC1 CHC2 Type of Drugs PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Tab Fluconazole:Stock Out in Last 6 Months Yes 1 1 - 1 No - - 1 - Tab Fluconazole:Irregular in Last 6 Months Yes - - - - No 1 1 - 1 Partograph:Stock Out in Last 6 Months Yes - - 1 1 No 1 - - - Partograph:Irregular in Last 6 Months Yes - - 1 - No - - - 1 MVA Syringe:Stock Out in Last 6 Months Yes 1 1 - - No - - 1 1 MVA Syringe:Irregular in Last 6 Months Yes - - - - No 1 1 - - Tab Ciprofloxacin:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Tab Ciprofloxacin:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Syp Cotrimoxazole:Stock Out in Last 6 Months Total 1 1 1 1 Yes 1 1 1 - No - - - 1 Syp Cotrimoxazole:Irregular in Last 6 Months Yes - - 1 1 No 1 1 - - Syp Paracetamol:Stock Out in Last 6 Months Yes - 1 1 - No 1 - - 1 Syp Paracetamol:Irregular in Last 6 Months Yes - - 1 1 No - 1 - -

105

Ringers Lactate:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Ringers Lactate:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Haemoccele:Stock Out in Last 6 Months Yes - 1 - - No 1 - 1 1 Haemoccele:Irregular in Last 6 Months Yes 1 - - 1 No - 1 - - AD Syringes:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - AD Syringes:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Disposable Gloves:Stock Out in Last 6 Months Yes 1 1 - 1 No - - 1 - Disposable Gloves:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 Bandages:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - -

Cont....

106


CHC1 CHC2 Type of Drugs PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Bandages:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 AYUSH Drugs:Stock Out in Last 6 Months Yes - - - - No 1 - 1 1 AYUSH Drugs:Irregular in Last 6 Months Yes - - - - No - - 1 - Dots Drugs:Stock Out in Last 6 Months Yes 1 1 1 1 No - - - - Dots Drugs:Irregular in Last 6 Months Yes - - 1 - No 1 1 - 1 MDT Drugs Blister Packs:Stock Out in Last 6 Months Yes - 1 1 - No 1 - - - MDT Drugs Blister Packs:Irregular in Last 6 Months Yes - 1 1 - No - - - - Service Outcomes

The service outcome data relating to the maternal and child health indicators have been

presented in Table P12. Overall, the data show that the people are making use of the

available facilities. Antenatal registration has been carried out in all the four PHCs and a

majority of the ANC cases are JSY cases. Data on other components of antenatal

checkups like women receiving TT, IFA etc also indicate the usage of these facilities in

the four PHCs. The data on child care services also show that children received different

vaccines and Vitamin A drops. The data on family planning services also indicate that

people do come to PHC for different services such as insertion of IU and female

sterilization in all the four PHCs. However, male sterilisation was carried out only in

107

Ballupet PHC. None of the PHCs had any indoor patients in the last three months. The

PHCs are also used for other kind of services like cataract surgery, TB treatment etc.

Table P-12: Service Outcome (based on data for last three months)

CHC1 CHC2 Indicator

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Total ANC Registration : SC 1 1 1 1 Total ANC Registration : ST 1 - - 1 Total ANC Registration : Others 15 10 32 9 Total ANC Registration : Total 31 10 50 12 Total JSY Case Registered : SC 10 * 15 1 Total JSY Case Registered : ST 1 - - 1 Total JSY Case Registered : Others 7 6 29 8 Total JSY Case Registered : Total 17 6 45 11 1st Trimester Registration : SC 13 1 333 1 1st Trimester Registration : ST 1 - 333 1 1st Trimester Registration : Others 14 5 3,333 8 1st Trimester Registration : Total 28 6 33,333 10 ANC Given 3 Checkups : SC 9 1 10 1 ANC Given 3 Checkups : ST 1 - - 1 ANC Given 3 Checkups : Others 9 10 23 8 ANC Given 3 Checkups : Total 19 11 32 10 ANC Given TT1 : SC 10 1 8 1 ANC Given TT1 : ST * - - * ANC Given TT1 : Others 10 4 14 8 ANC Given TT1 : Total 20 5 23 10 Note: replace *,-,33,333,33333 which 0 because this figures represent the cases for which


108

Table P-12: Service Outcome (based on data for last three months) CHC1 CHC2

Indicator PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


ANC Given TT2+ Booster : SC 15 1 7 1 ANC Given TT2+ Booster : ST 1 - - 1 ANC Given TT2+ Booster : Others 15 7 21 12 ANC Given TT2+ Booster : Total 31 8 29 14 ANC Completed IFA Prophylaxis : SC 3 2 19 1 ANC Completed IFA Prophylaxis : ST 1 - 4 1 ANC Completed IFA Prophylaxis : Others 3 15 54 9 ANC Completed IFA Prophylaxis : Total 7 16 78 12 Total Institutional Deliveries : SC 13 - 4 1 Total Institutional Deliveries : ST 2 - - 1 Total Institutional Deliveries : Others 4 - 18 8 Total Institutional Deliveries : Total 23 - 23 10 No of JSY Cases : SC 5 1 12 1 No of JSY Cases : ST 1 - - 1 No of JSY Cases : Others 7 2 26 7 No of JSY Cases : Total 13 3 37 10 No of Infants Given BCG : SC 11 * 5 2 No of Infants Given BCG : ST 1 - - 1 No of Infants Given BCG : Others 12 7 26 11 No of Infants Given BCG : Total 24 7 32 13 No of Infants Given DPT3 : SC 3 1 7 2 No of Infants Given DPT3 : ST * - - - No of Infants Given DPT3 : Others 6 5 26 9 No of Infants Given DPT3 : Total 10 5 33 11


109

Table P-12 Service Outcome (based on data for last three months) CHC1 CHC2

Indicator PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


No of Infants Given Measles : SC 12 1 7 1 No of Infants Given Measles : ST 1 - 1 2 No of Infants Given Measles : Others 10 5 26 9 No of Infants Given Measles : Total 23 6 34 13 No of Infants Given Vit A First Dose SC 12 1 7 1 No of Infants Given Vit A First Dose : ST 1 - 1 2 No of Infants Given Vit A First Dose : Others 10 5 26 9 No of Infants Given Vit A First Dose : Total 23 6 34 13 Syp IFA : SC 333 - 333 - Syp IFA : ST 333 - 333 - Syp IFA : Others 3,333 - 3,333 - Syp IFA : Total 33,333 - 33,333 - IUD (Copper - T) Inserted : SC 4 - 5 - IUD (Copper - T) Inserted : ST - - - - IUD (Copper - T) Inserted : Others 5 - 13 5 IUD (Copper - T) Inserted : Total 9 - 18 5 Male Sterlisation Carried Out : SC 2 - - - Male Sterlisation Carried Out : ST 1 - - - Male Sterlisation Carried Out : Others 2 - - - Male Sterlisation Carried Out : Total 4 - - - Female Sterlisation Carried Out SC 4 - 5 * Female Sterlisation Carried Out : ST - - - * Female Sterlisation Carried Out : Others 3 - 11 5 Female Sterlisation Carried Out : Total 7 - 16 5


110


CHC1 CHC2 Indicator PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally Total Indoor Patients : SC 333 - - - Total Indoor Patients : ST 333 - - - Total Indoor Patients : Others 3,333 - - - Total Indoor Patients : Total 33,333 - - - Total Out Patients : SC - - - 32 Total Out Patients : ST - - - 85 Total Out Patients : Others - - - 193 Total Out Patients : Total 748 382 210 310 RTI / STI Cases Treated : SC 19 - 14 3 RTI / STI Cases Treated : ST 5 - 1 5 RTI / STI Cases Treated : Others 17 - 26 13 RTI / STI Cases Treated : Total 41 - 40 22 No of Maternal Deaths in 2007 2008 : SC 333 - - - No of Maternal Deaths in 2007 2008 : ST 333 - - * No of Maternal Deaths in 2007 2008 : Others 3,333 - - - No of Maternal Deaths in 2007 2008 : Total 33,333 - - * No of Cases of Obstetric Complications Referred Beyond PHC : SC 333 - - - No of Cases of Obstetric Complications Referred Beyond PHC : ST 333 - - - No of Cases of Obstetric Complications Referred Beyond PHC : Others 3,333 - 1 - No of Cases of Obstetric Complications Referred Beyond PHC : Total 33,333 - 1 -


111


CHC1 CHC2 Indicator PHC1

Ballupet PHC2

Uchangy PHC1

Haranahally PHC2

Hirisadarahally No of Cataract Surgeries Carried Out : SC 1 - 1 - No of Cataract Surgeries Carried Out : ST - - 1 1 No of Cataract Surgeries Carried Out : Others * - 10 3 No of Cataract Surgeries Carried Out : Total 1 - 12 4 No of New TB Cases Enrolled For Dots : SC * - 2 * No of New TB Cases Enrolled For Dots : ST - - - * No of New TB Cases Enrolled For Dots : Others - 1 1 - No of New TB Cases Enrolled For Dots : Total * 1 3 1 No of New Leprosy Cases Registered for MDT : SC - - - - No of New Leprosy Cases Registered for MDT : ST - - - - No of New Leprosy Cases Registered for MDT : Others - - - - No of New Leprosy Cases Registered for MDT : Total - - - - No of Leprosy Cases Completed Treatment for Leprosy SC - - - - No of Leprosy Cases Completed Treatment for Leprosy : ST - - - - No of Leprosy Cases Completed Treatment for Leprosy : Others - - - - No of Leprosy Cases Completed Treatment for Leprosy: Total - - - -


112

Status of Record Maintenance

For the purpose of monitoring different activities, PHCs are expected to maintain certain

registers and records. Developing proper Management Information System (MIS) is an

integral component for proper monitoring of the NRHM activites. Table P3 provides the

data on the status of record maintenance. This table shows that in all the four PHCs all

the registers listed such as antenatal register, EC register, PNC register, FP register,

immunization register, meeting register, JSY register and register for untied funds have

been maintained properly.

Table P-13: Status of record maintenance

CHC1 CHC2 Type of Records

PHC1 Ballupet

PHC2 Uchangy

PHC1 Haranahally


Ante Natal Register Yes 1 1 1 1 No - - - - Eligible Couple Register Yes 1 1 1 1 No - - - - Post Natal Care Register Yes 1 1 1 1 No - - - - Family Planning Register Yes 1 1 1 1 No - - - - Birth and Death Register Yes 1 1 1 1 No - - - - Immunisation Register Yes 1 1 1 1 No - - - - Meeting Register Yes 1 1 1 1 No - - - - JSY Register Yes 1 1 1 1 No - - - - Untied Funds Register Yes 1 1 1 1 No - - - -

113

Summary

Overall, the survey shows the need for improvement in different areas in all the four

PHCs in order to be in compliance with the IPHS standards. Although the availability of

physical infrastructure is relatively better, the data on availability of manpower and

equipments and drugs indicate a need for improvement to be in compliance with the

IPHS standards. Another area which needs strengthening is the functioning of Aarogya

Raksha Samitis for the overall hospital management which is a core activity under

NRHM. Except in one PHC, no other PHC had formed Aarogya Raksha Samitis. If ARSs

have been formed in all the PHCs, probably that might have taken care of the short fall

in drugs and equipments as they are empowered to buy the required items needed for the

PHCs.

114

Chapter 5

Sub Centres

Introduction

In the Indian public health care system, sub centres serve as the interface between the

primary health care system and the community. As per the norms there is one sub centre

for every 5000 people in the areas of the plains and one for every 3,000 people in areas

that are in hilly, tribal or desert regions. The sub centre operates as the referral linkage

between people and the Primary Health Centre (PHC), which covers a population of

20,000 to 30,000 persons, as well as the Community Health Centre (CHC), which covers

a population of 80,000 to 1,20,000 persons.

A sub centre, in its capacity as the first point of contact with the community, is

responsible for providing all primary health care services, including immunization,

pregnancy and delivery care, prevention of malnutrition and common childhood diseases,

and family planning and counseling services. At the same time, sub centres should be

able to make available elementary drugs for minor ailments such as ARI, diarrhoea,

fever, worms etc, as well as deliver government implemented national health and family

welfare programmes.

Each sub centre is staffed by one Female Health Worker, also known as Auxiliary

Nurse Midwife (ANM) and one Male Health Worker. A female health assistant known as

the Lady Health Visitor (LHV) and a male health assistant, who are in position at the

PHC, are responsible for supervising all sub centres (usually six in number) which come

under the ambit of that PHC.

Guidelines have been prepared for sub centres according to the Indian Public Health

Standards (IPHS) to ensure that quality care is provided and maintained at the primary

level by submitting to a set of standards, keeping the available resources in mind. The

main objectives of sub centres according to the IPHS is to (i) provide basic primary

health care to the community, (ii) achieve and maintain an acceptable standard of quality

of care and (iii) make the services more responsive and sensitive to the needs of the

115

community (Ministry of Health and Family Welfare, 2007). The next few sections of this

chapter describe the results of a survey which was undertaken to evaluate the current

performance of sub centres in Hassan district given the standards prescribed by the IPHS.

Sub Centre Coverage and Infrastructure

The data collected from Hassan district during the months of November and December

2008 reveal that the coverage of sub centres in Hassan District of Karnataka does, on

average, serve the prescribed population level of 3,000 to 5,000 persons. The twelve sub

centres surveyed cover an average of 9 villages each and a population of 2, 838 persons.

In terms of physical infrastructure, most of the sub centres in Hassan did not meet the

prescribed standards. The data on infrastructure, presented in Table S-2, shows that a sub

centre is functioning in a separate designated government building in only four out of

twelve sub centre villages. In the remaining sub centre villages, the sub centre is

functioning in a rented building, or in the PHC, or in one case, the construction of a

building is being planned. When the sub centre is functioning in a separate building,

generally all types of infrastructure such as labour room, water, electricity and telephone

are available, with the water coming from a piped source, and electricity being supplied

regularly. In only one of these four sub centres, namely, Bage, is the sewage carried away

through an open drain, and in only one (Hosur) is the waste material disposed by being

thrown in the open. In the remaining sub centres which are functioning in a separate

building, the sewage system is either a soak pit or a sewage line, while the waste material

is disposed off by being buried in a pit.

116

Table S-1: Sub Centres Coverage

CHC CHC CHC1 CHC2

PHC1 PHC2 PHC1 PHC2 Coverage of Sub-Centre

Heggave Bage Hebbanahally Hosur Goddu Vanagur Kudu rasthe

Haranahally (B)

Kara Gunda

Kereko Dihally

Hire sadara Hally (B)

Kyatana hally

J.C. Pura (B)

Average per Sub Centre

Population coverage 2,399 3,049 2,853 2,568 1,811 1,178 4,423 3,785 4,745 2,290 2,184 2,773 2,838.2

Number of villages covered by Sub Centre

11 16 13 2 5 2 9 6 9 3 5 6 7.25

Distance between PHC and SC (in kms)

Farthest village to Sub Centre 12.0 5.0 12.0 5.0 18.0 3.0 6.0 10.0 8.0 5.0 5.0 7.0 8.0

Sub Centre to PHC 14.0 4.0 8.0 22.0 13.0 8.0 - 4.0 12.0 - 2.0 8.0 7.9

Sub Centre to CHC 26.0 12.0 18.0 50.0 50.0 55.0 10.0 15.0 25.0 29.0 30.0 20.0 28.3

Time Taken (In minutes) to travel in public transport / available mode from

Farthest village to Sub Centre 60.0 30.0 600 10.0 40.0 45.0 10.0 20.0 15.0 15.0 15.0 20.0 28.3

117

Sub Centre to PHC 45.0 10.0 45.0 45.0 30.0 30.0 - 10.0 30.0 - 10.0 20.0 22.9

Sub Centre to CHC 75.0 30.0 60.0 75.0 75.0 80.0 22.0 30.0 60.0 50.0 60.0 30.0

53.9 No. of ASHAs working in the Sub Centre

- - - - - - - - - - - - -

Table S-2: Sub Centres Infrastructure

CHC CHC CHC1 CHC2

PHC1 PHC2 PHC1 PHC2 Availability of Infrastructure in Sub Centres (Yes:1; No:0) Heggave Bage Hebbanahally Hosur Goddu

Vanagur Kudu rasthe

Haranahally (B)

Kara Gunda

Kereko Dihally


Kyatana Hally

J.C. Pura (B)

% of Sub Centre having

respective facility

Functioning in designated government building - 1 - 1 - - 1 - - - - 1 33.3 IPHS Facility Survey Done 1 - 1 - - - - - - - - - 16.6 Labour Room - 1 - 1 - - - - - - - 1 25.0 Piped water supply - 1 - 1 - - 1 - 1 - - 1 41.66 Regular electricity supply - 1 - - - - 1 - 1 - - 1 33.3 Telephone - 1 - - - - 1 - - - - 1 25.0 Type of

118

Sewerage System Soak Pit - - - - - - 1 - - - - 1 16.6 Connected to any Sewerage Line - - - 1 - - - - - - - - 8.3 Open Drain - 1 - - - - - - 1 - - - 16.6 Waste Material is Being Disposed Buried in Pit - 1 - - - - 1 - 1 - - 1 33.3 Collected by Agency - - - - - - - - - - - - - Incernation - - - - - - - - - - - - - Thrown in Open - - - 1 - - - - - - - - 8.3

119

All four sub centres which operate in a designated government building have residential

quarters for ANMs (see Table S-3). In two of these sub centres, in Bage and J.C.Pura (B)

villages, the ANMs are residing in these quarters at the time of the survey. In Goddu and

Vanagur Kudurasthe, the ANMs stay within the sub centre village. In all, seven of the

twelve sub centres had ANMs living in a village that was diffe rent from the sub centre

village and the reasons often cited for living away from the sub centre village are security

and family related issues.

The data on infrastructure reveal a serious need for the public health system in

Hassan district to ensure that buildings are constructed for the purpose they are meant,

i.e., the proper functioning of the sub centre to provide basic primary health care services

to the local communities in the district.

Human Resources, Facilities, and Equipment

The number of staff in position at the twelve sub centres is shown in Table S-4. The data

reveal that while ANMs or female health workers are in position in most of the sub

centres, there are no male health workers in all but one of the sub centres. That is, while 9

sub centres have a female health worker in position (ANMs were in position on a contract

basis in the remaining three), only one sub centre has a male health worker in position.

120

Table S-3: Sub Centres with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre quarter

Sub Centre

CHC1 CHC2 PHC1 PHC2 PHC1 PHC2 Residential status

of ANM (Yes: 1; No:0) Heggave Bage Hebbanahalli Hosur Goddu Vanagur

Kudurasthe

Harana halli (B)

Kara Gunda

Kereko Dihalli

Hiresa Dara Halli (B)

Kyatana halli

J.C. Pura (B)

% of Sub

Centres

Sub Centre with ANM quarter - 1 - 1 - - 1 - - - - 1 33.3 Sub Centre with ANM staying in SC's quarter - 1 - - - - - - - - - 1 16.6 Sub Centre with ANM staying within SC's village - - 1 - 1 1 - - - - - - 25.0 Sub Centre with ANM staying outside SC's village 1 - - 1 - - 1 1 1 1 1 - 58.3

Cont…

121

Reason for ANM not staying in SC quarter: Quality of quarter - - - - - - - - - - - - - Family related reasons - - - - - - 1 - - - - - 8.3 Security reasons - - - 1 - - - - - - - - 8.3 Education and other facilities for children not available - - - 1 - - 1 - - - - - 16.6 Water/ Power facility not available - - - - - - - - - - - - - Own residence is nearby - - - - - - - - - - - - -

Table S-4: Sub Centres with Staff in Position

Sub Centre CHC1 CHC2

PHC1 PHC2 PHC1 PHC2 Availability of Staff (Yes: 1; No:0) Heggave Bage Hebba

nahalli Hosur Goddu Vanagur Kudurasthe

Harana halli (B)

Kara Gunda

Kereko Dihalli


Kyatana halli

J.C. Pura (B)

% of Sub Centres

with specific

staff available

Health worker male in position - - - - - - 1 - - - - - 8.3

Health worker female in position

1 1 - - 1 - 1 1 1 1 1 1 75.0

Additional ANM contractual - - 1 1 - 1 - - - - - - 25.0

122

The availability of facilities again corresponds to whether the sub centre is

operating in a government designated building or not. This data is presented in Table S-5.

There are only three sub centres which have labour rooms, Bage, Hosur and JC Pura, of

which the labour room is currently in use only in Bage. The reason cited for not using this

facility in Hosur is that the ANM does not reside there, while in JC Pura the labour room

is said to be in poor condition and as well did not have any water supply. Thus, only the

sub centre in Bage village had deliveries performed in the year 2007-08, where thirteen

deliveries had taken place in that year.

The availability and functionality of various equipment in each of the twelve sub

centres is shown in Tables S-7A and S-7B. It is apparent that basic equipment such as

Thermometer, BP Apparatus, Weighing machines, Height measuring scale, Reagent strip

for urine test and Fetoscope are most likely to be available as well as functional. At least

eight of the twelve sub centres had these equipment and they were functional in almost

all cases (in three of the sub centres, the BP Apparatus were not functional). Vanagur

Kudurasthe, Hiresadarahally and Kyathanahally were the sub centres with only up to five

of the 12 cited equipments, with Hiresadarahalli being the most poorly equipped.

Drugs and Miscellaneous Items

With regard to the availability of drugs and other medical items, the data shows that iron/

folic acid, oral pills, condoms, IUD, vitamin A, and disposable gloves are available in

almost all the sub centres, while disposable delivery kits, emergency contraceptives,

ORS, syp cotrimoxazole and syp paracetamol are less frequently available, and tab

flucanazole vaginal, tab misoprostal, partograph and tab ciprofloxacin are rarely or not at

all available (see Table S-8). Of the twelve sub centres, the one at Hosur village is the

best equipped, with fourteen of the sixteen listed items available at the time of the survey.

123

Table S-5: Availability of Labour Room in Sub Centre


PHC1 PHC2 PHC1 PHC2 Labour Room (Yes:1; No:0)

Heggave Bage Hebbana hally Hosur Goddu Vanagur

Kudurasthe Harana hally (B)

Kara Gunda

Kereko Dihalli

Hiresa Dara

Hally(B)

Kyatana hally

J.C. Pura (B)

% of Sub

Centres

Availability of Labour Room - 1 - 1 - - - - - - - 1 25.0

Labour Room currently in use - 1 - - 1 - - - - - - - 16.3

Reasons for not using Labour Room

ANM not staying - - - 1 - - - - - - - - 8.3 Poor condition - - - - - - - - 1 - - 1 16.3 No power supply - - - - - - - - - - - - - No electric supply - - - - - - - - 1 - - 1 16.3 Other - - - - - - - - - - - - -

Table S-6A: Number of deliveries performed during 2007-08

Sub Centre

CHC1 CHC2

Average delivery

conducted per Sub Centre

PHC1 PHC2 PHC1 PHC2

Heggave Bage Hebbana Hally Hosur Goddu Vanagur

Kudurasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally

Hiresa Dara

Hally (B)

Kyatana hally

J.C. Pura (B)

Total deliveries conducted - 13 - - - - - - - - - - *

124

Table S-6B: Sub-Centres with Arrangement for Deliveries


PHC1 PHC2 PHC1 PHC2 Arrangement for deliveries (Yes: 1; No:0) Heggave Bage Hebbana

hally Hosur Goddu Vanagur Kudurasthe

Harana hally (B)

Kara Gunda

Kereko Dihalli

Hiresa Dara

Hally(B)

Kyatana hally

J.C. Pura (B)

% of Sub

Centres

Deliveries conducted at Sub Centre Itself if required referred to higher facility

- 1 - - - - - - - - - - 8.3

Deliveries not conducted at Sub Centre but referred to higher facility

- - - - - - - - - - - - 0.0

Referred to Private/NGO facility

- - - - - - - - - - - - 0.0

125

Table S-7 A: Sub Centres with Availability of Equipments


PHC1 PHC2 PHC1 PHC2 Availability of the equipments (Yes: 1; No:0)

Heggave Bage Hebbana hally Hosur Goddu Vanagur

Kudurasthe

Harana hally (B)

Kara Gunda

Kereko Dihalli

Hiresa Dara Hally (B)

Kyatana hally

J.C. Pura (B)

% of Sub Centres

with equipment available

Sterliser - - 1 - - - - 1 - - - - 16.7 Haemoglobinometer 1 - - 1 1 1 1 1 - - - - 50.0 Bag & Mask 1 1 1 - - - - - - - - 1 33.3 Suction Machine - - - - - - 1 1 1 - - - 25.0 Thermometer 1 1 1 1 1 1 - - 1 1 1 1 83.3 BP Apparatus 1 1 1 - 1 1 1 1 1 - 1 1 83.3 Weighing Machine 1 1 1 1 1 1 1 1 1 - 1 1 91.7 Height Measuring Scale 1 1 1 1 - - - 1 1 1 1 - 66.6 Reagent Strip for Urine Test 1 1 1 1 - - 1 1 1 1 1 1 83.3 Cuscos Speculum - 1 - - 1 - 1 1 1 - - 1 50.0 Mucus Extractor - 1 - - 1 - - - - - - - 16.7 Fetoscope 1 1 - 1 1 1 1 1 1 - - - 66.7

126

Table S-7 B: Percentage of SCs with Functional Equipments Sub Centre

CHC1 CHC2 PHC1 PHC2 PHC1 PHC2 Functional

equipments (Yes: 1; No:0)

Heggave Bage Hebbanahally Hosur Goddu Vanagur Kudurasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally


Kyatana hally

J.C. Pura (B)

% of Sub Centres

with functional equipment

Sterliser - - 1 - - - - - - - - - 8.3 Haemoglobinometer 1 - - 1 1 1 - 1 - - - - 41.6 Bag & Mask 1 1 1 - - - - - - - - 1 33.3 Suction Machine - - - - - - 1 1 1 - - - 25.0 Thermometer 1 1 1 1 1 1 - - 1 1 1 1 83.3 BP Apparatus 1 1 1 - - 1 1 1 1 - - - 58.3 Weighing Machine 1 1 1 1 - 1 1 1 1 - 1 1 83.3 Height Measuring Scale 1 1 1 1 - - - 1 1 1 1 - 66.6 Reagent Strips for Urine Test 1 1 1 1 - - 1 1 - 1 1 1 75.0 Cuscos Speculum - 1 - - 1 - 1 1 1 - - 1 50.0 Mucus Extractor - 1 - - 1 - - - - - - - 16.6 Fetoscope 1 1 - 1 1 1 1 1 1 - - - 66.6

127

Skills and Services Available

The information on the status of the specific skills and procedures at the sub centres (in Table S-

9) shows that in general, all sub centres register pregnancies within the first three months, carry

out three ANC visits as per RCH schedule (in the 6th, 7th and 9th month) conduct specific

examinations for Blood Pressure, Haemoglobin count and Urine, provide TT, IFA etc, are able to

identify high risk pregnancies and provide immunization. On the other hand, the ANM is trained

in the syndromic treatment of RTI/STI in only half of the sub centres and in most sub centres

coming under the ambit of PHC 1 and 2 in CHC1, the ANM is not carrying out IUCD or IUD

A380 insertion or removal.

The service outcome of the sub centres for the three months prior to the date of the survey is

shown in Table S-10. An average of 14 cases of antenatal care (ANC) were registered across the

twelve sub centres during that period, with the sub centre at Kerekodihally village registering the

highest number at 25, followed by Bage and Hebbanahally with twenty each. Out of all ANCs

registered, only an average of 8.8 cases was registered in the first trimester while 7.6 were given

three ANC visits as per the RCH schedule. An average of 2 cases each were reported as high risk

cases identified in the sub centres. Only one of the sub centres, in Bage village, had deliveries

conducted by the ANM in the sub centre, and these numbered a total of 4 in the three months. In

almost all sub centres, an average of 3 pregnancy cases was referred to the next higher facility.

In CHC 2 where IUCD insertions were being carried out, about 12 IUCD insertion cases were

reported for 2007-2008. In general, service provision is also directly related to the infrastructure

facility at the sub centre.

128

Table S-8: Status of Availability of Drugs


PHC1 PHC2 PHC1 PHC2 Type of Drugs Available (Yes: 1; No:0)

Heggave Bage Hebbanahally Hosur Goddu Vanagur Kudurasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally


Kyatana Hally

J.C. Pura (B)

% of Sub Centres

reporting availability

of drug on date of survey

Iron/ Folic Acid 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Disposable Delivery Kit 1 - - 1 - - - - - - - - 16.7

Oral Pills 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Emergency Contraceptive 1 - - 1 1 1 1 - - - - - 41.7

Condoms 1 1 1 1 1 1 1 1 1 1 1 1 100.0 IUD - 1 1 1 1 1 1 1 1 1 1 1 91.7 ORS - - - 1 1 1 1 - 1 - - - 41.7 Tab. Flucanazole Vaginal - - - - - - - - - - 1 - 8.3

Tab. Misoprostal - - - - - - - - - - - - 0.0 Partograph - - - 1 - - - - - - - - 8.3 Pregnancy Test Kit 1 1 1 1 1 1 1 - - 1 1 1 83.3

Syp Cotrimoxazole - - - 1 - - - 1 - - - - 16.7

Syp Paracetamol - - - 1 - - - 1 - - - - 16.7 Vi. A - 1 1 1 1 1 1 1 1 1 1 1 91.7 Tab Ciprofloxacin - - - 1 - - - - - - - - 8.3

Disposable Gloves 1 1 1 1 1 1 1 1 1 1 1 1 100.0

129

Table S-9: Status of Specific Skills and Procedures


PHC1 PHC2 PHC1 PHC2 Type of Skills/ Procedure (Yes: 1; No: 0)

Heggave Bage

Hebbana Hally Hosur Goddu

Vanagur Kudu rasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally


Kyatana hally

J.C. Pura (B)

% of Sub Centres

reporting availability of specific

skills/ procedure

Register pregnancy within three month 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Carry out 3 ANC visits as per the RCH schedule (1st: 6th month, 2nd: 7th month, 3rd: 9th month)

1 1 - 1 1 1 1 1 1 1 1 1 91.7

Carry out specific examinations like Blood Pressure, Hemoglobin, and Urine

1 1 1 - 1 1 1 1 1 1 1 1 91.7

Provision of TT, IFA etc. 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Identification of High Risk Pregnancies

1 1 1 1 1 1 1 1 1 1 1 1 100.0

Is the ANM carrying out IUCD insertion/ removal

- 1 - - - - - 1 1 1 1 1 50.0

Is IUCD insertion being carried out using IUD A380

- - - - - - - 1 1 1 1 1 41.6

130

Is the supply of IUD A380 regularly available

- - - 1 - - - 1 1 1 1 1 50.0

Has the ANM been trained on the insertion/ removal of IUD A380

- - - - 1 - 1 1 1 1 1 1 58.3

Is the ANM trained in syndromic treatment of RTI/ STI

- - 1 - 1 - 1 - 1 1 1 - 50.0

Immunization services 1 1 1 1 1 1 1 1 1 1 1 1 100.0

131

Table S-10: Service Outcome (Based on the data for last 3 months)


PHC1 PHC2 PHC1 PHC2 Indicator


Kudurasthe Haranahalliy

(B) Kara

Gunda Kereko Dihally


Kyatana Hally

J.C. Pura (B)

Average per Sub Centre

Total ANC registered 11 20 20 17 5 7 16 17 25 6 8 12 14

Out of total ANC, number registered in 1st trimester

11 15 20 1 5 5 15 11 6 5 6 6 9

No. given 3 ANC visits as per the RCH schedule

8 13 5 - 9 3 13 10 12 2 3 6 8

No. of High Risk Cases identified 2 3 1 - 1 - 2 1 4 2 1 4 2

Deliveries conducted by ANM at Sub Centre

- 4 - - - - - - - - - - *

Pregnancies referred and attended by the next higher facility

2 - - 5 3 1 8 3 - 1 8 1 3

No. of neonate infections identified and referred

- - - - - - 6 - - - 1 - 1

No. of IUCD insertions in 2007-2008

- 12 - - - - - 8 26 10 8 7 6

132

Record Maintenance

It is apparent from the data on the maintenance of records by the sub centres, presented in Table

S-11, that, in general, the status of record maintenance is fairly good. Records such as the ante

and post natal registers, and registers for family planning, birth and death, and immunisation

were maintained in all the twelve sub centres. All but one of them maintained registers for

household survey, eligible couples, JSY, untied funds and cash book. The remaining register,

i.e., the meeting register was maintained in only five sub centres.

JSY Sche me

Awareness of the JSY scheme is seen to be high in Hassan district. The data presented in Table

S-12 show that all twelve ANMs reported that they are aware of the scheme. The ANMs are also

correctly aware of the amounts to be given to the beneficiaries. Finally, all twelve ANMs

reported that there was an increase in institutional deliveries after the implementation of the JSY

scheme. Table S-12B provides information on the status of procedures under this scheme. To a

large extent, payments are being made by cheque to the beneficiaries. In about 92 per cent of the

cases, funds are paid by cheque and the remainder by cash while vouchers are reported as not

being used. In a majority of the cases (83 per cent) the average time taken after birth for the JSY

payment to be made to the beneficiary is more than two weeks. In twenty-five percent of the JSY

cases transport is available for shifting cases from the sub centre to the PHC/ CHC.

133

Table S-11: Status of Record Maintenance


PHC1 PHC2 PHC1 PHC2 Type of Records maintained (Yes:1; No:0)

Heggave Bage Hebbana Hally Hosur Goddu

Vanagur Kudu rasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally


Kyatana hally

J.C. Pura (B)

% of SCs reporting

maintenance of record

Household Survey Register 1 1 1 1 1 1 1 1 - 1 1 1 91.7

Ante Natal Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0 Eligible Couple Register - 1 1 1 1 1 1 1 1 1 1 1 91.7

Post Natal Care Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Family Planning Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Birth and Death Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Immunisation Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Meeting Register - 1 1 - 1 - - 1 1 - - - 41.7 JSY Register - 1 1 1 1 1 1 1 1 1 1 1 91.7 Untied Funds Register 1 1 1 - 1 1 1 1 1 1 1 1 91.7

Cash Book 1 1 1 1 1 1 1 1 1 1 1 1 91.7

134

Table S-12 A: Status of Awareness of ANM about JSY Scheme

ANM's awareness about JSY Value Aware about JSY Number of ANMs interviewed 12 Number of ANMs reporting awareness 12 Percent reporting awareness 100.0 Aware about average amounts to be given to beneficiaries for A. Institutional Delivery 700.0 B. Home Delivey 500.0 C. Transport Facility 109.1 ANM reporting increase in demand for Institutional delivery after implementation of JSY Scheme Number of ANMs interviewed 12 Number of ANMs reporting awareness 12 Percent reporting awareness 100.0

Table S-12 B: Status of procedure under JSY Scheme

ANM's awareness about JSY % of ANMs according to

response Funds being paid to beneficiaries by Cash 8.3 Cheque 91.7 Vouchers - Average time taken after birth for JSY payment to beneficiary Less than 1 Week 8.3 1 : 2 Weeks 8.3 More than 2 Weeks 83.3 Transport for shifting of cases available from Sub Centre to PHC/ CHC 25.0 Register available for recording of JSY expenditure 100.0 Total no. of ANMs interviewed 12

The performance of ANMs under the JSY scheme has also been evaluated in the survey. The

data in Table S-13 reveals that an average of 8 cases were registered in total across the twelve

sub centres in the three months prior to the survey, while an average of 5 cases resulted in an

institutional delivery during that time. The average amount of cash disbursed under the scheme

during the period was Rs.5, 267 per sub centre. JSY money was usually spent for institutional

135

deliveries in all twelve sub centres, with an average of Rs.8, 500 being spent per sub centre. In 9

of the sub centres, JSY money was disbursed on deliveries that took place at home and these

amounts ranged from a total of Rs.500 to a total of Rs.2,000 across these sub centres. Only one

sub centre, JC Pura (B) disbursed money for transportation.

In sum, the JSY scheme has been very successful in that all the ANMs are aware of the

details of the scheme, and have disbursed the money as prescribed.

Untied Grants

The final piece of information refers to the Untied Grants given to sub centres under the NRHM

scheme. All the sub centres reported that they received the grants, and all but four sub centres (in

Hosur, Haranahally (B), Karagunda, Kerekodihally villages), reported that expenditure from the

same had been made. In all twelve sub centres, the ANM had a joint account with the village

Sarpanch or another Gram Panchayat functionary. However, only eight of the sub centres

maintained a register to record the decisions taken to spend this amount, only eight sub centres

reported a written record of the transactions being carried out and only seven of the sub centres

reported that the Sarpanch or the GP functionary reviewed the expenditure records. At the same

time, the record of the expenditure under the Untied Grant scheme is poor. Only four of the sub

centres report that they spent money under this scheme on the purchase of drugs, while 8 report

miscellaneous expenditure.

136

Table S-13: Status of performance of ANM under JSY Scheme Sub Centre

CHC1 CHC2 PHC1 PHC2 PHC1 PHC2

Performance of ANM under JSY Scheme Hegga

ve Bage Hebbanahally Hosur Goddu Vanagur

Kudurasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally

Hiresa Dara

Hally (B)

Kyatana hally

J.C. Pura (B)

Average per Sub

Centre

Total cases of JSY registered in last 3 calendar months

1 9 15 4 - 1 5 14 23 8 11 5 8

Total number of JSY cases resulted in Institutional deliveries in last 3 months

5 9 8 3 - 1 5 13 - 7 11 5 6

Total cash disbursed in last 3 calendar months for JSY cases (Rs.)

700 6,300 5,400 2,600 - 700 10,000 10,200 10,600 3,500 9,300 3,900 5,267

Out of total amount disbursed, the amount disbursed on the following

Home Deliveries (Rs.) 500 500 1,000 500 500 - 1,500 1,000 500 - - 2,000 667

Institutional Deliveries (Rs.) 7,700 10,50

0 10,500 6,300 2,900 3,500 8,500 24,400 1,400 6,300 9,300 10,700 8,500

Transport Costs (Rs.) - - - - - - - - - - - 200 17

Amount given to ASHA (Rs.) - - - - - - - - - - - -

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Table S-14: Status of Untied Grants Sub Centre

CHC1 CHC2 PHC1 PHC2 PHC1 PHC2 Status of Untied

Grants (Yes:1; No:0)


Kudurasthe

Harana Hally (B)

Kara Gunda

Kereko Dihally


Kyatana hally

J.C. Pura (B)

% of Sub

Centres

Sub Centre received Untied Grant 1 1 1 1 1 1 1 1 1 1 1 1 100.0

Sub Centre reported expenditure from Untied Grant

1 1 1 1 1 1 1 1 1 1 1 1 100.0

ANM having a joint account with the Sarpanch/ any other GP functionary

1 1 1 1 1 1 1 1 1 1 1 1 100.0

Sub Centre reporting maintenance of register to record the decisions taken to spend this amount

1 1 1 - 1 1 - 1 - 1 1 - 66.7

Sub Centre reporting written record of transactions being carried out on Untied funds

1 1 1 - 1 1 - - 1 1 1 - 66.7

Cont…

138

Sub Centre reporting that Sarpanch/ others ever reviewed the expenditure records

1 1 1 - 1 - - - - 1 1 1 58.3

Sub Centre reporting expenditure from Untied Grant on the following:

Spent on Purchase of Drugs 1 - 1 - - - - - - 1 1 - 33.3

Arranging Transport - - - - - - - - - - - - -

Paying of Power/ Telephone bills - - - - - - - - - - - - -

Arranging facilities like Water Cooler etc. for patients

- - - - - - - - - - - - -

Other (like white wash, maintenance etc.)

1 1 1 - 1 1 - - - 1 1 1 66.6

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Summary

In sum, the major problem with the primary contact point between the health system and

the community in Hassan district is the absence of a separate building for the health

facility. The construction of buildings with all the necessary infrastructure requires urgent

attention. Aside from the physical infrastructure aspect, in general, sub centres are

functioning adequately with regard to the basic services and skills available, as well as

with regard to the availability of basic equipment and the supply of drugs. One aspect of

the primary health system which is very successful is the JSY scheme. It appears that the

ANMs and other health functionaries are well-versed in the workings of the scheme, and

are committed to ensuring its implementation. However, the sub centre system in Hassan

is less successful with regard to the spending of Untied Grants, with all twelve sub

centres yet to utilize these monies properly.

140

Chapter 6

Household Characteristics

The main objective of the present study is to evaluate NRHM programme in Hassan

district of Karnataka. For the study, data are gathered from 1,200 households in 24

villages belonging to 12 sub centers in two CHC areas.The information included socio-

economic characteristics of households, knowledge and utilisation of Janani Suraksha

Yojan (JSY), ASHA, existence of village health and sanitation committees, availability of

government health facilities and its client’s satisfaction, awareness of family planning

and AIDS, etc.

Background Characteristics of the Respondents

The background characteristics of the respondents have been provided in Table H-1 and

H-2. A majority of the respondents are females and over half of them are in the age group

of 30-49 years and nearly one third of them are in less than 30 years. More than three-

fourth of respondents are currently married and almost a quarter of the respondents are

illiterate. One-fourth of the respondents have completed 10 years or more schooling. A

comparison of literacy figures with that of Census and other surveys conducted in the

district show more or less similar level to that estimated from the present survey.

Ninety five percent of the respondents belonged to Hindu religion and among them 44

percent are from Backward Classes, 36 percent from forward castes and remaining are

Scheduled castes and scheduled tribes. Nearly two-third of the households was below

poverty line and a majority of them are living in kucha houses. On the other hand, about

92 percent of the households had electricity connection but only 38 percent households

have toilet facility. Less than half of them have piped water supply for their households

and only 16 percent are using LPG/Biogas for cooking. However, 71 percent of the

respondents said that they owned agricultural land but none of them owned television

sets. Data shows that over one-fourth of the households had low standard of living. The

141

percentage of children born in health institutions during the last 5 years was around 85

percent indicating that institutional delivery was normally high in this district.

Table H1. Characteristics of the respondents

Characteristics of the respondents Percent Age < 30 years 37.1 30-39 years 26.2 40-49 years 25.3 50-59 years 8.2 60 years or more 3.3 < 30 years 445 30-39 years 314 40-49 years 303 50-59 years 98 60 years or more 40 Sex Male 16.6 Female 83.4 Male 199 Female 1,001 Years of Schooling IIiterate 23.6 1-5 Years 16.8 5-9 years 30.9 10 years of more 28.7 IIiterate 283 1-5 Years 202 5-9 years 371 10 years of more 344 Marital status Unamrried 7.7 Currently Married 85.0 Divorced/Separated 1.1 Widowed 6.3 Unmarried 92 Currently Married 1,020 Divorced/Separated 13 Widowed 75 Total number of respondents

1,200

142

Waste Disposal and Mosquito Breeding

Data provided in Table H-3 highlights the method of waste disposal by the households,

sanitation around the house and the system of medicine they preferred. Even though 77

percent of the respondents mentioned no water stagnation around their houses, around 95

percent of them said that there are instances of mosquito breeding around the house. Most

of the respondents preferred allopathic system of medicine but around 10 percent also

preferred Ayurveda. There was not much difference between households located in the

sub-center headquarter villages and households located far from the sub-center

headquarter village in terms of waste disposal and system of medicine preferred.

Table H2. Characteristics of the household

Characteristics of the household Percent Social category Scheduled caste 17.4 Scheduled tribe 1.9 OBC 44.2 Others 36.5 Scheduled caste 209 Scheduled tribe 23 OBC 530 Others 438 Religion Hindu 95.3 Muslim 2.8 Christian 1.9 Sikhs - Other - Hindu 1,143 Muslim 34 Christian 23 Sikhs - Other - Households having BPL status Yes 62.7 No 37.3 Yes 752 No 448 Household living in pucca house Yes 9.5 No 90.5 No - Yes 114 No 1,086 No -

143

Households with electricity Yes 91.8 No 8.2 Yes 1,102 No 98 Households with toilet facility Yes 38.4 No 61.6 Yes 461 No 739 Households with piped water supply Yes 42.1 No 57.9 Yes 505 No 695 Households using LPG/Biogas for cooking Yes 16.3 No 83.7 Yes 196 No 1,004 Household with own agricultural land Yes 70.8 No 29.3 Yes 849 No 351 Households have a mobile phone Yes 34.7 No 65.3 Yes 416 No 784 Households own a colour/B&W television Yes 60.2 No 39.8 Yes 722 No 478 Households with low standard of living index Yes 27.3 No 72.8 Yes - No - - Number of living children born in last five years:Total Total 414 Institutional delivery:Total Total 351 % of children born in Health Institutions during last 5 years Total number of respondents 85

144

Table H3: Percent distribution of households by their waste disposal, stagnation of waste water and mosquito breeding around the house and system of medicine

preferred by them

Households

located in Sub Centre HQ Village

Households located in other

village All

Method of waste disposal by the household

Thrown in the open 14.2 12.3 13.3 Buried in a pit 1.2 0.8 1.0 Burnt 1.2 1.5 1.3 Other 83.5 85.3 84.4 Thrown in the open 85 74 159 Buried in a pit 7 5 12 Burnt 7 9 16 Other 501 512 1,013 Stagnation of waste water around the houshold

Yes 26.5 18.0 22.3 No 73.5 82.0 77.8 Yes 159 108 267 No 441 492 933 Instance of any mosquito breeding

Yes 95.0 93.5 94.4 No 5.0 6.5 5.6 Yes 151 101 252 No 8 7 15 Syestem of medicine preferred: Allopathic

Yes 99.0 98.7 98.8 No 1.0 1.3 1.2 Yes 594 592 1,186 No 6 8 14 Ayurveda Yes 6.8 11.8 9.3 No 93.2 88.2 90.7 Yes 41 71 112 No 559 529 1,088 Yoga and Naturopathy Yes - - - No 100.0 100.0 100.0 Yes - - - No 600 600 1,200 Unani Yes - - - No 100.0 100.0 100.0 Yes - - - No 600 600 1,200

145

Siddha Yes - - - No 100.0 100.0 100.0 Yes - - - No 600 600 1,200 Homeopathy Yes 0.3 0.2 0.3 No 99.7 99.8 99.8 Yes 2 1 3 No 598 599 1,197 Traditional healing Yes - 0.5 0.3 No 100.0 99.5 99.8 Yes - 3 3 No 600 597 1,197 Any other Yes - - - No 100.0 100.0 100.0 Yes - - - No 600 600 1,200 None Yes - - - No 100.0 100.0 100.0 Yes - - - No 600 600 1,200 Total Number of Households

600 600 1,200

Health Worker and Health Facilities

In the study, respondents are asked regarding the availability of health worker, health

facilities and mode of transportation used to take patients to health facility. This information

was collected both from sub-center headquarter villages and villages located far from the

sub-center. Data provided in Table H-4 reveals that most of respondents had heard about

ANM. But only one-third of the respondents had heard about male health worker. Sixty

three percent said that health workers are available at the time of their need. Regarding

availability of health facilities like RMP, sub-centre, PHC, CHC in need there had been

varied response. Nearly half of the respondents said that private or NGO health facilities are

available in need. But 60 percent of them considered that PHC was available in need as

well. Other public health system was mentioned by considerably lower percentage of the

respondents. This is true for both sub-centers headquarter villages and non sub-centre

villages. About half of the respondents mentioned that serious patients are taken to CHC

and they mostly used private vehicles or Bus for transportation.

146

Table H 4. Percent distribution of household respondents by their information about availability of health worker, health facilities and transport used to take

serious patients

Households located in Sub Centre HQ Village

Households located in other village

All

Heard about ANM Yes 98.5 99.2 98.8 No 1.5 0.8 1.2 Yes 591 595 1,186 No 9 5 14 Heard about male health worker

Yes 36.8 37.2 37.0 No 63.2 62.8 63.0 Yes 221 223 444 No 379 377 756 Visited by a Health Worker in last one month

Yes 61.3 54.8 58.1 No 38.7 45.2 41.9 Yes 368 329 697 No 232 271 503 Health worker available at the time of need

Yes 65.0 61.8 63.4 No 35.0 38.2 36.6 Yes 390 371 761 No 210 229 439 Available health facility in need: RMP

Yes 0.5 3.0 1.8 No 99.5 97.0 98.3 Yes 3 18 21 No 597 582 1,179 Private clinic/NGO Yes 50.8 54.2 52.5 No 49.2 45.8 47.5 Yes 305 325 630 No 295 275 570 Sub Centre Yes 19.3 26.7 23.0 No 80.7 73.3 77.0 Yes 116 160 276 No 484 440 924 PHC Yes 60.3 59.3 59.8 No 39.7 40.7 40.2 Yes 362 356 718 No 238 244 482

Cont…

147

CHC Yes 43.5 42.5 43.0 No 56.5 57.5 57.0 Yes 261 255 516 No 339 345 684 Other Yes 31.3 37.5 34.4 No 68.7 62.5 65.6 Yes 188 225 413 No 412 375 787

Cont...

Households located

in Sub Centre HQ Village

Households located in other village All

Facilities where serious patients taken: RMP/Private clinic

Yes 21.5 22.3 21.9 No 78.5 77.7 78.1 Yes 129 134 263 No 471 466 937 NGO hospital/clinic Yes 10.5 11.5 11.0 No 89.5 88.5 89.0 Yes 63 69 132 No 537 531 1,068 PHC Yes 32.7 32.3 32.5 No 67.3 67.7 67.5 Yes 196 194 390 No 404 406 810 CHC Yes 56.3 51.8 54.1 No 43.7 48.2 45.9 Yes 338 311 649 No 262 289 551 District/ Sub Divisional hospital

Yes 24.3 21.8 23.1 No 75.7 78.2 76.9 Yes 146 131 277 No 454 469 923 Other Yes 26.0 31.5 28.7 No 74.0 68.5 71.3 Yes 156 189 345 No 444 411 855

Cont…

148

Mode of transport for serious patient: Bullock cart

Yes 0.3 - 0.2 No 99.7 100.0 99.8 Yes 2 - 2 No 598 600 1,198 Bus Yes 41.7 42.7 42.2 No 58.3 57.3 57.8 Yes 250 256 506 No 350 344 694 Private vehicle Yes 85.8 87.2 86.5 No 14.2 12.8 13.5 Yes 515 523 1,038 No 85 77 162 Ambulance Yes 0.3 - 0.2 No 99.7 100.0 99.8 Yes 2 - 2 No 598 600 1,198 Other Yes 1.3 1.5 1.4 No 98.7 98.5 98.6 Yes 8 9 17 No 592 591 1,183 Total number of household respondents

600 600 1,200

Knowledge of ASHA, VHND, VHSC and JSY

The NRHM envisages that every village will have a female Accredited Social Health

Activist (ASHA) chosen by and accountable to the Panchayat to act as the interface

between the community and the public health system. Secondly, under NRHM, Gram

Sabhas shall be called upon to constitute Village Health & Sanitation Committees.

(VHSC) These committees shall steer the preparation of Village Health & Sanitation

Plans. Such committees are essential for broad approaches to health improvement that

involve a wide range of activities. This committee can coordinate and support the

different activities, provide leadership for the community and can serve as the community

contact point with local and district government functionaries under the NRHM

programme. Thirdly, the main objective of Janani Suraksha Yojana (JSY) under NRHM

is to promote institutional deliveries among poor pregnant women. In availing

institutional delivery services the client is usually escorted, will be requiring transport to

149

reach the institution and in case of complications, referral services will be required. The

scheme has considered all these elements and has made provision for transport including

referral and escort under the NRHM programme.

Table H-5: Percent distribution of household respondents by their knowledge about

NRHM,ASHA and her activities, VHND, VHSC and JSY

Households

located in Sub Centre HQ

Village


village All

Have heard of NRHM Yes 39.5 35.2 37.3 No 60.5 64.8 62.7 Yes 237 211 448 No 363 389 752 Source of information about NRHM: ASHA

Yes 0.4 2.4 1.3 No 99.6 97.6 98.7 Yes 1 5 6 No 236 206 442 Radio/television Yes 58.6 53.6 56.3 No 41.4 46.4 43.8 Yes 139 113 252 No 98 98 196 Newspaper Yes 8.4 6.2 7.4 No 91.6 93.8 92.6 Yes 20 13 33 No 217 198 415 Panchayat Yes 9.7 8.1 8.9 No 90.3 91.9 91.1 Yes 23 17 40 No 214 194 408 Community member Yes 3.4 4.3 3.8 No 96.6 95.7 96.2 Yes 8 9 17 No 229 202 431 Other Yes 42.2 46.4 44.2 No 57.8 53.6 55.8 Yes 100 98 198 No 137 113 250

Cont…

150

Number of respondents heard about ASHA

Percent 9.3 6.7 8.0 No 90.7 93.3 92.0 Number 56 40 96 No 544 560 1,104 ASHA carries a kit Yes - - - No - - - Yes - - - No - - - ASHA provides common medicine free of cost

Yes - - - No - - - Yes - - - No - - - ASHA held discussion about: Hand washing

Yes - - - No - - - Yes - - - No - - - ASHA held discussion about: Construction of household toilets

Yes - - - No - - - Yes - - - No - - - ASHA held discussion about: Safe drinking water

Yes - - - No - - - Yes - - - No - - - Village Health and Nutrition Day being organized in the village

Yes 45.7 34.0 39.8 No 54.3 66.0 60.2 Yes 274 204 478 No 326 396 722 Presence of village health and sanitation committee in the village

Yes 15.2 10.0 12.6 No 84.8 90.0 87.4 Yes 91 60 151 No 509 540 1,049

Cont...

151

Table H-5: Percent distribution of household respondents by their knowledge about NRHM,ASHA and her activities, VHND, VHSC and JSY

Households located in Sub Centre HQ

Village

Households located in other village

All

Frequency of Village Health and Nutrition

Weekly 1.8 2.5 2.1 Monthly 63.1 54.4 59.4 Quarterly 17.5 25.0 20.7 Annual 17.2 18.1 17.6 Don't know 0.4 - 0.2 Weekly 5 5 10 Monthly 173 111 284 Quarterly 48 51 99 Annual 47 37 84 Don't know 1 - 1 Number of respondents aware about the JSY scheme

Percent 97.7 98.0 97.8 No 2.3 2.0 2.2 Number 586 588 1,174 No 14 12 26 Radio/Television Yes 19.6 18.2 18.9 No 80.4 81.8 81.1 Yes 115 107 222 No 471 481 952 Pamphlets Yes - 0.5 0.3 No 100.0 99.5 99.7 Yes - 3 3 No 586 585 1,171 Hoardings at SC/PHC etc Yes 14.5 15.3 14.9 No 85.5 84.7 85.1 Yes 85 90 175 No 501 498 999 ASHA worker Yes 0.2 0.5 0.3 No 99.8 99.5 99.7 Yes 1 3 4 No 585 585 1,170 Anganwadi Centre/Worker

Yes 68.9 67.9 68.4 No 31.1 32.1 31.6 Yes 404 399 803 No 182 189 371

Cont…

152

ANM Yes 70.0 65.8 67.9 No 30.0 34.2 32.1 Yes 410 387 797 No 176 201 377 Doctor Yes 5.1 3.9 4.5 No 94.9 96.1 95.5 Yes 30 23 53 No 556 565 1,121 Gram Panchayat Yes 2.0 2.0 2.0 No 98.0 98.0 98.0 Yes 12 12 24 No 574 576 1,150 NGOs/SHGs Yes 2.6 1.7 2.1 No 97.4 98.3 97.9 Yes 15 10 25 No 571 578 1,149 Others Yes 20.5 22.3 21.4 No 79.5 77.7 78.6 Yes 120 131 251 No 466 457 923 Any one of household is JSY beneficiary

Yes 18.3 18.9 18.6 No 81.7 81.1 81.4 Yes 107 111 218 No 479 477 956 Total number of household respondents

586 588 1,174

Data provided in Table H-5 indicates the extent of respondent’s knowledge regarding

NRHM, ASHA, Village Health and Nutrition Day (VHND), VHSC and JSY. In the study

area ASHA programme has not been implemented. When we enquired during fieldwork

regarding ASHA, the concerned officials mentioned that recruitment for ASHA has been

done but training as well as supply of drugs to ASHA has not been completed. Therefore,

respondents do not have any knowledge about ASHA programme in the study area.

However, about one-third of the respondents are aware of NRHM programme through

radio/television. Regarding VHND, VHSC over one-third of the respondents said that

they are aware of nutrition day organized in the village and also 12 percent mentioned

health and sanitation committee existed in their villages. Regarding the frequency of

153

health and nutrition day meeting, over 60 percent of the respondents said that it was being

observed monthly. It seems that the programme was being carried out more frequently in

headquarter village as compared to far off village.

JSY is an integral component for safe motherhood under NRHM and promotes

institutional deliveries. The respondents are asked to ascertain whether they are aware of

the JSY scheme and further, if they are aware of the scheme, source of knowledge and

benefits they had received. Table H-5 clearly indicates that 98 percent of the respondents

are aware of JSY scheme and a majority of them came to know the scheme from the

Anganawadi centres or workers. About one-third of the respondents reported that they

came to know the scheme through ANM. Most of the respondents are aware of the JSY

scheme and 19 percent of the households benefited from the scheme.

Characteristics of JSY Beneficiaries

Out of the 1,200 households interviewed for the study, 218 households reported that they

had benefited from the JSY scheme. Over half of the beneficiaries are in the age group

20-24 years and another one-third in the age group of 25-29 years. Secondly, about 50

percent of the households benefited for the second parity and another 45 percent for the

third or fourth parity. Interestingly the beneficiaries belonged to all caste groups, 27

percent SC/ST, 36 percent each from OBC and Forward caste. A majority of the JSY

deliveries had taken place at the health institution. Data provided in Table H-6 show that

about one third of the JSY beneficiaries belonged to low standard of living category and

47.2 percent each were in medium standard of category. Around 90 percent of the

households are from high Standard of Living Index (SL1) category

154

Table H6. Pe rcent distribution of JSY beneficiaries by their background characteristics

Percent Total number of JSY beneficiaries

218 Age < 20 years 3.7 20-24 years 54.6 25-29 years 33.0 30-34 years 6.9 35-39 years 1.8 40-44 years - 45-49 years - < 20 years 8 20-24 years 119 25-29 years 72 30-34 years 15 35-39 years 4 40-44 years - 45-49 years - Parity 0 - 1 4.1 2 50.9 3 & 3+ 45.0 0 - 1 9 2 111 3 & 3+ 98 Social category SC 27.1 ST 1.4 OBC 35.8 Others 35.8 Scheduled caste 59 Scheduled tribe 3 OBC 78 Others 78 Religion of the household Hindu 95.4 Muslim 3.7 Christian 0.9 Sikhs - Other - Hindu 208 Muslim 8 Christian 2 Sikhs - Other -

Cont…

155

SLI of the household Low 33.9 Medium 47.2 High 18.8 Low - Medium - High - BPL household Yes 69.7 No 30.3 Yes 152 No 66 Place of last delivery Household 16.1 Health Institution 83.9 Household 35 Health Institution 183

Registration of JSY Beneficiaries

Regarding the registration of JSY beneficiaries, the questions included information on

timing when the beneficiary heard about the JSY scheme, the stage of pregnancy the

beneficiary registered for JSY scheme, and place of registration. Table H-7 reveals that

56 percent of JSY beneficiaries come to know about the scheme when they were pregnant

and 43 percent had heard about JSY before they became pregnant. Fifty percent of the

JSY beneficiaries registered for the scheme during their third month of pregnancy and

another 20 percent registered when they were in fifth month of pregnancy. ANM

registered about 60 percent of the beneficiaries and Anganwadi worker registered 37

percent. A majority of the registration was done in Anganwadi centre and only 18.8

percent registered with PHC and 7.8 percent with the sub center

Questions are asked to ascertain whether the beneficiary received the JSY card and who

helped them to get JSY card. About 55 percent (Table H-8) of the beneficiaries received

the card and remaining did not receive the card. They have not faced any problem in

getting the card. A majority of them received the card either from health workers or from

Anganwadi workers. Table H-9 presents data on the information provided to the pregnant

women on various aspects of pregnancy and delivery. Almost a quarter of the women

reported that they were not informed about the next visit for checkup. Around 50 percent

of them did not know the place of next checkup. However, 82 percent had been told

156

about their expected date of delivery and 59 percent had been told about their place of

delivery. The information on referred services are told to only 10 percent of the

beneficiaries. It, in general, indicates that the information provided to pregnant women on

various aspects of pregnancy and delivery was scanty reflecting the quality of the service.

Table H7. Timing, person place of registration for JSY scheme

Timing, place of registration for JSY card Percent Timing of hearing about JSY scheme Before being pregnant 43.6 During pregnancy 56.4 Before being pregnant 95 During pregnancy 123 Whether know about the stage of pregnancy when beneficiary registerd under JSY scheme

Yes 50.0 No 50.0 Yes 109 No 109 Stage of pregnancy when beneficiary got registered for JSY scheme

1st month 5.5 2nd month 12.8 3rd month 50.5 4th month 11.0 5th month or later 20.2 1st 6 2nd 14 3rd 55 4th 12 5th and above 22 Person who registered the beneficiary for JSY scheme

Doctor - LHV - ANM/FHW 60.6 Anganwadi worker 37.2 ASHA worker - Others 2.3 Doctor - LHV - ANM/FHW 132 Anganwadi worker 81 ASHA worker - Other 5

Cont…

157

Place where the beneficiary was registered for JSY scheme

District/Sub-DIstrict Hospital 1.8 Community Health Centre 0.5 PHC 18.8 Sub-Centre 7.8 Anganwadi Centre 60.1 Pvt. Hosp. accredited by the Govt. - At home 5.5 Other places 5.5 District/Sub-DIstrict Hospital 4 Community Health Centre 1 PHC 41 Sub-Centre 17 Anganwadi Centre 131 Pvt. Hosp. accredited by the Govt. - At home 12 Other 12 Total number of JSY beneficiaries 218

Table H8. Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the beneficiary in getting the JSY card

JSY Card Percent JSY card received by the beneficiary Yes 54.6 No 45.4 Yes 119 No 99 Total number of JSY beneficiaries 218 ASHA worker helped the beneficiary in getting JSY card

Yes - No - Not applicable 100.0 Yes - No - Not applicable 119 Beneficiary faced difficulty in procuring JSY card

Yes - No 100.0 Yes - No 119 Problem faced in procuring JSY card: Cards were not available

Yes - No - Yes - No -

Cont…

158

Formalities in making card were too cumbersome

Yes - No - Yes - No - Asked to pay money for card Yes - No - Yes - No - Other Yes - No - Yes - No -

Table H 9. Role of ASHA during the pregnancy of the beneficiaries

Percent ASHA worker provided any specific help to beneficiary in last pregnancy

Yes - No - Not Applicable 100.0 Yes - No - Not Applicable 218 Beneficiary received advice from ASHA-Diet Yes - No 100.0 Yes - No 218 Danger signs Yes - No 100.0 Yes - No 218 Delivery Care Yes - No 100.0 Yes - No 218 Breastfeeding Yes - No 100.0 Yes - No 218

Cont…

159

Newborn care Yes - No 100.0 Yes - No 218 Family Planning Yes - No 100.0 Yes - No 218 Not applicable (ASHA not appointed in the village)

Yes 100.0 No - Yes 218 No - Information given to the beneficiary - Date of next check-up

Yes 74.8 No 25.2 Yes 163 No 55 Place of next check-up Yes 51.8 No 48.2 Yes 113 No 105 Date of expected delivery Yes 81.7 No 18.3 Yes 178 No 40 Place of delivery Yes 58.7 No 41.3 Yes 128 No 90 Place of referral, if complications arise Yes 10.6 No 89.4 Yes 23 No 195 Total number of JSY beneficiaries 218

160

Place of delivery

One of the main objectives of JSY under NRHM is to promote institutional deliveries.

Data on place of delivery and reasons for opting institutional delivery are provided in

Table H-10. It indicates that a majority of the deliveries had take place in the health

institutions particularly at public hospitals. Overall 14 percent of the birth took place at

home. While 25 percent of deliveries were conducted at district hospitals, 23 percent

were at PHCs, 18 percent at CHCs and 17.7 percent in the private hospitals. The present

survey figures on institutional deliveries show higher than RCH-2 and NFHS-3 data. The

RCH-2 data on institutional deliveries for Hassan district was 65.9 percent and NFHS-3

for Karnataka was 64.7 percent (Raju et al , 2006; IIPS and Macro International, 2008).

Whereas the present survey data shows 85 percent deliveries are in health institutions.

For the question on reason for opting institutional deliveries a majority of the respondents

opined better access to health institutions and better care for mother and new born child

in the health institution are the important contributors. Interestingly JSY financial bene fit

was considered as important but only for 12 percent of the beneficiaries as a motivating

force behind institutional delivery.

Table H 10. Place of delivery and reason for opting institutional delivery

Place of delivery and reason for opting institutional delivery

Percent

Place of delivery District/Sub-District Hospital 25.8 Community Health Centre 18.7 PHC 23.0 Sub-Centre 0.5 Trust/NGO Hospital - Private Hospital 17.7 Pvt. Hosp. accredited by the Govt. - At home 14.4 District/Sub-District Hospital 54 Community Health Centre 39 PHC 48 Sub-Centre 1 Trust/NGO Hospital - Private Hospital 37 Pvt. Hosp. accredited by the Govt. - At home 30 Total number of JSY beneficiaries 209

Cont…

161

Reasons for opting Institutional Delivery-Money available under JSY scheme

Yes 12.3 No 87.7 Yes 22 No 157 Better access to institutional delivery Yes 81.6 No 18.4 Yes 146 No 33 Better care for mother and new born child Yes 74.3 No 25.7 Yes 133 No 46 Services in the area Yes 1.7 No 98.3 Yes 3 No 176 Support provided by ASHA Yes - No 100.0 Yes - No 179 Availability of transport assistance Yes 5.0 No 95.0 Yes 9 No 170 Previous child was born in an institution Yes 8.9 No 91.1 Yes 16 No 163 Others Yes 1.7 No 98.3 Yes 3 No 176 Total number of JSY beneficiaries 179

Difficulties in Availing Health Facility

To increase institutional deliveries, transportation of pregnant women to health institution

is important. Under JSY scheme either ASHA or health workers are to arrange/provide

referral transport as well as escort services for pregnant women to reach a health

institution. Table H-11 highlights the extent of difficulty faced in getting transport by the

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beneficiaries and those who facilitated them to reach hospitals. A majority of the

respondents mentioned that they did not get any referral slip to access delivery services

and only 8.4 percent got referral slip from health workers. Nearly half of the respondents

reported that they did not face any difficulty in reaching the hospital. However, 40

percent of the beneficiaries reported that they did not have sufficient money and for over

65 percent of the cases transport was not immediately available but faced little difficulty

in reaching hospitals. Seventythree percent said they used private vehicles to reach

hospitals and local health committees (26 percent) supported them. The average amount

of transport assistance received under JSY scheme was Rs 320 per beneficiary. In the

case of 85 percent of the women there was no serious problem in meeting the transport

cost. This is not surprising given the fact that Hassan district has a good network of roads

and other infrastructure.

Table H 11. Transport of the beneficiaries to reach the Health Institution

Process of Transport Percent Received referral slip from ASHA/health personnel to access delivery services Yes 8.4 No 91.6 Yes 15 No 164 Faced difficulty in reaching Health Institution Yes 16.2 No 83.8 Yes 29 No 150 Faced difficulty in reaching Health Institution: It was late in the night Yes 44.8 No 55.2 Yes 13 No 16 Did not have insufficient money Yes 41.4 No 58.6 Yes 12 No 17 Transport was not immediately available Yes 65.5 No 34.5 Yes 19 No 10 Male members in the household were not present Yes 3.4

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No 96.6 Yes 1 No 28 ASHA was not readily available Yes - No 100.0 Yes - No 29 Others Yes 13.8 No 86.2 Yes 4 No 25 Average distance to the ultimate place of delivery from the beneficary residence Average 13.5 Mode of transport used by the beneficiary to reach the ultimate place of delivery Government Ambulance 0.6 Private Vehicle 73.2 Vehicle arranged by Local Health Committee - Others 26.3 Government Ambulance 1 Private Vehicle 131 Vehicle arranged by Local Health Committee - Others 47 Persons facilitated in arranging the transport ASHA - ANM 1.1 Village Health Committee - Others 98.9 ASHA - ANM 2 Village Health Committee - Others 176 Beneficiary had money to pay for the transport services Yes 84.7 No 15.3 Yes 150 No 27 Average amount spent on transport (in Rs.) Average 1.1 Average amount of transport assistance received under JSY scheme Average 319.9 Person accompanied beneficiary to the health institution ASHA - Relatives 84.9 Others 15.1 ASHA - Relatives 152 Others 27 Total number of JSY beneficiaries 179

164

Waiting Time, Type of Delivery, Amount Spent

The important aspect of NRHM is to provide qualitative services in health centres. Table H-

12 reveals the attitude of health staff towards patients, type of delivery, amount spent in the

health centre and average number of days stayed at the health centre. It is interesting to note

that 69 percent of the deliveries were normal and about 26 percent were caesarean section

deliveries. The average amount spent in the health centre was Rs1,187.20 per patient. The

cost was inclusive of those deliveries that taken place in private hospitals as well. About 62

percent of the respondents reported that they had spent some money in the health facility.

Nearly half of the respondents are not fully satisfied with the health centre on the quality of

service. But, only 3.4 percent indicated complete dissatisfaction. The reasons for

dissatisfaction was poor quality services and rude behaviour of the staff.

Table H 12. Waiting time at the health facility, type of delivery, amount spent at the

health facility and satisfaction regarding services available in the

Percent Average waiting time at the facility until someone attended the beneficiary (in minutes) Average - Type of delivery beneficiary Normal 69.3 Assisted (Forceps, Vacuum) 5.0 Caesarean 25.7 Normal 124 Assisted (Forceps, Vacuum) 9 Caesarean 46 Average number of days spent in the facility till discharge Average 3.9 Percent beneficiary who have to pay at the health centre Yes 62.0 No 38.0 Yes 111 No 68 Average amount paid at the health centre (Rs.) Average 1,187.2 Satisfied with the services at health centre Satisfied 47.5 Somewhat satisfied 49.2 Not satisfied 3.4 Satisfied 85 Somewhat satisfied 88 Not satisfied 6

Cont…

165

Reason for non satisfied Staff was rude 33.3 Faciltiy was not clean - Poor quality of services 50.0 Others 16.7 Staff was rude 2 Faciltiy was not clean - Poor quality of services 3 Others 1

Reasons for Home Delivery

Home delivery had occurred in 15 percent of the cases (about 30 cases). A question was

asked to pregnant women regarding the reason for having home delivery though the cash

incentive was available under the JSY scheme for pregnant women who delivered in

hospitals. Table H-13 indicates reasons expressed by the women for not going to hospital for

delivery. About 17 percent said that home was more convenient, 7 percent mentioned fear of

stitches and caesarean and 40 percent opined that transport was not available during that

time. Other reasons like cultural factors etc were negligible.

Table H13. Reason for the JSY beneficiary to opt home delivery, in spite of cash

incentives being available under the JSY

Percent Reasons for home delivery: Home delivery is more convenient Yes 16.7 No 83.3 Yes 5 No 25 Fear of stitches/caesarean Yes 6.7 No 93.3 Yes 2 No 28 Indifferent behaviour of medical/paramedical staff Yes - No 100.0 Yes - No 30 Cultural/social reasons Yes 3.3 No 96.7 Yes 1 No 29

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Transport not being available Yes 40.0 No 60.0 Yes 12 No 18 Can't afford Yes 3.3 No 96.7 Yes 1 No 29 Others Yes 46.7 No 53.3 Yes 14 No 16 Total number of JSY beneficiaries under Home Delivery 30

Cash incentive

Table H-14 shows the number of JSY beneficiaries who received cash incentives, average

amount received, and other details of cash incentives. It is clear from the table that 88

percent of the JSY beneficiaries had received cash incentives and the average amount

received was Rs 721 and they got money at one time. A majority of the beneficiaries got

cash incentives from the ANM at sub-centres. Almost half of them received the money from

PHC and 16 percent received at the Anganawadi centre and 12 percent at their home. For

nearly 84 percent of the cases, it took more than a week to receive the money. Most of the

beneficiaries said they did not face any difficulty in getting cash incentives.

Table H.14 Cash incentive received by the beneficary under JSY scheme

Percent Beneficiary received cash incentive under JSY scheme Yes 88.1 No 11.9 Yes 192 No 26 Total number of JSY beneficiaries 218 Average amount received by beneficiary as cash incentive Average 721.1 Received the cash incentive In one go 99.5 In 2-3 installments 0.5 In one go 191 In installments 1

Cont…

167

Timing of the receipt of the cash incentive by beneficiary At the time of registration - At the time of antenatal check up - Much before delivery 0.5 Within a week before the EDD - Immediately after the delivery - Within a week of delivery 8.3 Much later 83.3 Not reveived yet 0.5 Other 7.3 Donot know/ Husband knows - At the time of registration - At the time of antenatal check up - Much before delivery 1 Within a week before the EDD - Immediately after the delivery - Within a week of delivery 16 Much later 160 Not reveived yet 1 Other 14 Donot know/ Husband knows - Person who delivered the cash incentive to the beneficiary Doctor 5.8 LHV 0.5 ANM/FHW 88.0 Anganwadi worker 4.7 ASHA worker - Other 1.0 Doctor 11 LHV 1 ANM/FHW 168 Anganwadi worker 9 ASHA worker - Other 2 Place where the cash incentive received by the beneficiary District/Sub-DIstrict Hospital 1.6 Community Health Centre 3.1 PHC 49.2 Sub-Centre 9.9 Anganwadi Centre 16.2 Pvt. Hosp. accredited by the Govt. - At home 12.0 Other 7.9 District/Sub-DIstrict Hospital 3 Community Health Centre 6 PHC 94 Sub-Centre 19 Anganwadi Centre 31 Pvt. Hosp. accredited by the Govt. - At home 23 Other 15

Cont…

168

Faced any difficulty in getting money Yes 1.6 No 98.4 Yes 3 No 188 Type of difficulty faced by the beneficiary Was asked to pay the bribe - Was paid by cheque/draft 33.3 Others 66.7 Was asked to pay the bribe - Was paid by cheque/draft 1 Others 2 Total number of JSY beneficiaries 3

Utilisation of Public Health Facility and Client Satisfaction

In the study, information was collected from the households regarding whether they

availed any health services from the Government health facility during the last six

months and the same data have been provided in Table H-15. It shows that over two-

third of the households had gone to public health facility and availed the services. There

was no difference in availing health services at government health facility between sub-

centre head quarter villages and villages located far from the sub-centre.

Table H 15. Utilization of government health facility in last 6 months

Percent of household

who availed health services in

government health facility in last 6 months

Households located in Sub

Centre HQ Village


village All

Yes 68.8 69.7 69.3 No 31.2 30.3 30.8

Yes 413 418 831 No 187 182 369

Total number of households

600 600 1,200

Data provided in Table H-16 show characteristics of respondents who availed

government health facility during the last six months. It appears from the table that a

large majority of females, less educated, currently married and people belonging to below

poverty line had availed the public health facility. As against the common belief, the

public health facility was sought by all caste groups. Twenty five percent of the people

with high standard of living also availed the Government health facility and remaining

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were from belong to low or medium standard of living. Nearly 75 percent of those

availed the service were females

Table H. 16 Characteristics of the respondents who have availed the services in

government health facility in last 6 months

Percent Age <16 years - 16-19 years 4.3 20-29 years 28.8 30-39 years 24.7 40-49 years 23.7 50-59 years 9.4 60 years or more 9.1 <16 years - 16-19 years 36 20-29 years 239 30-39 years 205 40-49 years 197 50-59 years 78 60 years or more 76 Sex Male 25.9 Female 74.1 Male 215 Female 616 Years of schooling completed Illiterate 26.8 1-5 years 16.4 6-9 years 30.8 10+ years 26.0 Illiterate 223 1-5 years 136 6-9 years 256 10+ years 216 Marital status Unmarried 7.7 Currently married 83.8 Divorced/Separated 0.7 Widowed 7.8 Unmarried 64 Currently married 696 Divorced/Separated 6 Widowed 65

Cont…

170

Social category of the household SC 16.8 ST 2.0 OBC 44.5 Others 36.6 Scheduled caste 140 Scheduled tribe 17 OBC 370 Others 304 Religion of the household Hindu 94.6 Muslim 3.2 Christian 2.2 Sikhs - Other - Hindu 786 Muslim 27 Christian 18 Sikhs - Other - BPL Household Yes 64.4 No 35.6 Yes 535 No 296 Standard of Living Index Low 29.5 Medium 44.6 High 25.9 Low - Medium - High -

Table H-17 presents data on client satisfaction of that using public health facility.

Regarding type of health facility and purpose of visit, about 29 percent visited CHC, 39.6

percent PHC and 15.6 percent district hospitals. The purpose of the visit was treatment of

minor ailments in a majority of the cases. Respondents visited health facility for

pregnancy care and child care were very less. A majority of the respondents opined that

the staff at the health facility were courteous, listened to complaints and enough privacy

existed for treating women patients. About 60 percent of patients with chronic disease got

medicines. However, only one-third of the patients were fully satisfied with the

government health facility and behaviour of the staff. At the same time those not at all

satisfied with facility were only 4 percent. In general, the level of satisfaction of public

health facility was far higher than usually observed from other studies.

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Table H.17 Type of health facility visitied, purpose visit and client satisfaction regarding behaviour of health worker, privacy and availability medicines

Percent Type of health facility where service availed District/ Sub district hospital 15.6 CHC 29.0 PHC 39.6 Sub Centre 14.1 AYUSH 1.7 District/ Sub district hospital 130 CHC 241 PHC 329 Sub Centre 117 AYUSH 14 Purpose of visit to health facility Treatment of minor ailment 55.7 ANC care 3.9 Child care 9.5 Immunisation 3.0 Other 27.9 Treatment of minor ailment 463 ANC care 32 Child care 79 Immunisation 25 Other 232 Behaviour of staff at health facility Courteous 58.2 Causal/Indifferent 39.7 Insulting/Derogatory 2.0 Courteous 484 Causal/Indifferent 330 Insulting/Derogatory 17 Listening of complaints by Doctor/staff Listened to compalaints 54.5 Somewhat listened 42.7 Not listened 2.8 Cannot say - Listened to compalaints 453 Somewhat listened 355 Not listened 23 Cannot say - Women patient were treated in privacy Yes 86.6 No 11.9 Donot know 1.4 Yes 720 No 99 Donot know 12

Cont…

172

Patients with chronic disease get regular medicines from health facility

Yes 60.6 No 18.2 Donot know 21.2 Yes 504 No 151 Donot know 176 Private practice of the doctors during and after the duty hours

Yes 22.5 No 43.2 Donot know 34.3 Yes 187 No 359 Donot know 285 Satisfied with overall services and staff of Govt Health Facility

Satistfied 31.9 Somewhat satisfied 64.5 Not satisfied 3.6 Satistfied 265 Somewhat satisfied 536 Not satisfied 30 Satisfied with the behaviour of staff at Govt. Health Facility

Satistfied 30.8 Somewhat satisfied 64.9 Not satisfied 4.3 Satistfied 256 Somewhat satisfied 539 Not satisfied 36

Table H-18 presents data on user fee in public hospitals. Among the respondents who

visited the health facility about 55 percent reported that no user fee was charged. Those

respondents who reported that they had paid money in the health facility, only 14 percent

got the receipt. It shows that no user fees except for some specific diagnostic services

were charged from the patients. But, the patients seemed to be paying bribe to get the

services in some instances.

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Table H.18 User fees and extra charges

Percent Total respondents who have availed the services in government health facility in last 6 months 831 User fees charged from the users Yes 45.5 No 54.5 Yes 378 No 453 If user fees charged, type of user fees: Registration Yes 16.7 No 83.3 Yes 63 No 315 X-ray Yes 5.6 No 94.4 Yes 21 No 357 ultrasound Yes 1.6 No 98.4 Yes 6 No 372 lab test Yes 3.7 No 96.3 Yes 14 No 364 other Yes 80.4 No 19.6 Yes 304 No 74 Receipt given for the user fees Yes 14.0 No 86.0 Yes 53 No 325 Extra money charged for any services Yes 30.2 No 64.8 Donot know 5.0 Yes 114 No 245 Donot know 19 Total respondents 378

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Services for BPL patients

Table H-19 gives information on the services for the BPL patients. Out of 1,200

households interviewed for the survey, 251 households belong to below poverty line. Of

these households, 28.7 percent said that they got free or subsidised services from health

facility. A majority of them faced some problem in processing their papers. The RKS

were not involved in sorting out the paper work of BPL households.

Table H19. Services for the BPL patients

Percent BPL patients provided free / subsidized services Yes 28.7 No 51.0 Donot know 20.3 Yes 72 No 128 Donot know 51 BPL patients faced any problem in paper work for free/subsidized services

Yes 18.7 No 37.8 Donot know 43.4 Yes 47 No 95 Donot know 109 RKS facilitated the paperwork for BPL patients Yes 2.0 No 23.9 Donot know 74.1 Yes 5 No 60 Donot know 186 Total BPL respondents 251

Outbreak and Control of Selected Diseases

In the study area, most of the respondents said that there were no major outbreak of

Malaria, Measles, Gastroenteritis and Jaundice diseases in their villages in the last six

months (Table H-20). Questions were asked in the survey to ascertain whether the

respondents had knowledge regarding preventive measures to be taken whenever there

was a major outbreak of diseases in their area. Table H-21 indicates that two-third of the

respondents reported that use of safe food and water could prevent diarrhoea. Twenty

three percent said proper hand washing before taking food prevent diarrhoea. For other

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diseases like high fever, persistent cough and breathing problems and loose motion, most

respondents opined taking patients to the nearest government health facility for treatment.

Table H 20. Outbreak of selected diseases in the respondents' area in the last six

months

Percent Malaria in last six months in the area Yes 5.2 No 94.0 Donot know 0.8 Yes 62 No 1,128 Donot know 10 Measles in last six months in the area Yes 2.5 No 96.8 Donot know 0.7 Yes 30 No 1,162 Donot know 8 Gastroenteritis in last six months in the area Yes 2.3 No 96.6 Donot know 1.2 Yes 27 No 1,159 Donot know 14 Jaundice in last six months in the area Yes 0.8 No 98.4 Donot know 0.8 Yes 9 No 1,181 Donot know 10 Other disease in last six months in the area Yes 19.9 No 79.3 Donot know 0.8 Yes 239 No 951 Donot know 10 Total number of household respondents 1,200

176

Table H 21. Action to be taken for selected diseases

Percent Prevention of diarrhoea: Hand washing Yes 23.8 No 76.3 Yes 285 No 915 Use of safe food and water Yes 65.9 No 34.1 Yes 791 No 409 Use of covered container Yes 15.0 No 85.0 Yes 180 No 1,020 Proper disposal of garbage Yes 17.6 No 82.4 Yes 211 No 989 other Yes 5.2 No 94.8 Yes 62 No 1,138 Don't know Yes 31.3 No 68.7 Yes 376 No 824 Action for high fever: Blood test for malaria Yes 5.6 No 94.4 Yes 67 No 1,133 Taken to RMP Yes - No 100.0 Yes - No 1,200 Taken to nearest govt health facility Yes 93.8 No 6.3 Yes 1,125 No 75 Consult ASHA Yes 0.3 No 99.8 Yes 3 No 1,197

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Try home remedies Yes 7.0 No 93.0 Yes 84 No 1,116 Other Yes 28.0 No 72.0 Yes 336 No 864 Don't know Yes - No 100.0 Yes - No 1,200 Action for persistent cough: Taken for sputum testing

Yes 3.7 No 96.3 Yes 44 No 1,156 Taken to RMP Yes 0.2 No 99.8 Yes 2 No 1,198 Taken to nearest govt health facility Yes 93.4 No 6.6 Yes 1,121 No 79 Consult ASHA Yes 0.1 No 99.9 Yes 1 No 1,199 Try home remedies Yes 19.8 No 80.3 Yes 237 No 963 Other Yes 21.3 No 78.7 Yes 256 No 944 Don't know Yes - No 100.0 Yes - No 1,200

Cont...

178

Table H 21. Action to be taken for selected diseases

Percent Action for loose -motions: Stop giving oral fluids/food etc

Yes 1.8 No 98.3 Yes 21 No 1,179 Start giving ORS Yes 11.0 No 89.0 Yes 132 No 1,068 Taken to RMP Yes 2.3 No 97.7 Yes 28 No 1,172 Taken to nearest govt health facility Yes 91.3 No 8.8 Yes 1,095 No 105 Consult ASHA Yes - No 100.0 Yes - No 1,200 Try home remedies Yes 21.0 No 79.0 Yes 252 No 948 Other Yes 21.7 No 78.3 Yes 260 No 940 Don't know Yes - No 100.0 Yes - No 1,200

Cont…

179

Action for persistent cough and breathing problem: Try home remedies

Yes 6.8 No 93.3 Yes 81 No 1,119 Taken to RMP Yes 0.3 No 99.7 Yes 4 No 1,196 Taken to nearest govt health facility Yes 93.3 No 6.7 Yes 1,120 No 80 Consult ASHA Yes - No 100.0 Yes - No 1,200 Other Yes 18.0 No 82.0 Yes 216 No 984 Don't know Yes - No 100.0 Yes - No 1,200 Total number of household respondents 1,200

Awareness of Family Planning Methods

In the survey questions were asked regarding knowledge of family planning, ideal gap

between first and second child and spacing methods. Data provided in Table H-22 reveals

that 97.7 percent of the respondents were aware of different family planning methods.

The present survey figures on awareness of different family planning were more or less

similar to RCH-2 and NFHS-3 data (IIPS, MOHW and ISEC, 2006; IIPS and Macro

International, 2008). About the ideal gap between first and second child, 24.1 percent

mentioned 2 years and 74.5 percent reported three or more years. A majority of the

respondents were aware of spacing methods, while 93.3 percent were aware of IUD, 87.1

percent Oral pills and 52 percent Nirodh/condom.

180

Table H 22. Awareness about spacing methods and ideal gap between 1st and 2nd

child Percent Aware of family planning methods Yes 97.7 No 2.3 Yes 1,172 No 28 Total number of household respondents 1,200 Ideal gap between first and second child 1 year 1.4 2 year 24.1 3 and more year 74.5 1 year 16 2 year 283 3 and more year 873 Spacing method: IUD Yes 93.3 No 6.7 Yes 1,093 No 79 Oral Pills Yes 87.1 No 12.9 Yes 1,021 No 151 Nirodh/Condom Yes 52.0 No 48.0 Yes 610 No 562 Any other Yes 8.4 No 91.6 Yes 98 No 1,074 Don't know Yes 0.2 No 99.8 Yes 2 No 1,170 Total number of household respondents 1,172

AIDS

All the respondents were asked whether they had ever heard of an illness called AIDS.

Respondents who had heard of AIDS were then asked a number of questions to ascertain

the mode of transmission and sources of their knowledge. When we compared the present

survey data with RCH-2 and NFHS-3 data regarding awareness of AIDS, the present

181

estimates were higher than the other two (RCH-2 and NFHS-3) surveys conducted in

Karnataka. The present survey results have been provided in Table H-23. It shows that

most of the respondents had heard of AIDS and they had correct knowledge of the mode

of transmission. A substantial proportion of respondents said that sexual contact, blood

transfusion and sharing of needle or syringes were the main mode of transmission of

AIDS. Regarding sources of information, about one-third had heard about it through

radio as well as from health workers, two-third from television, 23 percent from posters

and 13.5 percent from news papers. Over half of the respondents were aware of

HIV/AIDS counseling centers. Among those who were aware of counseling centers about

63 percent said it was in the district hospital and another 26 percent reported counseling

centers were in CHC.

Table H23. Awareness about modes of getting AIDS, source of information about

AIDS and awareness about VCTC

Percent Heard about HIV/AIDS Yes 96.8 No 3.2 Yes 1,162 No 38 Total number of household respondents 1,200 Mode of HIV/AIDS: Sexual contact Yes 86.3 No 13.7 Yes 1,003 No 159 Blood transfusion Yes 89.1 No 10.9 Yes 1,035 No 127 Sharing needles/syringes Yes 91.4 No 8.6 Yes 1,062 No 100 From mother to child Yes 18.7 No 81.3 Yes 217 No 945 Shaking hands Yes 0.5 No 99.5

182

Yes 6 No 1,156 Sneezing Yes 0.4 No 99.6 Yes 5 No 1,157 Insect bite Yes 4.0 No 96.0 Yes 46 No 1,116 Kissing Yes 0.4 No 99.6 Yes 5 No 1,157 Other Yes 4.8 No 95.2 Yes 56 No 1,106 Source of information on HIV/AIDS: Radio Yes 34.0 No 66.0 Yes 395 No 767 TV Yes 67.5 No 32.5 Yes 784 No 378 Health workers Yes 35.6 No 64.4 Yes 414 No 748 Posters Yes 23.2 No 76.8 Yes 270 No 892 News papers Yes 13.5 No 86.5 Yes 157 No 1,005 Other Yes 30.7 No 69.3 Yes 357 No 805

Cont…

183

Aware of HIV/AIDS counseling centre/VCTC nearby

Yes 54.4 No 45.6 Yes 632 No 530 Location of counseling centre PHC 2.1 CHC 26.1 District Hospital 63.4 Sub District Hospital 1.9 Private Hospital 4.1 Other 2.4 PHC 13 CHC 165 District Hospital 401 Sub District Hospital 12 Private Hospital 26 Other 15 Total number of household respondents 632

Summary

From the foregoing analysis it is clear that home deliveries had been reduced and

institutional deliveries, particularly at the public health institutions, had increased. This

might because of JSY scheme implemented in the district. Secondly, utilization of

government health services and knowledge of family planning particularly spacing

methods, had increased. Thirdly, awareness of AIDS and location of AIDS counseling

Centers had also increased. The increased awareness of health services and schemes

might have contributed to successful implementation of NRHM in the district.

184

Chapter 7

Role, Awareness and Involvement of Gram Panchayats

The National Rural Health Mission (NRHM) visualized the provision of decentralized

health system at all levels due to several reasons. First, a decentralized health system

ensures that the local needs of the health care are better addressed through the local

bodies empowered in India by proper legislation. Second, it is also possible to integrate

various other services like drinking water, sanitation, nutrition, empowerment etc, easily

and more efficiently through decentralized system of government. One of the major

objectives of the NRHM has been the integration of several services operated within the

health and allied system for an integrated approach to delivery of health services. Thus,

health is not purely seen as a disease but that which involves several complex processes.

The NRHM visualized the district health action plan as a major instrument in

planning inter-sectoral convergence. The district health mission under the Zilla Parishad

would get the district plan prepared covering health as well as other determinants of

health. Later, it is suggested to make village health plan as well, although, at the initial

stages of the mission, village health plan is not emphasized.

The Panchayat Raj institutions right from village to the district level is expected

to get the ownership of the public health system in their respective jurisdiction. While

CHC and PHC will have involvement of Panchayati Raj elected leader in its management

through Rogi Kalyan Samitis, the sub-centre will be accountable to the Gram Panchayat

through the local committee under the Village Health and Sanitation Committee (VHSC).

The objective of this chapter is to understand the current involvement of

Panchayati Raj institution in the health system particularly after the implementation of

the NRHM in the district of Hassan. The data have been gathered from 23 Gram

Panchayats under four PHC areas.

185

Status of Gram Panchayat

Table G-1 presents the status of selected Gram Panchayat in Hassan district of Karnataka.

Altogether, the information is gathered from 23 Gram Panchayats covering selected 24

villages for the survey. The average population size of a Gram Panchayat is close to 5000

population falling in 1200 households. The share of SC/ST population is about 25 per

cent (around 1200 population in 276 households). The share of Below Poverty Line

families as per the estimates given by the Gram Panchayats is 597 indicating that around

50 per cent of the families belonged to BPL. Among SC/ST households, around 79 per

cent belong to BPL families. Thus, the list of BPL families is significantly higher than the

estimated percentage of below poverty line population from Planning Commission

(Planning Commission 2007).

Table G-1: Status of Gram Panchayats Covered

Status of Gram Panchayat Covered Value A. Number of Gram Panchayats covered in the district 23 B. Average population of the Gram Panchayat covered Scheduled Caste 1,058.6 Scheduled Tribe 142.5 Total 4,944.8 C. Average number of Households in the Gram Panchayat covered Scheduled Caste 246.5 Scheduled Tribe 30.1 Total 1,201.4 D. Average number of BPL families in the Gram Panchayat covered Scheduled Caste 191.9 Scheduled Tribe 27.1 Total 597.2

Involvement of Gram Panchayat in the Public Health System

It is often found that although the Gram Panchayats are empowered through the

legislation by providing authority over public health system, the awareness levels of the

functioning of the health programmes are comparatively poor among the Gram Panchayat

members. In order to find out the awareness as well as the functioning of the public

health system several questions is asked to the members of Gram Panchayat on the

186

functioning of the health system. Table G-2 presents the level of awareness and

involvement of Gram Panchayat in the public health system in Hassan district.

Table 2: Level of Awareness and Involvement of Gram Panchayats

Level of awareness and involvement of Gram Panchayats Percent A. Percentage of Gram Panchayat reporting regular availability of ANM 86.4 B. Percentage of Gram Panchayat reporting timely services provided by Sub Centre to the patients 87.0 C. Percentage of Gram Panchayat reporting role of Gram Panchayat in conducting/finalizing IEC programme in Gram Panchayat 87.0 D. Percentage of Gram Panchayat reporting existence of VHSC in their Gram Panchayat 78.3 E. Percentage of Gram Panchayat reporting regular meetings of VHSC 50.0 F. Percentage of Gram Panchayat reporting Village Health Plan been prepared by VHSC 22.2 G. Percentage of Gram Panchayat reporting that VHSC has received any Untied Fund 66.7 H. Percentage of Gram Panchayat reporting ASHA worker in position 0.0 I. Percentage of Gram Panchayat reporting awareness of the benefits under JSY scheme 91.3 J. Percentage of Gram Panchayat reporting that NRHM brought about any improvement in their area 82.6 K. Distribution of Gram Panchayats covered by type of improvement reported due to NRHM Funds available for maintenance of Sub Centres 47.4 Community support is available as ASHA worker - Funds/facilities are available under JSY 84.2 Better facilities are available for CHCs/PHCs for referred patients 21.1 Transport facilities are available 15.8 Other - L. Distribution of Gram Panchayats by type of difficulties faced in implementing programme activities under NRHM Funds not available in time 8.7 Decision making with community leaders are difficult 30.4 ASHA has not been adequately trained 0.0 Adequate facility for institutional deliveries are not available 13.0 Other 8.7 M. Distribution of Gram Panchayats by kind of support required to implement programme more effectively More funds are required for maintenance/ effective functioning 82.6 Gram Panchayat should be given direct control over funds 39.1 More training is to be arranged for ASHA and Community members 17.4 Any other 4.3 Number of Gram Panchayat covered in the district 23

187

It is found that the percentage of Gram Panchayat reporting availability of ANM,

provision of timely services and involvement in the IEC programmes are relatively high

in the selected areas. For instance, over 86 per cent of the Gram Panchayats reported the

availability of ANM, provision of timely services and involvement of Gram Panchayats

in IEC programme in the district.

However, in the case of NRHM specific schemes like VHSC, although the

awareness is quite high, the implementation part is rather weak. For instance, it is found

that around 78 per cent of the Gram Panchayat members reported having VHSC in their

village but only 50 per cent reported about the conduct of regular VHSC meetings.

Further only 22 per cent of the VHSC reported having prepared a Village Health Plan.

This is despite the fact that 67 per cent of the VHSC received untied funds.

Awareness of Public Health System and NRHM

On the contrary, the awareness about the NRHM programme is relatively very high

among the Gram Panchayat members. Over 91 per cent are aware of JSY programme and

83 per cent among them thought that NRHM has brought about positive changes in the

public health system in the village. On specific questions on the improvement that are

vital as part of the NRHM, a majority of them (84 per cent) thought JSY programme is

the most important programme making considerable changes. The second most important

changes observed by the members are the availability of funds for the maintenance of the

sub centre (47.4 per cent). In addition, around 21 per cent reported that there are better

facilities in the PHCs and CHCs for the referral cases and 16 per cent are happy about the

transport system under NRHM.

Difficulties under NRHM

The members of the Gram Panchayats are asked about the difficulties faced in the

implementation of the NRHM programme and activities in the village. Interestingly, the

non availability of funds was reported as a lacuna only by 9 per cent of the Gram

Panchayat members. However, the major difficulty brought out by around 30 per cent of

the members is the difficulty in decision-making with community leaders etc. Around 13

188

per cent also reported that adequate facilities are not available for institutional deliveries.

Thus, it seems that the only major difficulty faced by the Gram Panchayat is the

coordination problem which has been also noted in the personal discussion with different

stake holders.

Support Needed for Better Functioning

The Gram Panchayat members are also asked about the support they require for the

effective functioning of the NRHM programme. Interestingly, most of the Gram

Panchayat members wanted more funds for maintenance/effective functioning of the

NRHM programme and around 39 per cent considered that the Gram Panchayat should

have direct control over the NRHM funds. The necessity of more training was

emphasized by around 17.4 per cent of the community members. Interestingly, funds are

not reported as a serious problem by the members when asked about the difficulties faced

in the implementation of NRHM.

Summary

In general, it is felt that NRHM is making progressive changes in integrating the

community with the health system by the involvement of Gram Panchayats. The

awareness of the Panchayat members on NRHM and related services provided by the

public health system is relatively very high. However, the implementation parts of the

programme like conducting regular VHSC meetings, preparation of village health action

plan etc are rather weak.

189

Chapter 8

Quality of Care and Client’s Satisfaction

Introduction

It is often argued that the major reason for the under-utilisation of public health services

in India is due to the poor quality of services. Utilisation of health services depends on

peoples’ experiences and perceptions about the quality of care they receive. In other

words, the quality of care involves provision of good medical facilities coupled with

positive attitude of the medical and non-medical staff towards the clients (Bruce, J. 1991;

Koeing et al. 1997; and Visaria, and Visaria 1992).

NRHM primarily aims to improve the quality of services provided through the

public health system for better utilization of services. In this chapter, an attempt is made

to understand peoples’ perception on the quality of services provided through exit

interviews at different health institutions.

As part of the NRHM rapid evaluation of out-patients as well as in-patients

visiting various public health facilities are interviewed to ascertain their perception on the

quality of care. Specific dimensions covered are waiting time before receiving the

services, time spent for the staff at the health facility, behaviour of the staff, privacy in

the facility and cleanliness. On the whole, the satisfaction level of patients regarding

services are tested through the schedules. There are two sections in this chapter: section

one deal with in-patients interview and second section is all about the out-patients

interview.

Section I: In-Patients Interview

Background Characteristics of the In-Patients

Background characteristics of the in-patients are presented in Table I-1. It can be seen

from the table that a majority of the in-patients are adults in the age group of 20-49. Most

of the patients are males, currently married and from rural areas. Out of the total in-

patients interviewed, four-fifths of them are in-patients of a CHC and 17 per cent are

from the district hospital. No in-patients are interviewed at the PHC.

190

Table I-1: Background characteristics of the in-patients

Background Characteristics of the In-Patients Percent Age < 20 years 6.7 20-29 years 26.7 30-39 years 20.0 40-49 years 20.0 50-59 years 13.3 60 years or more 13.3 Sex Male 70.0 Female 30.0 Marital status Unmarried 10.0 Currently married 90.0 Divorced/Separated - Widowed - Residence Rural 70.0 Urban 30.0 Type of Health Facility District Hospital 16.7 CHC 83.3 PHC - Total no. of in-patients interviewed 30

Purpose of Admission in the Health Institution

Table I-2 presents the reasons for admitting the patients in the hospital. Nearly three-forth

of the in-patients are admitted for illnesses such as typhoid, stomach pain, diabetes,

diarrhea, blood pressure and fever. Around 16 per cent of the in-patients in the CHC

reported delivery as the purpose of admission.

Table I-2: Purpose of the admission in the Health Institution

Type of Health Facility (Percent) Purpose of admission in Health Institution District Hospital CHC PHC All Minor illness 20.0 4.0 - 6.7 FP surgery - - - - Delivery - 16.0 - 13.3 Cataract surgery - 4.0 - 3.3 Child admitted - - - - Other 80.0 76.0 - 76.7 Total no. of in-patients interviewed 5 25 - 30

191

Table I-3: Waiting Time Type of Health Facility (Average waiting time in minutes) Average waiting time for: District Hospital CHC PHC All

Registration 10.0 11.2 - 11.0 Doctor's call 8.0 26.1 - 23.1 Doctor's examination 9.0 12.0 - 11.5 Admission to ward 7.0 25.6 - 22.5 Getting services 5.0 17.6 - 15.5 To get discharged 10.0 11.8 - 11.5 Total no. of in-patients interviewed 5 25 - 30

Table I-4: Satisfaction regarding Waiting Time

Type of Health Facility Waiting time for/Satisfaction District Hospital CHC PHC All Registration Too long - 4.0 - 3.3 Appropriate 80.0 44.0 - 50.0 Too short 20.0 52.0 - 46.7 Can't say - - - - Doctor's call Too long - 28.0 - 23.3 Appropriate 80.0 44.0 - 50.0 Too short 20.0 28.0 - 26.7 Can't say - - - - Doctor's examination Too long - 4.0 - 3.3 Appropriate 80.0 36.0 - 43.3 Too short 20.0 60.0 - 53.3 Can't say - - - - Admission to ward Too long - 24.0 - 20.0 Appropriate 80.0 48.0 - 53.3 Too short 20.0 28.0 - 26.7 Can't say - - - - Getting services Too long - 16.0 - 13.3 Appropriate 80.0 36.0 - 43.3 Too short 20.0 48.0 - 43.3 Can't say - - - - To get discharged Too long - 32.0 - 26.7 Appropriate 80.0 60.0 - 63.3 Too short 20.0 8.0 - 10.0 Can't say - - - - Total no. of in-patients interviewed 5 25 - 30

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Waiting Time

Table I-3 provides data on the average waiting time for different services like

registration, doctor’s call, doctor’s examination, admission to the ward and for getting

discharged. The average waiting time for different services ranges between 11 minutes to

23 minutes. However, the data show a longer waiting time for getting most of the

services in CHC as compared to the district hospital. On the whole, the waiting time is

not very high both in the district hospital and CHCs.

A question was also posed to the in-patients on the satisfaction of waiting time for

getting different services at the District Hospital and the CHCs. The data presented in

Table I-4 shows that on the whole, only a small proportion of the in-patients are not

satisfied with the waiting time for getting different services. For example, only 3 per cent

of the in-patients felt that the waiting time for registration and doctors’ call is too long.

More than one-fifth of the patients felt that the time taken for doctors’ call, admission to

the ward and getting discharged are too long. The data show that a majority of the

inpatients are satisfied with the waiting time for getting different services.

Staff Behaviour

Behaviour of the staff is yet another indicator used to understand the quality of services.

Behvaiour of the clinical as well as the support staffs are important indicators of client

satisfaction. The data provided in Table I-5 shows that in general, the behaviour of the

clinical staff is better compared to the other support staff. A majority of the respondents

rated the behaviour of the doctor and nurse as reasonable or good whereas the behaviour

of the support staff such as ayahs, ward boys and counter clerks as negligent, arrogant or

indifferent. Further, the staff behaviour is better in District Hospitals compared to CHCs.

Unique / Innovative Measure Taken to Improve the Staff Behaviour

Questions are asked to the in-patients whether the hospital authorities have taken any

unique/innovative measure to improve the staff behaviour (Table I-6). But it should be

remembered that the patients may be unaware of such measures even if it exists in the

hospital. As a result, all the patients from the district hospital said that no measures are

193

taken at the hospital while, in CHC, the percentage of patients telling that no measures

are taken is around 84 per cent.

Table I-5: Behaviour of Staff

Type of Health Facility (Percent) Staff Behaviour District Hospital CHC PHC All

Doctor greet in a friendly manner

Yes 100.0 60.0 - 66.7 Somewhat - 36.0 - 30.0 No - 4.0 - 3.3 Behaviour of Doctor Rude - 4.0 - 3.3 Reasonable 80.0 56.0 - 60.0 Good 20.0 40.0 - 36.7 Very kind - - - - Behaviour of Nurse Rude - - - - Reasonable 60.0 60.0 - 60.0 Good 40.0 40.0 - 40.0 Very kind - - - - Behaviour of Technical Staff

Rude - - - - Reasonable 60.0 66.7 - 65.5 Good 40.0 33.3 - 34.5 Very kind - - - - Behaviour of Ayah Negligent 20.0 4.0 - 6.7 Arrogant 20.0 20.0 - 20.0 Indifferent 40.0 32.0 - 33.3 Good 20.0 44.0 - 40.0 Behaviour of Ward Boys Negligent - - - - Arrogant 40.0 24.0 - 26.7 Indifferent 60.0 24.0 - 30.0 Good - 52.0 - 43.3 Behaviour of Counter Clerk Negligent - - - - Arrogant - 24.0 - 20.0 Indifferent 20.0 24.0 - 23.3 Good 80.0 52.0 - 56.7 Total no. of in-patients interviewed 5 25 - 30

194

Table I-6: Unique/ innovative measure taken to improve the staff behaviour

Type of Health Facility (Percent) Staff Behaviour District Hospital CHC PHC All Unique/innovative measure taken to improve the staff behaviour

5 25 - 30

Yes - 16.0 - 13.3 No 100.0 84.0 - 86.7 Don't know - - - - Total no. of in-patients 5 25 - 30

Privacy

Lack of privacy is yet another reason reported for the non-use of public health facilities.

An attempt has been made to understand whether the health facilities have ensured

privacy for their patients. The data presented in Table I-7 shows that a majority of the

respondents indicated that privacy exists at the place of examination. Further, a higher

proportion (88 per cent) of the patients from the CHCs reported privacy in the

examination room than patients from the District Hospital (60 per cent).

Table I-7: Privacy Privacy Type of Health Facility (Percent) Ptivacy District Hospital CHC PHC All Patients reporting presence of privacy at the place of examination

60.0 88.0 - 83.3

Total no. of in-patients interviewed 5 25 - 30

Patient- Doctor/ Provider Communication

The various dimens ions of the quality of doctor-patient communication are assessed by

enquiring whether the doctor listened to the problems of patients, whether the doctor

allowed the patients to ask questions and responded to them, whether the doctor

discussed about the ailments and their recovery and also whether the doctor gave other

advice or not. The data (Table I-8) indicate that a majority of the patients felt that they

had a positive interaction with the doctor. Most of them also felt that the doctor listened

to their problems. A higher proportion of the patients from the District hospital felt that

the health care providers are responsive to their problems than the patients of the CHC.

195

Table I-8: Patient-Doctor/ Provider Communication

Type of Health Facility (Percent) Patient-Doctor/ Provider Communication District Hospital CHC PHC All

Doctor listened to description of ailment patiently

Yes, somewhat 80.0 60.0 - 63.3 Yes, always 20.0 40.0 - 36.7 No - - - - Did not interact with doctor - - - -

Doctor allowed to ask question

Yes, somewhat 80.0 56.0 - 60.0 Yes, always 20.0 24.0 - 23.3 No - 20.0 - 16.7 Did not interact with doctor - - - -

Doctor responded to question

Yes, somewhat 80.0 60.0 - 63.3 Yes, always 20.0 28.0 - 26.7 No - 12.0 - 10.0 Did not interact with doctor - - - -

Doctor discussed about ailment

Yes 80.0 100.0 - 96.7 No 20.0 - - 3.3 Did not interact with doctor - - - -

Doctor talked about the recovery

Yes 100.0 96.0 - 96.7 No - 4.0 - 3.3 Did not interact with doctor - - - -

Doctor gave 'other advice'

Yes 80.0 72.0 - 73.3 No 20.0 28.0 - 26.7 Did not interact with doctor - - - -

Total no. of in-patients interviewed 5 25 - 30

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Cleanliness of the Facility

A clean and hygienic environment is an important component in bringing positive health

outcomes among the patients. Here, the question on frequency of cleanliness of various

aspects of the facilities such as cleanliness of floor, bathroom/toilet, frequency of

changing patients’ uniform and bed sheets are ascertained. Not only the frequency of

cleaning but the satisfaction of the patients regarding the cleanliness is also ascertained.

Table I-9 shows that, in general, the frequency of cleaning is better for common facilities

like floor and toilet/bathroom than the individual facilities like changing patients’

uniform and bed sheets. A majority of the patients felt that the floor and toilet/bathroom

of the hospital are cleaned either once or twice a day. However, a majority of the patients

reported that their uniform and bed sheet were not changed at all. Cleaning of common

facilities is better in the district hospitals than the CHC, whereas, cleanliness of

individual facilities like, uniform and bed sheets are better in CHCs as compared to the

district hospitals.

Table I-9: Cleanliness of the facility

Type of Health Facility (Percent) Type of facility/ Frequency of cleaning District Hospital CHC PHC All Floor Thrice a day - - - - Twice a day 40.0 20.0 - 23.3 Once a day 60.0 68.0 - 66.7 Less than once a day - 12.0 - 10.0 Not applicable - - - - Toilet/Bathroom cleaning Thrice a day - - - - Twice a day 20.0 16.0 - 16.7 Once a day 80.0 68.0 - 70.0 Less than once a day - 16.0 - 13.3 Not applicable - - - - Changing patient's uniform Twice a day - - - - Once a day - 24.0 - 20.0 Less than once a day - 12.0 - 10.0 Not changed 100.0 64.0 - 70.0 Not applicable - - - -

Cont…

197

Changing bed-sheets Twice a day - 8.0 - 6.7 Once a day - 24.0 - 20.0 Less than once a day - 16.0 - 13.3 Not changed 100.0 52.0 - 60.0 Not applicable - - - - Total no. of in-patients interviewed 5 25 - 30

Data on the satisfaction of patients regarding cleanliness of the health facility is

presented in Table I-10. This table shows that only a small proportion of the patients are

not satisfied with the cleanliness of the floor (6.7 per cent), whereas, more than one-fifth

of the patients opined that they are not satisfied with the cleaning of toilet and bathroom.

However, a majority of the patients are not satisfied either with the changing of patients’

uniform or with the changing of bed sheets. Perhaps, more attention is necessary in the

cleanliness of individual items in both health facilities.

Table I-10: Satisfaction of patients regarding cleanliness of the facility

Type of facility/ Satisfaction Type of Health Facility (Percent)

Type of facility/ Satisfaction District Hospital CHC PHC All

Floor cleaning Satisfied 40.0 20.0 - 23.3 Somewhat satisfied 60.0 72.0 - 70.0 Not satisfied - 8.0 - 6.7 Toilet/ Bathroom cleaning

Satisfied 40.0 8.0 - 13.3 Somewhat satisfied 40.0 68.0 - 63.3 Not satisfied 20.0 24.0 - 23.3 Changing patient's uniform

Satisfied - 8.0 - 6.7 Somewhat satisfied 40.0 28.0 - 30.0 Not satisfied 60.0 64.0 - 63.3 Changing bed sheets Satisfied - 8.0 - 6.7 Somewhat satisfied 40.0 36.0 - 36.7 Not satisfied 60.0 56.0 - 56.7 Total no. of in-patients interviewed 5 25 - 30

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Crowding in the Facility

Over-crowding is yet another important issue for non-use of public health facilities. An

attempt has been made to understand the situation of over-crowding in district hospitals

and CHCs. The data present in Table I-11 indicate that overall, over-crowding is not an

issue in the selected district hospital and CHCs. A vast majority of the in-patients

reported that they could get a cot immediately after admission and the cot is available till

the time of discharge. Only a small proportion of the in-patients reported that the space in

the ward is not adequate or not satisfied with the ward arrangement. Over-crowding is

least felt in the district hospital compared to the CHCs.

Table I-11: Crowding in the facility

Type of Health Facility (Percent) Crowding in the facility District

Hospital CHC PHC All

Availability of cot Immediately 100.0 88.0 - 90.0 Not immediately but same day - 12.0 - 10.0

Next day - - - - After more than a day - - - - Never got the cot - - - - Availability of cot/bed till the time of discharge

Yes 100.0 100.0 - 100.0 No - - - - Adequacy of space in the ward

Adequate 20.0 36.0 - 33.3 Somewhat adequate 80.0 48.0 - 53.3 Not adequate - 16.0 - 13.3 Satisfaction with the ward arrangement

Satisfied - 20.0 - 16.7 Somewhat satisfied 80.0 72.0 - 73.3 Not satisfied 20.0 8.0 - 10.0 Adequacy of space in IPD

Adequate - 36.0 - 30.0 Somewhat adequate 80.0 48.0 - 53.3 Not adequate 20.0 16.0 - 16.7 Total no. of in-patients interviewed 5 25 - 30

199

Amenities Provided by the Hospital

Availability of the amenities strengthens the hospital facilities and improves the quality

of services. Table I-12 provides information about the availability of amenities and

satisfaction regarding the available amenities. Almost all the patients reported the

presence of an ambulance in the health facility, whereas, a relatively lesser proportion of

patients are aware of the medical shops or telephone or the accommodation available for

the relatives. Except in case of telephone, the patients from the district hospital are better

aware of the amenities available in the facility than the patients from CHCs. The

Important thing here is that either in-patients are not aware of these facilities provided by

the hospitals or they are not told by the hospital personnel about these amenities available

in the hospital. The satisfaction levels of patients with regard to the available of amenities

are also found to be very high.

Table I-12: Amenities provided by the hospital

Type of Health Facility Percentage of in-

patients reporting availability/ % reporting satisfaction

Percent District Hospital Percent CHC Percent PHC Percent All

Availability of amenities

Television - - - - - - - - Canteen 20.0 1 16.0 4 - - 16.7 5 Medical shop 100.0 5 36.0 9 - - 46.7 14 Telephone 20.0 1 72.0 18 - - 63.3 19 Accommodation for relatives 60.0 3 60.0 15 - - 60.0 18

Ambulance 100.0 5 96.0 24 - - 96.7 29 Satisfaction among those who said the amenity is available

Television - - - - - - - - Canteen 100.0 1 100.0 4 - - 100.0 5 Medical shop 100.0 5 77.8 7 - - 85.7 12 Telephone 100.0 1 77.8 14 - - 78.9 15 Accommodation for relatives 100.0 3 86.7 13 - - 88.9 16

Ambulance 100.0 5 83.3 20 - - 86.2 25

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Continuity of Treatment

Continuity of treatment is a good indicator to understand the quality of service provided.

If the patient is satis fied with the facility in the earlier visit he/she may come again or

recommend others to avail these facilities. Table I-13 gives information about different

aspects of the quality of services which led to continuity of the treatment. This table

shows that none of the patients are dissatisfied with the services provided by the health

facilities. More than 95 per cent of the patients indicated the future use of the facility in

case they fell sick and all of them stated that they would recommend this hospital to

others.

Table I-13: Continuity of treatment

Type of Health Facility (Percent) Continuity of

treatment District Hospital CHC PHC All

Overall satisfaction on visiting to facility

Dissatisfied - - - - Somewhat satisfied 100.0 76.0 - 80.0 Satisfied - 24.0 - 20.0 Reason of dissatisfaction

Lack of facilities - - - - Bad experience with doctor - - - -

Poor quality of services - - - -

Charges are exobhitent - - - -

Other - - - - Would like to come again in case fell sick

Yes 100.0 96.0 - 96.7 No - 4.0 - 3.3 May come/unsure - - - - Whether recommend this hospital to other

Yes 100.0 100.0 - 100.0 No - - - - Total no. of in-patients interviewed 5 25 - 30

201

Section II: Out-Patient’s Interview

Background Characteristics of the Out-Patients

For this study, we interviewed 44 out-patients from different facilities like District

Hospital in Hassan, the Community Health Centres in Arsikere and Sakleshpur and

Primary Health Centres in Harnahally and Hiresadarahally of Arsikere taluk, Ballupet

and Uchangy of Sakleshpur taluk.

Out of 44 out-patients, half of the out patients are interviewed in PHCs followed

by CHCs (38 per cent) and District hospital (11 per cent). Among them, majorities (70

per cent) of the out-patient are males and thirty per cent are females. Similarly, four- fifths

of the out-patients are from rural areas and the rest from urban areas.

As far as age distribution is concerned, more respondents (43 per cent) are in the

age-group of 20-39 years followed by 60+ years (25 per cent). A majority of the

respondents are currently married (79 per cent). Unmarried and widowed category is just

nine and eleven per cent respectively (Table O-1).

Table O-1: Background characteristics of the out-patients Background Characteristics of the Out-Patients Percent Age < 20 years 2.3 20-29 years 34.1 30-39 years 9.1 40-49 years 18.2 50-59 years 11.4 60 years or more 25.0 Sex Male 29.5 Female 70.5 Marital status Unmarried 9.1 Currently married 79.5 Divorced/Separated - Widowed 11.4 Place of residence Rural 79.5 Urban 20.5 Type of Health Facility District Hospital 11.4 CHC 38.6 PHC 50.0 Total no. of out-patients interviewed 44

202

Purpose of Visit to the Health Institution

The purpose of visit to the facilities has been for different reasons like minor illness,

family planning services, antenatal care, post-natal care, eye checkup, MDT-DOTS, etc.

According to the available data (Table O-2), about 43 per cent of the out-patients visited

facilities for the treatment of illnesses such as asthma, piles, stomach pain, diabetes,

uterus problem, body pain, joint pain and neurological problem. Only eighteen per cent of

the patients visited OPD section for their children’s illness.

Table O-2: Purpose of visit to the Health Institution

Type of Health Facility (Percent) Purpose of visit in the

Health Institution District Hospital CHC PHC All Minor illness 80.0 29.4 36.4 38.6 FP services - - - - Antenatal care - - - - PNC - - - - Eye checkup - - - - MDT-DOTs - - - - Child illness - 29.4 13.6 18.2 Other 20.0 41.2 50.0 43.2 Total no. of out-patients interviewed 5 17 22 44

Waiting Time in the Hospital

Studies have found that the waiting time spent for availing different services has a direct

bearing on the satisfaction level of the patients. Table O-3 presents the waiting time for

different services like registration, injections, medicines, dressing and paying bills etc.

The data show that the average waiting time did not vary widely among district hospitals,

CHCs and PHCs for getting various services. It is also observed that the waiting time is

relatively short for all services.

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Table O-3: Waiting time

Type of Health Facility Waiting time for District

Hospital CHC PHC All Registration Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 11.0 8.5 7.8 8.4 Doctor's examination Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 12.0 22.6 25.5 22.9 Injection Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 9.0 10.1 6.1 8.0 Getting medicines Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 13.0 8.7 4.9 7.3 Dressing Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 16.0 9.9 11.3 11.3 Paying bill Number of patients availed the service 5 17 22 44

Average waiting time (in minutes) 10.0 8.1 7.6 8.1

Table O-4 shows the satisfaction level of patients regarding waiting time in the hospitals

for registration, doctor’s examination, injections, getting medicines, dressing and paying

the bills, etc. It shows that a majority of the out-patients expressed satisfaction on the

appropriateness of waiting time in the district hospital. In case of PHCs, however, there

has been some concern on the time spent by the health personnel for various services like

doctors’ examination. The data show that a majority of the out-patients are satisfied with

the waiting time for receiving different services in the health facilities.

204

Table O-4: Satisfaction regarding waiting time

Satisfaction Type of Health Facility (% of patients)

Satisfaction District Hospital CHC PHC All

Registration Too long - 6.3 - 3.4 Appropriate 80.0 37.5 50.0 48.3 Too short 20.0 56.3 50.0 48.3 Can't say - - - - Number of patients availed the services 5 16 8 29

Doctor's examination Too long - 29.4 30.0 26.2 Appropriate 80.0 41.2 15.0 33.3 Too short 20.0 29.4 55.0 40.5 Can't say - - - - Number of patients availed the services 5 17 20 42

Injection Too long - 7.1 5.3 5.3 Appropriate 100.0 35.7 15.8 34.2 Too short - 57.1 78.9 60.5 Can't say - - - - Number of patients availed the services 5 14 19 38

Getting medicines Too long - 6.7 - 2.5 Appropriate 100.0 40.0 20.0 37.5 Too short - 53.3 80.0 60.0 Can't say - - - - Number of patients availed the services 5 15 20 40

Dressing Too long 20.0 - 25.0 15.8 Appropriate 60.0 83.3 12.5 47.4 Too short 20.0 16.7 37.5 26.3 Can't say - - 25.0 10.5 Number of patients availed the services 5 6 8 19

Paying bill Too long - - - - Appropriate 80.0 80.0 57.1 70.6 Too short 20.0 20.0 14.3 17.6 Can't say - - 28.6 11.8 Number of patients availed the services 5 5 7 17

205

Table O-5: Behaviour of staff

Staff Behaviour Type of Health Facility

Staff Behaviour District Hospital CHC PHC All

Doctor greet in a friendly manner

Not friendly - 5.9 18.2 11.4 Yes, somewhat 80.0 82.4 81.8 81.8 Yes 20.0 11.8 - 6.8 Did not interact/ Not applicable - - - -

Behaviour of Doctor Rude - - - - Reasonable 40.0 76.5 54.5 61.4 Good 60.0 23.5 45.5 38.6 Very kind - - - - Did not interact/ Not applicable - - - -

Behaviour of Nursing Staff

Rude 20.0 - - 2.3 Reasonable 80.0 94.1 59.1 75.0 Good - 5.9 40.9 22.7 Very kind - - - - Did not interact/ Not applicable - - - -

Behaviour of Dispenser

Rude - - - - Reasonable 80.0 64.7 54.5 61.4 Good 20.0 35.3 45.5 38.6 Very kind - - - - Did not interact/ Not applicable - - - -

Behaviour of Technician

Rude - - - - Reasonable 60.0 82.4 27.3 52.3 Good 20.0 11.8 45.5 29.5 Very kind - - - - Did not interact/ Not applicable 20.0 5.9 27.3 18.2

Total no. of out-patients interviewed 5 17 22 44

206

Behaviour of the Staff in Hospitals

The behaviour of the staff is a very important aspect of the quality of services. The study

tried to assess the behaviour of various staff in the hospitals like doctor, nursing staff,

pharmacist and technicians, etc. According to the data, three-fifth of the out-patients

considered the behaviour of doctor as good in district hospital and with the forty per cent

it is reasonable. In PHCs and CHCs more than half of the out-patients expressed that the

behaviour of doctors are reasonable and the rest admitted it as good. There was, however,

no reporting of rude behaviour in any of these hospitals except the behaviour of nursing

staff in district hospital. One-fifth of the out-patients reported that the behaviour of the

nursing staffs is rude in the district hospital (Table O-5).

Privacy

Another important determinant of the quality of care is privacy in the health facilities. In

the present study, questions are asked to ascertain whether privacy exist during

examination. A majority of the out-patients interviewed reported that privacy exists at the

time of examination. All the patients from district hospital, 94 per cent from CHC and 82

per cent of the patients in PHC reported that privacy exists at the place of examination

(Table O-6).

Table O-6: Privacy

Type of Health Facility (Percent) Privacy District

Hospital CHC PHC All

Patients reporting presence of privacy at the place of examination

100.0 94.1 81.8 88.6


Patient- Doctor/Provider Communication

Table O-7 shows the details on the extent of patient-doctor/provider communication.

Most of the out-patients reported that the doctors listened to their ailments patiently,

allowed patients to ask questions and responded to them. Doctors discussed with them

207

about the ailments, the recovery time and gave advice regarding taking care of the

diseases.

Table O-7: Patient-Doctor/Provider Communication Type of Health Facility (Percent) Patient-Doctor

Communication District Hospital CHC PHC All Doctor listened to description of ailment patiently

Yes, somewhat 100.0 76.5 68.2 75.0 Yes, always - 17.6 31.8 22.7 No - 5.9 - 2.3 Did not interact/Not Applicable - - - -

Doctor allowed to ask questions

Yes, somewhat 100.0 70.6 40.9 59.1 Yes, a lways - - 9.1 4.5 No - 29.4 50.0 36.4 Did not interact/Not Applicable - - - -

Doctor responded to questions

Yes, somewhat 100.0 58.8 36.4 52.3 Yes, always - 17.6 18.2 15.9 No - 23.5 45.5 31.8 Did not interact/Not Applicable - - - -

Doctor discussed about the ailment

Yes 80.0 70.6 90.9 81.8 No 20.0 29.4 9.1 18.2 Did not interact/Not Applicable - - - -

Doctor talked about the recovery

Yes 80.0 64.7 86.4 77.3 No 20.0 35.3 13.6 22.7 Did not interact/Not Applicable - - - -

Doctor gave 'other advice' Yes 100.0 64.7 68.2 70.5 No - 35.3 31.8 29.5 Did not interact/Not Applicable - - - -


208

There are differences between district hospital, CHCs and PHCs on patient-doctor

communication. All the patients in district hospitals are extremely happy with all aspects

of doctor-patient communication. But, somewhat mixed picture is emerging from CHCs

and PHCs. Almost half of the patients from PHC and a quarter from CHC reported that

the doctor, neither asked questions nor responded adequately to their queries. Overall, the

doctor-patient communications are found to be good in the district hospital but a mixed

picture emerged from CHCs and PHCs.

Satisfaction of the OPD Patients Regarding Cleanliness of the Facility

The study/survey highlights the cleanliness of the health facility through clients’

perspectives. Questions are asked to the out-patients about the cleanliness of the health

facility they visited. Table O-8 shows that only a small proportion of the patients are not

satisfied with the cleanliness of the examination room, laboratory, injection room and

dressing room (2 per cent). However, there are some differences in the perception of

cleanliness between patients of the district hospital, CHCs and PHCs. A majority of the

patients in the district hospital perceived that health facilities in the hospitals are clean as

compared to the patients from CHCs and PHCs. The data show that cleanliness is ensured

in the health facilities as majority of the out-patients mentioned that the facilities are

clean.

Satisfaction of the OPD Patients Regarding Crowding of the Facility

Over-crowding is yet another important issue for non-use of public health facilities. An

attempt has been made to understand the situation of over-crowding in public health

facilities. Table O-9 indicates that, over-crowding is not an issue in the selected health

facilities. A majority of the in-patients reported that they have adequate space in OPD

room, examination room, dispensary, laboratory, injection room and dressing room. Only

a small proportion of the out-patients reported that the space is not adequate in the

available facilities in the hospital. Most of the out-patients are satisfied with the space

available in the selected health facilities.

209

Table O-8: Satisfaction of OPD patients regarding cleanliness of the facility

Type of Health Facility (Percent of patients) Satisfaction regarding cleanliness in the facility

District Hospital CHC PHC All

OPD Room Not clean - - - - Partially clean 20.0 70.6 63.6 61.4 Clean 80.0 29.4 36.4 38.6 No. of patients availed the services 5 17 22 44

Examination Room Not clean - - 4.5 2.3 Partially clean - 76.5 59.1 59.1 Clean 100.0 23.5 36.4 38.6 No. of patients availed the services 5 17 22 44

Dispensary Not clean - - - - Partially clean - 58.3 44.4 45.8 Clean 100.0 41.7 55.6 54.2 No. of patients availed the services 3 12 9 24

Laboratory Not clean - - 8.3 2.9 Partially clean - 76.5 66.7 61.8 Clean 100.0 23.5 25.0 35.3 No. of patients availed the services 5 17 12 34

Injection Room Not clean - - 4.5 2.3 Partially clean - 82.4 54.5 59.1 Clean 100.0 17.6 40.9 38.6 No. of patients availed the services 5 17 22 44

Dressing Room Not clean - - 7.7 2.9 Partially clean - 75.0 61.5 58.8 Clean 100.0 25.0 30.8 38.2 No. of patients availed the services 5 16 13 34

210

Table O-9: Satisfaction of OPD patients regarding crowding in the facility

Type of Health Facility (Percent of patients) Satisfaction regarding crowding in the facility District Hospital CHC PHC All OPD Room Not adequate - - 9.1 4.5 Somewhat adequate 40.0 47.1 77.3 61.4 Adequate 60.0 52.9 13.6 34.1 Not applicable - - - - No. of patients availed the facility 5 17 22 44 Examination Room Not adequate - - 13.6 6.8 Somewhat adequate 40.0 52.9 77.3 63.6 Adequate 60.0 47.1 9.1 29.5 No. of patients availed the facility 5 17 22 44 Dispensary Not adequate - - - - Somewhat adequate 66.7 46.7 50.0 50.0 Adequate 33.3 53.3 50.0 50.0 No. of patients availed the facility 3 15 8 26 Laboratory Not adequate - - 7.7 3.0 Somewhat adequate 25.0 43.8 53.8 45.5 Adequate 75.0 56.3 38.5 51.5 No. of patients availed the facility 4 16 13 33 Injection Room Not adequate - - 14.3 7.0 Somewhat adequate 60.0 58.8 76.2 67.4 Adequate 40.0 41.2 9.5 25.6 No. of patients availed the facility 5 17 21 43 Dressing Room Not adequate - - 14.3 5.7 Somewhat adequate 40.0 50.0 57.1 51.4 Adequate 60.0 50.0 28.6 42.9 No. of patients availed the facility 5 16 14 35

211

Continuity of Treatment

Continuity of treatment depends upon the overall level of satisfaction from different

services received from the hospital. Table O-10 gives the information about different

aspects of the quality of services which led to the continuity of treatment. This table

shows that none of the patients are dissatisfied with the services provided by the health

facilities. More than 85 per cent of the patients indicated the future use of the facility in

case they fell sick and a similar proportion of out-patients stated that they would

recommend this hospital to others.

Table O-10: Continuity of treatment

Type of Health Facility (Percent) Continuity of treatment District

Hospital CHC PHC Total

Satisfaction with the visit to the health facility

Dissatisfied - - - - Somewhat satisfied 80.0 88.2 86.4 86.4 Satisfied 20.0 11.8 13.6 13.6 Reason of dissatisfaction, if dissatisfied

Lack of facilities - - - - Bad experience with doctors - - - -

Poor quality of services - - - - Charges are exorbitant - - - - Other - - - - Visit again to the facility (if fell sick)

Yes 100.0 82.4 86.4 86.4 No - 5.9 4.5 4.5 May come/unsure - 11.8 9.1 9.1 Recommend this hospital to others

Yes 100.0 82.4 86.4 86.4 No - 17.6 13.6 13.6 Total no. of out-patients interviewed 5 17 22 44

212

Summary

The survey found that the time spent by the patients for different services has appropriate

and a majority of the patients’ weather in-patients or out-patients are satisfied with the

waiting time for getting these services. The behaviour of the staff in different health

facilities are found to be reasonably good with adequate privacy in places of examination.

However, there are some complaints about the behaviour of the supporting staff from in-

patients. In case of satisfaction about the cleanliness of health facility, a large proportion

of patients are satisfied with overall cleanliness in the facilities but they are not happy

with the personal cleanliness like changing uniform and bed sheets. Overall, it could be

seen that public health facilities are maintaining cleanliness. Doctor-patient

communications are found to be good in the district hospital, while it was moderate in

PHCs. None of the patients are dissatisfied with the services provided by the health

facilities. A majority of the patients indicated their preference for re-visiting the public

facility.

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Chapter 9

Insights from the field: A qualitative data analysis

Introduction

In order to further investigate the day-to-day functioning of the NRHM programme in the

selected district, in-depth interviews were conducted among medical officers, ANMs,

anganwadi workers and elected panchayat members. The discussions covered areas such

as the respondents’ opinion in general on NRHM and the four major components of the

programme, namely, ASHA, JSY, Untied Funds, and the involvement of Panchayati Raj

institutions.

It is felt that the NRHM has helped in improving the health of the mothers and

children through the implementation of its va rious programmes. It was mentioned in

particular that maternal and infant mortality have come down due to interventions

through the programme. This was on account of the increase in the institutional

deliveries. By and large, the doctors interviewed felt that institutional delivery has nearly

become universal in the district.

The availability of funds for maintenance of infrastructure, equipment and

medicine has been the highlight of the NRHM scheme. It was unanimously agreed upon

by the functionaries at various levels that the availability of these funds facilitated better

functioning and improvement of all health facilities at the primary health level.

However, the NRHM programme was not devoid of problems. A major obstacle noted by

many interviewees was the lack of proper coordination at different levels particularly

between elected local bodies and health functionaries. It was observed that the members

of the village panchayat are generally unaware of the aims and benefits of the NRHM

programme. As a result, cooperation between panchayat representatives and the medical

officers and ANMs is difficult to achieve. For further strengthening the implementation

of the NRHM programme, and particularly to achieve its objective of integrating the

214

panchayat raj institutions into the public health system, intervention is required through

training and orientation programmes.

Accredited Social Health Activists (ASHA)

As part of the NRHM programme, an ASHA worker is expected to be employed for

every 1000 population as a link between the community and the health functionaries.

However, after nearly two and a half years of the NRHM in operation, ASHA workers

have not been appointed in the district of Hassan. While ASHA workers have been

identified approximately 5 months prior to the time of the survey, and the list submitted

to higher officials, apparently no action has been taken towards confirming these

appointments. It is generally felt by the interviewees that this delay is likely to be on

account of political interference in the selection and placement of candidates.


The NRHM envisages the JSY to be an integral component of safe motherhood by

promoting institutional deliveries though cash incentives among poor pregnant women.

Women belonging to BPL families and with less than 3 children are provided the amount

of RS 700/- if the birth of their child takes place in an institution and the amount of Rs

500/- if the birth of their child takes place at home. In order to avail of this facility,

eligible pregnant woman have to be registered under the JSY scheme during her

pregnancy. The programme is unique in that it is tied up with a few approved private

hospitals where the woman can go for delivery care. In such instances an amount of

rupees 1500/ will be given to the mother.

In general this scheme is thought to be very innovative and has the ability to

address the problems associated with home deliveries. As pointed out earlier, this scheme

has helped in bringing down the number of home deliveries and as a result the infant and

maternal mortality. However, some aspects of the programme require smoothening for it

to run more efficiently. A major problem reported by MOs, ANMs and the community is

the delay in the disbursement of the JSY amount to the women.

215

It was mentioned that to begin with there is a considerable delay in receiving the funds

from head quarters after the registration of beneficiaries. Next, the issue of the

submission of the required documents at the time of delivery is the direct cause of delays

in the disbursement of funds. In many cases, the place of registration under the program

differs from the place of delivery of the birth. (For example, the woman might live and

register herself as a JSY beneficiary in one place and go to her natal village for the

delivery.) In these cases, the women are expected to take the JSY cards to the place of

delivery. It was found that illiteracy acts as a barrier here, especially in the case of poor

women from BPL households, where often they did not know that they had to carry their

cards with them. In addition, at the second facility, beneficiaries would have to produce

all the required documents again regarding their BPL status, number of children, etc, in

order to receive the JSY amount. Finally, woman who had no bank account would have

to open an account and the procedural delay both from the side of bank as well as from

woman in producing the appropriate documents is likely to lead to delays in the

disbursement of funds.

Another serious problem which came out of the discussion was the opening of a

bank account for poor women. To open an account a woman is expected to keep a

minimum balance with the bank. In the case of most women the account may not be

operated later in their life. As such the payment of minimum amount is considered by

them as a wasteful expenditure. It is also found that raising money to have a minimum

balance in the account at the critical time of delivery is a difficult task for many women

leading to the non-utilization of JSY money by the beneficiary. Even for those women

who went ahead with opening an account the net benefit accrued and to be availed of

during the time of delivery was found to be far less than the programme envisages due to

the minimum balance to be kept at the bank. It appears that the government is now in the

process of discussing with various banks the possibility of starting zero balance accounts

for JSY cases.

One possible option to overcome this obstacle is to give the woman a bearer

cheque (non account payee). However, in this case, the system could be misused by

intermediaries and actual beneficiaries may not receive the amount due to them. As well,

216

there are likely to be instances of misuse within the family by the spouse or other

members appropriating the amount as the woman may not be able to go to bank soon

after the delivery. An alternative option could be to send the money to the beneficiary in

the form of a money order. This will result in the money being handed over directly to

the women at her door step. Two other suggestions that arose in the discussion were to

give benefits in kind rather than in cash and to deposit this money in the name of the

child that is born so that the benefit occurs in the long term. Both these options have their

own merits and demerits. The former suggestion is likely to have the drawback of not

meeting the specific needs of the beneficiaries during the time of delivery, if these differ

from the type of benefits being distributed. While the latter suggestion is a good one to

avoid misutilisation of the programme, it has the drawback of being too small an amount

to be beneficial in the long run. Further, it may not take care of the immediate delivery

related expenditure.

Untied Funds

Untied funds are given to health facilities for expenditure on infrastructure, supply of

equipment and medicine. Arogya Raksha Samitis (ARS) are responsible for

administering these funds at the District Hospital, CHC and PHC, while at the sub centre

level it is the ANM and members of the local elected bodies that carry this responsibility.

From the discussions it emerged that the idea of Untied Funds is well received. One

benefit of the disbursement of funds through the Untied Fund program is that there is a

large degree of flexibility with respect to use of funds to attend to immediate needs since

the decisions can be made at the local level, by the health functionaries and the elected

representatives, and there is no need to refer to higher authorities elsewhere. Funds have

been used to improve the availability and supply of medicines and equipment at the

health facility, as well as in the better upkeep of the physical infrastructure. In one PHC

money had been used to hire a dai to assist the nurse in conducting deliveries, and money

for her salary was paid from untied funds.

From the visit to the field it was immediately apparent that there is under utilization of

these funds. In one facility, the MO reported that a reason for not using the funds is that

217

ANMs do not have the necessary skills to maintain accounts, and therefore the funds are

not used. Further, it appears that there is confusion with regard to the spending of money

from the Untied Funds. The guidelines for expenditure over the five years of the NRHM

programme are not clear to the health functionaries. In particular, it is not clear under

what heads the money can be spent in the future after the initial and immediate

expenditure on infrastructure and manpower development has been made. Another

reason that came out of the discussion with health functionaries for the underutilization of

funds is that in certain cases members of the gram panchayats are generally not

cooperative, and refuse to sign off on the expenditure without receiving some incentive of

their own.

Involvement of Panchayati Raj Institutions (PRI)

The involvement of panchayati raj institutions in the public health delivery system takes

place at each level of the primary health care system. The District Health Mission

(DHM), led by the Zilla Parishad, controls, guides and manages all public health

institutions in the district, CHCs, PHCs and subcentres. The PRI is also involved through

Arogya Raksha Samiti (ARS) for good hospital management and through the Village

Health and Sanitation Committee (VHSC) to prepare the village health plan, and promote

intersectoral integration.

The ARS is a committee formed with the MO, the ANM and representatives of

the gram panchayat to handle untied funds given to a health facility. The money provided

as Untied Funds for the particular facility is to be deposited in a joint account with the

ANM and a member of the village panchayat, and the committee is required to discuss

and agree upon the way that funds are to be used. The money cannot be used without the

signature of all the committee members.

The VHSC consists of representatives of the gram panchayat, ANM/ MPW,

Anganwadi worker, teacher, ASHA and community health volunteers. The main aim of

the VHSC is to formulate a health plan to promote joint Information-Education-

Communication (IEC) for public health, sanitation and hygiene at the village level.

218

These programmes have various benefits. In the first place, they integrate the community

with the health facility, and community members can have a say in the use of the funds

through their elected representatives. Further, by involving the local community in the

planning and decision-making regarding their own health care, there will be better

articulation of the felt need of the community with regard to health care.

Although the involvement of the panchayat raj institutions is a good idea, the

experiences from the field suggest that it is not a complete success as envisaged by the

NRHM. It appears that gram panchayat members are not properly aware of their role in

the above committees, or even of the purpose of the committees. As a result, they take

very little interest in the functioning of these committees, and either do not attend

meetings or place various hurdles for the smooth functioning of the committee. It was

found that some of the VHSCs, although formed, had never met to date. Also, the

VHSCs that had met were not competent enough to prepare a comprehensive health plan

for their village.

It was generally felt among the health staff that the involvement of local elected

representatives was an obstacle to the smooth functioning of the public health system as

there was a lot of interference from this quarter. However, given that the involvement of

the community in the decisionmaking and planning of public health care delivery is an

important step toward the better functioning of the health system, the gap between this

objective of the NRHM and its proper implementation has to be bridged. One way to do

this is by providing training and orientation on the NRHM and on public health to local

panchayati raj members so that they are better aware of their own role in the programme,

as well as the importance of the same to the long term welfare of their community.

Summary

The qualitative inputs gathered from the field serve to supplement the data from the

survey and have brought out certain points of interest. In general, the NRHM is

considered to be successful in reducing maternal and child mortality through the increase

of institutional deliveries. Most interviewees felt that the number of deliveries taking

219

place at home had dropped significantly, and it was likely that it would be negligible in

the future. The JSY scheme was felt to be a huge success in facilitating this improvement

in maternal and child health. However, a snag in the scheme is the delay in the

disbursement of money to the beneficiaries, mainly due to procedures required in opening

bank accounts as well as the production of necessary documents. On the other hand,

while the ASHA programme is innovative, it has not yet taken off in Hassan and workers

had not been appointed at the time of the survey. With regard to untied funds given to

health facilities to be spent at their discretion on infrastructure and development, the

general feeling was that it was beneficial, but it was found that the funds themselves were

underutilized due to a number of bottlenecks in the implementation. The involvement of

panchayat raj members in the health system was found to be unsuccessful in Hassan. This

component of the NRHM requires strengthening through the raising of awareness of the

role of the community in the health delivery system by imparting training to the PRI

members.

220

References

Bruce, Judith 1991, "Fundamental elements of the Quality of Care: A simple Framework", Studies in Family Planning, Vol. 2 (2), pp. 61-91. Census of India, 2001, “Final Population Totals”, Karnataka, Series 30.

International Institute for Population Sciences (IIPS) and Macro International, 2008, “National Family Health Survey (NFHS-3), 2005-06”, India, Vol. 1, Mumbai. Koening M. A., M. S. Hossain and M. Whittaker, 1997, "The influence of quality of care upon contraceptive use in Rural Bangladesh", Studies in Family Planning, Vol. 28-4, pp. 278- 289. Ministry of Health and Family Welfare, 2007, “Indian Public Health Standard (IPHS) for Community Health Centres”, Government of India. Ministry of Health and Family Welfare, 2007, “Indian Public Health Standard (IPHS) for Primary Health Centres”, Government of India. Ministry of Health and Family Welfare, 2007, “Indian Public Health Standard (IPHS) for Sub Centres”, Government of India. Ministry of Health and Family Welfare, “National Rural Health Mission, Meeting people’s health needs in rural areas, Framework for Implementation 2005-2012”, Government of India. Planning Commission 2007, Poverty Estimates for 2004-05, Government of India, New Delhi. Raju, K.N.M., et al., 2006, Institute for Social and Economic Change (ISEC), International Institute for Population Sciences (IIPS), and Ministry of Health and family Welfare, Government of India, “Reproductive and Child Health - District Level Household Survey 2002-04”, Karnataka, Mumbai. Visaria, Leela and P. Visaria 1992, "Quality of Family Planning Services in Gujarat State India: An Exploratory Analysis", in A. K .Jain (ed.) Managing Quality of Care in Population Programs, Kumarian Press, USA.

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Appendix

Pharmacy at Sakleshpur Community Health Centre

Labour Ward at Sakleshpur Community Health Centre

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In-patient Ward at Sakleshpur Community Health Centre

Primary Health Centre , Ballupet

223

Sub Centre , Bage under Ballupet Primary Health Centre

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