jharkhand monitoring visit report period: fourth quarter

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DR NAVNEET

RANJAN

CONSULTANT -PHP,NHSRC 30/04/2013

Jharkhand Monitoring Visit Report

Period: Fourth Quarter (January to March-2013)

Latehar

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Abbreviations

ANC Ante Natal Care ACMO Additional Chief Medical Officer ANM Auxiliary Nurse Midwife AMG Annual Maintenance Grant AYUSH Ayurveda Yoga Unani Siddha Homeopathy BSU Blood Storage Unit BEmOC Basic Emergency Obstetric Care CEmOC Comprehensive Emergency Obstetric Care CHC Community Health Center CMO Chief Medical Officer CS / C-section Caesarean Section DF Deep Freezer DH District Hospital DHAP District Health Action Plan DMO District Malaria Officer DP Delivery Points DPM District Programme Manager DPMU District Programme Management Unit EMRI Emergency Medical Research Institute FRU First Referral Unit HMIS Health Management Information System I/C In-charge IFA Iron Folic Acid IPD In-patient IEC / BCC Information Education communication / Behaviour Change Communication IUD Intra Uterine Device ILR Ice Line Refrigerator JSY Janani Suraksha Yojana LHV Lady Health Visitor LSAS Life Saving Anaesthesia Skills MCTS Mother & Child Tracking System MTC Malnutrition Treatment Centre NBCC New Born Care Corner NRHM National Rural Health Mission NSSK Navjat Shishu Suraksha Karyakram OBGY Obstetric and Gynaecologist ORS Oral Rehydration Salt PNC Post Natal Care PPP Public Private Partnership PPS Post Partum Sterilisation PW Pregnant Woman RIMS Rajendra Institute of medical sciences SC Sub Center SN Staff Nurse SNCU Sick Newborn Care Unit SAM Severely Acute Malnourishment VHND Village Health & Nutrition Day VHSC Village Health & Sanitation Committee

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Executive Summary The Fourth quarter monitoringreport for Jharkhand is based on the HMIS data of the state and

a field visit to Latehar. The visit was conducted during 02nd -05th April 2013. This visit was

carried out by a team with representatives from NHSRC, New Delhi, Govt. of Jharkhand and

District health officials with an objective to review the progress of NRHM/RCH program

including, implementation of JSSK scheme.

Maternal health: Maternal Mortality Ratio (MMR) has been reduced from 312 (SRS 04-06) to 261 (SRS 07-09). However it is higher than the National average of 212 maternal deaths per 100,000 live births (SRS 2007-09). Institutional arrangement:

The state has 23 DH, 188 CHC, 330 PHC, and 3958 SC to cater the health care needs of 32,966,238 people.

In the visited district 19 sub centers, 3 PHC, 6CHC and district hospital are prioritized for

RCH services. The civil works for 2 sub centers are undergoing. In Chandawa block-the

building of Laharsi PHC is completed but not yet notified as PHC.

Health Service delivery indicators:

As per HMIS (2012-13) ANC3 coverage in the district is 71%

However, only 40% pregnant women received IFA tablets. The shortage of IFA tablets

was also observed during the district visit. No record of hemoglobin levels of pregnant

women was maintained to identify high risk pregnancies (anaemic).

47% deliveries are institutional and equal number are home deliveries. Only 1.7%

deliveries are identified as complicated and most of them are attended at district

hospital. The DH started conducting C-sections after the establishment of blood bank.

The post natal care is poor as only few PW remain stayed at facility.

Only district hospital was found to be providing safe abortion services and that too to a

very small number of clients.

JSY:

JSY payments are made through bearer cheques to the beneficiaries. List of JSY

beneficiaries was available at facility.

HMIS 2012-13 statistics shows 88% mothers of reported institutional deliveries received

JSY payment. .

Maternal Death Review:

Total 450 maternal deaths were reported in the state of Jharkhand. The review

highlighted severe hypertension(31%),Bleeding(24%) and Obstructed/prolonged

labour(24%) are the leading cause of maternal deaths.

In Latehar total 5 deaths were reported, which were all were reviewed.

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Janani-Shishu Suraksha Karyakram (JSSK):

The level of awareness about cashless services for pregnant women and sick infants was

found very low. Although signage for JSSK was displayed at facilities visited.

OPD,IPD and diagnostic services are free across the facilities visited.

The prescribed drugs are ensured free of cost to most of the beneficiaries, however few

beneficiaries reported to have incurred OOPs on purchasing medicine from private

pharmacy

. Free diet is available up to CHC level. Nearly 40% of the interviewed women used

Mamta Vahan to reach the facility, while remaining came by hired or personal vehicles.

Informal payments to avail the medical services were also reported by beneficiaries

There

No robust mechanism for redressal of grievances exists in facilities visited.

Human Resources:

Total 28 positions of doctor/specialist are lying vacant in the district. The position of

District Malaria officer, District Filaria officer and District Leprosy officer is vacant.

One paediatrician and two gynaecologists under regular employment are in position at

Balumath CHC and district hospital respectively. However there is no anaesthetist

available in the district. Two and three MOs are trained in LSAS and EmOC respectively,

while 53 SN/ANM are SBA trained

Child Health:

In Latehar district 9 NBCC are present but no NBSU and SNCUs are available. A six bedded NBSU

for DH was approved in FY 2012-13 but not yet to be operationalised. There is an urgent need

to operationalise NBSU with appropriate human resources in DH to improve newborn survival.

Immunization:

As per HMIS analysis (Apr’12-Mar’13) fully immunized against estimated live births was

74%, very close to the last year’s figure (73%).

Malnutrition Treatment Centre (MTC):

There are 3 MTC established in the district.

At Chandawa, a 6 bedded NRC was functional, however only 50% beds were occupied. There is 1 doctor and 3 ANMs deployed at this NRC. So far there were 267 admissions,out of whch 245 were discharged, 7 readmitted, 9 referred and 21 were LAMA cases.

At district hospital only 4 children were admitted against the 15 beds. The utilization of MTCs is poor. There is need to sensitize the community about malnutrition and improved convergence of ASHA and AWW for identification and referral of SAM cases.

Family Planning:

As per HMIS (2012-13) sterilization (34% of all methods) is the most accepted method of family planning..

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There is need to improve the uptake ofspacing methods like IUD and PPIUD.

IEC related to family planning seems to be neglected. Outreach Services:

Out of 4 MMUs, 3 are functional in the district to cover 7 blocks. They are run and managed by NGOs under PPP. There is need to monitor and analyze the performance of MMU. Proactive involvement of ASHA and ANMs is required for effective utilization of MMU.

School Health program (SHP):

Total 466 schools have been covered so far under SHP. Out of 187,074 students 154,637

have been screened and 27,020 health cards distributed.

Adolescent Reproductive and Sexual Health (ARSH):

There are 7 ARSH clinics established in the district and all are functional. Every six

months kishori Swasthya Pakhwara is being observed. During these periods special

focus is given to identify severely anaemic adolescent girl and their further

management.

ASHA

There are 1325 ASHAs in position in the district. During the visit Round one training of

module 6 was undergoing.

District has distributed drug kits to all ASHAs however, many ASHAs complaint about not

refilling of drug kit.

Shayiya Helpdesk was functional at district hospital and Manika CHC. This helpdesk also

redress grievances of patient

Disease Control Program; Status of NPCDCS:

The NPCDCS program was piloted in Bokaro in year 2010-11 andscaled up to two more districts

i.e. Ranchi and Dhanbad next year. The screening statistics shows that proportion of suspected

hypertension cases (6. 6%) is higher than the proportion of suspected diabetics (5.6%).

Quality of Services:

Deep pits for disposal of bio medical waste were found at all the facilities visited. Colour

coded bins for biomedical waste disposal was being used in visited DH & CHCs. The

infection prevention practices were observed in the facility visited but it varied from

facility to facility.

Equipments were available at the facility visited as per the facility norms. The radiant warmers were not functional due to poor power supply and voltage. Stabilizer may be installed to make radiant warmer functional.

Program Management and Support services:

The position of District Data Manager is vacant however recruitment is going on for all 7

Block Data Manager. At block level, position of 2 BPM and 1 BAM is lying vacant.

Power backup and security personnel were available at every facility. Mobile/Internet

connectivity is poor in the district that affects service delivery and data entry

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1.1 Introduction

The Fourth quarter monitoring report for Jharkhand is based on visit to Latehar district and the

HMIS data analysis.

Latehar is one among the 30 districts classified for IAP 1 across the country. The visit was

conducted during 02nd -05th April 2013. There are 97 SC, 07 PHC, 7 CHC, 2 Malnutrition

treatment centre (MTC) and a district hospital functional in Latehar. Out of these 1 SHC, 1 PHC,

2 CHC, 2NRC and DH were selected as sample facilities to visit and understand program

management and implementation at field level. After this visit the findings were shared with

concerned officers at district level and state level. Table 1 shows the visit schedule and team

composition.

Table1- Visit Schedule and Team composition

Date 03rd April 2013 04th April 2013

Facility visited Latehar District Hospital, Chandwa CHC, Latdag SHC, NRC Chandawa, ASHAs training at Latehar

Chipadohar PHC, Manika CHC, NRC Latehar

Team Members Dr Navneet Ranjan,Consultant, NHSRC Mr Deepak Tubid, State Consultant, Quality Assurance. Ms Jaya Reshma Xaxa , DPM Latehar Mr. Pramod kumar sahoo, DAM, Latehar

1.1. Approach and methodology:

The methods used by observations at different facilities, patients’ interviews and interactions

with providers and beneficiaries. In meeting with civil surgeon, planning for the field visit was

discussed. Data was collected from the District Programme Management Unit and the facilities

visited.

The team interacted with medical officers, ANM, ASHA and discussed the different issues

related to health services at the visited facilities. Interviews were carried out with pregnant

women in the post natal ward of the visited facilities.

1 IAP = Integrated Action Plan (30 Districts) which include backward, tribal and LWE districts. The categorization is

done by statistical division of Ministry of Health & Family Welfare, Govt. of India

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1.2. Background Information

Latehar district was created on 4th April

2001 and falls under Palamu division.

Population is 725,673 as per Census 2011. It

is predominantly tribal district with almost

40% of the population belonging to the

schedule tribes and more than 66 % of total

population comprising of SCs and STs. There

are nine Development Blocks, namely

Latehar, Chandwa, Balumath, Bariyatu,

Herhanj, Manika, Barwadih, Garu and Mahuadar. The fertility of soil is poor due to extensive

erosion, acidic character and low retaining capacity. The district does not have any significant

industrial activities.

Table 2. Status of major health indicators

Health Profile

Indicator Jharkhand Latehar

CBR 23.7 24.8

CDR 6.1 5.9

IMR 41 49

MMR 278

310( Palamu division)

Source: DHAP

Table 3. Health Infrastructure in Latehar:

Source: District Data

Institutions No.

District Hospital 1

Block 09

CHC 07

PHC 07

SC 97

FRU 0

24X7 PHC --

No. of licensed blood banks (include pvt)

1

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2.0 Maternal Health:

Maternal Mortality Ratio (MMR) has been reduced from 312 (SRS 04-06) to 261 (SRS 07-09). There are 51 points drop in MMR. However it is higher than the National average of 212 maternal deaths per 100,000 live births (SRS 2007-09).

2.1. Institutional arrangement: The state has 23 DH, 188 CHC (out of these 150 are under construction) 330 PHC (out of these 92 are under construction), 3958 SC (out of these 775 are under construction) to cater the health care needs of 32,966,238 population.

In Latehar 97 SC, 07 PHC, 7 CHC, 2 Malnutrition treatment centre (MTC) and a district hospital is

functional. Out of these 19 sub centers, 3 PHC, 6CHC and district hospital are prioritized for RCH

services. The civil works for 2 sub centers are undergoing. In Chandawa block-the building of

Laharsi PHC is completed but not yet notified as PHC.

Beside this four private health facilities are accredited for JSY. The presence of private health

care providers is negligible in the district.

Table 3: Functional delivery points in Latehar

SNo. Type of Facility Latehar

Total number Functional Delivery points

Level I facility

1 Sub center 97 19

Level II facility

2 PHC 07 03

3 CHC 07 06

4 Other Hospital 00 00

Level III facility

5 SDH 00 00

6 DH 01 01

Total 112 29

Source: District Data

2.2. ANC Services

As per HMIS 2012-13, total ANC registration against expected pregnancies in district was 93%.

Out of the total registration 71% pregnant women underwent 3 ANC services. However only

40% of women received IFA tablets. The shortage of IFA tablets was confirmed during the visit

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to Chhipadohar PHC. It was also observed that, no record on haemoglobin levels of pregnant

women was maintained at the visited facilities to identify high risk pregnancy (anaemic). There

is need of line listing of high risk pregnant women to avert the maternal death.

2.3. Delivery services/ Labour room:

As per HMIS 2012-13, 47%

deliveries are institutional which is

very close to the state AHS 2011

statistics (45%). The proportion of

unreported deliveries is less (6%)

however home deliveries are same

the institutional deliveries i.e. 47%.

The reason for high proportion of

home deliveries is hilly terrain,

wide geographical stretch and,

scattered population. Also social

condition (LWE affected) of this

area is not conducive for the PW to

reach the facilities particularly at

night. Majority of the home deliveries are reported from Manika block.

98% of institutional deliveries are normal deliveries. However only 1.7% deliveries are

complicated and most of them are attended at district hospital. Only ten pregnancies (0.1%)

were taken up for C-section, which is nearly 100 times less as compared to the estimated no. of

women requiring C sections. The reasons for very few C-section are unavailability of blood bank

at DH. Recently the Blood bank has been operationalzed and the report of next few quarters

will show whether it was only the lack of blood leading to low C section rate.

Chipadohar PHC surrounded by live wire in night to protect building from LWE

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The labour room in district hospital has only 1 Labour table however the DH is conducting

nearly 100 deliveries per month. The Labour room was not found clean and tidy. The NBCC was

found functional. Oxytocin, IV fluid and other essential drugs were available in the emergency

tray. Distribution of institutional deliveries across the blocks of district is shown in the figure

given below.

Figure3.Distribution of institutional deliveries in CHC & DH: Q4

2.4. Post delivery stay / PNC

The infrastructure of the post natal ward of the health facilities visited was insufficient to cater

to mothers’ needs. It is difficult to deliver PNC at the facility as only few women stayed back at

facilities for the mandatory 48 hrs after delivery. The HMIS data suggests that 81% women stay

less than 48 hours in the facility after delivery.

C- section % 0.1%

Complicated Pregnancies attended %

1.7%

Normal deliveries %

98.2%

Figure 2: Latehar- C-Section, Complicated & Normal Deliveries against Reported Institutional Deliveries ( Pvt. & Public) Apr'12 to Mar'13

Balumath 8% Chandwa

9%

Barwadih 15%

Manika 4%

Latehar 7%

Mahuwadar 15%

Garoo 9%

DH 33%

% of institutional delivery

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During the visit it was observed that few facilities (Chipadohar PHC) do not have functional beds

to accommodate the post natal cases. There is need to improve the stay at facilities by providing

free diet and drop back facility. (Details in JSSK section).

2.5. Safe Abortion Services: Table.4: Abortions - Apr'12 to Mar'13

MTP Less than 12 weeks

MTP More than 12 weeks

Abortions (spontaneous/Induced)

Abortions in Pvt Facilities

Abortion Rate against expected

pregnancies

89 7 203 -- 1.6%

Only district hospital was found to be providing safe abortion services and that too to a very

small number of clients. However the rate of abortion against expected pregnancies is 1.6 %

which again is much lower than expected abortions/miscarriages. The concern is that abortion

services were not available in CHCs and PHCs.

2.6. Janani Suraksha Yojna (JSY):

HMIS 2012-13 statistics shows 88% mothers of reported institutional deliveries received JSY

payment. This figure is only for delivery at Public institution. JSY payments are made through

bearer cheques to the beneficiaries. List of JSY beneficiaries was available at facility.

2.7. Maternal Death Review: Total 450 maternal deaths were reported in the state of Jharkhand. The review highlighted

severe hypertension(31%),Bleeding(24%) and Obstructed/prolonged labour(24%) are the

leading cause of maternal deaths.

2.8. Janani shishu suraksha Karyakaram (JSSK)

The exit interviews were conducted at facilities visited where delivery conducted. Total (n=7)

beneficiary were interviewed.The key findings of interview are as follows:

Awareness about entitlements of JSSK

Almost all interviewed PW were not aware about cashless services being provided under JSSK to PW. The service providers also do not know about JSSK. Although signage for JSSK was displayed at facilities visited.

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OPD/IPD charges

The OPD and IPD charges were exempted to PW and sick new born at all facilities visited.

Drugs:

All the women interviewed were getting drugs free of cost from the facilities visited. At Latehar DH two women reported that they purchased medicine from private pharmacy and spent Rs. 50/- and Rs. 90/- respectively.

Blood bank was established recently and C-section was also carried out however adequate utilization of blood bank is stillto be acheived. The lab technician of blood bank reveals that blood was collected through blood donation camp organised by Red Cross but due to poor absorption the blood units were shifted to Palamu DH or RIMS, Ranchi.

Diet:

At DH, diet is being provided through in house kitchen to the pregnant women as

reported by facility in-charge. At Chandawa CHC, single pregnant women was present at

facility and confirmed about getting food from the hospital free of cost. A local

hotel/restaurant is empanelled to supply the cooked diet for pregnant women. During

the visit, l. Generally PW are not willing to stay more than 4-5 hours post delivery. At

Chipadohar PHC remaining visited facilities, the diet was not being arranged for PW

under JSSK..

Informal charges:

Out of 7 Post natal mothers interviewed 2 of them paid informal charges, 150/- and Rs

300/- to service providers.

Diagnostic facilities:

Labouratory tests are

available at the facilities

visited as per the facility

norms. The free diagnostic

services are available for

pregnant women and sick

new born. The line listing

of anaemic PW (whose Hb

level is <7mg) was not

practiced.

There is no OOPS incurred

on the diagnostic tests by

the interviewed PW.

Post Natal ward of Latehar District Hospital

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Transportation:

Seven ambulances are functional in the district out of which four are managed by NGO.

Out of 7 women interviewed only three used ‘Mamta vahan’ to reach facility for

delivery. Remaining PW reached facility either by own vehicle or through hired vehicle.

The out of pocket expense ranged from Rs 50/- to Rs 600/- for transportation depending

upon the distance travelled and type of vehicle used.

One PW revealed that the mobile network connectivity is one of the issues that’s why

she was not able to call Mamta Vahan. Five interviewed PW did not attempt to call

Mamta Vahan because they were not aware about the free transport facility.

Drop back to home is only provided to those who stayed mandatory 48 hours in the

facility. It was also observed through records that utilization of Mamta Vahan for drop

back is very less as beneficiaries left the facility soon after the delivery.

Inter-facility transfer:

For up referral Rs 1000/= is being provided to the PW and sick new born for

transportation. If government vehicle (ambulance) is available then this money is used

for the fuel. However generally the vehicle is arranged by the family member of

beneficiary.

Grievance Redressal Cell:

There is no mechanism to redress grievances under JSSK in facilities visited. Not even a suggestion box has been placed at the facility visited.

None of the interviewed PW knew where to contact in case they are charged for the cashless services under JSSK

3.0. Human Resources

Table: 5. Human resources available in the District

Required

Regular Contractual

Sanctioned posts

In position from State

Sanctioned

posts

In position (through

state/other sources)

In position from NRHM

Total in positio

n

1st ANM 119 119 82 0 0 0 82

2nd ANM 150 0 0 150 0 102 102

MPW/ Male HW 18 18 16 0 0 0 0

Staff Nurse total 59 3 0 0 2 29 31

DH 20 0 0 20 2 2 4

FRU/ CHC 36 0 0 36 0 7 7

24X7 PHCs 21 0 0 0 0 0 0 LHV/ PHNs Other supervisory cadre

7 7 5 0 0 0 5

LTs 23 23 4 23 4 11 19

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DH 4 4 0 4 1 2 3

FRU/ CHC 12 12 2 12 4 6 12

24X7 PHCs 14 14 4 14 7 3 14

Other facilities (Pls. specify)

0 0 0 0 0 0 0

Pharmacists 23 23 0 14 9 4 4

AYUSH Pharmacists 0 0 0 0 0 0 0

MOs total 15 9 6 1 0 3

AYUSH MOs 8 8 6 0 6 0 0

DENTAL MOs 8 1 0 0 8 0 1

Specialists total 10 2 0 0 8 0 0

Obstetricians &Gynaecologist

4 2 0 0 4 0 2

Anaesthetist 3 0 0 0 3 0 0

Paediatrician 3 0 0 0 0 0 Source: District Data

The details of the human resources available in the district are depicted in the table 5. One

paediatrician and two gynaecologists under regular employment are in position at Balumath

CHC and district hospital respectively. However there is no anaesthetic available in the district.

3.1. Vacancies: Total 28 positions of doctor/specialist are lying vacant in the district. The

position of District Malaria officer, District Filaria officer and District Leprosy officer are vacant.

3.2. Trainings: Two and three MOs are trained in LSAS and EmOC respectively. Total 53

SN/ANM is SBA trained

4.0 . Child health

In FY 12-13, total 7 SCNU were proposed out of which 2 were functional at Ghatshila in East

Singhbhum and Department of Pediatrics-RIMS, Ranchi. Also 32 NBSU were proposed out of

which 7 are functional.

In Latehar district 9 NBCC are present and situated in 6 CHC and 2 PHC and District hospital.

There is no NBSU and SNCU available in the district. A six bedded NBSU for DH was approved in

FY 2012-13 but not yet operationalise. There is an urgent need to operationalise NBSU with

appropriate human resources in DH to improve newborn survival.

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4.1. Immunization:

Table: 6.Immunization in Jharkhand & Latehar

Indicator Jharkhand Latehar

April'12 to Mar'13

Last Year 2011-12

April'12 to Mar'13

Last Year 2011-12

BCG to Measles dropout rate

6% 1% 6% 11%

Fully Immunized against estimated Live Births

75% 83% 74% 73%

Immunisation session held as % of required VHNDs

94% 99% 122% 73%

Childhood Diseases Measles 2908 8415 16 115

Source: HMIS 2012-13

As per HMIS (Apr’12-Mar’13) analysis fully immunized children against the estimated live births

was 74%. This is very close to the last year’s figure (73%). The dropout rate of BCG to measles

was 6%. The HMIS statistics also show 122% immunization sessions held as against the

required number of VHNDs in Latehar.

4.2. Malnutrition Treatment Centre (MTC): There are 3 MTC established in the district- at Chandawa CHC 6 bedded, Mahuadar CHC 6

bedded and district hospital 15 beded. The team visited to MTC wards of district hospital and

Chandawa CHC.

At Chandawa MTC it was observed that a 6 bedded MTC was functional. Out of six beds only

three beds were found occupied during the visit. Separate kitchen was created for NRC. There is

1 doctor and 3 ANM deployed at this NRC. So far 267 admissions have been recorded, out of

these 245 were discharged, 7 readmitted, 9 were referred and 21 were LAMA cases. After

discharge from NRC, ASHA follow up the cases. At district hospital only 4 children were

admitted against the 15 beds. The utilization of MTCs is poor. The facility in-charge told that

due to festivals the admissions are low. There is need to sensitize the community about

malnutrition and convergence of ASHAs and AWWs for identification and referral of SAM cases.

5.0. Family Planning:

The Total Fertility Rate (TFR) of Jharkhand is 3.2 whereas TFR of India is 2.6 (SRS 2008).

Jharkhand has high fertility rate and fall under the group of states having >3 TFR. The unmet

need for spacing is 16.2% and limiting is 14.2% in the state (AHS 2010).

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Table 07. Family Planning Methods in Latehar

Reported %age of All Reported FP

Methods

Total Reported FP Method (All types) Users

6,695 -

Sterilizations 2,272 34%

IUD 1,743 26%

Condom Users 1,421 21%

OCP Users 1,259 19%

Limiting Methods 2,272 34%

Spacing Methods 4,423 66% Source: HMIS (2012-13)

As per HMIS (2012-13) sterilization is the most accepted method of family planning. The proportion of sterilization is 34% in all reported FP methods. Table 8 shows that 96% female sterilization was conducted in Latehar district. The district hospital has Fixed Day Service. There is need to strengthen, with focus of spacing methods like IUD and PPIUD. IEC related to family planning seems to be neglected.

Table: 08. Status of Sterilizations in Latehar

Reported %age of Reported Sterilization

Total Sterilization 2,272

NSV 99 4%

Laparoscopic 15 1%

MiniLap 1,834 81%

Post Partum 324 14%

Male Sterilization 99 4%

Female Sterilization 2,173 96%

Source: HMIS (2011-12)

6.0. Outreach Services:

MMUs

Out of 4 MMUs, 3 are functional in the district covering 7 blocks. One MMU is allocated for 2

blocks and remaining three blocks are covered by one MMU. Two are run and managed by

Vikas Bharti and one by ICERT; both NGOs under PPP. There is need to monitor and analyze the

performance of MMUs which currently is lacking. Also, involvement of ASHA and ANMs is

required for effective utilization of MMU.

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7.0. School Health program (SHP):

Total 466 schools have been covered so far under SHP. Out of 187,074 students 154,637 are

screened and 27,020 health cards have been distributed.

8.0. Adolescent Reproductive and Sexual Health (ARSH):

There are 7 ARSH clinic established in the district and all are functional. The ARSH training

Module is made available in local language. There is one MOi/c, 3 LHV/ANM are engaged in this

program. Beside this a counselor was appointed in each facility. Every six months kishori

Swasthya Pakhwara is being observed. During these periods special focus was given to identify

severely anemic adolescent girl and their further management. Also supplementation of WIFS is

priority as told by civil surgeon.

9.0. ASHA Program:

ASHA Selection:

ASHA is known as Sahiya in Jharkhand. 1325 ASHAs have been selected in the district. The in-depth interview with ASHA shows that the workload and incentive varies, for some it is full time job whereas for some only few cases to attend. ASHAs Training: All ASHAs have been trained up to 5th Module. The training was ongoing on module 6 B during the visit. The district has proposed to train all 1325 ASHAs in Module 6 and 7 in FY 2013-14. The State has 15 State Trainers for Module 6 & 7.

Sahiyas undergoing Training of Module 6b at district

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Drug Kit:

All 1325 ASHAs in Latehar are equipped with drug kit. The drugs are replenished at facilities but

this is not a regular event. Many ASHAs complaint about not getting a drug kit refill.

ASHA Support Structure:

There are 69 ASHA facilitators and one District Program coordinator (equivalent to ASHA

coordinator) is in place in the district. 7 positions of block level ASHA coordinators are vacant. It

was observed that ASHA help desk was well functioning in the district hospital & Manika CHC.

10.0. Status of NPCDCS programme:

The NPCDCS program was piloted in Bokaro in year 2010-11, and further scaled up to two more

districts i.e. Ranchi and Dhanbad in 2011-12. The screening data under this program is given in

the table 9.

Table: 9. Status of screening

Districts No. of

persons screened

Suspected for Diabetes (

>140 )

Hypertension ( >90 )

% of Diabetes

suspected

% of Hypertension

Bokaro 185,420 10,529 18,778 5.67 10.12

Dhanbad 140,044 10,710 11,505 7.65 8.21

Ranchi 304,914 14,020 11,061 4.60 3.63

Total 630,378 35,259 41,344 5.59 6.56

The table 9 shows that proportion of suspected hypertension cases (6. 6%) is higher than the

proportion of suspected diabetics (5.6%).

11.0. Program Management

Programme Management Units has been established at districts & block levels to coordinate &

implement different activities of NRHM. The position of District data Manager is vacant

however recruitment is going on for all 7 Block Data Managers. At block level position of 2 BPM

and 1 BAM is lying vacant.

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12.0. Quality of Services:

12.1. Infection prevention practices and Biomedical

waste disposal:

Deep pit for disposal of bio medical waste was found

at all the facilities visited. Colour coded bins for

biomedical waste disposal were being used at visited

DH & CHCs. The infection prevention practices were

observed in the facility visited, but it varied from

facility to facility.

12.2. Information Display:

Shayiya Helpdesk was functional at district hospital and manika CHC.This helpdesk also redress

grievances of patient. The list of diagnostic tests performed was also displayed. IEC material

pertaining to various programmes including JSSK is displayed in the facilities visited however

name and contact number of the nodal person of JSSK should be displayed. There is need to

display the entitlements with pictorial diagram.

12.3. Equipments

All equipments are available at the facility visited as per the facility norms. O2 Cylinder was functional and SN was trained to operate them. The radiant warmerwas not functional due to poor power supply and voltage.

12.4. Records:

Labour room:

The labour room are clean and well

maintained at district hospital but at CHC

& PHC the cleanliness was lacking.

Technical protocols were not displayed in

the labour room at Chipadohar PHC. It was

also observed there is no consistency in

Partograph preparation. Emoc drugs (e.g.

Oxytocin, Prostaglandin etc) are available

in the labour room. The delivery records

were well maintained in all the facilities

visited.

Sahiya Help desk at Manika CHC

of 48

Laboratory Records:

Laboratory records were maintained at the facilities visited in the district. Routine Lab tests are conducted. However Line listing of anemic pregnant women is not done at the facilities.

13.0. Support services:

Power Back up:

Power back up as generator and inverter was available in all the facilities visited.

Security: Security personnel are hired for security purposes at every facility. Mobile/Internet connectivity: This is poor in the district that affects service delivery and data entry.

of 48

Annexure: - Comparison with Last Year Performance using HMIS data from National Web

portal :

Jharkhand - Apr'12 - Jan'13 AHS 2011

Population (Census-2011) 3,29,66,238 Estimated Pregnancies

8,77,048 ANC

CBR (AHS-2011) 23.7 Estimated Deliveries 7,97,316

ANC Check-up in first trimester 56.3

Apprehended Infant Deaths ( IMR = 41 taken from AHS - 2011 )

32033 Estimated Live Births 7,81,300

3 or more ANC Check-up 56.3

Estimated Eligible couples ( 17% of population)

56,04,260

Estimated Maternal Complications( 15% of

Estimated pregnancies)

1,31,557

Atleast 1 TT received

85.7

Indicator Apr'12 - Jan'13

Projected for April'12 to Mar'13

Last Year Apr'11-Mar'12

100 IFA Tablets

15.1

3ANC Check up against estimated pregnancies

44% 53% 51%

Deliveries

Institutional Deliveries (Public+Private) against estimated deliveries

46% 55% 46%

Institutional Delivery

37.6

Met need for EmOC * 20.57% 25% 14.17%

Home Delivery 62.0

Reported Live Births against estimated Live Births

66% 79% 75%

Home Delivery by SBA

24.7

BCG to Measles dropout rate 6% 6% 1%

New born & post natal care

Fully Immunised against estimated Live Births

68% 82% 83%

Abortion (Induced + Spontaneous) 4.2


102% 102% 99%

Still Birth

Childhood Disease Diphtheria 104 124.8 186

Live Birth

Childhood Disease Pertussis 58 69.6 75

Breastfed within 1 hour of birth 37.9

Childhood Disease Measles 2702 3242.4 8415 PNC within 48 hrs of delivery 59.1

Childhood Disease Malaria 19872 23846.4 38516 Immunisation Sterilization - Female per 1000 eligible couple

11.93

14.32

20.94 BCG

91.8

Sterilization - Male per 1000 eligible couple

1.16

1.40

2.33 DPT3

71.8

Reported Abortion Rate per 1000 Estimated live births

26.8

32.2 28.3

Measeles

79.0

OPD All (per 1000 population) 287.0

344.4 327.8

Full immunisation

63.7

IPD (per 1000 population) 14.2

17.0 18.4 Unmet need for FP

of 48

Operation Major (per Lakh population)

53.6

64.3 77.907 Spacing

16.2

Reported Infant and Child Deaths 1187

1,424.4 925 Limiting

14.3

Reported Maternal Deaths 395

474.0 372 Total

30.5

* Total Maternal complications ( C-section deliveries + Eclampsia cases )treated against estimated maternal complication

of 48

Jharkhand-Pashchimi Singhbhum - Apr'12 - Jan'13 AHS 2011

Population (Census-2011) 1501619

Estimated Pregnancies

43,788 ANC

CBR (AHS-2011) 25.8 Estimated Deliveries 39,807



2131 Estimated Live Births 38,742



2,55,275



6,568


74.3




100 IFA Tablets

21.1


64% 77% 68%

Deliveries


45% 54% 40%


28.0

Met need for EmOC * 1.32% 2% 0.69%

Home Delivery 71.3


73% 87% 81%


15.9

BCG to Measles dropout rate -4% -4% 1%



81% 97% 82%



164% 164% 145%

Still Birth

Childhood Disease Diphtheria 0 0 10

Live Birth

Childhood Disease Pertussis 0 0 2



Childhood Disease Malaria 1620 1944 3888 Immunisation

Sterilization - Female per 1000 eligible couple

2.97

3.57

6.75

BCG

90.7


1.77

2.12

3.65

DPT3

70.4


20.1

24.1 12.4

Measeles

79.0


470.0 422.0

Full immunisation

64.7




6.5

7.8 3.263 Spacing

19.4


237.6 139 Limiting

20.2

of 48

Jharkhand-Bokaro - Apr'12 - Jan'13 AHS 2011



54,304 ANC




1411 Estimated Live Births 48,661 3 or more ANC Check-up 71.4


3,50,526



8,146


95.0




100 IFA Tablets

19.3


52% 62% 60%

Deliveries


42% 51% 44%


48.9


Home Delivery 50.7


59% 70% 67% Home Delivery by SBA 16.3




77% 92% 87%



93% 93% 86% Still Birth


Live Birth






14.89

17.87

29.52

BCG

94.5


6.02

7.22

7.08

DPT3

86.2


111.7

134.0 89.0

Measeles

84.0


235.4 214.9

Full immunisation

79.0


39.6 28 Total

39.6


of 48




4.3

5.1 22.406 Spacing

11.2


42.0 38 Limiting

7.0


15.6 23 Total

18.2


of 48

Jharkhand-Chatra - Apr'12 - Jan'13 AHS 2011



28,585 ANC






1,77,192



4,288


70.3




100 IFA Tablets

7.7


34% 41% 43%

Deliveries


31% 38% 36%


25.5


Home Delivery 74.3


55% 66% 63%


17.9

BCG to Measles dropout rate 18% 18% -3%



57% 69% 76%



90% 90% 87%

Still Birth


Live Birth




Childhood Disease Malaria 1874 2248.8 3161 Immunisation


7.71

9.25

19.10

BCG

82.8


0.78

0.94

6.13

DPT3

55.7


1.0

1.2 9.9

Measeles

65.2


321.9 276.2

Full immunisation

49.0




6.4

7.7 54.207 Spacing

21.8

Reported Infant and Child Deaths 0 5 Limiting 17.2

of 48

Jharkhand-Deoghar - Apr'12 - Jan'13 AHS 2011



37,662 ANC







2,53,619



5,649


79.3




100 IFA Tablets

10.6


35% 42% 52%

Deliveries


43% 52% 57%


32.1


Home Delivery 67.6


59% 71% 80%


24.3

BCG to Measles dropout rate 19% 19% 4% New born & post

natal care


66% 80% 93%



97% 97% 111% Still Birth

Childhood Disease Diphtheria 0 0 0 Live Birth




Childhood Disease Malaria 45 54 1056 Immunisation Sterilization - Female per 1000 eligible couple

19.38

23.26

32.70 BCG

87.6


0.17

0.20

0.51

DPT3

55.8


13.1

15.8 19.8

Measeles

61.5

-


2.4 0 Total

39.0


of 48


272.8 299.6 Full immunisation

40.6




3.7

4.4 5.765 Spacing

18.4


19.2 16 Limiting

18.1


13.2 0 Total

36.5


of 48

Jharkhand-Dhanbad - Apr'12 - Jan'13 AHS 2011



72,711 ANC







4,56,053



10,907


90.8




100 IFA Tablets

20.3


49% 59% 28%

Deliveries


47% 56% 34%


46.9

Met need for EmOC * 51.99% 62% 25.07%

Home Delivery 52.7


59% 70% 51%


35.6




77% 93% 67%



90% 90% 78%

Still Birth


Live Birth






11.45

13.74

20.26

BCG

89.3


0.47

0.56

1.79

DPT3

70.1


6.4

7.6 7.9

Measeles

77.8


157.3 169.6

Full immunisation

60.2




35.9

43.1 66.166 Spacing

12.8


of 48

Jharkhand-Dumka - Apr'12 - Jan'13 AHS 2011



38,188 ANC

CBR (AHS-2011) 25.7 Estimated Deliveries 34,716 ANC Check-up in first trimester 53.0




2,24,586



5,728


85.4




100 IFA Tablets

16.2


41% 49% 48%

Deliveries


36% 43% 42%


19.4

Met need for EmOC * 9.08% 11% 10.51%

Home Delivery 80.4


64% 76% 78%


14.9




64% 77% 74%



138% 138% 135%

Still Birth


Live Birth

Childhood Disease Pertussis 0 0 6 Breastfed within 1 hour of birth 39.1




8.99

10.79

15.32

BCG

89.2


0.68

0.82

0.63

DPT3

71.8


49.2

59.0 46.6

Measeles

75.2

24.0


7.2 29 Total

19.1


of 48


436.1 445.0

Full immunisation

59.8




98.3

118.0 93.407 Spacing

15.7


27.6 25 Limiting

14.8


27.6 28 Total

30.5


Jharkhand-Garhwa - Apr'12 - Jan'13 AHS 2011



35,312 ANC






2,24,806



5,297


70.0




100 IFA Tablets

4.4


36% 43% 42%

Deliveries


53% 64% 51%


30.2

Met need for EmOC * 0.76% 1% 0.93% Home Delivery 69.5


67% 80% 72%

Home Delivery by SBA 50.1




65% 78% 82% Abortion (Induced + Spontaneous) 2.2


87% 87% 84%

Still Birth

Childhood Disease Diphtheria 0 0 12 Live Birth

Childhood Disease Pertussis 33 39.6 0





13.25

15.90

39.57

BCG

89.4


0.09

0.11

0.24

DPT3

74.9

of 48


1.4

1.6 3.4

Measeles

79.9


321.1 336.2

Full immunisation

68.0




63.9

76.7 43.860 Spacing

13.8


82.8 35 Limiting

10.7


42.0 12 Total

24.5


Jharkhand-Giridih - Apr'12 - Jan'13 AHS 2011



61,608 ANC







4,15,685



9,241


78.4




100 IFA Tablets

11.7


39% 46% 36%

Deliveries


42% 51% 26%


26.5

Met need for EmOC * 19.25% 23% 1.05%

Home Delivery 73.2


69% 83% 55%


26.7

BCG to Measles dropout rate 7% 7% 8% New born & post

natal care


86% 103% 70%



81% 81% 86%

Still Birth


Live Birth




of 48



10.95

13.14

6.36

BCG

84.4


0.94

1.13

1.61

DPT3

40.4


6.7

8.0 10.5

Measeles

59.1


122.3 118.2

Full immunisation

28.0




0.4

0.5 42.982 Spacing

21.0


13.2 8 Limiting

19.5


14.4 8 Total

40.5


of 48

Jharkhand-Godda - Apr'12 - Jan'13 AHS 2011



35,133 ANC






2,22,935



5,270


66.7




100 IFA Tablets

9.8


53% 64% 55%

Deliveries


51% 61% 48%


24.4


Home Delivery 75.2


73% 87% 82%


35.3




67% 81% 83%



110% 110% 105%

Still Birth


Live Birth






13.95

16.75

21.19

BCG

87.2


1.12

1.34

3.15

DPT3

55.3


6.2

7.4 8.8

Measeles

69.1


267.1 246.6

Full immunisation

44.1




35.5

42.6 79.458 Spacing

21.6

of 48

Jharkhand-Gumla - Apr'12 - Jan'13 AHS 2011



30,038 ANC

CBR (AHS-2011) 26 Estimated Deliveries 27,307 ANC Check-up in first trimester 53.0




1,74,362



4,506


92.1




100 IFA Tablets 12.2


46% 55% 55%

Deliveries


47% 56% 51%


25.6


Home Delivery 74.3


63% 75% 81%


17.6




58% 70% 75%



156% 156% 151%

Still Birth


Live Birth


Childhood Disease Measles 80 96 241 PNC within 48 hrs of delivery 34.5



7.85

9.41

13.97

BCG 94.3


4.03

4.83

7.44

DPT3 76.8


104.3

125.2 100.8

Measeles

85.3


3.6 5 Limiting

21.2


6.0 4 Total

42.8


of 48


471.6 423.5

Full immunisation

71.5




24.1

28.9 47.092 Spacing

18.7


122.4 33 Limiting

15.1


37.2 18 Total

33.8


Jharkhand-Hazaribagh - Apr'12 - Jan'13 AHS 2011



39,825 ANC





2,94,781



5,974


90.8




100 IFA Tablets 9.4


39% 47% 59%

Deliveries


64% 76% 63%


44.0

Met need for EmOC * 10.26% 12% 11.78%

Home Delivery 55.6


91% 109% 101%


34.2




79% 94% 103%



88% 88% 83%

Still Birth


Live Birth





16.29

19.54

36.44

BCG 97.0

of 48


0.22

0.27

0.49

DPT3 82.9


14.8

17.8 17.9

Measeles

84.3


259.8 232.2

Full immunisation

76.4




18.2

21.8 34.487 Spacing

14.4


90.0 62 Limiting

12.9


30.0 41 Total

27.3


Jharkhand-Jamtara - Apr'12 - Jan'13 AHS 2011



18,149 ANC







1,34,335



2,722


90.8




100 IFA Tablets

9.4


49% 59% 65%

Deliveries


47% 57% 50%


44.0


Home Delivery 55.6


79% 94% 101%


34.2




76% 91% 90%



128% 128% 122%

Still Birth


Live Birth


of 48




10.27

12.32

21.16

BCG 97.0


0.19

0.22

0.69

DPT3 82.9


12.5

15.0 14.0 Measeles

84.3



76.4




10.6

12.8 0.000 Spacing

14.4


21.6 16 Limiting

12.9


13.2 2 Total

27.3


Jharkhand-Kodarma - Apr'12 - Jan'13 AHS 2011



18,632 ANC







1,21,919



2,795


89.5




100 IFA Tablets

10.0


39% 47% 39%

Deliveries


71% 85% 71%


45.8

Met need for EmOC * 61.97% 74% 61.79%

Home Delivery 53.9


82% 98% 89%


54.5




65% 78% 73%

Abortion (Induced + Spontaneous)

2.8


81% 81% 73%

Still Birth

of 48


Live Birth






35.75

42.90

42.02

BCG

95.8


0.37

0.44

1.10 DPT3

70.9


10.6

12.7 4.2 Measeles

78.1


223.8 244.6

Full immunisation

58.5




0.0 -

0.000 Spacing 18.3


27.6 17 Limiting

16.0


7.2 13 Total

34.3


Jharkhand-Kodarma - Apr'12 - Jan'13 AHS 2011



18,632 ANC






1,21,919



2,795


89.5




100 IFA Tablets

10.0


39% 47% 39%

Deliveries


71% 85% 71%


45.8

Met need for EmOC * 61.97% 74% 61.79%

Home Delivery 53.9


82% 98% 89%


54.5

of 48




65% 78% 73%



81% 81% 73%

Still Birth


Live Birth





35.75

42.90

42.02

BCG 95.8


0.37

0.44

1.10 DPT3

70.9


10.6

12.7 4.2 Measeles

78.1


223.8 244.6

Full immunisation

58.5




0.0 -

0.000 Spacing 18.3


27.6 17 Limiting

16.0


7.2 13 Total

34.3


Jharkhand-Latehar - Apr'12 - Jan'13 AHS 2011



18,632 ANC





1,21,919



2,795


89.5






59% 70% 39%

Deliveries


43% 52% 71%


45.8


Home Delivery 53.9

of 48


87% 105% 89%


54.5




68% 82% 73%



134% 134% 73%

Still Birth


Live Birth





12.36

14.83

42.02

BCG 95.8


0.55

0.66

1.10

DPT3 70.9


15.7

18.8 4.2

Measeles

78.1


716.3 244.6

Full immunisation

58.5




49.1

58.9 0.000 Spacing

18.3


48.0 17 Limiting

16.0


6.0 13 Total

34.3


Jharkhand-Lohardaga - Apr'12 - Jan'13 AHS 2011



14,553 ANC





78,495



2,183


93.7






41% 49% 49%

Deliveries

of 48


57% 68% 60%


38.6

Met need for EmOC * 27.90% 33% 34.49%

Home Delivery 60.5


66% 79% 83%


15.2




71% 85% 78%



146% 146% 135%

Still Birth


Live Birth





13.50

16.20

22.15

BCG 95.5


2.45

2.94

5.08

DPT3 83.8


22.7

27.2 45.6

Measeles

95.1


505.4 445.1

Full immunisation

82.5




21.7

26.0 186.036 Spacing

17.4


13.2 9 Limiting

10.8


4.8 1 Total

28.2


Jharkhand-Pakaur - Apr'12 - Jan'13 AHS 2011



30,243 ANC






1,52,864



4,537


90.0




100 IFA Tablets

4.4

of 48

Jharkhand-Palamu - Apr'12 - Jan'13 AHS 2011



49,753 ANC




33% 39% 41%

Deliveries


28% 34% 28%


20.8


Home Delivery 79.2


54% 65% 65%


7.3




55% 66% 64%



115% 115% 115%

Still Birth


Live Birth






8.90

10.68

12.87

BCG

91.3


0.29

0.35

0.88

DPT3

72.4


8.2

9.8 2.4

Measeles

61.6


264.3 274.1

Full immunisation

45.7




1.1

1.3 7.451 Spacing

17.1


3.6 1 Limiting

23.1


4.8 2 Total

40.2


of 48





3,29,174



7,463


75.2




100 IFA Tablets

8.3


51% 61% 62%

Deliveries


46% 56% 46%


31.0

Met need for EmOC * 33.70% 40% 5.78%

Home Delivery 68.9


67% 81% 73%


19.1




70% 84% 80%



89% 89% 90%

Still Birth


Live Birth





15.00

18.00

32.65 BCG

91.1


0.42

0.50

2.04 DPT3

65.2


5.9

7.1 9.8 Measeles

69.2



54.2




63.8

76.5 33.362 Spacing

16.6


1.2 7 Limiting

16.9


28.8 1 Total

33.5


Jharkhand-Purbi Singhbhum - Apr'12 - Jan'13 AHS 2011

of 48



53,611 ANC

CBR (AHS-2011) 21 Estimated Deliveries 48,737 ANC Check-up in first trimester 72.3




3,89,475



8,042


95.0






52% 62% 67%

Deliveries


53% 63% 62%


63.0

Met need for EmOC * 43.66% 52% 37.38%

Home Delivery 36.8


63% 75% 78%


25.2




67% 81% 82%



77% 77% 82%

Still Birth


Live Birth





13.26

15.92

16.68

BCG 97.1


0.36

0.43

0.54

DPT3 86.4


33.9

40.7 41.0

Measeles

93.0


671.2 683.5

Full immunisation

82.7




336.7

404.0 494.057 Spacing

11.5


208.8 170 Limiting

9.6


43.2 52 Total

21.1


of 48

Jharkhand-Ranchi - Apr'12 - Jan'13

AHS 2011



76,593 ANC







4,95,044



11,489


93.0




100 IFA Tablets

14.8


35% 42% 47%

Deliveries


50% 60% 60%


52.3

Met need for EmOC * 63.57% 76% 54.46%

Home Delivery 47.0


61% 74% 78%


36.4




50% 59% 99%

Abortion (Induced + Spontaneous)

5.2


82% 82% 91%

Still Birth


Live Birth






9.09

10.91

15.18

BCG

94.5


1.60

1.92

2.03

DPT3

80.9


56.3

67.5 68.4

Measeles

89.7


441.1 364.7

Full immunisation

76.4




0.5

0.7 57.795 Spacing

16.2


of 48

Jharkhand-Sahibganj - Apr'12 - Jan'13 AHS 2011



31,778 ANC







1,95,506



4,767


78.0




100 IFA Tablets

4.1


33% 39% 41%

Deliveries


61% 73% 42%


22.8


Home Delivery 76.9


80% 96% 78%


13.1




65% 78% 84%



102% 102% 97%

Still Birth


Live Birth





8.28

9.94

14.50 BCG

88.0


0.11

0.13

0.31 DPT3

71.7


12.2

14.6 22.0 Measeles

63.5

48.0


45.6 19 Total

32.1


of 48



54.9




60.2

72.2 95.127 Spacing

20.6


84.0 57 Limiting

18.0


39.6 24 Total

38.6


jharkhand monitoring visit report period: fourth quarter

Documents