Bihar Monitoring Report
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National Health Systems Resources Centre 2013 Bihar Monitoring Report This report is based on health providers, beneficiary interviews and HMIS data analysis of Bihar state and Lakhisarai district. The monitoring visit includes all levels of health facilities in the district. One needs to be cautious in interpretation of HMIS data, the state and districts may have good health service delivery but there might be problem in reporting data Venkatesh Roddawar NHSRC, MoHFW New Delhi, India 2nd Quarter 2013-14
Transcript of Bihar Monitoring Report
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This report is based on health providers, beneficiary interviews and HMIS data analysis of Bihar state and Lakhisarai district. The monitoring visit includes all levels of health facilities in the district. One needs to be cautious in interpretation of HMIS data, the state and districts may have good health service delivery but there might be problem in reporting data
Venkatesh Roddawar NHSRC, MoHFW New Delhi, India
2nd Quarter 2013-14
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Table of Contents Executive Summary .................................................................................................................................. 4
1. Introduction ........................................................................................................................................... 8
2. State and District Profile ..................................................................................................................... 8
3. Key health and service delivery indicators ...................................................................................... 9
4. Health Infrastructure .......................................................................................................................... 11
5. Human Resources for Health ............................................................................................................ 12
6. Maternal Health .................................................................................................................................. 13
6.1 ANC and PNC ................................................................................................................................ 13
6.2 Institutional Deliveries ................................................................................................................ 14
6.3 Maternal Death Review ............................................................................................................... 17
6.4 Janani-Shishu Suraksha Karyakram (JSSK) ............................................................................ 18
6.4. A User fee in Out Patient Department (OPD) and In Patient Department (IPD) ........ 18
6.4. B. Drugs and Consumables .................................................................................................... 18
6.4. C. Diagnostics ........................................................................................................................... 19
6.4. D. Diet ........................................................................................................................................ 19
6.4. E. Referral Transport ............................................................................................................... 20
6.4. F. Display of entitlements ...................................................................................................... 21
6.4. G. Awareness of community .................................................................................................. 21
6.4. H. Grievance Redressal Cell .................................................................................................. 21
6.4. I. Out of pocket expenditure / informal charges ................................................................ 21
6.5 Janani-Suraksha Yojana (JSY) .................................................................................................... 21
7 Child Health .......................................................................................................................................... 22
7.1 SNCU ................................................................................................................................................. 22
7.2 Nutritional Rehabilitation Centre ............................................................................................. 23
7.3 Immunization ................................................................................................................................ 25
8. Family Planning .................................................................................................................................. 26
9. Quality in Health Services ................................................................................................................ 27
9.1 Infection Control and Bio-Medical Waste Management ....................................................... 27
9.2 Information Display ..................................................................................................................... 27
10. Community Processes ...................................................................................................................... 28
10.1 ASHA and MAMTA ................................................................................................................... 28
10.2 Skill Development ...................................................................................................................... 28
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10.3 Functionality of the ASHAs ...................................................................................................... 28
10.4 Village Health, Sanitation and Nutrition Committees (VHSNC) ..................................... 29
11. Disease Control Programme ........................................................................................................... 31
11.1 Revised National Tuberculosis Control Programme ........................................................... 31
11.2 National Leprosy Eradication Programme (NLEP) ............................................................... 32
11.3 National Vector Borne Diseases Control Programme .......................................................... 32
11.4 National Programme for Control of Blindness (NPCB) ...................................................... 33
11.5 National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular
Diseases and Stroke (NPCDCS) ....................................................................................................... 34
12 Others ................................................................................................................................................... 34
12.1 Information Systems .................................................................................................................. 34
12.2 OPD and IPD ............................................................................................................................... 35
12.3 Mortality ....................................................................................................................................... 35
Table 1 Description of the area and facilities visited in Lakhisarai, Bihar ........................................ 8
Table 2 State and District Profile Map 1 district map of Bihar state ............................................ 8
Table 3 key health and service delivery indicators .......................................................................... 10
Table 4 Health Facility Mapping – Bihar and Lakhisarai .................................................................. 11
Table 5 Block wise health facilities in Lakhisarai, Bihar Source: DHS, Lakhisarai ......................... 11
Table 6 Delivery points – Bihar and Lakhisarai .................................................................................. 12
Table 7 Human Resources Status in Bihar ........................................................................................... 12
Table 8 Selected maternal indicators of Bihar and Lakhisarai from April to July 2013 ................ 14
Table 9 Functional delivery points in public health facilities – Bihar and Lakhisarai ................... 15
Table 10 Type of deliveries from April to July 2013 – Bihar and Lakhisarai .................................. 16
Table 11 Causes of maternal deaths – Bihar and Lakhisarai, April to July 2013 ............................ 18
Table 12 Comparison of JSY Performance from April to July – Lakhisarai and Bihar .................. 22
Table 13 Status of different type of new born care facilities in Bihar and Lakhisarai ................... 22
Table 14 Immunization session held in Bihar and Lakhisarai from April to July 2013 ................. 26
Table 15 Family Planning Key Indicators – Bihar and Lakhisarai from April to July 2013 .......... 26
Table 16 Block wise ASHAs and ASHAs facilitators against target as on July 2013 ..................... 28
Table 17 performance of VHND from April to July 2013 – Bihar and Lakhisarai ......................... 29
Table 18 Status of Facility Wise Data Uploading, Lakhisarai ........................................................... 35
Graph 1Human Resources Status in Lakhisarai .................................................................................. 13
Graph 2 Block wise Institution Deliveries from April to July 2013 – Lakhisarai............................ 16
Graph 3 Utilization of drugs and consumables, Lakhisarai, Bihar................................................... 18
Graph 4Duration of stay after delivery in Lakhisarai district from April to July 2013 ................. 20
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Graph 5Beneficiaries response on utilization of ambulance services in Lakhisarai ...................... 20
Graph 6 Assessment of NBCC Centers – Lakhisarai, Bihar .............................................................. 23
Graph 7 Community wise and Age wise NRC admissions – Lakhisarai, Bihar............................. 23
Graph 8 NRC admission criteria and gender composition ............................................................... 24
Graph 9 Immunization Coverage against estimated live births from April to July 2013.............. 25
Graph 10 Correlation between no. of ASHAs and no. of Insti. Deliveries in Lakhisarai district . 29
Graph 11 Performance of RNTCP for the month of June 2013, Lakhisarai, Bihar ......................... 31
Graph 12 TB-HIV Cross-referrals, Lakhisarai ..................................................................................... 32
Graph 13 Performance of Vector borne diseases (Malaria) – Lakhisarai and Bihar ...................... 33
Graph 14 State level progress of NPCB, Bihar ..................................................................................... 33
Graph 15 Performance of Bihar NPCDCS from April to July 2013 .................................................. 34
Graph 16 information on Mortality from April to July 2013 – Lakhisarai and Bihar .................... 35
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Executive Summary
State and district profile
Bihar, third most populated state in the country has four regions, nine divisions and 38 districts. Bihar population constitute 8.58% of total India’s population.
Lakhisarai is one of the 38 districts located at South of the state with a population of 1 million, which is 1% of the state population.
Bihar state density of population is 1100/km2, which is higher by 285 persons/km2 in comparison with Lakhisarai district, 815 persons/km2.
Key health and service delivery indicators
The key health indicators of Bihar reflects poor performance in comparison with national average.
The MMR of Bihar and Lakhisarai reported 305 and 295 maternal deaths per 100,000 live births from any cause related to or aggravated by pregnancy.
Bihar and Lakhisarai is short of 50% (28 points) and 49% (26 points) in achieving MDG’s IMR goal by 2015.
Bihar and Lakhisarai reported 77 and 70 U5MR as per AHS 2011 and they shortfall of 45.45% and 40% to reach the goal of MDG by 2015.
Services delivery indicators like ANC, PNC, institutional deliveries, TFR and unmet needs for family planning indicates Bihar performance far below than national average.
Health infrastructure
In terms of required facilities, there is a deficit of 83.5%, 67.5%, 53.8% and 26.9% of health sub-centers, additional PHC’s, Community health centers and sub-divisional hospitals in the state.
On average every block of Lakhisarai has 14 to 15 health sub-centers and each sub-center covers minimum seven thousands to maximum nine thousand population, which is above the population norms.
Excluding HSC, state has 45% of health facilities operationalized as delivery point, which is below than the 50% of total health facilities.
Human Resource for Health
State has huge gap of medical, nursing and paramedic staff in terms of requirement, sanctioned and in position at different level health facilities.
The state has 13 medical officers and 27 staff nurse per one lakh population in public health sector.
Out of 370 sanctioned HRH, only 78% of them are available in Lakhisarai district.
Maternal Health
Ante-natal Care
Identifying severe anemia and hypertensive cases who are at high risk during pregnancy is one of the concern in the state.
Only 50% three ANC check-ups achieved against ANC registration during April to July 2013. Monitor regular ANC clinics and develop mechanism to follow-up remain ANC in the state and district.
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The state needs to stress all districts at all levels of facilities, particular health sub-center, to maintain the line listing of high risk pregnant women to closely monitor and provide support during institutional delivery.
Only 16% of pregnant women received IFA tablets in Lakhisarai district, which is 37% lower than the state average.
State and district administration should take action to prevent delays in procuring essential drugs that determines the outcome of the maternal health.
Institutional Deliveries
The state needs to review the low performance of C-section deliveries, which is mere 1.5% at state level and the Lakhisarai district reported none.
It is observed that the LSAS trained MO’s are hesitant to perform even selective C-Sections due to unavailability of required instruments in health facilities.
Three blocks, Barahiya, Surajgadha and Lakhisarai contributes 89% and remaining Halsi, Piprahiya and Ramgarh contributes mere 11% of total institutional (public) deliveries in the district.
The district should evaluate poor performing blocks and prepare action plan to improve the institutional delivery, which should reflect in the district health action plan.
Unreported deliveries are as high as 36% in Lakhisarai to 44% at state level. Until APHCs and HSC are not strengthen to handle delivery load the situation remains the same in the district and state.
The state and district authority should identify geographical areas where migration is high, and design appropriate IEC and BCC campaigns to create awareness about available health schemes. Home deliveries are high among the migrant population in the district.
Janani-Shishu Suraksha Karyakram
Out of 19 beneficiaries interviewed in Lakhisarai, 68% informed receiving partial drugs and 16% received all drugs and consumables from the facilities. Remaining three beneficiaries were home deliveries.
The beneficiaries who received partial drugs spent on an average Rs. 150 to buy medicines.
Exit interview with beneficiaries revealed that almost all beneficiaries undergo partial laboratory test. None of the health facility have ultrasonography for diagnosing ANC cases.
Provision of free diet is not available in the district, however, the state government made diet provision compulsory across the state prior to JSSK programme.
Need for coordination within health department for monitoring and implementation of free diet provision.
It is reported that on an average each beneficiaries shell out Rs.100 to Rs.150 rupees on transportation.
Plan, procure and display IEC materials and information on various NRHM schemes at
health sub-center level.
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Janani-Suraksha Yojana (JSY)
Number of women registered under JSY from April to July has increased by 8.7% in
comparison with last year same period at the state level.
Percentage of JSY registration to total ANC registration has increased by 3.5% from 93.6% to
97.1% in comparison with last year’s performance.
Incentives paid for home deliveries have drastically reduced by 78% and 97% at state and
district level. But at the same time, incentives paid for institutional delivery has increased
by 35% and 67% at state and district level.
ASHA’s incentives under JSY has improved by 21% in comparison with last year.
Child Health
SNCU in Lakhisarai approved during 2011-12 but yet to start the center as per plan.
295 SAM children admitted in NRC covering 16 batches in Lakhisarai. 89% of the children
admitted based on MUAC <115mm criteria and remaining 11% based on WFH<-3SD
criteria.
Total 62% children gained more than 15% weight, one defaulter and one death reported.
Around 19% children completed follow-up and 281 children’s follow-up still going on.
Immunization
The full immunization coverage of Lakhisarai is 76%, which is 2% lower than state average.
The district shows good performance of planned versus held immunization sessions which
correlates well with immunization achievement in the district.
Family Planning
2.7% of the total unmet needs were catered in the district, which is 1.35% lower than the
state average, 4.05, in meeting family planning needs.
Quality in health services
Many of the health facilities do not have proper coded buckets for segregation of biomedical
waste, some facilities have coded buckets but they are in partial usage.
Needles and syringes are not properly mutilated and disinfected before putting in waste
bin.
The district hospital, Lakhisarai scored 202 out of 280 during pre-assessment audit for ISO
certification.
Community processes
District Community Mobilizer (DCM) position is vacant since from the beginning of NRHM
programme in the district.
All ASHA were trained up to module 4 and 99% (750) of ASHA were trained in first round
of module 6 and 7, which is fully residential.
Number of ASHAs significantly correlated with number of institutional deliveries in each
block of Lakhisarai district.
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There are total 10 ASHA’s dropout and reasons for dropout is lack of interest and some of
them are migrated to other areas.
There is no formal grievance redressal mechanism available for ASHA in the district.
Village Health, Sanitation and Nutrition Committees (VHSNC)
At the state level, total 3.29 lakhs VHND sessions planned and 96.3% sessions held during
four months period from April to July.
During these sessions, around 18727 women identified with below 7 mg. hemoglobin and
2.37 lakh women with a range of 7-11 gm hemoglobin who are considered to be high risk
mothers.
Disease control programmes
District has various administrative and operational problems associated with RNTCP
programme. DTCO position is vacant in Lakhisarai and MO of DH has taken in-charge of
the programme.
From January to June, around 732 TB suspected cases were referred from DMCs to ICTC
center and confirmed 5 HIV+ cases.
Total 44 leprosy cases detected in April to June 20013, which include 21 PB and 23 MB that
include 5 child cases. Around 42 cases were released from treatment and 169 cases under
treatment in the district by the end of June
State has examined 69,926 blood smear and confirmed 1565 cases of which 29% of them are
Plasmodium falciparum (Pf) cases and remaining cases are Plasmodium Vivax (Pv).
The state has annual target of 607070 cataract operations and 85640 free spectacles to school
children out of which 46.2% and 7.1 achieved for cataracts and spectacles by the end of May
2013.
Around 36,145 people attended out of 750 camps organized for diabetes and hypertension
(NPCDCS). Of the attended only 31% of them undergone screening for diabetes and
hypertension. Of screened, 34% were suspected for diabetes and 23% for hypertension in
the district.
Others
On an average 257 OPD per 1000 population at state level and 254 OPD per 1000 population
at district level reported from April to July 2013. 13 IPD per 1000 population recorded at
state and district level.
Around 15990 and 278 deaths reported from Bihar and Lakhisarai from April to July, of
which, 74% belongs to communicable diseases including maternal and perinatal deaths in
the state.
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Bihar Monitoring Report – 2nd Quarter 2013-14
1. Introduction The report is based on monitoring visit carried out in Lakhisarai district of Bihar from 30th July
to 2nd August 2013. The monitoring visit include all levels of health facilities – Health Sub
Centre (HSC), Additional Primary Health Centre (APHC), Primary Health Centre (PHC),
Community Health Centre (CHC) / Referral Hospital (RH) and District Hospital (DH). PHCs
and CHC/Referral hospitals are catering to the health needs of the people. Details of visit
provided in the below table.
Table 1 Description of the area and facilities visited in Lakhisarai, Bihar
Block Description Facilities visited
Lakhisarai Comprise of one DH, one PHC 24x7, Two APHC's and 18 HSC's which caters to 2.20 lakhs population
District Hospital, DTCO, DLO, DBCS, DMO
Barahiya Comprise of one RH (FRU), three APHC's and 17 HSC's which caters to 1.29 lakhs population
Barahiya RH, DMC Shivpuri tola VHND, Pratappur APHC, Daryapur HSC
Halsi Comprise of one PHC (24x7), three APHC's and 15 HSC's which caters to 1.13 lakhs population
Halsi PHC, Pratapur HSC
Ramgarh Comprise of one PHC (24x7), one APHC and 14 HSC's which caters to 1.06 lakhs population
Ramgarh Chowk PHC, Ramgarh DMC
2. State and District Profile
Table 2 State and District Profile Map 1 district map of Bihar state Bihar, third most populated state in the
country has four regions, nine divisions
and 38 districts. Bihar population
constitute 8.58% of total India’s
population. The state has 534 blocks,
Bihar state and Lakhisarai district profile
State/District Bihar Lakhisarai
State/Dist. Headquarters Patna Lakhisarai
No. of Blocks 534 7
No. of Revenue Villages 45,103 484
No. of Panchayats 8463 80
Population (2011) 103804637 1000717
Literacy 63.82% 62.42%
Sex Ratio 919 902
Density of Population 1100/km2 815/km2
State/District Boarder
North Nepal Begusarai,
Patna
East West
Bengal Munger
West Uttar
Pradesh Shekhpura,
Nalanda
South Jharkhand Jamui
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45103, revenue villages and 8463 Panchayats. Lakhisarai is one of the 38 districts located at
South of the state with a population of 1 million, which is 1% of the state population. Lakhisarai
as a new district formed on 3rd July 1994 as a result of its separation from Munger district. The
district literacy rate is 62.42%, which is 1.40% lower in comparison with state literacy rate,
63.82%. Bihar state density of population is 1100/km2, which is higher by 285 persons/km2 in
comparison with Lakhisarai district, 815 persons/km2.
Map 2 Lakhisarai district map
3. Key health and service delivery indicators
The key health indicators of Bihar reflects poor performance in comparison with national level.
Bihar recorded 305 Maternal Mortality Ratio (MMR) per 100,000 live births, which is 93 points
higher in comparison with national average, 212/100,000 live births. However, when compare
with Lakhisarai district, 83 points higher than national average and 10 points lower than state
average. The MMR of Bihar and Lakhisarai indicate 305 and 295 female deaths per 100,000 live
births from any cause related to or aggravated by pregnancy.
Maternal health is one of the eight goals of Millennium Development Goals (MDG’s) that
targets to reduce MMR by three quarters (of 1990) by 2015. India has substantially reduced the
MMR from 523 in 1990 to 212 in 2007-09. Despite the progress, India tends to fall short to
achieve MDG maternal goal by 135 per 100,000 live births in 2015. The southern states like
Kerala and Tamil Nadu have achieved considerable success in arresting incidence and tend to
reach targets before 2015. Whereas northern states like Bihar, Uttar Pradesh, Madhya Pradesh
and Rajasthan might fall behind the targets.Broadly, some of the challenges include socio-
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economic barrier, human resource and management, monitoring and accountability, linkages
and role of local institutions.
Table 3 key health and service delivery indicators
Sl. No. Health indicators India Bihar Lakhisarai
1 MMR 212 (SRS '07-09) 305 295
2 CBR 21.8 (SRS 2011) 26.7 24.0
3 CDR 7.1 (SRS 2011) 7.2 6.5
4 IMR 44 (SRS 2011) 55 53
5 Neo- natal Mortality Rate 33 (SRS 2010) 35 29
6 Under Five Mortality Rate 59 (SRS 2010) 77 70
7 Antenatal Care (AHS 2011)
a ANC Check-up in first trimester - 44% (HMIS '12-13)
54% (HMIS '12-13)
b 3 or more ANC Check-up 69% (HMIS '11-12)
44% (HMIS '12-13)
33% (HMIS '12-13)
8 Postnatal Care (AHS 2011)
a Breastfed within 1 hour of birth - 30.3% 19.2%
9 Instit. Deli. Against Esti. Deliveries
62% 47.7% 57.1%
10 Total Fertility Rate 2.5 (SRS 2010) 3.7 (SRS 2010) -
11 Full Immunization 82 (HMIS '11-12) 64.5 59.6
12 Unmet Need for FP 12.8 (DLHS '05-06) 39.2 43.3
a Spacing 6.2 21.3 19.8
b Limiting 6.6 17.9 23.5 Source: AHS 2011
IMR for the country declined by nine points between 2008 and 2011 with IMR at national level
being 44 in 2010. However, the set target of MDG is to reduce IMR by 27 per 1000 by 2015.
Bihar IMR is 55 per 1000 live births, which is 11 points higher than national average and 2
points higher than Lakhisarai district. Bihar and Lakhisarai is short of 50% (28 points) and 49%
(26 points) in achieving MDG’s IMR goal by 2015. Under 5 Mortality Rate (U5MR) in India for
the year 2010, stands at 59 and it varies from 66 in rural areas to 38 in urban areas. Given to
reduce U5MR to 42 per thousand live birthsby 2015, India tends to short of 28.8% at the current
rate of U5MR. Bihar and Lakhisarai reported 77 and 70 U5MR as per AHS 2011 and they
shortfall of 45.45% and 40% to reach the goal of MDG by 2015.
Services delivery indicators like ANC, PNC, institutional deliveries, TFR and unmet needs for
family planning indicates Bihar performance far below national average. % of three ANC
check-ups and institutional deliveries against estimated deliveries in Bihar is 25% and 14.3%
lower than national average. Bihar state unmet need for family planning is 39.2%, which is
26.4% higher than national unmet need.
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4. Health Infrastructure Bihar has inadequate health infrastructure as per population norms. In terms of required
facilities, there is a deficit of 83.5%, 67.5%, 53.8% and 26.9% of health sub-centers, additional
PHC’s, Community health centers and sub-divisional hospitals in the state. The state of the
health infrastructure in such a condition, which is one of the essential factor, shows deficiency
in providing public health services in the state. Similar picture reflects in Lakhisarai district in
terms of required facilities, only 10.78%, 33.3% and 62.5% of health sub-centers, additional
PHC’s and CHC available in the district.
Table 4 Health Facility Mapping – Bihar and Lakhisarai
Health Facility Level
Bihar Lakhisarai
Required Existing Under Const.
Short fall
Required Existing Under Const.
Short fall
District Hospital 38 36 4 2 1 1 0 0
Sub-Divisional Hospital
63 46 9 8 0 0 0 0
Referral Hospital NA 71 NA NA 1 1 0 0
Community Health Centre
864 399 NA 465 8 0 5 3
Additional PHCs 3460 1122 381 1957 33 11 3 19
Health Sub-Centre
20761 3415 3983 13366 399 43 59 297
Source: Bihar State PIP 2013-14
Lakhisarai district has 7 blocks with 1 million population as per 2011 census. Block population
range from minimum 52 thousands in Pipariya block to maximum 2.2 lakhs in Lakhisarai block.
On average every block has 14 to 15 health sub-centers and each sub-center covers minimum
seven thousands to maximum nine thousand population, which is above the population norms.
The catchment area of APHCs covers minimum 37 thousands to maximum of 100 thousand in
Lakhisarai district.
Table 5 Block wise health facilities in Lakhisarai, Bihar Source: DHS, Lakhisarai
Name of Block
Population Sub Centers Additional
PHCs PHC
Referral Hospital
Lakhisarai 220353 18 2 1 0 Channan 108000 na na na 0 Ramgarh 106640 14 1 1 0 Pipariya 52430 6 1 1 0 Surajgarha 280157 32 6 1 0 Halsi 113270 15 3 1 0 Barhaiya 129541 17 3 1 1
Total 1010391 102 16 6 1
There are total 11,584 health facilities available at different level in the state and out of which
only 8% of them are serving as delivery points. Mere 8% health facilities catered to 3.1 million
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expected pregnancies and 2.9 million expected deliveries during these five months in the state.
By this calculation every delivery point in the state need to cater 263 deliveries per month.
Excluding HSC in calculating delivery points, the state has only 45% of health facilities
operationalized as delivery point, which is below than the 50% of total health facilities. The
situation is different across different delivery points and mostly PHCs and above level facilities
supply the needs of pregnant women. There is a need for strategy to strengthen APHCs and
HSC as delivery points in the state.
The situation remains the same at district level, for example in Lakhisarai district out of 128
health facilities only 8.6% serve as delivery points that catered to 8806 expected pregnancy and
8218 expected deliveries during these four months. Similarly, excluding HSC, the district has
31% of available health facilities operationalized as delivery points in the district. The below
table provides facility level institutions and delivery points.
Table 6Delivery points – Bihar and Lakhisarai
Health Facilities Bihar Lakhisarai
State Total Delivery Points District Total Delivery Points
HSC 9696 74 102 3
PHC 1243 204 24 06
CHC Non FRU/PHC 588 588 na na
CHC/FRU 20 20 1 1
DH/DWH 37 37 1 1
Total 11584 923 [8%] 128 11 [8.6%] Source: State and district PIP 2013-14
5. Human Resources for Health Large number of vacancies in regular posts in Bihar – Medical Officers 2476, ANMs 2388, LT
1925, MPW 1216, LHV 749, and Staff nurses 393. State has huge gap of medical, nursing and
paramedic staff in terms of requirement, sanctioned and in position at different level health
facilities. Irregular recruitment and lack of qualified manpower has led to vacancies in critical
healthcare workforce both in regular and contractual positions. There is no mechanism exist in
the state to regularise contractual medical officers under NRHM in the state. The state has 13
medical officers and 27 staff nurse per one lakh population in public health sector as per public
health workforce study of NHSRC.
Table 7Human Resources Status in Bihar
HR categories
HR Requirement Current HR Situation
Delivery points
All Facilities
In position
Sanctioned posts
Regular Contractual Total Shortfall/
Excess
ANM 2784 23928 23772 9420 8196 17616 -6312 SN 9029 12146 13415 393 1619 2012 -10134 LHV 204 1243 1181 432 0 432 -811 LT 1642 2681 2207 282 387 669 -2012
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Pharmacist 960 1999 NA NA NA NA NA MO 3003 12094 7315 2464 1581 4045 -8049 Specialist 878 878 NA 684 273 957 79 Source: Bihar state PIP 2013-14
The situation in Lakhisarai is similar to the state. There are around 290 various para-medical
personnel available across different health facilities. Out of 370 sanctioned HR, only 78% of
them are available in the district. Regarding medical officers, out of 154 sanctioned posts, only
50% of them are in position. In Lakhisarai district, 8 MO’s and 4 staff nurse per 1 lakh
population available in public health sector, which is below the state average.
Graph 1Human Resources Status in Lakhisarai
Source: District PIP 2013-14
6. Maternal Health
6.1 ANC and PNC
ANC registration against expected pregnancies in Lakhisarai recorded above 3% in comparison
with state. At the same time ANC in first trimester against reported ANC of Lakhisarai district
recorded below 6% in comparison with state average. However, the major concern across the
state and district is identifying severe anemia and hypertensive cases who are at high risk
during pregnancy. Reported number of severe anemia and hypertension cases in the state and
district is far below than expected level.
DHIS data reflects that both, state and district, recorded only 50% three ANC check-ups
achieved against ANC registration during April to July 2013. There is a greater need to monitor
regularANC clinics and develop mechanism to follow-up remain ANC in the state and district.
The state needs to stress all districts at all levels of facilities, particular health sub-center,to
maintain the line listing of high risk pregnant women to avoid complications during delivery.
6 313
42
77
226
11 20 21
78
154
240
0
50
100
150
200
250
300
LT LHV Pharmacist SN MO ANM
HUMAN RESOURCES- SANCTIONED VS POSITIONED LAKHISARAI, BIHAR 2013
In Position Sanctioned posts
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The state needs to conduct regular training programmes for ANM’s in identifying high risk
pregnant and lactating mothers in their catchment area. Another grave concern is distribution
of IFA (Iron/Folic Acid) tablets to pregnant women against ANC registration. DHIS data
suggests that the state provided on an average 53% of pregnant women with IFA tables as
against ANC registration during April to July 2013. During the same period, only 16% of
pregnant women received IFA tablets in Lakhisarai district, which is 37% lower than the state
average. As per the GoI guidelines every single pregnant women should receive regular dose
of iron folic acid during the first trimester for the management of prevention and/or treatment
of anemia. However, it is observed during the field visit that there was shortage of IFA tablets
due to delay in procurement. State and district administration should take action to prevent
delays in future in procuring essential drugs that determines the outcome of the maternal
health.
Table 8 Selected maternal indicators of Bihar and Lakhisarai from April to July 2013
Sl. No. Key Indicators April to July 2013
Bihar Lakhisarai
1 ANC Registration against Expected Pregnancies 97% 100%
2 ANC Registration in first trimester against Reported ANC registration
43% 37%
3 Severe anemia (Hb<7) treated against reported ANC registration
0.4% 0.3%
4 Hypertension in pregnancy- detected against ANC reported
2% 5.7%
5 Institutional Deliveries against Estimated Deliveries 42.1% 47.2%
6 Home deliveries( SBA& Non SBA) against estimated deliveries
13.4% 16.7%
7 C Section deliveries against institutional deliveries 1.5% 0.0% Source: DHIS2
6.2 Institutional Deliveries
As shown in the table 8 above, institutional deliveries of the district is higher by 5% in
comparison with state average during April to July 2013. The state needs to review the low
performance of C-section deliveries, which is mere 1.5% and the district reported none. This
raise many question related to pregnancy complication management in the state and district
that needs to be answered. However, to improve the situation, the state has trained 101 medical
officers in EmOC and 113 MOs in LSAS in the year 2012. State needs to develop a mechanism
to follow-up trained MOs whether they are using acquired skills in preventing and reducing
maternal mortality at health facility level. It is observed that the LSAS trained MO’s are hesitant
to perform even selective C-Sections due to unavailability of required instruments in health
facilities.
Only 8% of the total available health facilities are operationalized as delivery points in the state
and district. State and district needs to prioritize health sub-centers as delivery points based on
maternal indicators and needs of the locality. Only 1% of sub-centers are operationalized as
delivery points at state level and 3% in Lakhisarai district are operationalized as DP who are
Page | 15
conducting >3 deliveries. Availability of round the clock FRU services in the state and district is
questionable.
Table 9 Functional delivery points in public health facilities – Bihar and Lakhisarai
Sl .No
Health facilities Bihar Lakhisarai
1 Total No. of SCs/conducting >3 deliveries per month 9696/74 102/3
2 Total No. of 24X7 PHCs/conducting >10 deliveries per month
496/496 6/4
3 Total No. of any other PHCs/Conducting >10 deliveries per month
1243/204 16/2
4 Total No. of CHCs ( FRU) conducting > 20 deliveries /month /C-section
67/67/8 NA
5
Total No. of any other FRUs (excluding CHC-FRUs)/conducting > 20 deliveries per month with C-section
45/45/12 1/1/0
6 Total No. of DH conducting > 50 deliveries /month with C-section
36/36/36 1/1/1
7 Total No. of Medical colleges conducting > 50 deliveries/month with C-section
06/06/06 0/0/0
8 No. of Blood bank licensed / functional 34/28 1/0
9 No. of Blood Storage Units licensed / functional 115/9 NA Source: State and district PIP 2013-14
There are total 34 blood bank and 115 blood storage units
available but only 28 BBs and 9 BSUs are functional in the state.
Renewal of license for existing BSU’s is a concern in the state and
there should be proper action plan for the renewal and
maintenance of these BSU’s. However, in Lakhisarai district one
blood bank available but non-functional due to delay in license.
Required equipment and human resource available for blood
bank but due to administrative issues no use of facility. Such
delays in issuing license and administrative barriers should
overcome by state and district authorities by appropriate
mechanism to provide better and improved health services to the
people. These small fragmented issues will impend on health
outcome of the district and state.
Out of total deliveries, Lakhisarai Sadar hospital alone
contributes 31% and rest of the health facilities contribute 69% in
the district. Three blocks, Barahiya, Surajgadha and Lakhisarai
contributes 89% and remaining Halsi, Piprahiya and Ramgarh contributes mere 11% of total
institutional (public) deliveries in the district. However, APHC’s, which are equal to PHC in
comparison with other states contributedaround 1% of total deliveries during April to July 2013.
Non-function Blood Bank, DH
Page | 16
Only 12% [2] of available 16 APHCs are conducting more than ten deliveries. Strategically 3 to
6 APHCs are located in every block serving 40 to 70 thousand population, which are best
positioned to meet the demand of maternal services. However, the state adopted to
operationalize these APHCs equal to PHCs but the progress is very slow. Mere 3 HSC
conducted deliveries during first quarter of financial year 2013-14. The district should evaluate
poor performing blocks and prepare action plan to improve the institutional delivery, which
should reflect in the district health action plan.
Graph 2 Block wise Institution Deliveries from April to July 2013 – Lakhisarai
Source: DHIS2
Expected deliveries calculated based on population and crude birth rate for the period of April
to July 2013 for Lakhisarai district and Bihar state. Out of expected deliveries, only 47% and
42% were reported as institutional deliveries from Lakhisarai and Bihar state. Around 3% to 6%
reported home deliveries with skill birth attendant and 11% home deliveries without skill birth
attendant. However, unreported deliveries as high as 36% in Lakhisarai to 44% state average.
Until APHCs and HSC are not strengthen to handle delivery load the situation remains the
same in the district and state.
Table 10 Type of deliveries from April to July 2013 – Bihar and Lakhisarai
Deliveries Bihar Lakhisarai
Expected deliveries 949267 8218
Institutional deliveries 399780 42.11% 3881 47.23%
Skill Birth Attendant (Home) 27524 2.90% 465 5.66%
None-Skill Birth Attendant (Home) 99881 10.52% 907 11.04%
Unreported deliveries 422082 44.46% 2965 36.08% Source: HMIS/DHIS, 2013
96525%
2968%
60%
1374%
129333%
118430%
Institutional Deliveries - PHC wise (Block) from April to July 2013
Barahiya
Halsi
Piprahiya
Ramgarh
Surajgadha
Lakhisarai SH
Page | 17
Non-performing EmOC trained doctors is one of the major concern in the state. Quality of
training and post training follow-up needs to strengthen to improve the utilization of acquired
skills in the health facilities. Rational deployment of human resources particularly in APHCs
and PHCs to ensure functionality of health facilities at primary level would improve the
maternal outcomes. Almost all APHCs are run by AYUSH doctors with ANMs and hence there
is a need to prioritize all APHCs into delivery points.
During visit to Shivpuri tola, Kaindi village in Halsi block, come across three home deliveries in
the village. These families depend on sessional migration to other states for work (below
photo). One family migrated to Panipat in Haryana and another to Khanpur city in Uttar
Pradesh. When enquired aboutreasons for home delivery, they believed that home delivery is
safe and secure without any expenditure
on drug, diet, and transportation.
Cultural barriers and popular belief among
community for example, presence of evil in
government hospitals, restrain them using
public health facilities. Bihar being densely
populated state, high trend of inter-state
migration as well as intra migration (rural
to urban) for employment. The state and
district authority should identify these
communities and geographical areas,
where migration is high, and design appropriate IEC and BCC campaigns to create awareness
about available health schemes. ASHAs should identify such communities in her catchment
area and provide appropriate information and to motivate them to use available health services.
6.3 Maternal Death Review
Bihar is one of the high MMR (305/100,000) burden state in India but yet to establish robust
mechanism to review maternal deaths in the district and state level. No facility and community
based MDR committees are constituted in the district. From April to July 2013, no maternal
death reported in Lakhisarai district, whereas the MMR of district is 2.95 per 1,000 population
(295/100,000). This indicates serious lapse in reporting maternal deaths (MDs) in the district.
Reporting MDs would have benefit district authorities in reviewing the causes and reasons for
maternal deaths, which would help in strategizing appropriate interventions to reduce MMR.
There is need to constitute/strengthen MDR task force at district and state level to regularly
review MDs and follow-up action to reduce MMR. Of total 346 reported MDs in the state
during April to July 2013, 72% of cases fall under other causes that includes causes not known.
Second major cause of death is bleeding followed by severe hypertension/fits. Priority of the
state is to train district, block MOs, MOICs and private hospitals on maternal death review in
regular interval to strengthen MD reviews, to understand major cause of death and to reduce
MMR burden.
Page | 18
Table 11 Causes of maternal deaths – Bihar and Lakhisarai, April to July 2013
Maternal Deaths Bihar Lakhisarai
Abortion 12 [3%] 0
Obstructed/prolonged labor 13 [4%] 0
Severe hypertension/fits 18 [5%] 0
Bleeding 40 [12%] 0
High fever 14 [4%] 0
Other Causes (including causes not known) 249 [72%] 0
Total 346 0 Source: DHIS2
6.4 Janani-Shishu Suraksha Karyakram (JSSK)
6.4. A User fee in Out Patient Department (OPD) and In Patient Department (IPD)
User charge of Rs. 1 observed for OPD in district hospital, Lakhisarai and IPD services are free
in all facilities. Out of 19 beneficiaries interviewed, three of them were home deliveries and rest
institutional deliveries. These interviews conducted at different health facilities and one VHND
village. No one reported paying any money for IPD services.
6.4. B. Drugs and Consumables
It is observed that there was shortage of drugs in all health facilities in the district. Out of 19
beneficiaries interviewed at VHND Kaindi village, PHC, Ramgarh chowk and DH Lakhisarai,
68% informed receiving partial drugs and 16% received all drugs and consumables from the
facilities. Remaining three beneficiaries were home deliveries. The beneficiaries who received
partial drugs spent on an average Rs. 150 to buy medicines. Most of the prescribed medicine
are either multivitamin or pain killer and some of them are anti-biotic. Below is the list of drugs
generally prescribed at health facilities.
1. Epidosin 2. Polybion 3. Misoprostol 4. Methylergometrine 5. Iron syrup
Graph 3 Utilization of drugs and consumables, Lakhisarai, Bihar
316%
1368%
316%
Beneficiaries response on drugs and consumables
All drugs/consumablesfrom Facility
Partial drugs/cons. fromfacility
All Medicines fromoutside
Page | 19
6.4. C. Diagnostics
Pregnant women are exempted from paying money for laboratory tests.Diagnostic services are
outsourced to IGE Medical Systems, Patna in the district. Except few, such as chest x-ray,
routine blood and urine examination, none of the diagnostic services are available in the
district. None of the health facility have ultrasonography for diagnosing ANC cases.
Nevertheless, these services were outsourced to third party to provide uninterrupted diagnostic
services, which are non-functional and many beneficiary dependent on private diagnostic
services. However, exit interview with beneficiaries revealed that almost all beneficiaries
undergo partial laboratory test. For ultrasonography, they shell out on an average Rs. 200 to Rs.
300 that include transportation and diagnostic cost. It is evident from the visited facilities that
due to lack of human resource and inadequate facilities, these services are not available. Hence,
many of the pregnant women dependent on private labs for diagnostic test which has direct
implication on out of pocket expenditure.
6.4. D. Diet
Provision of free diet is not available in the district, which is mandate under JSSK programme.
However, the state government made diet provision compulsory across the state prior to JSSK
programme. Therefore, the
supervisory of diet provision in the
state remains with the directorate of
health services. When interacted with
state level SPMU and DPMU officials
regarding the situation of diet
provision, they expressed helplessness
in monitoring because the budget
flows from state treasury route. There
is a greater need for coordination
within health department for
monitoring and implementation of free
diet provision. It is learned that the
district health society called for tenders and selected an agency to supply free diet in the district.
But, it never implemented in the district since from the beginning due to various technical and
financial reasons.
Observed across all the facilities that more than 90% of the beneficiaries leave the health
facilities immediate after delivery, within 2 to 6 hours. All most all deliveries are normal
deliveries and no other health facility including DH Lakhisarai caters to complications.
Page | 20
Graph 4Duration of stay after delivery in Lakhisarai district from April to July 2013
Source: DHIS2
6.4. E. Referral Transport
In Lakhisarai district, there are 7 blocks and each block has one Janani Shishu Arogya Express
(102) exclusively for pregnant women to transport nearby health facility. Out of 19
beneficiaries interviewed,42% of them availed the ambulance service to reach the health facility
and for drop-back 47% beneficiaries utilized or utilizing the services. Remaining 7 beneficiaries
are not aware how they will go. It is reported that on an average each beneficiaries shell out
Rs.100 to Rs.150 rupees on transportation.
It is evident from the reported data that only 40 to 50 percent of the beneficiaries are availing
the ambulance facility and remaining of them are dependent on private vehicles which is one of
the major contribution for out of pocket expenditure among the PWs.
Graph 5Beneficiaries response on utilization of ambulance services inLakhisarai
Source: Beneficiaries interview
0
200
400
600
800
1000
1200
1400
1600
April '13 May '13 June '13 July '13
D U R A T I O N O F S T A Y - L A K H I S A R A I , B I H A R
Deliveries conducted at Public InstitutionsOf which Number discharged under 48 hours of delivery
842%
842%
316%
Utilization of Ambulance Servies, Lakhisarai
Hired
Govt. Ambulance
Other
Page | 21
6.4. F. Display of entitlements
The signage of JSSK well displayed in PHC and
above health facilities but there is no display of
entitlements at HSC level, which is first point
contact for ANC mothers. At HSC level, state
and district authorities should plan, procure
and display IEC materialsand information on
various NRHM schemes.
6.4. G. Awareness of community
When enquired about JSSK entitlements with
beneficiaries, there is no clear differentiation
between JSY and JSSK. Almost all aware about
Rs.1400 incentives under JSY but no clarity about JSSK entitlements like assured referral
transport, diet, diagnostic and medicines for mothers and new born babies. The source of
information for PWs are ASHAs. Out of 19 beneficiary’s interview, 42% respondent partially
and another 8 persons expressed fully aware of the JSSK entitlements. Three PNC mothers, who
delivered at home are not aware about the scheme.
6.4. H. Grievance Redressal Cell
There is no formal grievance redressal mechanism available in the visited facilities, when
enquired with the beneficiaries, 7 out of 19 informed that they will approach ASHA and rest of
them said they don’t know whom to approach for their grievances.
6.4. I. Out of pocket expenditure / informal charges
Interaction with beneficiaries revealed that out of pocket expenditure arise mostly on
transportation, diet and drug charges. Regarding informal charges, there are some instance
where paramedics also demand money after delivery in the health facilities.
Regarding diet, DHS empanelled agencies to provide cooked food, but the agency yet to start
services in the health facilities. The state and district authorities should take appropriate action
against the agency to start the diet services in all delivery points.
6.5 Janani-Suraksha Yojana (JSY)
JSY is known as JBSY (Janani-Bal Suraksha Yojana) in Bihar and the DHS has made every effort
to disburse the prescribed money to beneficiary on the same day of delivery. It is observed that
there is no pending amount under JSY and regularly disbursing amount to the beneficiaries
within one or two days of time.
Number of women registered under JSY from April to July has increased by 8.7% in comparison
with last year same period at the state level. However, there is slight decrease by 2.45% in
Lakhisarai district for the same period in comparison with last year’s performance. Percentage
Page | 22
of JSY registration to total ANC registration has increased by 3.5% from 93.6% to 97.1% in
comparison with last year’s performance.
Table 12 Comparison of JSY Performance from April to July – Lakhisarai and Bihar
JSY Incentives Bihar Lakhisarai
2013-14 2012-13 2013-14 2012-13
Number of Women registered under JSY 953,481 870,511 9,601 9,837
% JSY registration to Total ANC Registration 97.1% 93.6% 100% 100%
Mothers paid JSY incentive for home deliveries 732 3,320 2 67
% Mothers paid JSY Incentive for Delivery at Public institution to Total Public Deliveries
89.9% 55.1% 90% 22.4%
% of cases where JSY Incentive paid to ASHA for Delivery at Public institution to Total Public Deliveries
52.6% 32.5% 26.9% 5.8%
Source: DHIS2 and HMIS
However, incentives paid for home deliveries have drastically reduced by 78% and 97% at state
and district level. But at the same time, incentives paid for institutional delivery has increased
by 35% and 67% at state and district level. This indicates either home deliveries have
significantly reduced or there might be some technical reasons, which state should clarify.
Disbursement of ASHA’s incentives, one of the key community mobilizer for institutional
deliveries, under JSY has improved by 21% in comparison with last year. Except home
deliveries, DHIS data suggest overall improvement in JSY incentives disbursement across the
state.
7 Child Health
7.1 SNCU
According to AHS (2011) IMR of the state was 55 and the Lakhisarai was reported 53, which is 2
points below the states average. State has 484 NBCCs, 7 NBSU and 37 nutritional rehabilitation
centers operational. However, in the district one SNCUapproved during 2011-12 but yet to start
the center as per approved plan. No separate building or required infrastructure available even
though the plan was approved two years back.
Table 13 Status of different type of new born care facilities in Bihar and Lakhisarai
Status NBCC NBSU SNCU NRC
Approved Operational Approved Operational Approved Operational Approved Operational
Bihar 484 484 40 7 39 8 38 37
Lakhisarai 5 5 1 0 1 0 1 1 Source: Bihar PIP 2013-14
UNICEF in collaboration with State Health Society, Bihar conducted state wide quality
assessment of NBCC in April 2012. The assessment conducted in 4 NBCC in Lakhisarai district
and found that 50% of NBCC’sare fully functional and remaining 50% NBCCs are partially
Page | 23
functional.Almost allNBCCs are located inside labor room and remaining in the district.
Around 16ANM/Staff Nurse trained and only 75% of them possess required skills for NBCCs.
Graph 6 Assessment of NBCC Centers – Lakhisarai, Bihar
None of the NBCC were reported with essential drugs in place and only one units reported
with all consumables. All visited units displayed proper protocols and only 2 showing utility of
protocol. However, all facilities have updated NBCC registers and regular monthly report but
none of the center have equipment maintenance register.
7.2 Nutritional Rehabilitation Centre
Malnutrition1 is a serious issue in Bihar with a high prevalence of 58.4% (NFHS-3; 2005-06).
Children suffering from severe and acute malnutrition are reported to be 8.3%. Based on
population figures, it is estimated that in Bihar 2.5 million children under 5 years of age are
threatened to face the consequences of severe malnutrition.
Graph 7Community wise and Age wise NRC admissions – Lakhisarai, Bihar
1Severe and acute malnutrition (SAM) is defined by a very low weight for height, below -3 z scores of the median WHO growth
standards, presence of visible severe wasting or ‘bipedal Oedema’, or mid - upper arm circumference (MUAC) of <11 or 11.5 cm in children between 6 to 60 months.
0
1
2
3
4
5
6
7
8
Radiantwarmer
Photo Therapy OxygenConcentrator
SuctionMachine
AMBU Bag &Mask
Stablilizer
Assessment of NBCC centres - Lakhisarai, Bihar (2012)
Available Functional
Page | 24
Source: DHS
District health society manages NRC through qualified NOGs and UNICEF continuously
provide technical and supervisory support. NRC located in old sub-divisional hospital building
in Sadar hospital campus, Lakhisarai. Kasturva Mahila Vikash Kalyan Samithi (KMVKS), Patna
runs NRC with the support from DHS. It is 20 bedded facility staffed by a nurse, a Feeding
Demonstrator (FD), a cook, two helpers and a pediatrician who checks children for their
nutritional and medical needs.
Graph 8 NRC admission criteria and gender composition
Source: DHS, from December 2011 to June 2013
The first batch under KMVKS started in December 2011 and currently admitting for 17thbatch.
For the past 16 batches, NRCadmitted 295 SAM children, which is 92.1% total bed occupancy.
All admitted children belongs to SC/EBC/OBC, of which 36% male and 64% females. Of the
total 295 children, 50% children’s belongs to 6 to 12 months, 34% belongs to 1 to 2 years and
remaining 16% of children’s belongs to 2 to 5 year’s category.
The admission criteria include Weight for Height (WFH) <-3SD, Mid-Upper Arm
Circumference (MUAC) <115mm and bilateral pitting edema. 89% of the children admitted
based on MUAC <115mm criteria and remaining 11% based on WFH<-3SD criteria. Total 62%
13747%
00%
11840%
3311%
72%
Community wise NRC admissions
SC ST OBC EBC GEN
14950%
10134%
3512%
83%
2
1%
Age wise NRC admission
06-12m 13-24m 25-36m 37-48m 49-60m
10636%
18964%
NRC Admissions - Male and Female
Male Female
3611%
29589%
10%
NRC Admission Criteria
WFH < -3 SD MUAC < 115 MM
Bilateral Pitting Edema
Page | 25
children gained more than 15% weight, one defaulter and one death reported. Around 19%
children completed follow-up and 281 children’s follow-up still going on. None of the children
were transferred or referred to any other facilities during admission period. It is observed that
there is no proper follow-up mechanism exist with NGO to do continues monitoring of the
children after discharge from NRC. As per the financial year 2013-14, Rs. 5 million sanctioned
for NRC Lakhisarai that comes to Rs.20000 per child per batch. One needs to critically analyze
the sustainability of the NRC modelin relations to outcome of the project.
7.3 Immunization
Cumulative figures of Lakhisarai from April to July 2013 shows declinedtrend as compared to
Bihar state. The full immunization coverage of Lakhisarai is 76%, which is 2% lower than state
average. Except BCG and measles, all other immunization coverage in the district comparably
higher than state’s average. DPT3 to Measles dropout observed in Lakhisarai and Bihar, by 12%
and 6%. However, BCG-DPT3 drop out percentage decreased by 26% and 18% in Lakhisarai
and Bihar. Facilities visited had functional ILR and deep freezer with temperature card duly
filled and adequate temperature maintained. In Bihar, due to shortage of power supply, most of
the ILR/deep freezer dependent on power generator, which were outsourced to third party.
Facility level official informed that in case of generator failure, they depend on ice cubes which
are locally available.
Graph 9 Immunization Coverage against estimated live births from April to July 2013
Source: HMIS
The district shows good performance of planned versus held immunization sessions which
correlates with immunization achievement in the district. However, in comparison with state,
improvement shown in sessions held in the district. It is concern to note that only 85% to 86%
of immunization sessions were attended by ASHAs who are supposed to do community
mobilization.
73%
85% 85%80% 78%
70%
88%
100%
78% 76%
0%
20%
40%
60%
80%
100%
120%
BCG DPT 3 OPV 3 Measles Full Immunization
% I M M U N I Z A T I O N C O V E R A G E - B I H A R A N D L A K H I S A R A I
Bihar Lakhisarai
Page | 26
Table 14 Immunization session held in Bihar and Lakhisarai from April to July 2013
Immunization Sessions % of immunization sessions held vs planned
% of immunization sessions where ASHA were present (out of the held sessions)
Bihar 97.4% 85%
Lakhisarai 98.6% 86%
8. Family Planning
Performance of family planning programmes reflects poor outcome in the state and district. As
per the DLHS III, state and district has 39.2% and 43.3% total unmet needs and on the basis of
district population, total eligible couples for unmet need calculated for four months (April to
July) 2013. 2.7% of the total unmet needs were catered in the district, which is 1.35% lower than
the state average, 4.05, in meeting family planning needs. State and district shows similar
performance in providing IUDs against total reported FP users, which is 57% of total reported
FP users.
Table 15 Family Planning Key Indicators – Bihar and Lakhisarai from April to July 2013
FP Key Indicators Bihar Lakhisarai
Unmet Need 39.2 43.3
Eligible Couples for unmet need- Calculated Using DLHSIII Unmet need
6917541 73663
Total reported FP Users against estimated eligible couples 4.05%
[280609] 2.7%
[1998]
Total IUDs reported against total reported FP users 56.5%
[158620] 57%
[1140]
Total OCP users against total reported FP users 7.8%
[22089] 9.3% [186]
of Total sterilization (against Estimated Level of Achievement)
0.95% [66193]
0.6% [447]
Postpartum sterilization out of total female sterilizations 4%
[2929] 0.45%
[2]
Male sterilizations out of total sterilizations 1%
[792] 0.45%
[2]
Female sterilizations out of total sterilizations 99%
[65401] 99.5% [445]
Source: DHIS2
99% of total sterilization are female sterilization, hence there is a need to motivate and counsel
male partners for sterilization. OCP users remain the same across state and district level
trainings are held for MO in PPIUCD to promote spacing between child births. The unmet need
(43.3) for Lakhisarai district well correlate with literacy rate of the district (62.42). Yet, there is
huge gap between demand and supply but the district health facilities are not equipped to fill
the gap. Need to apprise family planning activities in the district, which should accommodate
demands of the district.
Page | 27
9. Quality in Health Services
9.1 Infection Control and Bio-Medical Waste Management
The state has outsourced the Biomedical Waste Management (BWM) system for all health
facilities from medical colleges to PHC level. MOs and paramedical staff are satisfied with
outsourced agency and they are regular in picking biomedical-waste. Infection prevention
practices needs improvement in all health facilities. Many of the health facilities, which visited
do not have proper coded buckets for segregation of biomedical waste, some facilities have
coded buckets but they are in partial usage. Disposable gloves and masks are not available
almost in all health facilities. Needles and syringes are not properly mutilated and disinfected
before putting in waste bin. The district needs additional trainings and robust monitoring as far
as infection prevention (IP) practices are concerned.
Lakhisarai district hospital aiming for ISO
certificate and they are in the process of
audit. However, there are many gaps, which
needs to close before applying for ISO. For
example, some basic things like mosquito
screens for doors and windows, attached
toilet, fetoscope, wheel chair, glutaraldehyde
try, urine albumin sugar strip etc. are not
available in the labour room. Fire safety
equipment installed but no regular check for
their functionality and there is no defined fire
escape routes available in the district
hospital. The district hospital, Lakhisarai scored 202 out of 280 during pre-assessment audit.
However, to improve the quality of delivery of diagnostic services, state needs to develop
program for capacity building and quality assurance in laboratory and radiology services.
Standardized quality norms should be maintained at sub-centre, APHC and PHC level for
delivery of effective RCH services. Supportive supervision at block level, district level and
follow-up action by state level should be streamlined.
9.2 Information Display
Information related to health programs are not well displayed in PHCs and below health
facilities. Information related to national schemes like JSSK well displayed in the DH campus
but yet to displaycitizen charter. However, no sub-center has any IEC material on any health
programme, which are first contact point for community for accessing basic health services.
Proper display of information will benefit local population and have positive impact on
utilization of health services. This will also improve the accountability of health system.
Page | 28
10. Community Processes
10.1 ASHA and MAMTA
The state currently has about 84,365 ASHAs, representing 97% of the total selected. As per the
revised norm, Lakhisarai requires 802 ASHAs and only 756 ASHAs are placed, which is about
94% of the required ASHAs. There are total 39 mamatas position approved in the district and
all of them are placed in DH and RH/CHC hospitals.
Table 16 Block wise ASHAs and ASHAs facilitators against target as on July 2013
Sl. No.
Block
ASHA Selection
ASHA Facilitator Selection
Target Achievement Target Achievement
1 Surajgarha 262 224 10 10
2 Barhiya 114 114 6 4
3 Pipariya 55 47 2 2
4 Halsi 96 96 5 5
5 Ramgarh chowk 88 88 4 4
6 Lakhisarai Sadar 187 187 9 9
Total 802 756 36 34 Source: DHS, Lakhisarai
The state has established support structures at state, divisional, district, block level for ASHA
functioning. There are 34 ASHA facilitator available in the district out of 36 positions available
and 5 Block Community Mobilizer (BCM) available out of 6 approved post. However, DCM
position is vacant since from the beginning of NRHM programme. District Planning
Coordinator (DPC) has taken additional in-charge for community mobilization. Except
uniforms no other benefits such as mobile recharge support, insurance and bicycles etc. not
available for ASHAs in the district.
10.2 Skill Development
All ASHA were trained up to module 4
and 99% (750) of ASHA were trained in
first round of module 6 and 7, which is
fully residential. Round 2nd, only 64
ASHAs trained and round 3rd and 4th, of
module 6 and 7 yet to start. District has
distributed drug kits to all ASHAs
however, no HBNC kits were
distributed. The district has identified
IL&FS India, for rolling out trainings for ASHA in the district. It is learned that due to
unavailability of training site, some constraints in rolling out training for ASHAs in the district.
10.3 Functionality of the ASHAs
There are total 10 ASHA’s dropout and reasons for dropout is lack of interest and some of them
are migrated to other areas and some expired. There is no formal grievance redressal
Page | 29
mechanism available for ASHA in the district. The process of refilling of drug kit of ASHAs is
done from PHC once in a year. The payment of ASHAs in the state and district is through bank
account and there is no pending of ASHA payment in the district. However, ASHAs lack the
provision of rest houses in the health facilities, no help desk available in the district.
10.4 Village Health, Sanitation and Nutrition Committees (VHSNC)
Total 80 VHSNCs have been constituted at Panchayat level in the district. During last financial
year 8 lakhs fund released in two installments. VHSNC committee constituted as per the norms
and ASHA being member of the committee look after the activities of VHSNC. It seems,
members of VHSNC finds difficult in coordination with other departments due to different
priorities with different departments. At the state level, total 3.29 lakhs VHND sessions
planned and 96.3% sessions held during four months period from April to July. During these
sessions, around 18727 women identified with below 7 mg. hemoglobin and 2.37 lakh women
with a range of 7-11 gm hemoglobin who are considered to be high risk mothers. The below
table provides the performance of VHND from April to July 2013.
Table 17 performance of VHND from April to July 2013 – Bihar and Lakhisarai
Performance VHND Session
Held
Hemoglobin
Below 7 gm. 7-11 gm. 11+ gm.
Bihar state 317205 18727 237396 137050
Lakhisarai 3001 17 516 90
Graph 10 Correlation between no. of ASHAs and no. of Insti. Deliveries in Lakhisarai district
Page | 30
Number of ASHAs significantly correlated with number of institutional deliveries in each block
of Lakhisarai district. Hence, statistically evident that number of institutional deliveries well
correlate with number of available ASHA in a particular area. However, when tried to correlate
with number of available ANMs in each block with number of institutional deliveries, which do
not correlate well and indicates statistically significant difference.
Page | 31
11. Disease Control Programme
11.1 Revised National Tuberculosis Control Programme
Lakhisarai has 2 Treatment Units (TUs), 4 Designated Microscopic Centers (DMCs) with 2
Senior Treatment Supervisor (STSs) and 2Senior TB Laboratory Supervisor (STLS). As per the
population norms there should be one DMC for every 100,000 (50,000 per tribal and hilly areas)
population and one TU per 5 lakh population (2 to 2.5 lakhs tribal and hilly areas). As per the
population norms, the district has inadequate RNTCP facilities available for screening,
diagnosing and treatment.
Graph 11Performance of RNTCP for the month of June 2013, Lakhisarai, Bihar
District has various administrative and operational problems associated with RNTCP
programme. DTCO position is vacant and MO of DH has taken in-charge of the programme.
No shortage of TB drug including Pediatric medicine.Yet, it is observed that there is no referral
linkages of TB suspected cases from the field, only OPD cases were screened in the DMCs.
Donor funded AXSHYA project on ACSM (Advocacy, Communication and Social Mobilization)
is implemented in the district through local NGO with an objective to create awareness and
improve cases detection. However, the district performance yet to reflect the impact of the
AKSHYA project in terms of improved referrals and case detection. Need for reorientation of
LT as per RNTCP modules and many of the LTs do not have information on referral of
suspected MDR cases in the district.
250
178
268
276
186
0
50
100
150
200
250
300
Lakhisarai TU Surajgarha TU
Performance of RNTCP, Lakhisarai
Sputum (-) Sputum (+) Referred for diagnosis
Page | 32
Graph 12 TB-HIV Cross-referrals, Lakhisarai
From January to June, around 732 TB suspected cases were referred from DMCs to ICTC center
and confirmed 5 HIV+ cases. However, there is no record of cross-referrals from ICTC to
RNTCP observed in the district. As per RNTCP, it is estimated 75 new smear-positive (NSP)
cases per 100,000 population and the national target is to detect at least 70% of the total
estimated cases, which is 53 cases per 100,000 population. However, the performance of the
district shows far below the national target of the total NSP cases per annum as per estimated
district population.
11.2 National Leprosy Eradication Programme (NLEP)
Bihar is one of the high burden state for leprosy with a prevalence of 0.89 cases per 10,000 and
2.51 child cases per 100,000 population with 16.77 annual new case detection rate as on March
2012. There is no adequate staff for leprosy detection at PHC level and Deputy Superintendent
(DS) of DH is the in-charge of DLO. There is no skin smear test available in any health facility
and almost all cases were detected based on nerve and skin patches. Total 44 cases detected in
April to June 20013, which include 21 PB and 23MB that include 5 child cases. Around 42 cases
were released from treatment and 169 cases under treatment in the district by the end of June
2013. Every block has one non-medical assistant for leprosy outreach activities and other para-
medic staff. ASHA also supports leprosy outreach activities in the district. However, health
facilities do not have the capacity to treat disabilities and they refer to nearby referral center in
the district.
11.3 National Vector Borne Diseases Control Programme
From April to July 2013, the state has examined 69,926 blood smear and confirmed 1565 cases,
which is 2.23% positivity. Out of 1565 positive cases, 29% of them are Plasmodium falciparum
(Pf) cases and remaining cases are Plasmodium Vivax (Pv).The below graph indicates that the
number of Pf cases are increasing every month from 12% in May to 42% in July. State needs to
2
0
2
1
0 0
188
300 290
336
295
369
92 104
138118
133147
0
0.5
1
1.5
2
2.5
0
50
100
150
200
250
300
350
400
January February March April May June
TB-HIV Cross Referrals
HIV + TB suspect from OPD RNTCP to ICTC
Page | 33
identify the geographic locations where the number of Pf cases are reporting and alert the local
administration to prevent the widespread malaria.
Graph 13Performance of Vector borne diseases (Malaria) – Lakhisarai and Bihar
Similarly, Lakhisarai district examined 2274 blood smear and 45 found positive out of which
22% cases are Pf. No adequate number of basic health worker (BHW) sanctioned in the district
who are focal point person for identifying vector breeding grounds further preventing vector
borne diseases.
11.4 National Programme for Control of Blindness (NPCB)
The state has annual target of 607070 cataract operations and 85640 free spectacles to school
children out of which 46.2% and 7.1 achieved for cataracts and spectacles the end of May 2013.
The district MIS data reflects very poor performance and DHIS data do not reflects the
performance of blindness control programme. No cataract identified and operated in
Lakhisarai district from April to July 2013. Around 14 refractive errors detected among school
going children but none of them received free glasses.
Graph 14 State level progress of NPCB, Bihar
169 487 234 22173 83 109 189
18522
17458 17953
15993
0
200
400
600
800
14000
15000
16000
17000
18000
19000
April '13 May '13 June '13 July '13
Malaria Performance - Bihar
Pv Pf BS Examination
1 4 19 113 2 2 3
497
312
815
650
0
10
20
30
40
0
200
400
600
800
1000
April '13 May '13 June '13 July '13
Malaria Performance - Lakhisarai
Pv Pf BS Examination
0 5000 10000 15000 20000 25000
IOL Implanted
Cataract Operated
Performanc of NPCB - April to July 2013, Bihar
0 1000 2000 3000 4000 5000 6000
Free Glasses toChildren
Refractive errorsdetected
Page | 34
11.5 National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
India is experiencing rapid health transition with a rising burden of Non-Communicable diseases
(NCDs). The NPCDCS program aims at integration of NCD intervention in NRHM framework
for optimization of available resources. Five district are reporting the performance of NPCDCS
at the state level through DHIS2 and the data reflects for these five district from April to July
2013. The main activities under NPCDCS is to screen for diabetes and hypertension at block
level PHCs. The program has distributed 162801 glucostrips for screening of diabetes from
April to July 2013. NPCDCS program staff is not available but utilizes available PHC staff to
screen diabetes and hypertension. Estimated population of 35 years and above calculated based
on Census 2011 for Bihar state.
Graph 15 Performance of Bihar NPCDCS from April to July 2013
The programme envisages to screen 35 years and above for diabetes and hypertension.
However, the programme could screen less than 1% of the total population. The programme
would achieve the target if it is population based approach rather than clinic based approach.
Around 36,145 people attended out of 750 camps organized for diabetes and hypertension. Of
the attended only 31% of them undergone screening for diabetes and hypertension. Of screened,
34% were suspected for diabetes and 23% for hypertension in the district. The percentage of
suspected cases are greater number due to clinical approach and many of them would be known
hypertensive or diabetic case. The above graph provides NPCDCS performance from April to
July 2013.
12 Others
12.1Information Systems
In Bihar, DHIS2 application is in use for HMIS and data entry takes place at block level. Block
level BPMU structure is similar to DPMU, but district and block level HMIS analysis needs to be
strengthen to provide feedback and improve the facility level performance. RHMIS indicates
98% facility wise data uploading in Lakhisarai district.
591
2537
2919
8653
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
People Suspected
People Screened
People Suspected
People Screened
Hy
pe
rten
sio
nD
iab
ete
s
NPCDCS Performance
Page | 35
Table 18 Status of Facility Wise Data Uploading, Lakhisarai
Facility No. of Facility Facility wise uploading
SC 102 102
PHC 24 22
CHC 1 1
SDH 0 0
DH 1 1
Total 128 126
Source: RHMIS
12.2 OPD and IPD
On an average 257 OPD per 1000 population at state level and 254 OPD per 1000 population at
district level reported from April to July 2013. 13 IPD per 1000 population recorded at state and
district level. However, when correlated district OPD and IPD with available human resources,
it doesn’t correlate well with available resources in the district. The staff include medical
officers, ANM and staff nurse grade-A.
12.3 Mortality
Around 15990 and 278 deaths reported from Bihar and Lakhisarai from April to July, of which,
74% belongs to communicable diseases including maternal and perinatal deaths in the state.
Whereas, 40% and 46% deaths reported under CDs and others category, which include acute
and chronic diseases reported from Lakhisarai for the same period. Injuries remains the same,
across the state and district, from 3% to 3.6%.
Graph 16 information on Mortality from April to July 2013 – Lakhisarai and Bihar
CDs including
Maternal & Perinatal
74%
NCDs7%
Injuries 3%
Others 16%
Bihar Mortality
CDs including
Maternal & Perinatal
40%
NCDs10%
Injuries 4%
Others 46%
Lakhisarai Mortality
