monitoring report, jan-march 2013; bihar (east champaran)
TRANSCRIPT
2013
V Roddawar
NHSRC
Monitoring Report, Jan-March 2013; Bihar (East Champaran)
1
Executive Summary
The report is based on monitoring visit to East Champaran of Bihar from 9th
to 11th
April 2013.
The monitoring visit included all levels of health facilities in the district. Details of visit are
provided in the annexure-A
1. Status of health facilities
The district has inadequate health facilities as per the population norms. In terms of required
health facilities, there is a deficit of 54%, 59% and 26% of health sub-centers, additional
PHCs and PHCs respectively.
On an average each PHC performs 200-250 deliveries per month. None of the health sub-
centers and APHCs are operational as delivery point. Operationalisation of some delivery
points at these facilities is necessary to ease out the case load of PHCs.
East Champaran ranks 34th
out of 38 districts based on composite health indicators as on
February 2013.
2. Maternal Health
Key maternal health indicators show poor performance of the district. Institutional deliveries
are only 29% as against estimated deliveries, 3% are home based Skill Birth Attendant
(SBA) and remaining 8% are home based non SBA deliveries.
Only 0.1% of C-section deliveries are reported against institutional deliveries. One of the
major concern is high percent of unreported deliveries, which is about 60%.
The unmet need of EmOC correlates well with the shortage of specialists in the district.
Gynecologist and anesthetist are not available in the PHCs, which caters high load of
deliveries.
29% of deliveries are being conducted in Public facilities with PHCs alone contributing to
80%.
There is an urgent need to prioritize health sub-centers and additional PHCs as operational
delivery points in the district to ease out delivery load of PHCs
The MDR conducted provides hardly any clarity on cause of maternal deaths. The district
reported 239 maternal deaths during 2012-13, and all except 2 deaths were recorded under
‘other causes’
3. Janani-Shishu Suraksha Karyakram (JSSK)
OPD and IPD services are free but there is a shortage of drugs in all health facilities in the
district.
86% of beneficiaries, out of 14 interviewed, reported buying prescribed medicine from
private medical store. On an average, each beneficiary spent minimum of Rs.100 to
maximum Rs.700 for buying prescribed medicines.
However, 50% of the interviewed beneficiaries did not undergo any laboratory test in the
visited health facility. Due to inadequate human resource and lack of equipment, diagnostic
services are not available at many health facilities.
2
Provision of diet is available across all health facilities designated as delivery points but due
to immediate discharge, utilization of diet service is questionable.
75% of the interviewed beneficiary did not avail the ambulance service to reach the facility.
Only 30 to 40 percent of the beneficiaries are availing the ambulance facility and remaining
dependent on private vehicles. Cost of hiring private vehicles range from Rs.100 to Rs.1000
based on time and distance.
The signage of JSSK not displayed in health visited health facilities, however district
received material from the state to display JSSK entitlements.
The source of information for Pregnant Women are ASHAs, 16 out of 16 (100%)
beneficiaries informed that ASHAs are the point person for the information.
4. Immunization
The full immunization cover for the district is 49%, however, the sharp fall is observed in
measles immunization, which dropped by 28% in comparison with previous year.
BCG-measles drop out percentage has increased from 17% in 2012 to 26% in 2013. At the
same time dropout from BCG to DPT3 has decreased from 23% in 2012 to 6% in 2013.
Only 59% of immunization sessions were attended by ASHAs who are supposed to do
community mobilization.
5. ASHA
85% of the required ASHAs (4326) are placed in the district. 73% (2686) of district ASHA
were trained up to module 4 and 49% (1786) of ASHA were trained in first round of module
6 and 7.
Round 3rd
, 4th
, and 5th
of module 6 and 7 yet to start. District has distributed drug kits to all
ASHAs however, no HBNC kits were distributed.
6. Child Health
The recent assessment in East Champaran found that none of the NBCC is fully functional.
14 NBCCs are partially functional and 4 NBCCs are non-functional.
10 out of 18 NBCCs are located inside labor room and remaining 8 were reported outside of
the labor room. None of the ANM/Staff Nurse is either trained or possess required skills for
NBCCs.
7. Nutritional Rehabilitation Centre
Out of 280 SAM children, the cure rate of NRC center in East Champaran was only 60%.
14% children did not respond to nutritional therapy and 2% referred to other hospital.
Around 2% of children defaulted and one death was reported. Rest remained under treatment
8. Family Planning
As per the DLHS III, the district has 44.8 unmet need for family planning and only 5% of the
total unmet needs were catered in the district. Estimated eligible couples for unmet needs is
3,98,144 based on DLHS III.
Only 4% of total sterilization was achieved against estimated number and 12% of postpartum
sterilization achieved against total female sterilization in year 2012-13.
3
9. Quality
9.1. Infrastructure
Visited PHCs, APHCs and HSC lack proper infrastructure as per the standard norms.
Electrical wires were exposed and switch boards broken. Rooms are dumped with
condemned articles and no mosquito screens present.
9.2. Information Display
Information related to health programs is not well displayed. Facilities like APHC, Pipra do
not have a single display of IEC material.
9.3. Infection prevention
Biomedical Waste Management services are available only in seven out of 19 PHCs (37%).
Visited facilities do not have proper coded buckets for segregation of biomedical waste
management, some facilities have coded buckets but they are in partial usage.
9.4. Program Management:
The position of DPM in East Champaran is vacant and block health manager has taken over
as in-charge of the East Champaran district. There is a shortage of all other positions
sanctioned at district level project management unit.
10. Disease control programme
Pediatric TB medicine is not available at district but available at state level. Suspected 41
Multi Drug Resistant (MDR) cases in the district, of them 24 sent for bacteria culture and 14
confirmed as MDR as of March 2013.
East Champaran achieved only 60% of the total New Sputum Positive cases per annum as
per estimated population.
For leprosy detection, no skin smear test was available in any health facility and almost all
cases were detected based on nerve and skin patches
District health facilities do not have capacity to treat disabilities and they refer to Leprosy
Mission in Muzaffarpur, nearby district.
4
Detailed Report
District background
1. District Health Facilities
Table 1. Status of Health Facilities – East Champaran, Bihar
Sl.
No.
Health
Facility
Level I Level II Level III Total
Requir
ed
Sanctio
ned
Requir
ed
Sanctio
ned
Requir
ed
Sanctio
ned
Requir
ed
Sanctio
ned
1 PHCs 0 0 27 20 0 0 27 20
2 APHCs 128 53# 0 0 0 0 128 53
3 HSCs 780 356* 0 0 0 0 780 356
4 SDH 0 0 0 0 6 0 6 0
5 CHC/RH 0 0 0 0 3 3 3 3
7 DH 0 0 0 0 1 1 1 1 Source: District health Society, East Champaran
*Functional indicates as health facility but not fully operationalized MCH wing (no deliveries)
# Only one facility fully operational as MCH I – Rajheepur
1.1. Facility Mapping
The district has 6 divisions, 27 blocks, 403 gram panchayats, and 1355 revenue villages. Each
block has one PHC, which caters to approximately 1 to 1.5 lakh population. Out of 27 PHCs
East Champaran Profile
State Bihar
Administrative Division Tirhut
Dist. Headquarters Motihari
No. of Blocks 27
No. of Villages 1355
No. of Panchayats 403
Population (2011) 50,82,868
Literacy 58.26%
Sex Ratio 901
Density of Population 1281/KM2
District Boarder
North Nepal
East Sitamadhi and Sheohar
West Gopalganj
South Muzaffarpur
5
only 20 PHCs are functional as Level 3 performing over 200 to 250 deliveries per month and 7
PHCs are yet to operationalize.
Graph 1. Sanctioned Vs Functional Health facilities of East Champaran, Bihar
On an average each block has 10 to 12 Health Sub Centre (HSC) and none of them are functional
as delivery points. There are total 53 Additional Primary Health Centre (APHCs), which fall
below PHCs and above HSC and only 1 APHCs are functional as delivery points – Rajeepur,
which conducts 30 to 40 deliveries per month.
Table 2. Key health indicators of Bihar Vs East Champaran
Sl. No. Health indicators Bihar East Champaran Difference
1 MMR (per 100,000 live
births) 305 319 14
2 CBR ( per 1000
population) 26.7 30.4 3.7
3 CDR ( per 1000
population) 7.2 8.1 0.9
4 IMR 55 57 2
5 Neo- natal Mortality Rate 35 37 2
6 Under Five Mortality Rate 77 75 -2
Source: AHS 2011
Key health indicators of East Champaran is far below the states average as reflected in the above
table. To monitor district wise performance, state health society has developed dashboard
monitoring system, a tool that provides visual representation of performance of districts to
review block, district and divisional performance. The dashboard is based on composite health
indicators which broadly covers, MCH, family planning, disease control programmes, finance,
27
128
780
6 3 1 20
53
356
0 3 1 0
100
200
300
400
500
600
700
800
900
PHCs APHCs HSCs SDH CHC/RH DH
Sanctioned Vs Functional Health Facilities East Champaran
Sanctioned Functional
6
and administration. East Champaran ranks 34th
out of 38 districts as on February 2013 as seen
from the below graph.
Graph 2. Bihar District wise rank as on February 2013
2. Maternal health
Comparison of East Champaran District Health Information System (DHIS) for the last quarter
of 2012-13 shows drop in percent of pregnant women registered for ANC, percent of
institutional delivery and C-section delivery by 23%, 3.4% and 1.9% respectively. On the other
hand there is miniscule improvement with respect to home deliveries. However, percent of
unreported deliveries increased by 4 percent in comparison with previous quarter.
7
Table 3. Comparison of selected maternal indicators of East Champaran - 4th
quarter 2011-12 to
2012-13 (financial year)
Sl. No. Key Indicators - East Champaran Jan to Mar
2012
Jan to Mar
2013
1 % ANC Registration against Expected Pregnancies 66 43
2 % ANC Registration in first trimester against Reported ANC
registration 45 45
3 % Severe anemia (Hb<7) treated against reported ANC registration 0.1 0.1
4 % Hypertension in pregnancy- detected against ANC reported 1.9 2.8
4 % Institutional Deliveries against Estimated Deliveries 32.3 28.9
5 % Home deliveries( SBA& Non SBA) against estimated deliveries 11.8 11.1
6 C Section deliveries against institutional deliveries (Pvt & Pub) 2 0.1
7 % Unreported deliveries in the quarter (total deliveries reported
against estimated level) 56 60 Source: District HMIS
East Champaran is one of the backward districts of north-west region of Bihar and shares its
boundary with Nepal. It is one of the high priority districts of Bihar and 92% of the population is
rural. It is important to note that in East Champaran, out of total deliveries almost 60% are
unreported, 29% are institutional deliveries, 3% home based Skill Birth Attendant (SBA) and
remaining 8% are home based non SBA deliveries. 29% of deliveries are being conducted in
Public facilities with PHCs alone contributing to 80%.
Graph 3. PHC wise delivery load from January to March 2013
115 141 140 167 150 183 201
163 165 199 199
0 219 230 256 271 290
411 564
94 118 135 107 148
141 127
163 177 148 166
271 163
222 164
217 249
361 370
80 99 112 132 121
110 110 119 122
158 161
292 186
132 199
163 184
350 487
0 200 400 600 800 1000 1200 1400 1600
Dhaka
Ramgarhwa
Turkauliya
Paharpur
Pakaridayal
Adapur
Sugauli
Ghorasahan
Madhuban
Harsidhi
PHC wise Delivery load Jan to Mar 2013 - East Champaran
Jan-13 Feb-13 Mar-13
8
It is clearly evident from the field visit that there is a demand for public health services but due
to inadequate facilities and lack of manpower, high number of beneficiaries avail private
facilities. The second reason may be that the public sector has fewer options available (due to
non-functionality). Out of 356 health sub-centers in East Champaran none of them function as
delivery point. Except one APHC-Rajeepur none of the 52 APHC are functional as delivery
point. The third reason, out of 27 PHCs only 19 PHCs are functional, which are located at block
level with high load of deliveries. However, many of the PHCs have inadequate facilities and
fewer human resources with these limited resources and challenging environment they cater high
load of deliveries. The above graph gives month wise PHC wise delivery load in East
Champaran district.
The unmet need of EmOC correlates well with the shortage of specialists in the district. There is
no gynecologist and anesthetist available in the PHCs, which caters high load of deliveries.
During field visit, it is observed that due to lack of specialist PHCs are not accommodating
complicated cases and referring to district hospital, Motihari or tertiary level hospital, which
needs immediate attention.
Table 4. East Champaran Human Resource for Health (regular + Contractual)
Source: District PIP 2013-14
2.1 Maternal Death:
The district has high burden of maternal death but there is no proper death review has been
conducted at district level. The district has reported 239 maternal deaths during 2012-13. The
Maternal Death Review (MDR) reported these deaths under other causes except two deaths due
to sepsis. There is an urgent need to orient district health officials in conducting MDR with the
help of prescribed verbal autopsy format. However, these deaths also reflects inadequate
infrastructure, equipment and manpower at different levels of health facilities. Information from
these MDR reviews are quite resourceful for the prevention further deaths and strengthen health
facilities in the district.
Sl. No Human Resource 2012-13
1 Specialists 16
2 MOs 100
3 AYUSH MOs 56
4 Dental Mos 33
5 SN 48
6 LHV/PHN 2
7 ANMs 660
8 LTs 20
9 Pharmacists 0
10 AYUSH Pharmacists 0
11 MPWs 0
12 DEOs 23
9
Table 4. Maternal Death Review 2012-13 – East Echamparan
Sl. No. Indicator 1st
quarter
2nd
quarter
3rd
quarter
4th
quarter
1 No. of MDs reported (community and
facilities)
48 59 63 69
2 No. of MDR reviewed 0 0 0 0
2.1 No. due to PPH 0 0 0 0
2.2 No. due to Eclampsia 0 0 0 0
2.3 No. due to Sepsis 1 1 0 0
2.4 No. due to Obstructed labor 0 0 0 0
2.5 No. due to Referral delays 0 0 0 0
2.6 No. due to severe anemia 0 0 0 0
2.7 No. due to other causes 52 39 48 32
3. Janani-Shishu Suraksha Karyakram (JSSK)
3.1 User fee in Out Patient Department (OPD) and In Patient Department (IPD)
OPD and IPD services are free in all the facilities. Out of 16 beneficiaries interviewed across
different health facilities, no one reported paying any money for OPD and IPD services.
3.2 Drugs and Consumables
It is observed that there is shortage of drugs in all health facilities in the district. Out of 14
beneficiaries interviewed at PHC, Turkoulia and DH Motihari, 12 beneficiaries reported buying
prescribed medicine from private medical store. On an average, each beneficiary spent
minimum of Rs.100 to maximum Rs.700. Beneficiaries revealed that after delivery MOs
prescribed few medicine, which are common across beneficiaries. The frequently prescribed
medicines are Drotin, and Anafortan.
3.3 Diagnostics
Diagnostic services are available at the facilities visited, which include routine blood and urine
examination. Pregnant women are exempted from paying money for laboratory tests. However,
exit interview with beneficiaries revealed that 8 out of 16 beneficiaries did not undergo any
laboratory test. 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 beneficiaries (pregnant
women) dependent on private labs for diagnostic test which has direct implication on out of
pocket expenditure.
3.4 Diet
Provision of free diet available in the facilities visited. At DH Motihari, food catering services
outsourced to third party, which provides lunch for all in-patients including Pregnant Women
10
(PW). During the field visit, it is observed that the food quality was not good and many of the
patients refuse to take the food prepared by outsourced agency.
It is observed across all the facilities that 85 percent of the beneficiaries leave the health facilities
immediate after delivery, within 2 to 6 hours. All most all deliveries are normal deliveries
except DH Motihari, no other PHC and CHC/RH caters to complications. Hence, most of the
deliveries discharged within few hours. Although the provision of diet is available across all
health facilities designated as delivery points but due to immediate discharge, utilization of diet
service is questionable.
Graph 4. Duration of stay after delivery in East Champaran district from Jan to March 2013
Source: district HMIS
3.5 Referral Transport
In East Champaran district, there are 27 blocks and each block has one Janani Shishu Arogya
Express (102) exclusively for pregnant women to transport nearby health facility. Out of 16
beneficiaries interviewed only four of them availed the ambulance service to reach the health
facility and for drop-back 6 beneficiaries utilized the service. Remaining 10 beneficiaries hired
private vehicles which cost in the range of Rs. 100 to Rs.1000 based on time and distance.
4962 4395 4159 4037 4047
3466
0
1000
2000
3000
4000
5000
6000
Jan '13 Feb '13 March '13
D U R A T I O N O F S T A Y - E A S T C H A M P A R A N
Deliveries conducted at Public Institutions
Of which Number discharged under 48 hours of delivery
11
Graph 5 Month wise ambulance service (both to and fro) against reported deliveries – East
Champaran
It is evident from the reported data that only 30 to 40 percent of the beneficiaries are availing the
ambulance facility and remaining dependent on private vehicles which is one of the major
contribution for out of pocket expenditure among the PWs.
Referral transport vehicle
3.6 Display of entitlements
The signage of JSSK not displayed in health facilities visited, when discussed with the block and
district officials, they informed that the display material received from the state and soon they
will display across all the facilities in the district. In Bihar, JBSY (Janani Bal Suraksha Yojana)
is quite popular and no clarity among service providers and service receivers about JSSK
entitlements.
49
62
43
95
41
59
24
20
26
84
26
25
J A N ' 1 3 F E B ' 1 3 M A R ' 1 3
A M B U L A N C E S E R V I C E A G A I N S T D E L I V E R I E S - E A S T C H A M P A R A N
Deliveries conducted at Public Institutions
Total Number of times the Ambulance was used for transporting patients during the month
12
3.7 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, 16 out of 16
beneficiaries informed that ASHAs are the point person for the information.
3.8 Grievance Redressal Cell
There is no grievance redressal mechanism available in the visited facilities, when enquired with
the beneficiaries, 4 out of 16 informed that they will approach ASHA and rest of them said they
don’t know whom to approach for their grievances.
3.9 Out of pocket expenditure / informal charges
Interaction with beneficiaries revealed that out of pocket expenditure arise mostly on
transportation and drug charges. Regarding informal charges, there are some instance where
paramedics also demand money after deliveries in the health facilities. The money range from
Rs.100 to Rs.500 depends on gender of the new born and social status of the beneficiaries.
Regarding diet, PHCs, SDH/RHs and DH empanelled agencies to provide cooked food, but
hardly any beneficiaries stay more than 6 hours in PHC and SDH/RH because most of the
deliveries are normal and complications are referred to DH or nearby private hospitals.
4. Outreach activities
4.1 Immunization
Cumulative figures of East Champaran in last quarter of 2012-13 shows overall drop as
compared to the last year. The full immunization was 54% in the last quarter of 2012 while it is
49% in the fourth quarter of 2012-13. However, the sharp fall observed in measles
immunization, which dropped by 28% in comparison with previous years last quarter. BCG-
measles drop out percentage has increased from 17% in 2012 to 26% in 2013. At the same time
dropout from BCG to DPT3 has decreased from 23% in 2012 to 6% in 2013. Facilities visited
had functional ILR and deep freezer with temperature card duly filled and adequate temperature
maintained. In Bihar, due to short 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.
13
Graph 6 Coverage of immunization – East Champaran
The district shows poor performance of planned versus held immunization sessions which
correlates with immunization achievement in the district. However, in comparison with previous
year a slight improvement shown in sessions held but the number of sessions planned was lower
than the previous year. It is concern to note that only 50% to 59% of immunization sessions
were attended by ASHAs who are supposed to do community mobilization.
Table 5 Comparison of Immunization sessions held in two different years of 4th
quarter
East Champaran
% of immunization sessions held vs planned
% of immunization sessions where ASHA were present (out of the held sessions)
2011-12 82% 50%
2012-13 89% 59%
4.2 ASHA
The state currently has about 84,365 ASHAs, representing 97% of the total selected. As per the
revised norm, East Champaran requires 4326 ASHAs and only 3679 ASHAs are placed, which is
about 85% of the required ASHAs. 73% (2686) of district ASHA were trained up to module 4
and 49% (1786) of ASHA were trained in first round of module 6 and 7. Round 3rd
, 4th
, and 5th
of module 6 and 7 yet to start. District has distributed drug kits to all ASHAs however, no
HBNC kits were distributed.
The state has established support structures at state, divisional, district, block and ASHA
facilitator levels. At district level, District Community Mobilizer (DCM) and Block Community
Mobilizer (BCM) at block level take responsibility of ASHAs. There are 15 BCM placed out of
required 27 BCMs and 162 ASHA facilitators placed out of 206 positions in the district.
0102030405060
70
80
90
100
BCG DPT 3 OPV 3 Measles FullImmunization
94
73 69
78
54
68 64 63
50 49
% O F I M M U N I S A T I O N C O V E R A G E B E T W E E N T W O D I F F E R E N T Y E A R O F 4 T H Q U A R T E R - E A S T C H A M P A R A N
2011-12 2012-13
14
5. Child Health
According to AHS (2011) IMR of the state was 55 and the East Champaran was reported 57,
which is 2 points above the states average. State has 484 NBCCs, 7 NBSU and 37 nutritional
rehabilitation centers. However, in the district there are no SNCUs and only one nutritional
rehabilitation center available in Chakia block.
New born care
Table 6 Status of different type of new born care facilities in Bihar
Status
NBCC NBSU SNCU NRC
Sanctioned
Functional
Sanctioned
Functional
Sanctioned
Functional
Sanctioned
Functional
Bihar 484 484 40 7 0 0 38 37
East Champaran
20 20 1 0 0 0 1 1
Source: 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 18 NBCC in East Champaran
district and found that none of the NBCC is fully functional, 14 NBCCs are partially functional
and 4 NBCCs are non-functional. 10 out of 18 NBCCs are located inside labor room and
remaining 8 were reported outside of the labor room. None of the ANM/Staff Nurse either
trained or possess required skills for NBCCs.
Graph 7 Assessment of 18 NBCC units – East Champaran (April 2012)
18
11
18
9
4
11
17
11
17
7
4
10
0
2
4
6
8
10
12
14
16
18
20
Radiantwarmer
Photo Therapy OxygenConcentrator
SuctionMachine
AMBU Bag &Mask
Stablilizer
Assessment of 18 NBCC centres - East Champaran (2012)
Available Functional
15
None of the NBCC were reported with essential drugs in place and only 2 units reported with all
consumables. Only 6 units displayed proper protocols and 2 showing utility of protocol.
However, the report says none of the facility have updated NBCC registers but visited Turkoulia,
Chakia, Mehasi NBCC facility registers were updated.
6. Nutritional Rehabilitation Centre (NRC)
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 8 Caste wise composition of admitted SAM children in East Champaran
1 Severe 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.
[VALUE], [[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
Caste wise Composition of Admitted SAM children
SC/EBC/OBC ST GEN
16
State health society, Bihar in collaboration with UNICEF established NRC in East Champaran in
2007 as a pilot project, which resulted in extremely productive. Over a period of time NRCs run
through district health society via qualified NOGs and UNICEF continuously provide technical
and supervisory support to NRCs. In East Champaran, NRC is located in Chakia block run by
district health society through NGO Jan Pragati Sansthan (JPS). NRC, Chakia 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. NRC, Chakia admitted 280 SAM
children and completed 15 batches. Total 14% children not responded for nutritional therapy
and 2% referred to hospital, 21% children were followed up till 8th
week, 2% children defaulted
and one death occurred. However, total 60% children cured and discharged from the NRC
center in East Champaran.
Graph 9 Output indicators of NRC, Chakia – East Champaran as on 11th
April 2013
7. Family Planning
Performance of family planning programmes reflects poor outcome in the district. As per the
DLHS III, the district reported 44.8 total unmet needs and on the basis of district population,
total eligible couples for unmet need calculated for the quarter. Only 5% of the total unmet
needs were catered in the district, which remains constant between two different quarters without
improvement. The demand for unmet needs jumped around 3% from previous year. However,
there is huge gap between demand and supply but the district health facilities are not equipped to
fill the gap. There is an urgent need to apprise family planning activities in the district, which
should accommodate the needs of the district.
[VALUE], [[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
[VALUE],[[PERCENTAGE]]
[VALUE], [[PERCENTAGE]]
Performance of NRC Chakia - East Champaran
Cured (C) Defaulter (DF)
Non Respondent (NR) Medical Transfer/ Referred (R)
Deaths (D) Under follow up till 8th week
17
Table 6 Family planning indicators of East Champaran 4th
quarter (Jan to Mar)
FP Key Indicators 2012
Jan to Mar
2013
Jan to Mar
Estimated eligible couples for
unmet need - Calculated using
DLHSIII for the quarter - East
Champaran
3,87,111 3,98,144
% Total reported FP Users against
estimated eligible couples
5%
[19040]
5%
[18379]
% Total IUDs reported against total
reported FP users
31%
[5841]
7%
[1236]
% Total OCP users against total
reported FP users
4%
[773]
4%
[715]
% of Total sterilization (against
Estimated Level of Achievement)
3%
[11,400]
4%
[15181]
% Postpartum sterilization out of
total female sterilizations
12%
[1359]
12%
[1897]
% Male sterilizations out of total
sterilizations
0.33%
[38]
0.36%
[55]
% Female sterilizations out of total
sterilizations
99.67%
[11362]
99.64%
[15126]
Source: DHIS and HMIS
8. Quality of services
8.1 Infrastructure
According to population, the state has inadequate health infrastructure at all levels. State has
slightly different hierarchy in comparison with
other public health institutions2. There is an
urgent need for increasing indoor capacity of
these PHCs.
Visited PHCs, APHCs and HSC showed lack of
proper infrastructure as per the standard norms.
Electrical wires were exposed and switch boards
broken. Rooms are dumped with condemned
articles and no mosquito screens present. No
running water available for 24 hours in labor
room, OT and toilets. While, purified drinking
2 In Bihar, Additional PHC (APHC) correspond to PHC anywhere in India, which caters to average 20 to 30 thousand population. On the other hand PHCs in Bihar located at block level on average catering to 1.5 lakh population, which can be compared with CHC on the basis of population norm. But the service provision on these PHCs are same as compared to anywhere else in India usually having 6 indoor beds providing BEmONC services.
APHC, Pipra – East Champaran
18
water available for for staff but not for patients in OPD and IPD.
8.2 Information Display
Information related to health programs are not well displayed. Facilities like APHC, Pipra do
not have a single display in the district. PHCs like Turkoulia, Chakia and Mehasi displayed
information on family planning, immunization, and essential drug list but no display on JSSK.
8.3 Infection prevention
The state has outsourced the Biomedical Waste Management (BWM) system for all health
facilities from medical colleges to PHC
level. In East Champaran, SembRamky
provides BWM services only in seven
out of 19 PHCs. However, when
interacted with MOs and paramedical
staff, they expressed unsatisfactory
about these services because of
irregularity. 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 management, 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 has need for additional
trainings and robust monitoring as far as infection prevention (IP) practices are concerned.
8.4 Emergency preparedness
Emergency services are still in very primitive stage. They are not prepared for mass casualty and
disaster. In many of the PHCs, RH/SDH including district hospital there is no dedicated
infrastructure for Accident and Emergency Services.
8.5 Program Management:
The position of DPM in East Champaran is vacant and block health manager has taken over as
in-charge of the East Champaran district. There is a shortage of all other positions sanctioned at
district level project management unit. There are total 15 Block Planning Managers (BPM) are
placed against sanctioned 20 and similarly 16 Block Account Managers (BAM) available against
20 sanctioned. No Block Data Manager (BDM) positioned against sanctioned 20 positions.
However, due to shortage of MOs, many of the MO i/c are acting as additional in-charge for
disease control programme like vector borne, leprosy, blindness control and tuberculosis
programme at district level.
Monitoring mechanism includes district, block and facility level monthly meeting. There are
total 86 monthly review meetings held at block level PHCs and 4 review meetings at district
Waste Bins outside Labor room, DH Motihari
19
level under district magistrate and 12 meeting by CMO in 2012-13. However, it seems there is
no impact of these meeting on programme performance at block level. These reviews should
also consider including disease control progammes such as TB, leprosy and blindness control.
The performance of disease control programmes also poor in the district.
9. 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. East Champaran is one among the piloted district in
Bihar during 2012-13. The main activities under NPCDCS is screening for diabetes and
hypertension at block level PHCs. The program has provided 598000 glucostrips to PHCs for
screening of diabetes and the NPCDCS program utilizes available PHC staff to screen diabetes
and hypertension. However, there is no additional staff at PHC level to screen under the
programme. Estimated population of 35 years and above calculated based on Census 2011 for
Bihar state. The programme envisages to screen 35 years and above for diabetes and
hypertension. Only 4.5% of total estimated population were screened in the district. Of
screened, 13.7% were suspected for diabetes and 7.4% for hypertension in the district. The
below graph provides NPCDCS performance from April 2012 to March 2013.
Graph 10 Performance of NPCDCS – East Champaran
4825
8853
64539
1443535
0 400000 800000 1200000 1600000
Hypertension (>90)
No of Suspected for Diabetes (>140)
No of Persons Screened
Total Population to be screened (>35years)
NPCDCS performance from April 2012 to March 2013- East Champaran
20
10. Disease control programme
10.1 Revised National Tuberculosis Control Prgramme (RNTCP)
East Champaran district has 9 Treatment
Units (TUs), 26 Designated Microscopic
Centers (DMCs) with 8 Senior Treatment
Supervisor (STSs) and 6 Senior 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, diagnosis and
treatment. District has various administrative
and operational problems associated with
RNTCP programme, which revealed during interaction with District TB Officer (DTO).
Pediatric TB medicine not available at district but available at state level. RNTCP programme
suspected 41 Multi Drug Resistant (MDR) cases in the district, of them 24 sent for bacteria
culture and 14 confirmed as MDR as of March 2013.
There is no supply of disposable gloves and masks in visited DMCs. It is observed that there is
no referral linkages for TB suspect in the field, only OPD cases were screened in the DMCs.
Need for reorientation of LT training as per RNTCP modules and many of the LTs do not have
information on referral of suspected MDR cases 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 that it has achieved only 60% of the total NSP cases per annum
as per estimated district population.
Graph 11 Quarterly Performance of RNTCP 2012-13 – East Champaran
0
200
400
600
800
1000
1st Qtr 12 2nd Qtr 12 3rd Qtr 12 4th Qtr 12
784 805 655 648
474 454 365 374
Performance of RNTCP 2012-13 East Champaran
Total Cases NSP cases
21
10.2 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. In East Champaran, the District Leprosy Officer (DLO) was hired on contractual basis
and there is no adequate staff for leprosy detection at PHC level. There is no skin smear test
available in any health facility and almost all cases were detected based on nerve and skin
patches. In PHC, Turkoulia 4 leprosy cases detected in March 2013, out of them 1 MB and 3 PB
cases that consist of 1 male and 3 female. In PHC cum RH, Chakia, detected 10 leprosy cases
with 4 PB and 6 MB without any disabilities. However, these health facilities do not have
capacity to treat disabilities and they refer to Leprosy Mission in Muzaffarpur nearby district.
22
Annexure: A
Facilities visited – East Champaran, Bihar
Sl. No. Date Facility visited Block Persons interacted
1 09.04.2013 PHC, Turkoulia Turkoulia
1. Dr. Ravi Shankar,
MOIC
2. Ayushi Verma, BHM
3. Deepak Kumar, BCM
4. Ashok Poddar, BAM
2 09.04.2013
Health Sub
Centre,
Purushothampur
Turkoulia
1. Manorama Kumari,
ANM
2. Sunitha Devi, ASHA
3 09.04.2013 Health Sub
Centre, Patkoulia Sadar
1. Bharati Bal Rai, 1st
ANM
2. Lalitha K Sinha, 2nd
ANM
3. Nilima, ASHA
4 10.04.2013 PHC cum RH,
Chakia Chakia
1. Dr. Arshad Ayub,
MOIC
2. Dr. Md. Parveez, MO
3. Anil Kumar, BHM
4. Gajnafer Alam, DCM
5. Shalu, LT (RNTCP)
6. Manoj Kumar, STS
(RNTCP)
7. Suresh Pandit, NMA,
NLEP
8. Raj Kumar, Data
Oper.
5 10.04.2013 APHC, Pipra Chakia
6 10.04.2013 PHC, Mehasi Mehasi
1. Dr. Omprakash,
MOIC
2. Dr. Uday Ban Sing,
MO
3. Brijkishor Singh,
BCM
4. Sunitha Kumari, LT
(RNTCP)
5. Mohan Singh,
Counselor (BSACS)
7 10.04.2013
Health Sub
Centre,
Baragobind
Mehasi
8 10.04.2013 Nutritional Chekia 1. Counselor
23
Rehabilitation
Centre (NRC),
Chekia
2. Food Demonstrator
9 11.04.2013 Sadar Hospital,
Motihari Sadar
1. Saroj Singh, CS
2.
10 11.04.2013 NPCDCs Project Sadar 1. Dr. Omprakash, DPO
2. Murthunjay, PA
11 11.04.2013 ICTC, Motihari Sadar 1. LT
2. Counselor
12 11.04.2013 DTO, Motihari Sadar 1. DTO
2. Programme manager