PUNJAB STATE REPORT

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Punjab

Index

S. No. Content Page No.

1 Summary of Approvals 2 – 5

2 Demographic Profile 6 – 7

3 Progress of NRHM 8 – 12

4 Reproductive & Child Health 13 – 16

5 Immunization 17 – 17

6 Revised National Tuberculosis Control Programme (RNTCP) 18 – 20

7 National Vector Borne Disease Control Programme (NVBDCP) 21 – 21

8 National Leprosy Eradication Programme (NLEP) 22 – 22

9 Integrated Disease Surveillance Project (IDSP) 23 – 24

10 National Programme for Control of Blindness (NPCB) 25 – 25

11 National Iodine Deficiency Disorder Control Programme (NIDDCP) 26 – 26

12 RoP Approvals under Mission Flexible Pool 27 – 31

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PUNJAB

Summary of Approvals

Financial Management under NRHM (Rs. in crore)

Years Allocation Release Expenditure % Release

against Allocation

% Expenditure against Release

2005-06 75.09 94.13 58.61 125.35 62.27 2006-07 128.44 173.50 119.81 135.08 69.05 2007-08 161.97 118.89 111.39 73.40 93.69 2008-09 173.24 197.58 188.39 114.05 95.35 2009-10 174.45 0.00

Total 713.20 584.11 478.21 81.90 81.87

S. No. Timeline Activities Achievement %

1 ASHA Selection 16388 102 Training

2 VHSC 12001 95 3 24X7 PHCs 109 23 4 Mobile Medical Unit 16 80 5 Rogi Kalyan Samiti 167 24

Budget Allocations (2005-09) ( Amount in Crores) Allocation Releases Expenditure

RCH Flexipool 2005-06 29.44 17.42 5.02 2006-07 39.32 23.72 11.17 2007-08 27.14 13.89 17.30 2008-09 48.13 56.63 42.36 2009-10 49.21

Total (A) 193.24 111.66 75.85 NRHM Flexipool

2005-06 24.37 1.95 2006-07 33.00 42.41 5.15 2007-08 57.68 26.08 21.37 2008-09 41.92 48.65 61.00 2009-10 43.42

Total (B) 176.02 141.51 89.47 National Disease Control Programme

2005-06 7.68 5.14 14.07 2006-07 10.75 9.89 20.92 2007-08 11.05 4.78 6.63 2008-09 13.77 7.59 8.04 2009-10 15.40 0.00 0.00

Total (C) 58.66 27.40 49.66 Grand Total (A + B + C) ������ ������ �����

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Record of Proceedings (2005-2009) for Mission Flexible Pool

Approval for Infrastructure Facilities (Rs. in Crore)

S. No Health Facilities 2005-06 2006-07 2007-08 2008-09 2009-10 1 Sub C 2.85 10.00 0.00 6.40

2 PHC 30.01 0.00 2.00

3 CHC 10.20 13.00 13.00 0.00 8.80

4 DH 3.70 82.39 4.33

5 Equipment 0.00 0.00 0.54

6 Transport 0.00 30.41

7 Others 8.30 0.00 0.00 2.25

Total 13.05 21.30 56.71 82.39 54.73

Approval for Human Resource Support (Rs. in Crore) S. No Personnel 2005-06 2006-07 2007-08 2008-09 2009-10

1 Doctors 0.00 57.79 12.92

2 Specialists 0.00 0.41

3 Staff Nurses 0.00 12.17

4 ANM 0.00 6.87

5 Others 0.00 4.98

Total 0.00 0.00 0.00 57.79 37.34

Approval of other activities (2005-2009) in Rs. Lakh

S.No Initiative 2005-06 2006-07 2007-08 2008-09 2009-10 Remark

s Released Approved Approved Approved Approved

ASHAs

1 ASHA 1058.44 449

TOTAL 1058.44 449 Untied Funds, Annual Maintenance Grants and RKS funds related matters

2 Rogi Kalyan Samiti 244 33.00

3 Rogi Kalyan Samiti- DH 100 100

4 Rogi Kalyan Samiti- CHC& SDH

128 147

5 Rogi Kalyan Samiti-PHC 121 396 6 Untied Fund 7 Untied Fund for CHC 64 64 63 8 Untied Fund for PHC 121 121 121 99

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9 Untied Fund for SC 285 285.8 285.00 286.20 285.80 10 Untied Fund for VHSC 1230 1273.8

11 Annual Maintenance Grant

123 Annual Maintenance Grant - CHC

128 112

13 Annual Maintenance Grant -PHC 242 242 198

14 Annual Maintenance Grant- SC

286.2 144

TOTAL 285 892.8 503 2706.4 2818.6 Infrastructure related matters

15 MMU 829.8 680.01 360

16

Emergency & Referral Services

2561

TOTAL 829.8 680.01 2921

Status of Infrastructure 2005-2010 As per RHS 2008 New Construction Upgradation / Renovation Number of Sub Centre 2858 116 227 Number of PHC 484 4 198 Number of CHC 126 4 141 Number of DH 20

As per State Data Sheet, NRHM

0 20

Status of NRHM as on 15.05.2009

1 ASHA Selection 16388 Training

2 VHSC 12001

3 Joint A/C @ Sub Centre and VHSC 2858

4 24X7 Facility 169 5 FRU 137

6 Contractual Manpower

Doctors & Specialist 90 AYUSH Doctors 98

Staff Nurse 589 Paramedics 589

ANM 0 7 JSY Beneficiaries (in Lakhs) 1.72

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National Disease Control Programme

NLEP

The state has already achieved the goal of elimination of leprosy. The state is advised to carry out indepth situational analysis in districts/blocks reporting large number of new cases and take suitable actions.

IDSP

It is a Phase III state. The recruitment of key human resources (Data managers, Epidemiologists, microbiologists etc) needs to be fast tracked and completed in a time bound manner. The data reporting should start from all the districts.

NBCP UCs for GIA released to State Blindness Control Society not being received timely. SOE for Cash Grant are also not being received timely. Performance of School Eye Screening Programme needs to be improved.

NVBDCP Filaria, Kala-azar, J.E. and Chikungunya are not endemic in the state of Punjab.

RNTCP Weak supervision is affecting the quality of programme as evidenced by low sputum conversion and cure rates and high default rates in some districts.

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Demographic, Socio-economic and Health profile

HEALTH INDICATORS OF PUNJAB The Total Fertility Rate of the State is 2. The Infant Mortality Rate is 43 and Maternal Mortality Ratio is 192 (SRS 2004 - 06) which are lower than the National average. The Sex Ratio in the State is 876 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows: Table I: Demographic, Socio-economic and Health profile of Punjab State as compared to India figures S. No. Item Punjab India

1 Total population (Census 2001) (in million) 24.36 1028.61 2 Decadal Growth (Census 2001) (%) 20.10 21.54 3 Crude Birth Rate (SRS 2007) 17.6 23.1 4 Crude Death Rate (SRS 2007) 7.0 7.4 5 Total Fertility Rate (SRS 2007) 2 2.7 6 Infant Mortality Rate (SRS 2007) 43 55 7 Maternal Mortality Ratio (SRS 2004 - 2006) 192 254 8 Sex Ratio (Census 2001) 876 933 9 Population below Poverty line (%) 6.16 26.10 10 Schedule Caste population (in million) 7.03 166.64 11 Schedule Tribe population (in million) 0 84.33 12 Female Literacy Rate (Census 2001) (%) 63.4 53.7

Table II: Health Infrastructure of Punjab

Particulars Required In position shortfall Sub-centre 3219 2858 361 Primary Health Centre 536 484 52 Community Health Centre 134 126 8 Multipurpose worker (Female)/ANM at Sub Centres & PHCs 3342 2706 636

Health Worker (Male) MPW(M) at Sub Centres 2858 1983 875 Health Assistant (Female)/LHV at PHCs 484 179 305 Health Assistant (Male) at PHCs 484 139 345 Doctor at PHCs 484 201 283 Obstetricians & Gynaecologists at CHCs 126 46 80 Physicians at CHCs 126 56 70 Paediatricians at CHCs 126 39 87 Total specialists at CHCs 504 210 294 Radiographers 126 61 65 Pharmacist 610 666 - Laboratory Technicians 610 270 340 Nurse/Midwife 1366 1024 342

(Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI)

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The other Health Institution in the State are detailed as under:

Health Institution Number Medical College 7 District Hospitals 20 Referral Hospitals City Family Welfare Centre Rural Dispensaries Ayurvedic Hospitals 15 Ayurvedic Dispensaries 507 Unani Hospitals - Unani Dispensaries 35 Homeopathic Hospitals 5 Homeopathic Dispensary 107

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Note on Progress of NRHM in Punjab (June 2009)

Punjab has implemented the activities of National Rural Health Mission efficiently and effectively

for attaining the goals and objectives of National Population Policy and Millennium Development Goals. The State is committed to enhance the health status of its population with strong focus on improving health outcomes especially among women, children and vulnerable populations. NRHM has transformed public health service delivery in the State. The decentralization, responsiveness to local needs, paradigm shift in health system management and availability of untied funds has improved the facilities and their credibility among members of the public. Brief information on progress of activities is as follows:

Institutional Framework of NRHM

Meeting of State & District Health Mission have been held regularly. Over 12001 VHSCs have been constituted & 2858 Joint Accounts have been operationalised at sub centre level. Rogi Kalyan Samities are operational at 20 DH, 147 CHCs & 0 PHCs. All districts have started developing their own IDHAP.

Infrastructure Improvements

A total of 101 PHC have been strengthened with three Staff Nurses each to make them functional on 24x7 works. State has 60 CHC functioning on 24X7 basis & facility survey completed in 116(including others health institution also). A total of 20 District Hospitals are functioning as FRUs. 16 districts have functional Mobile Medical Unit (MMU)

Human Resources

A total of 16388 ASHA selected till date out of which 13190 ASHAs in 2007-08 and 3198 ASHAs in 2008-09. 2290 Sub-centers are functional with an ANM. 98 Contractual AYUSH Doctors have been appointed. As far as Manpower augmentation is concerned, 90 specialists, 589 SN recruited on contractual basis

Services Institutional deliveries improved from 2.33 lakhs (2006-07) to 2.24 lakhs (2007-08). During the year 2008-09 there has been 2.41 lakhs Institutional deliveries in the state. JSY beneficiaries increased from 0.17 lakhs (2006-07) to 0.29 lakhs (2007-08). The numbers of JSY beneficiaries 0.68 lakh during the year 08-09. Female sterilizations have increased from 0.88 lakh (2006-07) to 0.91 lakh (2007-08) and male sterlisation has increased from 5615 (2006-07) to 13110 (2007-08). During year 2008-09, 84879 female & 12760 male sterilization have been reported. 4 districts are implementing IMNCI & 2107 people trained so far. 45330 VHND held since the launch of NRHM.

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General Overall improvement in health system since NRHM Achievements Made

• 16 districts have functional MMUs and reaching health services to remote locations. • Village Health & Sanitation Committees constituted in coordination with PRIs at each village

level. • Improved Out Patient and In Patient attendance. • There is an increase in institutional deliveries. • Campaign has been launched to strictly enforce PNDT and licenses of 305 Centres were

suspended/cancelled. • Provision of Mobiles phones to ANMs for continuous contacts and information. • Rogi Kalyan Samitis are registered up to DH level

Areas for Further Improvement

• Maternal health services, especially for the vulnerable sections needs attention. • % of children immunized has come down, needs strengthening. • Community processes are still to take off. ASHAs selected but training yet to begin. • Registration of District Health Societies should be fast tracked. • Need for capacity building of VHSCs to enable them to discharge their responsibilities for

better health outcomes. • The ASHAs need to be provided with drug kits.

Infrastructure

• Residential facilities for health personnel should receive attention. • 20% PHCs have been upgraded and functioning as 24x7, need to augment the process of

upgradation. • Need to optimise utilisation of existing infrastructure through HR rationalisation and better

supervision to ensure accountability.

Human Resources

• The department has acute shortage of Doctors and other Para-Medical staff. • Strengthen SPMU, DPMU and BPMU by filling the vacant positions at the earliest. • An integrated comprehensive approach to strengthen facilities and HR is desirable. • Recruitment of Medical Officers (Specialist Doctors) on regular basis is under process through

Departmental selection committee.

Service Delivery

• 24X7 days PHCs are not fully functional. • Needs to strengthen AYUSH and integration with modern medicine is required • Poor institutional set up for establishing HMIS

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An Analysis of Financial Monitoring Report for the FY 2008-09 A. RCH Flexible Pool

Component wise expenditure & Utilization under RCH against the approved PIP

Rs. In Lakhs

Activities SPIP Expenditure % Utilization against PIP

Maternal Health 466.59 466.78 100.04 Child Health 106.15 14.03 13.22 Family Planning Services 934.60 848.62 90.80 Adolescent Reproductive and Sexual Health/ Arsh 27.07 15.75 58.18 Urban RCH 153.00 123.70 80.85 Innovations/PPP/ NGO 507.34 154.30 30.41 Infrastructure & Human Resources 1543.35 1075.83 69.71 Institutional Strengthening 323.78 157.61 48.68 Training 461.88 165.41 35.81 BCC / IEC 288.11 247.46 85.89 Procurement 122.50 488.94 399.13 Programme Management 760.64 477.92 62.83 Total 5695.01 4236.35 74.39

Based on table above and records available in FMG, following are the observations:- General Observations:

1. Total Reported Expenditure i.e 74.39% of the approved PIP of Rs.56.95 crore under RCH-II as compared to national level expenditure of 71% is a good sign.

2. There is 120% increase in total expenditure as compared to last year 2007-08.

3. Since the launch of RCH-II, Rs. 77.78 crores, i.e. 70% has been utilized by the state against

the release of Rs. 111.66 crores during the period 2005-06 to 2008-09.

4. Remarkable expenditure of 100% on Maternal Health, 90.80% on Family Planning Services has been noticed.

. Areas of Concern

1. Nil expenditure is reported under Infrastructure, HR and Institutional Strengthening. 2. Expenditure under Programme Management is very high in relation to approved PIP. All

Programme Management expenses are booked only at Block level. They should be booked at State, District or block levels respectively to the level they belong.

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3. No expenditure other than JSY was booked under Maternal Health and no other activities were planned under Maternal Health during 08-09.

4. FMR was not sent on prescribed format.

A. Mission Flexible Pool:-

Componet-wise expenditure under NRHM against approved PIP Rs. In Lakhs

Activites SPIP Expenditure %Utilisation against PIP

ASHA 0 77.75 - Untied Funds 1701.20 2289.17 134.56 Hospital Strengthening 8239.43 1815.64 22.04 Annual Maintenance Grants 656.20 199.25 30.36 New Constructions/ Renovation and Setting up 0 0 - Corpus Grants to HMS/RKS 363.14 0 0 Action Plans (District, Block, Village) 0 42.08 - Panchayati Raj Initiative 0 638.60 - Mainstreaming of AYUSH 0 0 - IEC-BCC NRHM 0 2.86 - Mobile Medical Units 680.01 859.75 126.43 Referral Transport 0 0 -

School Health Programme 500.00 174.53 34.91

Additional Contractual Staff (Selection, Training, Remuneration) 4884.96 0 0

PPP/ NGOs 0 0 -

Training 0 0 -

Regional Drug Warehouses 50.00 0 0

New Initiatives/ Strategic Interventions (As per State health policy) 0 0 0

State level health resources center(SHSRC) 0 0 0 NRHM Management Costs/ Contingencies 1125.81 0 0 Other Expenditures (Power Backup, Convergence etc) 0 0 0 Total 18200.75 6099.63 33.51

Based on table above and record available in FMG, observations are as under:-

General Observations

1. As compared to 2007-08, 325% increase has been noticed in expenditure during 2008-09, however, the expenditure in 2007-08 was Rs.18.77 Crores against the releases of Rs.26.08 Crores.

2. Since the start of the programme, Rs.141.51 Crores were released to the state, the utilization is only Rs.86.87 Crores (61%) and Rs.54.64 Crores (39%) remains unutilized.

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Areas of Concern

�� Out of Rs.182 crores approved by the NPCC and Rs. 48.65 crores released, the state has utilised Rs.61 crores during the year i.e. 34% of approved PIP, while the national average of expenditure is 68.14%. State need to improve the level of expenditure.

2. More than 65% expenditure of the total spending has been incurred under Untied Fund and Hospital Strengthening. The expenditure on District Action Plan (Rs..42 Cr.) and BCC/IEC (Rs.0.03 Crore) is very less.

3. Expenditure on School Health Programme Rs.1.74 Cr. is very less, therefore, State need to plan this activity in a proper way.

4. FMR is being submitted in old format, State is advised to prepare FMRs in the new format as provided on the MoHFW website.

5. Expenditures in the FMR are not being bifurcated as per the activities under sub-heads. 6. Calculations mistakes should be checked properly before sending the report, specially

formulae for sub head total does not appear in the FMR.

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BRIEFING NOTE ON RCH II IN PUNJAB A. Background/ current status

1. RCH II Goals Punjab’s MMR has increased from 178 in SRS 01-03 to 192 (SRS 04-06). The IMR (SRS 2007) at 43 has reduced from 49 (SRS 2003). With a TFR of 2.0 (SRS 2007), the state has already surpassed the national target of 2.1 for the year 2012 (refer Annex 1). 2. RCH II Outcomes Punjab’s progress during the four year period between DLHS 2 (2002-04) to DLHS 3 (2007-08) is mixed (refer Annex 1):

• Mothers having full ANCs have decreased from 18.4% to 14.3%. • Institutional deliveries have increased from 48.9% to 63.3%. • Full immunisation in children aged 12-23 months increased from 72.9% to 79.9%. • Children with diarrhoea receiving ORS has increased markedly from 26.2% to 52.1%. • Unmet need for family planning has increased from 10.3% to 11.9%. Further, use of modern

contraceptives has increased from 57.2% to 62.9%.

3. Expenditure Audited expenditure has increased from Rs. 5.02 crores in 05-06 to Rs. 11.17 crores in 06-07 and Rs. 19.22 crores in 07-08; reported expenditure in 08-09 is Rs. 42.36 crores i.e. 74% of allocation (Rs. 56.95 crores). B. Key achievements 1. Maternal Health, including JSY

• Number of JSY beneficiaries in the state decreased from 0.16 lakh in 06-07 to 0.10 lakh in 07-08, increasing to 0.68 lakh in 08-09. The state has accredited 227 private facilities under JSY for providing ANC and delivery services.

• Training in Life saving anaesthesia skills (LSAS): 6 medical colleges have been identified for training, and10 MBBS doctors have been trained against the target of 142 by the year 2012.

• Skilled Birth Attendant (SBA) training: 5 districts have been identified, 40 district level master trainers and 101 Staff Nurses and 138 ANMs have been trained in SBA as against the target of 1411.

• 46.25% of the planned 110500 VHNDs were held as on April 2009. 2. Child Health

• IMNCI is ongoing in 4 (out of 20) districts of the state. The number of personnel who have been trained in IMNCI are 2107

• Pre-Service IMNCI is being implemented in 1 Medical College in Punjab

3. Other initiatives • Considering lack of specialists in the system, state has made provision for on-call

anaesthetists, as per requirement at the facility level. The anaesthetists from nearby areas are empanelled for the FRUs where they are not available.

• State Government has made provision for an extra incentive to Gynaecologists working in un-served and underserved areas w.e.f. July, 2009 and an incentive for Female Medical Officers, NRHM for working in un-served and underserved areas.

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• 34 sub-centres in the State & 16 slum areas in Distt. Ferozepur have been adopted for co-ordination in MCH services by NGOs.

• Balri Rakshak Yojana: A state funded scheme, for promotion of cause of the girl-child. Incentive is paid for adopting terminal method of sterilization after the birth of only one or two girl children @ Rs. 500/- and Rs. 700/- respectively.

• Alternate Health Delivery System: To provide health services in 1310 Subsidiary Health Centres (SHCs) through Zila Parishad (PRIs) by engaging doctors on contract basis. This leads to increased oversight and accountability to the public, and to increased utilisation of services.

• Mobile Medical Units - 24 MMUs and 6 Rajiv Gandhi mobile vans have been deployed to cover the un-served areas. Mobile Medical Units are well equipped with Laboratory, X-Ray and MOs and Staff Nurses.

C. Key issues 1. Maternal Health, including JSY

• Punjab along with Haryana are the only two states which have shown an increase in MMR between 2001-03 to 2004-06

• JSY is not being aggressively promoted in the state; more than half the JSY beneficiaries each year are still home deliveries.

• While monthly NRHM report submitted by the state reports 109 PHCs operationalised to provide 24-hour services there are no 24x7 PHCs that fulfil all the 3 critical criteria of functionality (as reported during a recent review). A large number of 24x7 PHCs do not provide the stipulated range of services due to lack of lack of availability of referral transport services beyond CHCs and acute shortage of doctors owing to irrational deployment.

• Facility operationalisation needs to speed up. The state reported that facility surveys have been carried out; they need to be used for facility-wise microplanning to ensure coordinated provision of inputs.

• Pace of SBA training is slow. EmOC training has not yet begun. LSAS training for MBBS doctors has been launched since the last 2 years but the progress of training is poor and even those trained have not been posted to functional facilities.

• Though there has been an increase in institutional deliveries, the latter account for only 41.4% of total beneficiaries. The proportion of mothers receiving full ANC checkups has declined (18.4% to 10.7%).

2. Child Health

• Neonatal mortality rate (NMR – infant deaths within 4 weeks of life per 1000 live births) at 29 (SRS 2007) accounts for 67.4% of the IMR, while early NMR (infant deaths within one week of life per 1000 live births) at 20 (SRS 2007) accounts for 69% of the NMR.

• Exclusive breastfeeding till 6 months of age has declined (23.1% to 7.3%). • IMNCI training of paramedical and ICDS staff is yet to take place. Saturation of training/

other components (community activities, health system strengthening) takes time, nearly 2 years in a district.

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ANNEX 1 A. Progress on Key Indicators

1. RCH II Goals

INDICATOR PUNJAB INDIA Trend (year & source) Current status RCHII/NRHM

(2012) goal Maternal Mortality Ratio (MMR)

178 (SRS 01-03) 192 (SRS 04-06) 254 (SRS 04-06) <100

Infant Mortality Rate (IMR)

49 (SRS 2003) 43 (SRS 2007) 55 (SRS 2007) <30

Total Fertility Rate (TFR) 2.3 (SRS 2003) 2.0 (SRS 2007) 2.7 (SRS 2007) 2.1

2. RCH II Outcomes

S. No. RCH OUTCOME INDICATOR

PUNJAB INDIA* DLHS–2 (2002–04)

DLHS–3 (2007–08)

DLHS–2 (2002–04)

DLHS–3 (2007–08)

1. Mothers who received 3 or more antenatal care checkups (%) 63.5 65.1 50.4 51.0

2. Mothers who had full antenatal check-up (%) 18.4 14.3 16.5 19.1 3. Institutional deliveries (%) 48.9 63.3 40.9 47.0

4. Children 12-23 months age fully immunised (%) 72.9 79.9 45.9 54.1

5. Children age 6-35 months exclusively breastfed for at least 6 months (%) NA 9.1 22.7 24.9

6. Children with diarrhoea in the last 2 weeks who received ORS (%) 26.2 52.1 30.3 33.7

7. Use of any modern contraceptive method (%) 57.2 62.9 45.2 47.3

8. Total unmet need for family planning - both spacing methods and terminal methods (%) 10.3 11.9 21.4 21.5

* - Provisional results for DLHS-3 B. Trends in Financial Expenditure

(Rs. crores) FY 2005-06 FY 2006-07 FY 2007-08 FY 2008-09 Release 17.42 23.72 13.89 56.63 Audited Expenditure 5.02 11.17 19.22 42.36* * - Audited expenditure for 2008-09 is not yet available; reported expenditure is provided. - Allocation for 2008-09: Rs. 56.95 crores.

C. Progress on Key Strategies

1. Demand side interventions

S. No.

Indicators

Achievement (no. of beneficiaries) 2005–06 2006–07 2007–08 2008–09

1 Janani Suraksha Yojana 11,595 16,079 9,917 68,000 2 Total Sterilisation 1,07,591 93,758 94,673 na 3 IUD Insertions 3,41,365 3,35,263 3,11,557 na

(Source: M&E Division reports, and JSY reports from the states)

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2. Technical interventions

S. No. Indicators

Achievement upto March 2009

1. No. of First Referral Units (FRUs) operationalised 137 2. No. of PHCs operationalised to provide 24-hour services 109 3. No. of private institutions accredited under JSY 227 4. No. of districts implementing Integrated Management of

Neonatal & Childhood Illness (IMNCI) 4

5. No. of people trained in IMNCI 2,107 6. No. of Village Health & Nutrition Days (VHNDs) held 45,330

(Source: NRHM MIS report, April 2009)

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Immunization

Punjab

Evaluated Immunization Coverage

Survey Indicator

NFHS 1 (1992-93)

NFHS 2 (1998-99)

NFHS 3 (2005-06)

CES (2005)

CES (2006)

DLHS 2 (2002-04)

DLHS3 (2007-08)

FI 61.9 72.1 60.1 83.5 75.3 72.9 79.9 BCG 77.4 88.7 88.0 93.7 93.2 88.0 94.9 Measles 64.8 76.5 78.0 87.5 82.1 76.0 90.0 DPT3 73.6 82.0 70.5 87.5 82.1 82.0 84.9

Progress

� As per the evaluated survey the full immunization is 79.9 % in 2007-08 (DLHS 3).

� The State has constituted AEFI committees in all the districts.

� The progress on health workers training is to be communicated by the state.

Issues

� There is high dropout from BCG to DPT 3 at 10%. Better tracking of beneficiaries by

ensuring availability of beneficiary/due list with the ANM/AWW/ASHAs at the session sites.

Counterfoils with tracking bags also need to be used for reducing dropouts.

� The State needs to strengthen AEFI reporting further to improve reporting of AEFI cases.

� ASHA, AWW or link worker cannot be used for Alt Vaccine delivery, this should be done

by volunteers from outside the system

� Immunization training of Health workers needs to be expedited. Further the training plan for

MOs may be revised with batch size of 20 instead of 30 to ensure quality of training

� Human Resource: Seven positions of DIO and Six of Cold chain mechanics need to be filled up.

� The State needs to improve coverage of Hepatitis B under routine immunization.

Comments

� The State needs to further improve service delivery and other infrastructure as Rubella vaccine is

going to be introduced shortly in form of MR vaccine for children of 16-24 months.

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Brief on National TB Control Programme in Punjab 1. Infrastructure

Total No. of Districts/Reporting Units - 20 No. of TB Units (TUs) - 57 No. of Designated Microscopy Centres (DMCs) - 283

Total Population - 269 lakh

2. Status of Implementation

• Punjab achieved full coverage under RNTCP in December 2004.

3. State level Performance (Based on recent quarterly reports for 1st quarter of 2009)

• Sputum of 162 TB suspects/lakh pop/quarter examined for diagnosis which is higher than national average.

• Overall total case detection rate of 138/lakh and new sputum smear positive case detection rate of 58/lakh (61%) are better than corresponding quarter last year but are still low due to suboptimal involvement of large Private hospitals, Medical Colleges and NGOs.

• TCD rate is very low because NSN patients are only 29% of all new pulmonary TB patients which is very low. It appears that the State is not able to capture all the NSN patients.

• Sputum conversion rate of 91% and cure rate of 87% in new smear positive patients are now satisfactory.

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•Population projected from 2001 census

•Estimated no. of NSP cases - 95/100,000 population per year (based on recent ARTI report)

Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, Punjab,2000-2009*

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4. District-wise Performance: (Based on recent quarterly report for 1st quarter of 2009)

• TCD rate of less than 128/lakh (50%) is very low in 6 districts (Barnala, Firozpur, Gurdaspur, Kapurthala, Moga and Tarn Taran) whereas new sputum positive (NSP) case detection rate of less than 48/lakh (50%) is very low in only 2 districts (Barnala and Firozpur).

• Cure rate in NSP patients is very low (<80%) in 4 districts (Barnala, Fatehgarh Sahib, Firozpur and Patiala).

District

TB Suspects examined/lakh

population

Annualised case detection rate (against >180/lakh)

Annualised new sputum positive case

detection rate (against >67/ lakh)

Sputum conversion rate new cases

(against >90.0%)

Cure rate new cases (against >

85.0%)

Amritsar 159 173 65 68% 90% 81% Barnala 152 101 46 48% 86% 79% Bathinda 187 159 69 73% 91% 92% Faridkot 189 170 60 63% 90% 87% Fatehgarh Sahib 197 142 62 65% 70% 71%

Firozpur 127 102 38 40% 88% 78% Gurdaspur 145 113 55 58% 92% 88% Hoshiarpur 192 136 59 62% 94% 87% Jalandhar 155 140 59 62% 88% 81% Kapurthala 157 117 54 57% 96% 89% Ludhiana 159 158 60 63% 92% 87% Mansa-PU 193 146 73 77% 89% 89% Moga 126 101 58 61% 97% 93% Mohali 172 172 63 67% 90% 80% Muktsar 173 146 59 62% 93% 86% Nawanshahr 188 131 71 75% 96% 90% Patiala 179 140 48 50% 80% 72% Rupnagar 222 143 76 80% 98% 93% Sangrur 150 135 54 57% 83% 81% Tarn Taran 125 125 53 56% 91% 86% Total 162 138 58 61% 91% 87%

5. Funds Status as on 31st March 2009 (Rs in lakh)

6. Drugs

Orders for RNTCP drugs are issued based on the requirement projected in the quarterly reports of most recent quarter. Status is satisfactory.

C/F Released Expenditure Balance 89.98 432.00 439.00 82.98

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20

8. Issues • Human Resource

o No sanctioned posts of 2nd MO DTC who can assist District TB Officers (DTO) in supervision and monitoring of the programme at the district level. A post of 2nd MO-DTC needs to be sanctioned for each DTC.

o Posts of 6 MO-TCs, 4 STSs and 1 STLS are vacant. Vacant posts of these key personnel need to be filled.

• Logistics – AMC of Binocular Microscopes is pending for 8 months. • Supervision and Monitoring

o Supervision is variable, but overall weak at all levels o Programme review by district and state level officials is limited. Programme needs to

be reviewed regularly at the districts and the State level to ensure accountability and effective quality implementation of the programme.

o Weak supervision is affecting the quality of programme as evidenced by low sputum conversion and cure rates and high default rates in some districts.

• Performance

o Overall TCD rate of 138/lakh is low mainly because NSN patients are only 29% of all new pulmonary TB patients. In 6 districts TCD rate is very low <128/lakh (50%).

o NSP case detection rate of 58/lakh (61%) is better but still low and only in 2 districts it is very low (<48/lakh (50%)).

o Overall sputum conversion rate of 91% and cure rate of87% in NSP patients are satisfactory but 3 districts have very low sputum conversion rate of <85% and 4 districts have very low cure rate <80% due to high default rate. These districts need to strengthen default retrieval mechanism at all the Centres.

• State Training & Demonstration Centre (STDC)/Intermediate Reference

Laboratory (IRL) o State Training & Demonstration Centre (STDC)/Intermediate reference Laboratory

(IRL) of the State is established at Patiala. They are doing training, field supervision & monitoring and external quality assurance (EQA).

o IRL was renovated three years back as per RNTCP guidelines. Walk in Incubator and walk in Cold Room have been established. However, Bio safety cabinet and hood have not yet been received. Supply of deep freezer, vertical and horizontal autoclave, fluorescent microscope are also awaited.

o Training of STDC Director, Microbiologist and Lab Technician is pending

• DOT Plus o The Medical College Patiala has provided space for 40 beds (20 for male and 20 for

female) for MDR patients. There is requirement of funds (Approx 5 lakh) for preventing air born infection.

o Treatment of MDR patients is slated to start in Punjab in 2009-10.

• Involvement of Other Sectors o Yet there is more scope for involvement of more NGOs, PPs and community

volunteers in the programme in the State to improve case finding. o All large hospitals especially in the non-health public sectors need to be involved

under RNTCP.

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21

Fact Sheet on- Punjab Background Information

The State has 20 districts with a population of 24.36 million. There are 126 CHCs, 484 PHCs, 2858 Sub-centres and 12673 villages. There are 2515 Multipurpose Workers (Female)/ANM, 1375 Health Worker (Male), 264 Health Assistants (Female)/LHV, 208 Health Assistant (Male) and 523 Laboratory Technician. In addition, the state has 284 Fever Treatment Depots (FTDs) and 80 Malaria clinics.

Malaria

Epidemiological Situation

Dengue/DHF: Epidemiological data for last three years are as under:

Year Cases Deaths 2006 1166 6 2007 28 0 2008 4349 21 2009(till 27th May) 0 0

Actions taken by Govt. of India For proactive surveillance Civil Hospital, Ludhiana has been identified as Sentinel Surveillance Hospitals (SSH), with laboratory support in 2007. Five more Sentinel Surveillance Hospitals have been identified in 2009 with consultation of State Health Authorities. All these are linked with PGI, Chandigarh, Sector 12, which has been identified as Apex Referral Laboratory. NIV Pune has been entrusted the supply of IgM ELISA test kits to these identified institutes. Filaria, Kala-azar, J.E. and Chikungunya are not endemic in the state of Punjab.

Central Assistance

(Rs. In lakhs) Year Allocation Release/Expenditure

Cash Kind Total Cash Kind Total 2004-05 0.00 63.16 63.16 0.00 45.85 45.85 2005-06 0.00 104.79 104.79 39.19 21.22 60.41 2006-07 26.68 88.19 114.87 0.00 40.98 40.98 2007-08 29.50 67.43 96.93 11.16 45.91 57.07 2008-09 65.75 146.64 212.39 28.78 63.93 92.71 2009-10(B.E.) 40.00 673.5 107.35

Year Total slide examined Total Malaria cases Total Pf cases Deaths

2006 2581686 1888 37 0

2007 2723293 2017 41 0

2008 2979882 2494 38 0 2009(Upto Mar.) 639804 80 2 0

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STATUS OF NATIONAL LEPROSY ERADICATION PROGRAMME IN PUNJAB

• Epidemiological scenario- Punjab is low endemic for leprosy and has already achieved the goal of elimination of leprosy (i.e. prevalence rate of less than 1 case /10000 population). There were 868 leprosy cases on record as on March 2009.

• New case detection and treatment completion-

During 2008-09, a total of 933 new leprosy cases were detected as compared to 964 new cases detected during the corresponding period of previous year. Out of 962 cases discharged during the year, 847 cases (88%) were released as cured after completing treatment.

• During 2008-09, NLEP action plan amounting to Rs.130.30 lakh has been approved for the

State. Issues -

1. New leprosy cases are being detected in the state every year which suggest active transmission of the disease in the community. The state is advised to carry out in-depth situational analysis in districts/blocks reporting large number of new cases and take suitable actions like –

(i) Ensuring completion of treatment in each of the new cases detected. (ii) Enhance awareness of the community to improve self reporting of suspected

cases to health facility and (iii) Carrying out family contact survey against all multibacillary and child cases.

2. There are about 30 leprosy colonies in the state. The state should ensure provision of proper

health care facilities like ulcer care, provision of supportive drugs and dressing materials to the persons affected with leprosy residing in these colonies.

3. The state has reported low treatment completion. It needs to be ensured by repeated follow up and absentee retrieval that every case complete treatment.

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23

State- Punjab

Integrated Disease Surveillance Project (IDSP) –Fact sheet as on 17 June 2009

The state of Punjab has an area of 50,362 sq. km. and a population of 24.36 million. There are 20 districts, 141 blocks and 12673 villages. The State has population density of 483 per sq. km. (as against the national average of 312). The decadal growth rate of the state is 20.10% (against 21.54% for the country) and the population of the state is growing at a slower rate than the national rate. (source:www.mohfw.nic.in/nrhm.htm)

1. Project Launch:- The IDSP is given priority for implementation at the State level in Punjab State. The Punjab State was placed in Phase-3 of project and was launched on 12th June, 2007 only.

• The State Surveillance Officer(SSO)/ State Project Coordinator has been identified and appointed .

• District Health Officers in all the 20 districts have been nominated as District Surveillance Officers.

• Epidemiologists and Microbiologists, wherever posted in the districts, have been identified as members of District Outbreak Investigation Team(DOIT) and District Epidemic Investigation Team(DEIT) and included in the nominated list of members of ToT who will further impart training to Medical officers/Lab. Technicians/ MPW’s.

2. Objectives:- The RRTs who will work as District Outbreak Investigation Team(DOIT) and District Epidemic Investigation Team(DEIT) have already been identified in all the districts and include District Health Officer, Physician/Pediatrician, Epidemiologist, Microbiologist/Pathologist or Senior Lab. Technicians where Microbiologists are not available as member and will be imparted training as member of ToT who will further train the field staff already identified for the training.

• A system for reporting under Weekly Syndromic Surveillance right from CHC, PHC, Civil Hospital level has already been initiated where all the communicable diseases, there investigation reports and data pertaining to disease prevalence are communicated electronically to District Surveillance Unit(DSU) and further to State Surveillance Unit(SSU) by DSU. State Surveillance unit assimilates the data from all districts and communicates every week to Central surveillance Unit(CSU). A system of EDUSAT and Video Conferencing(VC) has already been installed at State Head Quarter and also in three Medical Colleges for rapid transmission of disease prevalence data.

• The Rapid Response Teams(RRT’s) are already visiting any site of outbreak/reported case, where investigation of the case and control measures are adopted by the concerned Health institutions.

• All the laboratories in 20 districts have been identified for up gradation under IDSP. Procured all approved equipments at SSU level for State & Distt. Health Labs & supplied to Distt. Labs.

• State Priority Lab. identified Lab. at Civil Hospital Mohali on the basis of infrastructure and staff strength.

3. Manpower:- The details of manpower under IDSP in Punjab State are as follows. At State Level (SSU):-

• State Surveillance Officer:- Dr. Deepak Bhatia • Data Manager:- Nitin Kondal • Consultant Finance:- Mr. Tejinder Pal Singh • Data Entry Operator:- Miss. Gurdeep Kaur (One post of DEO vacant) • Administrative Assistant:- Miss. Narinderjit Kaur

At District Level (DSUs):- Total 20 DSUs • District Surveillance Officers:- 20

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24

• Data Managers:- 20 • Accountants:- 15 • Administrative Assistants:- 16 • Data Entry Operators:- 13 (7 posts vacant) • Distt. and State Epidemiologist, Distt. Microbiologist at Priority Lab and one

Entomologist at State Lab being appointed as per selection by GOI 4. VSAT and Broadband Sites:-

• VSAT Sites:- 4 (One at SSU and 3 at Govt. Medical Colleges at Amritsar, Faridkot and Patiala)

• Broadband Sites:- 20 6. Data Reporting:-

• New S, P and L forms issued to DSUs. Registers printed at SSU level, Early Warning Signal Report performa already issued. S-form printed in Punjabi (for Health Workers).

• Data now being reported to CSU through weekly surveillance reports by SSU. Also, online entry through data portal has been initiated.

• Presently the reporting is being done considering the PHC as one RU under which SCs/Mini PHCs/Dispensaries etc send the concerned data. Shortly the reports from individual SC, Dispensary/Mini PHC etc will be received as individual RU.

7. Outbreak Year Number Type 2008 17 Acute Diarrhoeal Disease,

Malaria 2009 4 Malaria

8. Finance & Expenditure:- Year Amount Released by GOI Expenditure till

31.03 2006-07 164.00 0.00 2007-08 -- 46.94 2008-09 30.00 95.20 Balance – 51.86 lakhs

FMR:- Sent regularly ( Latest sent up to March 2009)

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25

NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS STATUS NOTE ON PUNJAB

Magnitude: Prevalence of blindness: 2001 1.01 %

Estimated blind persons 2.45 lakhs Infrastructure developed

Upgraded Medical Colleges 3 Upgraded District Hospitals 12 District Blindness Control Societies 15

Mobile Eye Care Units 10 Eye Banks 2

Upgraded PHC’s 128 Cataract Performance

YEAR TARGET ACHIEVEMENT 2007-2008 160000 167256

2008-2009* 180000 116585 School Eye Screening

YEAR TEACHER TRAINED IN SCREENING FOR REFRACTIVE ERRORS

SCHOOL GOING CHILDREN SCREENED

DETECTED WITH REFRACTIVE ERRORS

PROVIDED FREE

GLASSES

2007-08 2947 521940 35587 9664

2008-09 1650 343081 26580 4104 GIA released to Distt.Blindness Control Societies/State Blindness Control Society

(Rs in lakhs) YEAR RELEASED EXPENDITURE BALANCE

2007-2008 72.00 78.62 -6.62 2008-2009 94.80 85.00 9.50

Issues:

• UCs for GIA released t • o State Blindness Control Society are not being received timely. • SOE for Cash Grant are also not being received timely. • Performance of School Eye Screening Programme needs to be improved. • UC for funds released for ophthalmic equipments not received resulting in delay in further

release of funds.

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26

NIDDCP

Punjab

Rs. Lakh

Activity Amount proposed Amount Approved Remarks

1 Establishment of IDD Control Cell 6.00 6.00

The State Government may carry out the activities as per the fund allocation of GOI.

2 Establishment of IDD Monitoring Lab 3.50 3.50

3 Health Education and Publicity 8.00 8.00

4 IDD surveys 2.50 2.50

Total 20.00 20.00

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27

Mapping of Record of Proceedings of the NPCC of NRHM for

2005-06 to 2009-10 The mapping charts the NRHM Mission Flexipool approvals contained in the RoP in following broad thematic chapters 1. ASHA (including selection, training, drug kits, mentoring, specific performance incentives and anything else associated with ASHA) 2. Infrastructure related matters (including construction, strengthening, renovation, new construction etc), equipments, transport (ambulances, EMRI, associated expenses) and others) 3. Human Resource related matters (including HR salary, contractual payments, incentives, etc) 4. Programme Management related matters (including PMUs, SHS/DHS, SHSRC, IDHAP, M&E, Mobility support to SHS etc) 5. Untied funds, AMG & RKS related mattes 6. Training & Capacity Building related matters (including trainings, workshops, training institutions including their upgradation or new construction, courses, etc) 7. Innovations (including Procurement of medicines, School Health, Health Mela, Insurance, Accreditations, Monthly VHND etc)

NATIONAL RURAL HEALTH MISSION Punjab

Total MFP Approvals 3300 6773.8 18201 11276.3

RoP Approvals for Various Years in Rs. Lakh

S.No Initiative 2005-06 2006-07 2007-08 2008-09 2009-10 Remarks Released Approved Approved Approved Approved

ASHAs 1 ASHA 1058.44 449 TOTAL 1058.44 449 Infrastructure related matters 2 Upgradation of DH 370.00 1370.00 200.00

3 Renovation of District Hospitals 140

4 Major repairs and renovation in SDH 380

5 Upgradation of SDH/ FRU 2145.00

6 Construction of FRU 200

7 Upgradation of CHC to IPHS 1020 1300 1300 150

8 Construction of CHC 300 9 Construction of PHC

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28

10 Upgradation of PHC 3000.80 1515.00 200.00

11 SMC for PHC 35.50

12 Construction of SC 640 13 Upgradation of SC 1000.00 330.00

14

Upgradation of Subsidiary Health Centre

1310.00

15 Repair/Renovation of SC 225

16 Equipment/Furniture for 20 DH 100

17

Equipments for CHCs on basis of facility survey 200

18

Furniture for 18 CHCs @ Rs. 1.2 lakh per CHC based on facility survey. 21.6

19

Furniture for 97 PHCs @ Rs. 45,500 per PHC based on Facility Survey 44.62

20 Equipment for CHC 887.6

21

Equipment for 97 PHCs @ Rs. 1 lakh per PHC on basis of facility survey 97

22 Equipment for PHC 139.38 23 Equipment for SC 356.95

24 State & regional Warehouses 50

25 MMU 829.8 680.01 360

26

Emergency & Referral Services

2561

TOTAL 1020 2129.8 5670.8 8969.44 5669.22 Human Resources related matters

27 Human Resource

28 Contractual Gynaecologist 126 40.5

29 Contractual Paediatrician 189

30 Contractual Anaesthetist 189

31 OT Assistants 54

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29

32 Contractual Epidemiologist 176.53

33

Contractual Public Health Programme Managers 384

34 Medical Officers for Mini PHCs 180

35 Medical Officers in CHC 315.23

36 Incentives to doctors in remote areas 40

37

Engagement of Contractual Hospital Administrators 9

38 Salary of contractual ANM 2060.64 686.88

39 Staff Nurses at CHC 461.16 40 Staff Nurses at PHC 639

41 other staff at CHC (clerks, UDC, etc) 413.71

42 Other contractual support staff at PHC 290.4

43

Reimbursement of monthly cell phone bill to State Officers/ Civil Surgeons/DPMs/BSMOs 1.8

44

Statistical Asst for Block Programme Management Units 127.44

45 Block Accountant cum cashier 127.44

46

Reimbursement of monthly cell phone bill to ANM/LHV 22.90

47

Computer operator for strengthening of District Society and DPMU 116.43 3

TOTAL 5298.67 1329.49 Programme Management related matters

48

Monitoring & Evaluation (HMIS) including digitalisation of CRS records, procurement of computer systems and strengthening of CRS system with Civil Registration Asst 78.7

49 Preparation of DHAP 170 50 BPMU 231.28

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30

51

Publishing of RKS guidelines in local language 5

52

Travel support & contingency expenditure-ANMs 480.82

TOTAL 170 712.1 83.7 Untied Funds, Annual Maintainence Grants and RKS fundsrelated matters

53 Rogi Kalyan Samiti 244 33.00

54 Rogi Kalyan Samiti- DH 100 100

55 Rogi Kalyan Samiti- CHC& SDH 128 147

56 Rogi Kalyan Samiti-PHC 121 396

57 Untied Fund 58 Untied Fund for CHC 64 64 63 59 Untied Fund for PHC 121 121 121 99 60 Untied Fund for SC 285 285.8 285.00 286.20 285.80

61 Untied Fund for VHSC 1230 1273.8

62 Annual Maintenance Grant

63 Annual Maintenance Grant - CHC 128 112

64 Annual Maintenance Grant -PHC 242 242 198

65 Annual Maintenance Grant- SC 286.2 144

TOTAL 285 892.8 503 2706.4 2818.6 Training & Capacity Building related matters

66 Orientation of RKS 14.14

67

Preparation of modules for orientation of PRIs 0.15

TOTAL 14.14 0.15

Innovations related matters 68 Health Melas 104 69 School Health 500 200

70 Alternate Health Delivery System 173.4 600

71 Drugs @ Rs. 10 lakh per DH per annum 200

72

Drugs for SDH @ Rs. 3 lakh per SDH per annum 108

73 Drugs for all CHCs @ Rs. 2.30 lakh per CHC 289.8

74

Drugs for all 396 PHCs @ Rs. 1 lakh per PHC 97

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31

75

Procurement of Calcium tablets and zinc sulphate. 23

76

BCC/ IEC activities related to water and sanitation 8.34

77

Drug supply for CHC/FRU 690

78 Drugs for all PHCs 1452 TOTAL 690 277.4 600 1952 926.14