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Evaluation of Programme Implementation Plan (PIP) under NRHM in Begusarai and Sitamarhi districts in Bihar State Study Team Dilip Kumar U. K. Sahay Kishor Kumar (A collaborative study by PRC, Patna and RET, MoHFW, GoI, Patna Office) Population Research Centre

48436827Evaluation of PIP Under NRHM in Bihar State (Phase 2)

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Page 1: 48436827Evaluation of PIP Under NRHM in Bihar State (Phase 2)

Evaluation of Programme Implementation Plan (PIP) under NRHM in Begusarai and Sitamarhi districts in Bihar State

Study Team

Dilip KumarU. K. Sahay

Kishor Kumar

(A collaborative study by PRC, Patna and RET, MoHFW, GoI, Patna Office)

Population Research CentreDepartment of Statistics

Patna UniversityPatna-800005

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Executive Summary

It is the rapid evaluation of the PPI of National Rural Health Mission (NRHM). As suggested, a collaborative team of trained technical staff of the Center along with the members of Research and Evaluation Team (RET) of Regional Office of Health and Family Welfare (GoI), Patna had visited in the selected districts to interview the health functionaries in the district hospital, PHCs and Health Sub Centers (HSCs) to assess the availability of infrastructure facilities etc. The framed schedules were used for collection of information from the State Health Society at state level, selected districts level and PHCs and HSCs level during 18 th Oct. 2012 to 23rd Oct. 2012 in Begusarai district and 8th Nov. 2012 to 12th Nov. 2012 in Sitamarhi district of Bihar State.

I. Status of NRHM Interventions at the State level in Bihar: The Existing facility of PHCs (APHCs) is 1243. Further requirement is of 1544 PHCs (APHCs). Most of the quarters of existing APHCs are damaged. Good number of existing APHCs is without quarter. Most of the HSCs are not in good condition and require the renovation and new construction.

JBSY is not about promoting institutional deliveries alone. The key challenge for JBSY programme in Bihar is that the full potential of JBSY in terms of provision of essential newborn care and post partum family planning counseling is yet to be realized. State wide system for improving reporting of maternal deaths is planned for the effective implementation.

There is inability of the programme to alter fertility preferences of eligible couples through effective behavior change communication (BCC) in most of the districts.

The Toll free number 102 and 108 were launched and are running in all the six regional headquarters successfully.

State has accepted HMIS as one source of data for monitoring as well as the basis for planning. The strategy has dramatically improved the data quality in the state and civil surgeons are made accountable for the data uploaded in HMIS. The waste management operation is in the districts through PPP.

II. Situational Analysis in Begusarai district: The district hospital is functioning from the own building. The new born care corner is functioning in the hospital. The Bakhri PHC is also functioning from the own building. The Teghra PHC is also functioning from the own building. Some of the essentials items like disposable delivery kit, emergency contraceptive pills and other essential drugs are lacking in the selected HSCs of the Bakhri and Teghra PHCs.

There is no full strength of the medical officers in the district hospital and in the selected PHCs for the study. The public health facilities providing obstetric and gynecological care at district and PHCs levels are inadequate. The OT and its condition with OT table are not good in the selected PHCs. There is shortage of gynecologists and obstetricians to provide maternal health services at PHC level. There is an inadequate skilled birth attendant also to assist in home-based deliveries. There is weak referral network for emergency medical and obstetric care services.

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There is inadequate supply of all of the drugs except IFA, OPs, IUD 380, ORS packets and Vitamin A in the selected PHCs.

At the district level, there was training on the IUCD 380A providers. The strengthening of fixed day of IUCD services at various facilities are lacking. There was no increased focus on IUCD services at the HSCs. The issues affecting the implementation of the Family Planning programme are due to inability of the programme to change fertility preferences of eligible couples through effective behavior change communication (BCC).

There was no access to information on Adolescent Reproductive & Sexual Health (ARSH) through services at District Hospital, PHCs & HSC level. There was no increase of awareness levels on adolescent health issues. There are no regular health camps at gram punchayat and village level.

There is a provision of incentive/ awards etc. to ANMs etc. (Muskaan Programme -Incentive to ASHA and ANM) in the district. This programme launched in October 2007. Under this programme ASHA, AWW and ANM hold meeting with Mahila Mandals in AWCs with objectives for more ANC and immunization coverage.

In Begusarai district, Rogi Kalyan Samitis has been formed in all health facilities till PHC level; registration of RKS has been completed. There is a provision of Janani Bal Suraksha Yojana Helpline in each block through Rogi Kalyan Samitis. There is a Hospital Management Committee/Rogi Kalyan Samiti at all PHCs and CHCs.

The district does not have any comprehensive BCC strategy. All the programme officers implement the BCC activity as per their respective programmes.

The District Health Society is not monitoring the progress and neither are the committees at the Block and Gram Panchayat levels. No Verbal Autopsies (Maternal, Neo-natal, Infant & Child Death audits) are carried out any levels.

Data validation and computerized data availability up to PHCs with district linkages. The Data Centers are available in the hospital, Sub-Divisional Hospital & PHC etc. The Data Centers contain one computer with UPS, printer, phone connection, Internet connection, Computer operator, Misc. etc.

The District Health Officer is the Nodal Person in the district for ensuring the proper disposal of Biomedical Waste.

III. Situational Analysis in Sitamarhi district: The district hospital has its own good building. It has the facilities of the labour room, laboratory, OPD room; JSY maintained records, piped water supply and etc. The new born care corner was available in the hospital.

The Belsand PHC is functioning from the own building with the facilities of labour room, laboratory, OPD room but irregular electric supply with having the generator facility. The quarters of Medical Officers and other paramedical staff were not in good conditions which need immediate repairing. The Belsand PHC has the facilities of functional new born care corner (NBCC).

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The Nanpur PHC is also functioning from the its own dilapidated condition of building which needs immediate thorough repairing with having no facilities of labour room as such the patients are referred in district hospital etc., irregular supply of electricity with having no generator facility, poor facility of water supply but having the OPD on regular basis. It has no facilities of new born care corner (NBCC) etc. The cleanliness of OPD room, other room/ward and premises was not proper.

There is no full strength of the medical officers in Sitamarhi district hospital and the selected two PHCs namely; Belsand and Nanpur.

There is a lack of some of the equipments like; sterilizer, haemoglobinometer, mucus extractor, fetoscope, IUD insertion kit etc. in the selected HSCs of the Sitamarhi district.

C- Section deliveries are not conducted in institution. The public health facilities providing obstetric and gynecological care at district and PHCs level are inadequate.

There is lack of regular supply of essential items such as disposable gloves, bandages, IFA tablets, Iron syrup, Oral Pills, IUD insertion kit in the selected PHCs. Reporting of home delivery is not done so the PNC is not provided.

There is inadequate training to ANMs on operating baby warmer machines. It lacks inter-personal communication by health and nutrition functionaries during the fixed health & Nutrition days. The district hospital has not introduced Cu IUCD 375 at other facilities. There is no training programme for adolescent particularly health and sex. There is lack of awareness in the community about the importance of Zinc& ORS through various BCC & Social Mobilization activities. No Verbal Autopsies (Maternal, Neo-natal, Infant & Child Death audits) are carried out at the PHC level.

Computers have been supplied up to the PHCs. The HMIS software is developed by health department on their Web Portal and monthly reports are sending through the software. The District Health Officer is the Nodal Person in the district for ensuring the proper disposal of biomedical waste. Proper supervision is lacking.

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Evaluation of Programme Implementation Plan (PIP) under NRHM in Begusarai and Sitamarhi districts in Bihar State

Background

At the instance of Ministry of Health and Family Welfare, Government of India, New Delhi our Centre has undertaken the study on the evaluation of PIP under NRHM in Bihar State on urgent basis. It is the rapid evaluation of the National Rural Health Mission (NRHM). The NRHM was launched by the Govt. of India in April 2005 with the aim of providing equitable, affordable and quality health care services to the vulnerable sections of the population, particularly among the poor, women and children residing in rural areas.

As suggested, a collaborative team of trained technical staff of the Center along with the members of Research and Evaluation Team (RET) of Regional Office of Health and Family Welfare (GOI), Patna had visited in the selected districts to interview the health functionaries in the district hospital, PHCs and Health Sub Centers (HSCs) to assess the availability of infrastructure facilities etc. The framed schedules were used for collection of information from the State Health Society at state level, selected districts level and PHCs and HSCs level. All of the information collected at the field level was during the period of 18 th Oct. to 12th Nov. 2012, apart from observational analysis etc.

List of PHCs and HSCs covered in the selected districts of Bihar StateName of State Name of District Name of PHC Name of HSCBihar 1. Begusarai 1. Bakhri 1. Ratan

2. Lawchhe2. Teghra 1. Barauli

2. Pidauli2. Sitamarhi 1. Belsand 1. Patahi

2. Garhwa Sukhi2. Nanpur 1. Janipur

2. Bela

Results

I. Status of NRHM Interventions at the State level in Bihar: Here we discuss about the status of health infrastructure, facility up gradation under NRHM and availability of Human Resources, Rogi Kalyan Samiti (RKS) and assessment of health and family welfare situation etc. at the state level.

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1. Infrastructure

The Existing facility of PHCs (APHCs) is 1243. Further requirement is of 1544 PHCs (APHCs). Most of the quarters of existing APHCs are damaged. Good number of existing APHCs is without quarter. There are 533 existing PHCs and 8858 Sub Centres in the state. Primary health Centres (PHCs) are reported to be working as 24x7. Focus on 24-hour institutional delivery with basic emergency care in all PHCs and referral of obstetric emergencies care.

Most of the HSCs are not in good condition and require the renovation and new construction.

2. Maternal health

There are three minimal essential services on a 24X7 basis like; safe delivery services, emergency newborn care and referral transport. 24 x 7 Health Services is available in 533 Primary Health Centres, 29 SDHs and 36 DHs of the State. The total no. of institutional delivery has increased from 45000 in the year 2005-06 to 1074996 in 2010-11 (fig till Dec 2011). On an Average 80-90 thousand Institutional deliveries are taking place every month.

JBSY has resulted in increased number of deliveries at the institutes (approximately 12 lakhs) and there is increased perceived need to provide PPFP services to these eligible females before they leave institution. JBSY is not about promoting institutional deliveries alone. Programme objectives for reduction of maternal mortality and morbidity will be achieved when women coming to facilities receive quality delivery and post partum care services. In the absence of corresponding inputs for human resources, additional labour rooms and post natal beds, drugs and other supplies, quality of services, etc. have been a major casualty.

Maternal Death Audit has been initiated across the State wherein verbal autopsy is conducted, data analyzed and shared. State wide system for improving reporting of maternal deaths is planned.

3. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and etc.

Training of EmOC, Life Saving Anesthesia Training, IMNCI, ASHA, HMIS, DPMUs, BPMUs, SBA training, Immunization and Neonatal resuscitation started. This includes the regular monitoring and corrective actions taken.

As reported, newborns in the State receive home visits through IMNCI trained worker. Trainings are being regularly conducted under different programmes in the state. The state has already initiated trainings of IMNCI. Integrated Management of Neonatal Care Initiative (IMNCI) is being implemented in 24 districts and nearly 60% newborns are visited within 24 hrs by the trained worker. The State is trying to operationalise 22 ANM schools in full fledged manner.

4. Village Health & Nutrition Day (VHND)

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VHND every Wednesday is being organized in all of the districts where ASHA worker and ANM and AWW mobilize the beneficiaries for MCH services and the community participation. The Sarpanch and Mahila member of Gram Panchayat are encouraged to attend VHND.

5. Family Planning

The State Co-ordination Committee has adopted the procedures of District-level committees to submit quarterly reports in the prescribed formats to the state committee regarding the performance of family planning programme. It gives the direction on the implementation of measures for improving the quality of maternal, neonatal, child health and family planning (including sterilization services) in the state.

The key challenge for JBSY programme in Bihar is that the full potential of JBSY in terms of provision of essential newborn care and post partum family planning counseling is yet to be realized.

6. Adolescent Reproductive & Sexual Health

Bihar has one of the highest rates of early marriage (69% among women aged 20-24 years) and high rate of childbearing, and a very high rate of iron-deficiency anemia. Specific capacity building initiatives to orient the health providers at various levels to specific necessities of the ARSH program like adolescent vulnerability to RTI/STI/HIV /AIDS, communication with adolescents, gender related issues, designing adolescent friendly health services, body and fertility awareness, contraceptive needs etc. have not been actively taken up.

7. Vulnerable Groups Health Camps in Maha-Dalit Tola

Health Camps are being organized for health check-ups for school children. About 2131139 children have under gone health check up through 23744 health camps till Nov’ 2011.

Health Camps and other health related activities / functions would be organized in state and each district from time to time to expand reach of different programmes. In all the programmes efforts it is being considered the needs of vulnerable groups and ensure equity.

8. PNDT Act

The state of Bihar is implementing the PC- PNDT Act at right earnest. The CivilSurgeons are the nodal person in the district in this regard. However, it is reported that the monitoring of the activity is still a big problem.

9. MUSKAAN Programme

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The ICDS has been taken care of to cover immunization and ANC Service. ASHA, AWW and ANMs together hold monthly meetings with Mahila Mandals under

MUSKAAN Programme. The state has started a New Programme called MUSKAAN Programme to track pregnant women and NewBorn Child. Under this programme ASHA, AWW and ANMs jointly track the pregnant mothers and NewBorn Child. This programme launched in October 2007. Under this programme ASHA, AWW and ANM hold meeting with Mahila Mandals in AWCs. The main objective is to cover ANC coverage and Immunization. As reported, after the introduction of this programme it has been seen that the coverage of ANC and Immunization has been increased.

10. Rogi Kalyan Samiti (RKS)

Rogi Kalyan Samitis at PHC, CHC, Sub Divisional Hospitals, District Hospitals and Medical Colleges have been set up. Many health facilities have improved their infrastructure and logistics availability due to proactive RKS.

11. ASHA Training etc.

ASHA’s training is weak. Thirty six of Bihar’s districts are in the category of backward districts in the country. One round of ASHA training was conducted four years ago, and covered the topics under the national Module 1. To expedite training, Modules 2, 3, and 4 have been clubbed and a combined ten day training. ASHA training has been outsourced to PRANJAL, a set up by the Public Health and Engineering Department. With little experience in community based health interventions and limited coordination with state and district health structures, the ASHA training component lags behind the other states. The state now has established an ASHA Resource Center (ARC) to ensure the training, monitoring and supervisory functions related to ASHA and other community processes are effectively coordinated, of high quality and move at a more rapid pace.

12. Behavior Change Communication (BCC)

There is inability of the programme to alter fertility preferences of eligible couples through effective behavior change communication (BCC) in most of the districts. Mass media is now covering the entire state; mid-media and inter-personal communication also covers the districts. There is a need to involve ICDS and PRI networks in behavior change communication for immunization.

13. Convergence/Coordination

Convergence with ICDS has been taken care of to cover immunization and ANC Service. ASHA, AWW and ANMs together hold monthly meetings with Mahila Mandals under MUSKAAN Programme. Government of Bihar has decided to merge “Village Health and Sanitation Committee” with “Lok Swasthya Pariwar Kalyan and Gramin Swaschata Samiti” constituted by Department of Panchayat Raj in Bihar. The PHED has been entrusted to train ASHAs as per GOI norm. Adolescent councilors are placed in each district from State AIDS Control Society. The Health department is

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looking to cooperate with them by giving training to these councilors for implementing ARSH programme.

14. PPP Initiatives

This year the various PPP initiatives introduced earlier are re-focus upon for ensuring quality services and better partnership. The Toll free number 102 and 108 were launched and are running in all the six regional headquarters successfully. Under this scheme Ambulance for emergency transport is being provided in all the districts of Bihar. The empanelled ambulance & ambulance available in Govt. institutions are made available on receipt of calls from the beneficiaries. This service has been outsourced to a private agency for operationalisation. The telephone charges for the free toll free number is paid to BSNL by SHSB. The amount required would be for payment of incoming calls received from the beneficiaries.

15. Monitoring and Evaluation

There is poor monitoring and evaluation framework – regular monitoring visits by programme officers. However, a triangulated process of Monitoring and Evaluation was introduced which aimed to enable cross checking and easy collection, entry, retrieval and analysis of data. Need of placement of trained people at such facilities where infrastructure is in place. The government has taken up on priority the placement of the trained doctors to the FRUs where there is no such facility.

16. HMIS Supportive Supervision, Data Validation & Reports

State has accepted HMIS as one source of data for monitoring as well as the basis for planning. The strategy has dramatically improved the data quality in the state and civil surgeons are made accountable for the data uploaded in HMIS. District as well as Block level Capacity Building Workshop (HMIS Training) in the year FY- 2009-10 on Revised HMIS Reporting Formats and Web Portals of NRHM and NHSRC has been completed with the help of resource persons from National Health System Resource Centre (NHSRC), New Delhi for District M & E Officer, District Programme Manager, DS of District/Sub Div. Hospital, MOIC, BHM and BAM but training on HMIS is the continuous process for quality movement. HMIS has been strengthened right till the HSC level and daily reporting from nearly 100% of the blocks is being ensured through the Monitoring and Evaluation Officers. For successful completion of HMIS training for ANMs, LHVs and Data Centre Operators at block level, a HMIS resource Pool was constituted at the State level through standard procedures of selection. A three days residential training for these resource pool members was organized in two batches. These resource pool members have actively facilitated in the block level trainings and also supported the existing team of trainers at the block level. Representatives of ROHFW, Patna and PRC, Patna have also participated in the three days residential training of HMIS Resource Pool members.

17. Bio Medical Waste Management

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The state has started a CWTF facility at Indira Gandhi Institute of Medical Sciences, Patna (autonomous institute). The facility has been approached for undertaking waste treatment for all PHCs to DHs in all the six districts of Patna division. Services have already been initiated in all these districts. The GoI has issued the IMEP guidelines for HSCs, PHCs and CHCs, proper dissemination of the bio medical waste has to be ensured through a technical agency. The state has identified agencies for undertaking the task of Bio-Waste Management and Treatment. Necessary approval and clearance from Bihar State Pollution Control Board has also been received. The waste management operation is in the districts through PPP. The state has outsourced the Biomedical Waste Management system for all the Government hospitals.

II. Situational Analysis in Begusarai district

1. Infrastructure

The district hospital is functioning from the own building. It has the basic facilities having the telephone, computer with internet. The new born care corner is functioning in the hospital. The cleanliness of labour room, ward, compound and the premises was reported to be fair.

The Bakhri PHC is also functioning from the own building. There is the availability of the facilities of labour room, laboratory, OPD room, regular electric supply having generator facility also. This PHC has also facilities of telephone, computer with internet. The Bakhari PHC has also the facility of new born care corner (NBCC). The cleanliness of OPD room, other room/ward, compound and premises was reported to be good. However, some of the essentials items like disposable delivery kit, emergency contraceptive pills and other essential drugs are lacking in both of the selected HSCs in the Bakhri PHC.

The Teghra PHC is also functioning from the own building. It has the facilities of labour room, OPD room, laboratory and the electric supply with having the generator facility. This PHC has also facilities of telephone, computer with internet connectivity. It has the facilities of new born care corner units. The cleanliness of room/ward was fair and the cleanliness of compound and premises was reported to be good. However, some of the essentials items like disposable delivery kit, emergency contraceptive pills, IFA tablets and other essential drugs are lacking in both of the selected HSCs in the Teghra PHC.

2. Maternal Health

There is no full strength of the medical officers in the district hospital and in the selected PHCs for the study. There are shortage of skilled health personnel (Nurses) and other paramedical staff to provide timely and quality ANC and PNC services at the district hospital and in the selected PHCs (Bakhri and Teghra). The HSCs have the working one ANM and 7-9 ASHAs in selected two HSCs from each of the PHC. The sanctioned one post of male health worker is vacant in all of the selected HSCs.

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The public health facilities providing obstetric and gynecological care at district and PHCs levels are inadequate.

There is lack of regular supply of essential items such as disposable gloves, weighing and height measuring scales, safe delivery kits, etc. at the PHC level and HSC level. The OT and its condition with OT table are not good in the selected PHCs.

There is shortage of gynecologists and obstetricians to provide maternal health services at PHC level. There is an inadequate skilled birth attendant to assist in home-based deliveries. There is weak referral network for emergency medical and obstetric care services. There is lack of knowledge about antenatal, perinatal and post natal care among the community especially in rural areas in the selected PHCs.

There is inadequate supply of all of the drugs except IFA, OPs, IUD 380, ORS packets and Vitamin A in the selected PHCs. It ultimately affects the supply of drugs also at the HSCs level. There is lack of knowledge of basic child health care practices among the community. There is failure to generate community awareness regarding essential sanitation and hygiene practices that impact on the health of children.

3. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and etc.

Training of personnel like; pre service IMNCI training, safe abortion methods, skill birth attendant training and new born care unit are lacking among the health functionaries in the district. There is inadequate monitoring of this activity at field level. Most of the ASHAs are not trained on IMNCI. There is inadequate training to ANMs on operating baby warmer machines. ANMs can not recognize early sign and symptoms of illness of new born babies. There is no fixed day in a week for IMNCI related work at HSC level. All the selected health Centres have the facilities of immunization of the children.

4. Village Health Sanitation & Nutrition Day

Under the NRHM, the Village Health and Nutrition Day is planned to provide comprehensive Maternal and Child health and nutrition and sanitation services, and ensure early registration, identification and referral of high risk children and pregnant women. The VHSND is to be organized once every month (preferably on Wednesdays and for those villages that have been left out, on any other day of the same month) at the AWC in the village. This ensures uniformity in organizing the VHSND. The VHSND is not being conducted on regular basis and the maintenance of records for such is poor.

5. Family Planning

At the district level, there was training on the IUCD 380A providers. The strengthening of fixed day of IUCD services at various facilities are lacking. There was no increased

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focus on IUCD services at the HSCs. There was no inclusion of Cu IUCD 375 in the health centres During FY 2010-11, 1274 persons were trained on Minilap as a type of sterilization method. However, there was no training on the Lap and NSV methods for sterilization. The insertion of IUD at the HSCs level is poor. The issues affecting the implementation of the Family Planning programme are due to inability of the programme to change fertility preferences of eligible couples through effective behavior change communication (BCC). Some of the other reasons for such are over emphasis on permanent family planning methods such as, sterilization ignoring other reversible birth spacing methods that may be more acceptable to certain communities and age groups.

6. Adolescent Reproductive & Sexual Health

There was no access to information on Adolescent Reproductive & Sexual Health (ARSH) through services at District Hospital, PHCs & HSC level. There was no increase of awareness levels on adolescent health issues.

7. Vulnerable Groups Health Camps

There are no regular health camps at gram punchayat and village level. Improved health care system in existing health institutions are lacking. As such, there is low water, sanitation and hygienic condition among the villagers.

8. PNDT Act

There is a provision of quarterly review meeting and district level orientation with IMA people, MOIC, NGO, ultrasound clinic as the Beti Bachao Abhiyaan – As female foeticide is a concern both in rural and urban areas. Human Chain, rallies, seminars, workshops and press conferences will be organized for the same in FY 2012-13.

9. MUSKAAN Programme

There is a provision of Incentive/ Awards etc. to ANMs etc. (Muskaan Programme -Incentive to ASHA and ANM) in the district. This programme launched in October 2007. Under this programme ASHA, AWW and ANM hold meeting with Mahila Mandals in AWCs with objectives for more ANC and immunization coverage. As reported, after the introduction of this programme it has been seen that the coverage of ANC and immunization has been increased. As reported about 2337 ASHA @ Rs. 200 per session (Maximum) and 726 ANM @ Rs. 150.00 per session (Max.) would be benefited to enhance this programme.

10. Rogi Kalyan Samiti (RKS)

There is a provision of transfer of funds, functions and functionaries to Panchayati Raj Institutions (PRIs) and also greater engagement of Rogi Kalyan Samiti (RKS). In Begusarai district, Rogi Kalyan Samitis has been formed in all health facilities till PHC

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level; registration of RKS has been completed. There is a provision of Janani Bal Suraksha Yojana Helpline in each block through Rogi Kalyan Samitis There is a Hospital Management Committee/Rogi Kalyan Samiti at all PHCs and CHCs.

11. ASHA Training etc.

The ASHA candidates were trained in all preventive healthcare aspects of pregnancy, antenatal care, intranatal care, postnatal care, neonatal care, diarrhoea, acute respiratory infections, first-aid and treatment of minor ailments, in a four-week training program. This training was conducted at Durgabai Mahila Sishu Vikasa Kendram in coordination with Women & Child Welfare department. The overall organization, monitoring and coordination of the ASHA training has been entrusted to M/s Academy for Nursing Studies, Hyderabad as a State Level Nodal Agency for guidance and supervision and district level training agency in 23 districts. The ASHA days are also celebrated at the PHC level.

12. Behavior Change Communication (BCC)

The district does not have any comprehensive BCC strategy. All the programme officers implement the BCC activity as per their respective programmes.

The IEC logistic is designed, developed and procured at the district level and distributed to the PHC in an adhoc manner. However, some activity is done at the state level. There is no credible study available to identify the areas / region specific knowledge, attitudes and practices pertaining to various focus areas of interventions like breast feeding, community & family practice regarding handling of infants, ARSH issues etc. At present there is no impact assessment of the IEC and BCC activities at the PHCs and HSCs level. It is very important to assess the impact of IEC/BCC activities, resources and methods to undertake mid way corrective measures.

13. Convergence/Coordination

The PRIs have been envisaged to play a very important role in NRHM. At the village level they are motivating the community. There is availability of personnel and joint review and monitoring. At the Gram Panchayat level they are part of the Gram Panchayat health committee. Similarly at the Block and the District they are part of the Block and District health mission.

14. PPP Initiatives

Operationalisation of Mobile Medical Unit in district is under progress .This project is undertaken under PPP. SHS, Bihar used to finalize firm and rate for the project. Private Service Providers are providing mobile health care services in rural Bihar of curative, preventive and rehabilitative in nature. At present, mobile clinic is also working in the selected PHCs with the limited scope of the facilities of medicine, oxygen cylinder, one trained manpower with stretcher facility for carrying the patient of BPL on free of cost basis from his residence to the PHC.

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15. Monitoring and Evaluation

Monitoring is an important aspect of the programme but it is not happening effectively and regularly. Each officer and the MOIC, MO, BHM at PHCs are supposed to make regular visits and monitor the progress and check on the activities and also the data provided by the ANMs. The reports have to be submitted and discussed in the monthly review meetings at the entire forum. The District Health Society is not monitoring the progress and neither are the committees at the Block and Gram Panchayat levels. No proper Check-lists exist for monitoring. Also analysis is not done of the visits and any data collected. No Verbal Autopsies (Maternal, Neo-natal, Infant & Child Death audits) are carried out any levels. The Role & Functioning of the Sub centre level Committee, PHC level Committee, RKS at PHC and VLC need to be clearly defined. There is no system of concurrent Evaluation by independent agencies so that the district officials are aware regarding the progress.

16. HMIS Supportive Supervision, Data Validation & Reports

Data validation and computerized data availability up to PHCs with district linkages. The Data Centers are available in the hospital, Sub-Divisional Hospital & PHC etc. The main purpose of these Data Centers of Hospitals is to gather and maintain health related data under RCH/NRHM programme in their computer system and they upload the gathered health related data on the web-server of SHSB on daily basis. The Data Centers contain one computer with UPS, printer, phone connection, Internet connection, Computer operator, Misc. etc. The mobile sets have been given to each and every data centers. To capacitate the effective delivery of the programme there is a need of proper HMIS system so that regular monitoring, timely review of the NRHM activities should be carried out. The quality of MIES in the district is in progress. Reporting and recording of RCH formats (Plan and monthly reporting) are regular keeping in view of complete and consistent information. The ANM are trained at the HSC level and reporting on the formats on 2nd day of each of the months. Formats are getting filled up completely at the sub center level and reported to the concerned PHC. There information is properly reviewed at the PHC level. Feedback is provided upon that information. From the PHC level the collated data information of each of the HSCs supplied on the web portal. For overall management of the programme, there is a Mission Directorate and a State Programme Management Unit in the state. .At district level, there is a District Health Society who is responsible for the data dissemination from the sub-district level to the district level. District M & E Officer at the district level and Accountant cum M& E Officer at block level are responsible for management of HMIS. As such, there is a Monitoring Team constituted district level as well as block level to monitor the implementation of the NRHM activities.

17. Bio Medical Waste Management

There is provision of services of hospital waste treatment and disposal of Bio-Medical Waste Management in all govt. health facility up to PHC. As per the Bio-Medical Waste Rules, 1998, indiscriminate disposal of hospital waste was to be stopped with handling of Waste without any adverse effects on the health and environment. In

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response to this the Government has taken steps to ensure the proper disposal of biomedical waste from all Nursing homes, hospitals, pathological labs and blood banks. The District Health Officer is the Nodal Person in the district for ensuring the proper disposal of Biomedical Waste. However, proper supervision is lacking and used to burn the waste material in the open space and buried some of the waste outside the campus of the health centre.

III. Situational Analysis in Sitamarhi district

1. Infrastructure

The district hospital has its own good building. It is the 100 beds hospital. It has the facilities of the labour room, laboratory, OPD room; JSY maintained records, piped water supply and etc. Some of the gadgets like; telephone, computer and internet are also available in the working condition. The new born care corner was available in the hospital. The cleanliness of room/ward, compound and the premises was reported to be fair.

The Belsand PHC is functioning from the own building with the facilities of labour room, laboratory, OPD room but irregular electric supply with having the generator facility. The quarters of Medical Officers and other paramedical staff were not in good conditions which need immediate repairing. This PHC has the facilities of telephone, computer with poor internet connectivity. The Belsand PHC has the facilities of functional new born care corner (NBCC). The cleanliness of OPD room, other room/ward, compound and premises was reported to be good.

The Nanpur PHC is also functioning from the its own dilapidated condition of building which needs immediate thorough repairing with having no facilities of labour room as such the patients are referred in district hospital etc., irregular supply of electricity with having no generator facility, poor facility of water supply but having the OPD on regular basis. This PHC has availability of telephone and one functional computer with poor internet connectivity. It has no facilities of new born care corner (NBCC) etc. There is non-availability of the suggestion/complaint box. The cleanliness of OPD room, other room/ward and premises was not proper. There was no compound wall of the Nanapur PHC.

2. Maternal Health

There is no full strength of the medical officers in Sitamarhi district hospital and the selected two PHCs namely; Belsand and Nanpur. There is shortage of skilled health personnel (Nurses) and other paramedical staff to provide timely and quality ANC and PNC services at the district hospital and in the selected PHCs (Belsand and Nanpur). The HSCs have the working two ANMs and the presence of ASHAs also reported from 2 to 9 in the selected HSCs. The sanctioned one post of male health worker is vacant in the selected HSCs except in Bela HSC.

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The x-ray machine is working on the hired basis in the district hospital. There is a lack of some of the equipments like; sterilizer, haemoglobinometer, mucus extractor, fetoscope, IUD insertion kit etc. in the selected HSCs of the Sitamarhi district.

C- Section deliveries are not conducted in institution. An infection control protocol is not at all maintained at all facilities. Reporting of maternal death is usually not reported by worker. The public health facilities providing obstetric and gynecological care at district and PHCs level are inadequate.

There is lack of regular supply of essential items such as disposable gloves, bandages, IFA tablets, Iron syrup, OPs, IUD insertion kit in the selected PHCs. Similarly, MVA syringe and other medicines were not available in the selected PHCs.

Home Delivery is still prevailing through untrained traditional Dai’s. Reporting of home delivery is not done so the PNC is not provided. There is an inadequate skilled birth attendant to assist in home-based deliveries.

There is weak referral network for emergency medical and obstetric care services. Complicated delivery cases are not being attained at any facilities. There is lack of knowledge of basic child health care practices among the community. There is failure to generate community awareness regarding essential sanitation and hygiene practices that impact on the health of children.

3. Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and etc.

The IMNCI activities have been initiated among the ANM in the district hospital. However, there is inadequate monitoring of this activity at field level. Most of the ANMs and ASHAs are not trained on IMNCI. There is inadequate training to ANMs on operating baby warmer machines. ANMs can not recognize early sign and symptoms of illness of new born babies. There is no fixed day in a week for IMNCI related work at HSC level. There is no awareness generation among mothers, families and community on IMNCI issue. The training of safe abortion methods was also missing at the HSC level. Only skill birth attendant training and new born care unit has successfully completed in the Belsand PHC. The facilities of regular immunization are reported to be available in all of the selected health Centres.

4. Maternal, Child Health and Nutrition Days

Fixed Maternal, Child Health and Nutrition Days (MCHN days) are being organized sometimes but the announcement of such days among the community was poor.

It lacks inter-personal communication by health and nutrition functionaries during the fixed health & Nutrition days. As reported, it is the need of developing instruction for holding Fixed Health & Nutrition days to be distributed to all MOs, ANMs and AWWS.

5. Family Planning

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There is no fixed day of IUCDs insertion at the facilities. However, there is increased focus on IUCD services at the PHCs and HSCs level. The district hospital has not introduced Cu IUCD 375 at other facilities. The steps have been taken up for strengthening Post-Partum IUCD (PPIUCD) services at the district hospital. None of the persons have been trained on the Minilap, Lap and NSV sterilization in the last financial year.

Some of the issues affecting the implementation of the Family Planning programme are reported to be over emphasis on permanent family planning methods such as, sterilization ignoring other reversible birth spacing methods that may be more acceptable to certain communities and age groups. Behavior change communication (BCC) is poor and there are no strong public-private partnerships, social marketing to promote and deliver family planning services.

6. Adolescent Reproductive & Sexual Health

There is no training programme for adolescent particularly health and sex. There are inadequate interventions for empowering adolescent girls in the district. AWCs are not equipped to promote activities for girl empowerment.

7. Untied Funds and Incentive Fund for the Village Level Committees

The PHC has the lack of capacity to use untied fund. It is also important to note that no Sub centre in the district has received untied funds. Always it is found that the stationary is lacking at the HSCs level. There is no Village Health & Water Sanitation Committee (VHWSC) in each of the villages. In Sitamarhi district these committees have been formed but need strengthening to improve their functioning. The selection of ASHA, her working, progress of the village is part of the responsibilities of the Gram Panchayat. There is poor coverage of identifying Socially Backward, Slums & Maha Dalit Tolas at the PHC level.

8. PNDT Act

There is strategy to enforce PNDT Act and to increase sex ratio of female child. Advisory committees have been constituted in Sitamarhi district and their meetings are not held periodically. The topics of PNDT Act, Gender issues and Declining Sex ratio have been included in RCH training for Medical Officers conducted at SIHFW, Patna.

9. MUSKAAN Programme

The state has initiated a New Programme called MUSKAAN Programme to track pregnant women and New Born Child. Under this programme ASHA, AWW and ANMs jointly track the pregnant mothers and NewBorn Child. Under this programme ASHA, AWW and ANM hold meeting with Mahila Mandals in AWCs. The main objective is to cover ANC coverage and Immunization. As reported, after the initiation

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of this programme, the coverage of ANC and Immunization has been enhanced. The ANM and ASHA are being given incentives for promotion of this programme.

10. Rogi Kalyan Samiti (RKS)

In Sitamarhi district, Rogi Kalyan Samiti (RKS) have been formed in the hospital and in the selected PHCs. The registration of RKS is completed. The meeting of the RKS was not held regularly on the basis of NRHM norm.

The formation of the RKS has resulted in satisfaction amongst the patients and also the staffs since now funds are available with the facilities to care for the people. No trainings have been given for the skill building of the incharges of these facilities. There is no standardized reporting format and information regarding these RKS is available. It is required to formation of Rogi Kalyan Samiti at all HSCs for better management of facilities.

11. ASHA Training etc.

Through the records/register, it was observed that the involvement of ASHAs in the institutional deliveries was not satisfactory due to the non-cooperation among the ANMs and ASHAs. Most of the ANMs know ANC but they were not acquainted with the activities of the PNC. In Sitamarhi, AWW/ASHA lacks training on the different kind of family planning methods and RTI/STI and HIV /AIDS.

12. Behavior Change Communication

There is lack of awareness in the community about the importance of Zinc& ORS through various BCC & Social Mobilization activities. There is a lack of IEC/BCC for awareness available RTI/STI services at all health facilities. As such, the district does not have any comprehensive BCC strategy. There is lack of awareness regarding the services, schemes including the Fixed Health days. The personnel have had no training on interpersonal communication.

13. Intersectoral Convergence/Coordination

The District Health Society has been formed consisting of members of various departments. Block health societies are formed and also at the sector, and village level. At the Gram Panchayat level under the Sarpanch Gram Panchayat committees have been formed consisting of various sectors. In order to deal with the critical cultural issues, that might be hampering the performance of child immunization indicators, convergence with PRI through gram panchayat, other influential members of the community and local NGOs/CBOs is considered significant. In reality these committees need to be strengthened since they are not functional. All the various sectors are working separately although for the same cause.

14. PPP Initiatives

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There is introduction of PPP Scheme to overcome shortfall of specialist at PHC level. There is only one mobile dispensary is available in Sitamarhi district hospital. But most of the time the vehicle is busy in some other activities. As per the NRHM guideline, there is no Mobile medical unit exists. At present, mobile clinic is also working in the selected PHCs with the limited scope of the facilities of medicine, oxygen cylinder, one trained manpower with stretcher facility for carrying the patient of BPL on free of cost payment basis from his residence to the PHC. It is proposed joint meeting of the District Health Society and the Swasthya Kalyan Samiti (SKS) to decide the appropriate modality for operationalization of the MMU, formation of a Monitoring Committee. As reported, the SKS will operate the MMU for long-term sustainability of the intervention and Staff will be hired on contract by the SKS.

15. Monitoring and Evaluation

Members of PRIs and MNGOs/ FNGOs and civil society groups are involved in the district health plan activities. Data validation and availability of computerized data is up to PHCs with district linkages. Monitoring is an important aspect of the programme but it is not happening effectively and regularly. The District has not monitoring the progress and neither are the committees at the Block and Gram Panchayat levels. It was reported that Medical Officers lack time to visit in the field to monitor various health activities. No proper check-lists exist for monitoring. Also analysis is not done of the visits and any data collected.

No Verbal Autopsies (Maternal, Neo-natal, Infant & Child Death audits) are carried out at the PHC level. There is no system of concurrent evaluation by independent agencies so that the district officials are not aware regarding the progress and the lacunae.

16. HMIS Supportive Supervision, Data Validation & Reports

Computers have been supplied up to the PHCs. The HMIS software is developed by health department on their Web Portal and monthly reports are sending through the software. The ANM are trained at the HSC level and reporting on the formats on 2nd

day of each of the months. Formats are getting filled up completely at the sub center level and reported to the concerned PHC. There information is properly reviewed at the PHC level for uploading on the web portal. Feedback is provided upon that information. For overall management of the programme, there is a Mission Directorate and a State Programme Management Unit in the state. .At district level, there is a District Health Society who is responsible for the data dissemination from the sub-district level to the district level. District M & E Officer at the district level and Accountant cum M& E Officer at block level are responsible for management of HMIS. As such, there is a Monitoring Team constituted district level as well as block level to monitor the implementation of the NRHM activities.

17. Bio Medical Waste Management

At present, the district hospital and the selected PHCs used to burn the waste material in the open space and buried some of the waste in the campus of the health centre. Biomedical waste management is not properly taken care off at all institution.

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The District Health Officer is the Nodal Person in the district for ensuring the proper disposal of biomedical waste. Trainings to the personnel for sensitizing them have been imparted. Pits have been dug. Proper supervision is lacking. The GoI has sanctioned a Plasma Pyrolysis Plant. Plasma Pyrolysis is a state-of-the-art technology for safe disposal of medical waste. Plasma Pyrolysis plant will soon be installed and training will be imparted to two persons from the district.

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