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Quality Monitoring of State Programme Implementation Plan 2012-13 under NRHM

in Haryana

Report for the Second Quarter (July- September 2012)

Submitted to

Ministry of Health and Family Welfare Govt. of India, New Delhi

By

Population Research Centre Panjab University

Chandigarh

November, 2012

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KEY FINDINGS

Qualitative Monitoring of PIP 2012-13 Haryana

Second Quarter Report July-September, 2012

Mandatory Disclosures

1. Human Resource: Information Uploaded on the Website

2. MMU: Micro plan of MMU for 2012-13 uploaded

3. Patient Transport Ambulance: Information upto March 2012 uploaded

4. Procurement ( Equipment): Information Uploaded on the Website

5. Building under construction/Renovation: Required information uploaded.

Key Conditionalities

1. Rational deployment policy including-Posting of staff on the basis of case

load, rational deployment of specialists, priority to HF districts is not fully

implemented

2. There is no Facility wise audit due to n on availability of facility level of

HMIS portal.

3. JSSK is implemented but with limitations. Weak area is diet for pregnant

women. Incase of neonates SNCU is functional in one district. NBSU are not

fully functional.

4. Appointment of Second ANM has been done. No separate job responsibilities

have been charted.

5. MCTS data is being updated. Up dation of data is not been done regularly.

Strengths

DPMU has been established.

JSSK is implemented in DH,CHC and PHC but with limitations.

AYUSH doctors co located at health facilities.

Strong referral transport system is in place in both districts.

SNCU is functional in GH Narnaul.

ARSH functional in District Mahendergarh.

Second ANM is in place in most of the SCs.

Urban RCH centres functioning properly.

SKS constituted at DH,CHCs and PHCs.

Appraisal of para medical staff done

Performance of all doctors regularly assessed.

All ASHA workers have received HBNC training.

Some of the ASHA workers have not received ASHA kit.

Weakness

Monitoring and supervision is weak.

Severely anaemic women line listing is not in place in any of the

sampled facilities.

Number of position of MO's are vacant.

SNCU not functioning in GH Panipat.

ARSH clinic not functional in Panipat.

Quality of ANC services provided to pregnant women is poor.

Shortages of medicines at sampled Sub centres and some of the PHCs.

MDR and IDR is not being in some of the sampled facilities.

Facility wise reporting is not done under HMIS

MCTS is not fully functional and no work plan are being generated.

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Executive Summary

To monitor the progress made by the Haryana state in implementation of

annual PIP during the second quarter the PRC, Panjab University, Chandigarh

selected two districts of Haryana state i.e. Panipat and Mahendergarh after

consultation with the MD, NRHM Haryana, . In each district, District Hospital,

Community Health Centres, Primary Health Centres, Sub Centres and urban slums

were selected and visited for study purposes.

At the district level, Programme Management Units (PMU) has been

established. The post of District Account Manager is vacant in both the districts

District Actions Plans for the two districts has not been prepared till yet. AYUSH

doctors have been posted at District Hospitals and CHC/PHC. There is a rational

allocation of AYUSH doctors in the field. AYUSH doctor are also the members of

SKS of the facility and are involved in the ARHS and IBSY programme. The

functioning of these clinics is monitored by the District Ayurvedic Officer whose

office is located outside the premises of district hospital.

Quality Assurance cell has been established in the state and MOU has been

signed with Quality Council of India. In the first phase three hospitals have been

identified for up gradation and accredited by NABH.

In both the districts there is shortfall of Doctors. Status of regular para

medical staff is relatively better as number of vacant post's both regular and

contractual is fewer. There is no rational deployment of medics and para medics. A

performance appraisal system is in place for doctors and para medical staff.

At district hospital and CHCs the EDL is available, but not all of the visited

PHC have EDL. At sub centre level, no EDL is available and the ANM is not aware

that a EDL for the SC has been formulated. The procurement of drugs is decentralized

and is being done regularly by the District Health Society. The procurement of drugs

are done one quarter advance.

At district level the procedure for allocating drugs and consumables to various

health facilities is on the basis of demand and consumption pattern. In Panipat and

Mahendergarh district, the district Central drug store is facing the problem of

procurement from the CPSU as it is not supplying medicines as per the demand given

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to them. During the visit to various health facilities in two districts it was found that

all the generic medicines are available at DH and CHC. However few medicines like

PCM and Cetrizine are not available. These two medicines are in short supply for

more than a year or so. This is also true for PHC. The situation regarding availability

of medicine at Sub centre is grim. At number of SC's just IFA tablets were available

and in one sub centre no IFA tablets was available for the last month or so. Vaccines

like Hepatitis II and DPT were not available at Sub centre. In one of the sampled

urban RCH centre expired drugs were lying.

Every district has a bio-medical Engineer to look after the maintenance of

equipment in the district. A complete list of all the equipment and its condition is

available with the district bio medical engineer.

A robust referral transport system is in place in both the district. All the

ambulances are fitted with GPS but it is not functional in all the ambulances in

Mahendergarh district. The universal toll free number 102 is functional. The response

time of Ambulance reaching the patient residence is about 20-30 minutes. There is

one MMUs in Mahendergarh district and the micro plan is followed.

There is one ALS Ambulance in Panipat and in Narnaul. However there is no

Emergency Medical Technicians in Panipat while in Narnaul this position is filled.

In Panipat General hospital a separate AYUSH building has been constructed

under the NRHM and the OPD clinic of AYUSH are functioning from there

The cleanliness in maternity ward of the district hospital Narnaul is lacking.

One of the reason is overcrowding of the patients and also the Class IV do not clean

and mop the wards at regular intervals. It was also observed that in no disinfectant is

being used for cleaning the toilets and wards. Some of the Sub centre buildings need

repair.

At district level SMO or MO has been designated as nodal person for the

monitoring and supportive supervision. However in both the districts monitoring and

supervision is slack. Regular review meetings are held at the district block and sub

block level.

VLCs cum VHSCs have been created but are not playing a constructive role in

implementation of various components of NRHM. There is hardly any community

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involvement in the implementation of components of NRHM. SKS has been

constituted at DH, CHC and PHC level

The ANMs are not aware of MDR and IDR and few ANMs especially in

Mahendergarh district have not been given the forms, although proper formats have

been printed and distributed in both the districts. Reverse tracking of severe anemic

cases has not been implemented in these two selected districts. System of

identification of high risk pregnancies has not been initiated and these cases are not

underlined by red ink.

Under HMIS facility based reporting is not being uploaded in Panipat and

Mahendergarh district. MCTS is not fully functional for regular and effective

monitoring. Both the districts are lagging behind in MCTS.

Provision of C section deliveries is there in both the General hospitals and

complicated pregnancies are referred to Rohtak and of late GH Panipat refers

complicated pregnancy cases to Medical college Khanpur Kalan.

Districts have implemented free entitlements under JSSK, i.e. pick up, drop

back facility, free meals and free medicines and diagnostic. In Panipat district hospital

there is proper arrangements for providing meals to pregnant women while in

Mahendergarh GH, alternative meals (biscuits, fruit, juice) are being provided. In

some of the sampled CHC’s alternative meals or Rs 25/ per diet is given to the

woman. Yasodha's and a Yasodha supervisor have been appointed in both the districts

Quality of ANC services is poor. ANMs do not regularly check the Hb and

blood pressure on every ANC visit, although entries are made in the ANC register.

Some of the ANMs do not know how to check BP and some do not have the BP

apparatus. The staff nurses motivates/ensure that the mothers initiate breast feeding

within one hour of delivery or before discharging the patient. Post natal care is a

neglected area.

In Mahendergarh district there is a functional SNCU which has 5 baby warmer

and one incubator but in Panipat district there is no proper SNCU but only one baby

warmer has been installed in labour room.

The districts have initiated IMNCI training. IFA tablets are not distributed to

all children under 6 months - 5 years of age. Only those children who are found to be

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anaemic are given IFA tablets Supply of ORS is regularly available but presently

there is dearth of Zinc and IFA tablets in some sub centres.

In Mahendgarh district there is an ARSH clinic at DH, SDH and CHCs. but in

Panipat district ARSH clinics are not functional. School Health Programme (SHP) is

functioning and all children below 6 years of age coming to AWC have undergone

health check up at AWC.

The selection of ASHA is made on the basis of the recommendation of ANM

and the VHSC in Panipat and Mahendergarh districts. In both the districts, nearly all

posts of ASHA are filled. ASHA workers have completed the HBNC training. All the

ASHA workers in the districts have not been provided ASHA kits.

Information regarding facility wise deployment of staff, details of the all

procurements including equipment, buildings under construction/renovation number,

name of the facility/hospital along with costs, executing agency and execution charges

(if any), date of start & expected date of completion is uploaded on the NRHM. The

Website contains information on referral transport but it is not updated and

information regarding MMUs is also uploaded.

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Introduction

Since the launch of National Rural Health Mission the states were

implementing the approved PIP and there was no mechanism in place to monitor as to

how far the state PIPs were implemented. Although some studies were undertaken to

know the impact of NRHM but these studies were quantitative in nature and time

consuming and moreover it did not reflect how the PIPs are implemented. Keeping in

view the enhanced allocation under NRHM, MOHFW entrusted the continuous

qualitative monitoring of PIPs to PRCs to monitor the progress made by the states in

implementation of annual PIP and state’s adherence to the mutually agreed road map

and conditionalities.

Hence it was decided that all PRCs would undertake qualitative monitoring of

PIPs in the designated states. This monitoring is a continuous exercise and in each

quarter PRC will cover two districts to monitor the progress of PIP implementation in

their respective state. The PRC has completed the qualitative monitoring of the PIP of

the first quarter in two districts namely Ambala and Mewat of Haryana state and

report has been submitted to MOHFW and the MD, NRHM Haryana. For the second

quarter two districts were selected after consultation with Mission Director NRHM.

Most of the findings of the study are based on the field visits conducted in the two

selected districts. The objectives of the study are as follows:

Objectives

To undertake qualitative monitoring of PIPs for the state of Haryana

To visit health facilities in two selected districts for monitoring the

implementation of PIP at the grassroots level

Methodology

For undertaking quality monitoring of PIP during the second phase, (July-

September) two districts, i.e. Panipat and Narnaul were selected after consultation

with Mission Director NRHM. In each district, District Hospital (DH), 2 Community

Health Centres (CHC), 2-3 PHCs and 2-3 Sub Centres, 2 urban RCH centres were

selected and visited for study purposes. At district level it was decided to contact the

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respective programme in charge to get first hand information on NRHM components.

The list of selected facilities is given in Annexure-1.

Different types of questionnaires were developed to get the first hand

information. These questionnaires were canvassed to (i) State Level Officials, (ii)

Chief Medical Officer, (iii) SMO, District Hospital, (iv) Block Medical Officer, (v)

MO, Primary Health Centre, and (vi) ANMs at the Sub Centre including ASHA.

Questionnaire contained information of various aspects related to implementation of

different components of NRHM and the road map for priority action.

Data Collection

In the month of October, the two selected districts were visited by the PRC

team to get the information about the implementation of various components of PIP.

At the district level CMO, SMO, MO in charge, DPM, District Ayurvedic Officer,

Chief Pharmacist, Referral Transport Fleet Manager, Bio-medical Engineer and other

officials were contacted to get the information. These officials were requested to

provide information on the structured questionnaires. Similar exercise was done at the

CHC, PHC and SC level.

Public Health Planning and Financing

The state of Haryana has established a full fledged Programme Management

Unit. At the district level, Programme Management Unit (DPMU) has been

established in both the selected districts. The Deputy CMO is designated as in charge

NRHM to look after the Programme Management Unit. It may be pointed out that due

to shortage of Doctors in both districts there is frequent change of programme

officers and they are also given additional charge and hence are overburdened and

cannot do proper monitoring and supervision of the programme's. During the visit to

the two districts it was noted that the post of District Account Manager (DAM) is

vacant in both the districts. The task of filling the post of DAM is underway.

At the block level there is no block programme management unit (BPMU). At

block level there is a post of Accountant who looks after the financial matters of CHC

and other PHCs falling under the block and there is a post of an Information Assistant

who has been recruited for HMIS and MCTS.

District Actions Plans for the two districts has not been prepared till yet.

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The training requirement of PMU is reviewed from time to time and training

workshops are held regularly at district and block level. HMIS data is used for review

of performance. Recently single reporting system has been initiated in Haryana.

Funds are transferred electronically from state to districts and then to various

health facilities. At district level CMO, BMO and MO in-charge have been given

powers to utilize the NRHM funds. For the first time the funds have been allocated to

various health facilities on the basis of case load and previous year’s utilization of

resources. In both the districts funds from the state were received at the district

headquarter in the beginning of second quarter. However there has been delay in

transferring funds to some facilities in Annual Distinct. For instance, in CHC Nangal

Chaudhary the funds were transferred in the last week of September and the funds

were yet to be transferred to PHCs and SCs falling under this CHC. It is important to

mention that the Doctors and ANMs in the field are not aware of the basis of

allocation of untied funds and Annual maintenance Grants.

A separate directorate of AYUSH has been established at the state

headquarter. AYUSH clinics are co-located at District Hospital, CHC’s and PHC's.

Two streams of AYUSH Ayurvedic and Homeopathic doctors are posted at District

Hospitals while at PHC/CHC it is either one of them. The functioning of these clinics

are monitored by the District Ayurvedic Officer whose office is located outside the

premises of district hospital. In Panipat district, under NRHM a separate AYUSH

building has been constructed in the complex of district hospital from where AYUSH

doctors run their OPD. It may be mentioned that there is a rational allocation of

AYUSH doctors in the field. This is to say that, in most of the visited health facilities

in both the districts, a homeopathic Doctor is posted in PHC or CHC. In facility’s

where AYUSH doctor is posted a AYUSH pharmacist is in place. AYUSH doctor

posted at CHC/PHC is a member of SKS and are involved in the implementation of

national health programme like ARSH, IBSY, Polio, etc. There is shortage of

AYUSH medicines due to irregular supply of medicines- both Ayurvedic and

homeopathic. AYUSH OPD clinics are monitored by MO in charge of the health

institution and on an average 30-40 patients visit the AYUSH clinic. However the

number of patients attending AYUSH is relatively more at district hospital. It has

been noted that comparatively greater number of patients prefer going to Ayurvedic

doctor than homeopathic.

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The state is still in the process of establishing/creating a separate public health

cadre on the lines suggested by high level expert group set up by the Planning

Commission of India to improve the functioning of the system by enhancing the

efficacy, efficiency and effectiveness of health care delivery.

Quality Assurance cell has been established in the state and MOU has been

signed with Quality Council of India. The state is in the process of evolving a quality

policy for the state. In the first phase the state has identified three hospitals which will

be upgraded and accredited by NABH and later on 18 district hospitals will be

accredited by NABH on three types of services mainly Maternal health, Accident and

Emergency (A&E) and Clinical laboratory.

Human Resources

In spite of the best of efforts of the state health department to minimize the

vacancies of doctors and it being an ongoing process, there is an acute shortfall of

doctors in both Panipat and Mahendergarh district both at district hospital and in the

field. In both the districts the posts of para medical staff, i.e. ANM, MPW(M) LHV

and BEE are practically filled while post of Doctors are vacant. In Mahendergarh

district in both the CHC's the post of SMO is vacant, whereas in case of PHCs the

post of MO is filled although on the day of visit MO's were not available in two PHCs

due to some or other reason. Dental Surgeon or AYUSH Doctor was available. The

doctor in charge of the CHC Nangal Sirohi is DDO (Disbursing and Distributing

Officer) of SDH Mahendergarh, PHC Pali and PHC Satnali and the doctor visits the

CHC twice or thrice a week. Post of Laboratory technician and Pharmacist was vacant

in PHC Mundia Khera.

In Mahendergarh district there is a short fall doctors in the field. In stand alone

PHCs there are 40 sanctioned posts of Doctors and 28 posts are filled. Out of the 28

posts filled some are deputed to other PHCs, few on deputation, three are doing PG

course and one doctor is absent. Twelve posts of doctors are vacant in the field. One

third posts of Doctors are vacant in the GH Narnaul. There are 27 MO in GH Narnaul

and out of which 5 Doctors are absent from duty. Thus there is a paucity of Doctors.

In case of Panipat district, the post of SMO is vacant in CHC Bapoli and Ahar.

Among the 3 PHCs visited in Panipat district, the post of MO was vacant in 2 PHCs

and in the third PHC the MO position was filled. In the absence of the MO the

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pharmacist is managing the OPD. It may be mentioned here that there no post of

LMO in any of the CHC and PHC. Also it was observed that there is no rational

deployment of Staff Nurses and ANM's. For instance in CHC Ahar 8 Staff nurses

were in position (2 contractual and 6 regular). Out of 8 staff nurses one is on

deputation to Dadlana. Also at three Sub centres namely Ahar, Naultha and Bapoli.

three ANMs are posted.

Thus out of 3 CHCs in only one CHC the post of SMO is filled. There are 13

stand alone PHCs and in only four PHCs all sanctioned posts of MOs are filled, in 2

PHCs no post of MO is filled and in remaining PHCs one or two posts of MO's are

vacant. It is obvious that there is a crunch of Doctors in the field as half of the posts of

Doctor's are lying vacant while the posts of para medical staff (both regular and

contractual) is more or less filled.

A performance appraisal system is in place for doctors and para medical staff.

The performance of all the doctors especially specialists is regularly assessed through

a proper format. Similarly the appraisal of paramedical staff is also done. The

contract of the staff especially para medical is renewed on the basis of their

appraisal/performance as targets have been fixed and if they fail to achieve their

targets then there is time gap in renewing the contract.

Strengthening Services

The district has implemented the policy to provide free and uninterrupted

supply of medicines free of cost to all OPD patients/Causality and Delivery cases in

all Government health institutions as per the guidelines of the state. The state has

formulated Essential Drug List (EDL) for DH, CHC, PHC and SC. At district hospital

and CHCs the EDL is available, but at PHC's level not all of the visited PHC have

EDL. At sub centre level, no EDL is available and the ANM is not aware that an EDL

for the SC has been formulated. The state and district have a computerized list of

drugs and consumables. EDL includes drugs of RCH, safe abortion services and

RTI/STI. Quality assurance of drugs is done through lab test of the medicine when the

drugs are supplied.

During the visit to various health facilities in two districts it was found that all

the generic medicines are available at DH and CHC. However at some of the visited

PHC's few medicines like PCM and Cetrizine are not available. These two medicines

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are in short supply for more than a year or so. The situation regarding availability of

medicine at Sub centre is grim. At number of SC's just IFA tablets were available and

in one sub centre no IFA tablets was available for the last month or so. Since the

medicine Kit is not supplied to the sub centre's any more there is a shortage of

medicines at the sub centre and no uniform pattern is being followed for the supply

and distribution of medicines to the sub centre's. Medicines like ORS, Zinc Sulphate

PCM and even contraceptives like Oral Pills and Copper T were not available on the

day of the visit. In fact in one immunization session at the sub centre there was no

stock of Hepatitis II dose. In another sub centre DPT was not available and the mother

of the children was asked to come on the next immunization session.

Doctors are prescribing generic medicines which were available at health

facility. All the OPD coming to the health institutions are distributed free drugs.

However at one of urban RCH centre in Panipat it was observed that expired

drugs were lying and have not been destroyed.

Procurement

Drugs

The procurement of drugs is decentralized and is being done regularly by the

District Health Society. At district level there is a drug procurement committee to

ensure the availability of all kinds of essential medicines required in the hospital.

For timely procurement of drugs and consumables, these are purchased one

quarter in advance. The essential drug list of 102 medicines is purchased through

Central Pharmaceutical Units and the remaining through State RC and ESI RC. At

district level the same process is followed for procuring drugs and consumables.

At district level the procedure for allocating drugs and consumables to various

health facilities is on the basis of demand and consumption pattern. In Panipat and

Mahendergarh district, the district Central drug store is facing the problem of

procurement from the CPSU as it is not supplying medicines as per the demand given

to them. For instance the District authorities place an order of 5000 tablets of a

particular medicine with CPSU and they supply of 200 tablets then how do they

distribute the medicine in the field. In Panipat district there is shortage of X-ray films

in the district. The drug procurement committee placed the order of X-ray films with

company as per the DGS&D and the company informed the district authorities to

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procure it from authorized local dealer and for which quotation has to be called as no

direct purchase from the local dealers can be made. Thus this whole process involves

time and thereby delaying the procurement of films.

Equipment

The state has formulated an integrated policy for procurement of equipment. A

state level pre procurement cell is functional under the state level technical committee

(Hospital Management Division) to assess the need and specifications of the

equipment. Then the requirement is sent to the procurement cell which procures

equipment through UNPOS.

Both the district has a bio-medical Engineer to look after the maintenance of

equipment in the district and they have maintained a complete record of the

equipment available in the district and its condition. The state is making efforts to put

in place procurement contract having in built AMC and a system for preventive

maintenance of equipments.

Referral Transport and MMU

A strong referral transport system has been put in place in the two selected

districts since 2009. Referral transport is free for pregnant women and sick neonates

assessing public health facilities and road side accidents and other casualty cases. All

the ambulances for referral transport are fitted with GPS but it is not functional in all

the vehicles in Mahendergarh district due to some or other reason. In case of Panipat

district GPS is functioning and all the vehicles can be tracked. Regular monitoring of

usage of vehicles is being done as the driver maintains the log book. Proper records

are maintained at the call centre. In Panipat 15 and in Narnaul 17 Ambulances are

being used for Referral Transport and NRHM logo is displayed on the vehicles.

There is a universal toll free number 102 for availing free transport. The

response time of Ambulance reaching the patient residence is about 20-30 minutes.

Mobile Medical Unit

There is one MMU in Mahendergarh district which is stationed at GH Narnaul

and has been in operation since 2009. Micro plan for the MMU is in place and the

route chart is followed. The MMU visit's the village as per schedule. The services are

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provided by one pharmacist and MO in charge of the nearest PHC (deputed by SMO).

The post of Staff Nurse and ANM is vacant and is likely to be filled shortly. There is

one ALS Ambulance in Panipat and in Narnaul. However there is no Emergency

Medical Technician in Panipat while in Narnaul this position is filled. In

Mahendergarh district ALS is being mostly used to transfer sick neonates to JK Lone

hospital in Jaipur.

New Infrastructure

New infrastructure is being created as per IPHS standards. Standard cost

estimates have been prepared by the PWD (B&R), the executing agency for civil

works in Haryana. Most of the works taken up under NRHM are now either complete

or going to be completed within few months. In Panipat district hospital a separate

AYUSH building has been constructed under the NRHM and the OPD clinic of

AYUSH are functioning from there

The cleanliness in maternity ward of the district hospital Narnaul is lacking.

One of the reason is overcrowding of the patients and also the Class IV do not clean

and mop the wards at regular intervals. It was also observed that in no disinfectant is

being used for cleaning the toilets and wards. Some of the Sub centre buildings need

repair.

Community Involvement

During the visits to several health institutions of the two districts it was noted

that the mechanism of feedback from patients is not in place. The system of grievance

redressal is in place but there are hardly any complaints put in the complaint box. In

case there is any grievance then it is the responsibility of the MO in charge to redress

the grievance.

For generating awareness and promotion of health seeking behaviour among

the masses the main focus is on inter personal communication, through SMS and

ASHA. Although ANM reported that the SMS are not active.

Convergence, Coordination and Regulation

District Health societies receive adequate cooperation from the various related

departments. In CHC Kanina the doctor reported that there was lack of coordination

with the education of department and they have problem in visiting the schools under

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the school health programme. At village level, VLCs cum VHSCs have been created

but are not playing a constructive role in implementation of various components of

NRHM.

Monitoring and Supervision

At district level SMO or MO has been designated as nodal person for the

monitoring and supportive supervision. The nodal officer prepares a monthly schedule

of visits and checklist for the monitoring at different levels involving MO, BEE,

LHV, etc. However monitoring and supervision is lax in both the districts. In Panipat

district no schedule has been prepared for the last 2 months as there has been a change

in nodal officer overseeing this work and in case of Mahendergarh district no

schedule has been made for October as the nodal officer being pre occupied with

other health programmes is not able to devote much attention and time to supportive

supervision.

Apart from this, supportive supervision has been initiated through the state

with the help of residents from Department of Social and Preventive Medicine

PGIMS Rohtak, in a phased manner.

Regular review meetings are held at the district block and sub block level.

The state has initiated Maternal Death Review and Infant Death review. The

ANMs are not aware of MDR and IDR and few ANMs especially in Mahendergarh

district have not been given the forms, although proper formats have been printed and

distributed in both the districts. Reverse tracking of severe anemic cases has not been

implemented in these two selected districts System of identification of high risk

pregnancies has not been initiated and these cases are not underlined by red ink and

neither ANC card with high risk pregnancy cases is stamped. This practice is not

being followed in Mahendergarh District where the number of severe anaemic women

is high. On examining the ANC register it was found that severe anaemic women are

not being referred to CHC/FRU and even if they are referred it is done in second or

third semester. A visit to maternity ward revealed that women having extremely low

Hb are delivering babies.

HMIS and MCTS

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Under the HMIS, district level monthly consolidated reports are being

uploaded but facility based reporting is not being uploaded in Panipat and

Mahendergarh district. MCTS is not fully functional for regular and effective

monitoring. Both the districts are lagging behind in MCTS. No work plans/due lists

are being generated and tracked under MCTS. However at the same time there are

also some operational difficulties in entering information about MCTS like internet

and power problem and shortage of manpower.

Maternal Health

Provision of C section deliveries is there in both the General hospitals and

complicated pregnancies are referred to Rohtak and of late GH Panipat refers

complicated pregnancy cases to Medical college Khanpur Kalan due to its proximity

to GH Panipat. Provision of 1st and 2

nd Trimester abortion is available in both DH.

Janani Shishu Suraksha Karyakaram(JSSK)

Districts have implemented free entitlements under JSSK, i.e. pick up, drop

back facility, free meals and free medicines and diagnostic. In Panipat district hospital

there is proper arrangements for providing meals to pregnant women while in

Mahendergarh GH proper meals are not being provided. Eatables like biscuits (one

packet), rusk (one packet), Frooti juice (tetra pack) and one apple is distributed to

them. On an average the district authorities spend Rs 100 per day for the diet of one

woman. However there are no proper arrangements for providing free meals at

CHC/PHCs. At the CHC if the woman stays less than 6 hours which is the usual

practice then either the patient is given Rs 25/ cash or in kind is given milk or fruit

depending upon what the patients likes to have. In all the visited PHCs no patient is

given any free meals. Moreover it was observed that the relatives of the patient want

the mother and baby to be discharged within 2-3 hours of delivery and in that case no

meals are given. With the district, the CHC and PHC do not follow a uniform pattern

for providing meals. Some CHC distribute fruit and biscuit, some give Rs 25/ and

some do not give any meals/fruit/milk or money. It is surprising to note that the

ANMs at Sub centre are not aware of the terminology JSSK although wall writing

about the facilities given under JSSK are written on the wall of the Sub centre. This

indicates a need for sensitizing the ANMs regarding different schemes initiated in the

state from time to time.

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Yasodha's and a Yasodha supervisor have been appointed in both the districts

and are posted in General Hospital and they counsel the pregnant women about breast

feeding the new born

During the field visits to the SCs in both the districts, it was observed that

quality of ANC services provided to the pregnant women is poor. On every ANC

visit the ANM does not check the Hb of PW. During the ANC check up, the pregnant

woman is given TT, IFA tablets and weight is taken. During the first visit BP is

measured but Hb is not done for every pregnant woman ANM may check Hb on

subsequent visit. During the visit to the selected Sub centres it was noted that some of

ANMs are not having BP apparatus. Some of the ANM's do not know how to use

haemoglobinmeter and nor did know how the measure the BP with stethoscope. In

Mahendergarh district the ANM are not referring women having Hb 7 or less. They

are not aware of reverse tracking of severe anaemic women and also are not informed

that severe anaemic women are to be underlined with red ink. Post natal care a

neglected area.

The staff nurses motivates/ensure that the mothers initiate breast feeding

within one hour of delivery or before discharging the patient. The condition of

building of some sub centres is bad. In CHC Kanina the delivery hut is functioning in

a separate building where there no water supply and attached bathroom due to

seepage in the wall as they had cut the water supply and only one baby warmer has

been installed while two are lying unused. In most of the visited delivery points there

is no proper NBCC.

Regarding the payment of JSY, it is made rather late. In fact there is no fixed

time frame for giving payment. It depends upon the presentation of proper documents

submitted by the beneficiary and availability of funds. The payment is made through

cheque to the beneficiary at PHC level.

Child Health

In Mahendergarh district there is a functional SNCU which has 5 baby

warmers and one incubator but in Panipat district there is no proper SNCU. Only one

baby warmer has been installed in labour room. The staff posted at SNCU and NBSU

have been trained in Newborn sick care. Some of the ANM's and ASHA workers are

not aware of SNCU services at District Hospital.

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The districts have initiated IMNCI training. The state is yet to open a Nutrition

Rehabilitation Centre. IFA tablets are not distributed to all children under 6 months -

5 years of age. Only those children who are found to be anaemic are given IFA tablets

Supply of ORS is regularly available but presently there is dearth of Zinc and IFA

tablets in some sub centres.

It was also observed that Immunization Session’s in outreach area are

held. The ASHA worker informs the beneficiary about the sessions and requests them

to get their infant/new born immunized. The ANM prepares the list of beneficiaries

due for immunization and same is given to the ASH worker.

Both the districts have prepared a plan for intensification of RI for low

immunization coverage and to cover outreach/inaccessible areas.

At District Hospitals, three birth doses of immunization are given. It is not so

at CHC, PHC where only Hepatitis 0 and Polio 0 is given. Cold chain mechanic is in

position for maintenance of cold chain system.

Family Planning

ANMS have been trained for IUCD 380A and daily IUCD services are being

provided at GH and CHC. IUCD 375 has not yet been introduced in the state as well

at the district level although training has been initiated for IUCD 375. Post partum

IUCD (PPIUCD) services are being provided in the district's hospital. There is a FDS

centers for sterilization at the district level. Camps are held in the district for which a

monthly schedule is prepared or days are fixed.

Adolescent Reproductive and Sexual Health (ARSH) and Menstrual Hygiene

Scheme (MHS)

At district level there is a nodal officer looking after adolescent health. In

Mahendgarh district there is an ARSH clinic at DH, SDH and CHCs. ARSH clinic

provide ARSH services from 11 am to 1 pm on Saturday. Trained manpower has been

deployed at ARSH clinics. In Panipat district ARSH clinics are not functional.

Training of peer educators has been initiated in both the district. Post of ARSH

coordinator and counselor has not been filled in both the districts.

Menstrual Hygiene Scheme has not yet been implemented.

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School Health Programmed

Under the SHP the state has adopted the GOI guidelines. Under the SHP the

weight and height measurement of students of government schools and government

aided schools is taken. Programme also focuses on three D’s (Deficiency, Disease and

Disability) and referral of children is tied with higher facilities. All children below 6

years of age coming to AWC have undergone health check up at AWC. Distribution

of weekly Iron and Folic Acid tablets is not yet started. Drugs are under procurement

Urban RCH

In Panipat and Mahendergarh district urban slums have been mapped. There 7

urban RCH centres in Panipat district and two in Mahendergarh district. In Panipat

district two urban RCH centres located in city slums were visited by the team. The

urban RCH centres are usually manned by MO (hired on contract basis), Pharmacist,

Lab. Technician, two ANMs and one class IV person. In Panipat post of 4 MOs are

filled and in 3 urban RCH centre post of MO is vacant whereas in Mahendergarh

district post of MO is vacant in one urban RCH centre.

In Panipat in the urban RCH centres the average number of OPD varies. On an

average 30 to 40 patients avail the services at these centres depending upon

availability of the Doctor. Lab tests like Hb, TLC, DLC, VDRL, Widal tests are

carried out. In one of visited urban RCH centre there was shortage of medicines like

PCM and Amoxcillin.

On examining the ANC register it not noted that it is not well maintained.

Pregnant women having Hb < 7 gm are not referred. ANM does not have a BP

apparatus of her own and it seems she is not trained to check the BP. ANM was not

aware of MDR and IDR and neither did she have any booklet. One third of deliveries

in her area were home deliveries.

ASHA

The selection of ASHA workers is made on the basis of the recommendation

of ANM and the VHSC in Panipat and Mahendergarh districts. In both the districts,

nearly all posts of ASHA are filled. No ASHA day is celebrated. From this year

ASHA award has been initiated in which 3 best performing ASHA workers will be

selected and awarded cash prize of Rs.1500, Rs.1000 and Rs.500 and this function is

19

planned to be held quarterly. The state has initiated the process of identifying ASHA

coordinators and facilitators and starting ASHA resource centre at state and district

level. The state/district prepares monthly ASHA master chart and on that basis

appraisal is done. The districts have identified non/under performing ASHA workers.

On an average the ASHA worker receives a monthly payment of Rs.1500. However

this amount varies from district to district.

ASHA workers have completed the HBNC training, ASHA workers has been

provided with just an overcoat and a diary. All the ASHA workers in the districts

have not been provided ASHA kits. Among those who have been given Kits the

medicines in the kit have not been exhausted. All the ASHA workers have received

Training up to Module 5.

Untied Funds/SKS/AMG

SKS has been constituted at DH, CHC and PHC level. VLC cum VHSC have

been setup at village level although they are not active. Untied funds and SKS funds

have been provided to all the VHSCs. Differential budgeting for all levels of facilities

has been done on the basis of case deliveries. Funds have already been made available

in the second quarter. AMG grant has been released for all the health facilities located

in the government buildings on the basis of previous year's utilization for all the

facilities that is for SC, PHC, CHC, and SDH.

No formal training of the PRIs and members of RKS/SKS has been done.

Information regarding the amount of Untied/SKS/AMG funds received and amount

utilized last year was not displayed publically at any of the health facilities visited by

the team. Audit of Untied/SKS/AMG funds takes place regularly.

Website Disclosures

Facility wise deployment of all contractual staff Uploaded on

Engaged under NRHM with name and designation website

MMUs- total number of MMUs, registration numbers, Information on micro

operating agency, monthly schedule and service delivery plan of MMU for

data on a monthly basis. 2012-13 uploaded

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(Specifically for Districts which are served by MMU)

Patient Transport ambulances and emergency response Information

ambulances- total number of vehicles, types of vehicle, uploaded up to

registration number of vehicles, service delivery data March 2012

including clients served and kilometres logged on a

monthly basis

Procurements- details of equipments Uploaded

Procured

Buildings under construction/renovation –total Uploaded

number, name of the facility/hospital along with

costs, executing agency and execution charges

(if any), date of start & expected date of completion.

------------------

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Annexure I

List of Facilities Visited

District Narnaul

GH – Narnaul

CHC – Kanina and Nangal Sirohi

PHC - Mundia Khera, Sirohi Bahalia and Dhanaunda

SC - Bhungraka, Nangal Kaliya, Kothal Kalan and Palh

District Panipat

GH – Panipat

CHC – Ahar and Bapoli

PHC - Naultha, Mandi and Ujha

SC - Pradhana, Balana, Chamrara, Palri, Rishalu

Ur.RCH Centres - Ugrakheri and Batra Colony