Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.

Qualitative Monitoring of PIP 2012-13 in Chhattisgarh Second Quarter Report July-September 2012

PRC, Sagar Team Dr. (Mrs.) Reena Basu, Assistant Director Dr. Nikhilesh Parchure, Research Investigator RET, RoHFW, Bhopal Team Mr. B. K. Minj, Technical Assistant

Population Research Centre

Department of General and Applied Geography Dr. H. S. Gour Central University Sagar (M.P.) 470003

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Contents
Executive Summary 1. 2. 3. 4. 5. Introduction Objectives Methodology . Data Collection . Key Observations 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 5.12 5.13 5.14 5.15 5.16 5.17 5.18 5.19 5.20 5.21 5.22 5.23 Programme Management Planning . Supportive Supervision Human Resource . Strengthening Services Procurement of Drugs and Equipments . Vehicles and Referral Transport . Mobile Medical Units . New Infrastructure .. AYUSH .. ASHA .. Urban RCH . Untied Funds . Maternal Health . Janani Shishu Suraksha Karyakram (JSSK) Janani Suraksha Yojana . Family Planning .. Child Health Adolescent Reproductive and Sexual Health and MHS .. HMIS / MCTS .... Maternal Dealth Review / Infant Death Review . Coordination . NGO/PPP/Civil Society/ Community Involvement . 1 2 2 2

3 5 5 6 9 10 11 11 11 12 13 13 14 14 15 16 16 17 18 18 18 19 19 20 21 21 22 22

6. Interaction with Beneficiaries .. 7. Financial Outlay .. 8. Mandatory Disclosures .. 9. Status of Key Conditionalities ... 10. Facilities visited in Jashpur District

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Quality Monitoring of PIP in Chhattisgarh - Second Quarter (July-September 2012) Executive Summary
To monitor the progress made by Chhattisgarh state in implementation of annual PIP and states adherence to the mutually agreed road map and conditionality, PRC Sagar selected Jashpur a high focus district of Chhattisgarh in the second quarter. Certain new dimensions have been included for monitoring during the second quarter like VHND, delivery points, training component, flow of budget and expenditure and issues focused upon in RKS meeting. For monitoring the District Hospital of Jashpur, 2 CHCs Bagicha and Lodam, 3 PHCs Sanna, Paiku and Aara and 4 Sub Centres Tatkela, Putri Choura, Neemgaon and Aara were selected and visited for study purposes. In C.G. a functional Programme Management Unit is in place at the state as well as in the districts. There is full time MD (NRHM) and Director (Finance) in the SMPU. New recruitments have taken place in the SPMU and DPMUs. State Training Coordinator, State Data Officer, 3 Sub-Engineers, 3 Programmers, and one Accountant have recently joined the SPMU. In Jashpur, DMPU is fully staffed but some of the posts in BPMUs are vacant. Programme Managers from Directorate Health Services CG are coordinating with state NRHM office for ARSH, Child Health, Urban Health, AYUSH programmes. Progress of VHND and Mitanin programme is being coordinated by the SHRC. For minimizing the regular vacancies of doctors the state has adopted a system of direct recruitment through which 85 MOs have been appointed recently. The new system is taken out of the purview of the state public service commission. Recruitment of medical officers is being done on quarterly basis. However, due to a number of reasons like remote area postings, non-availability of residence, security and lack of proper transfer policy for medical doctors only few of them are joining public services. There is a paucity of medical specialists too in the state. State has taken various steps to increase the intake of medical graduate for government service. Incentivisation such as CRMC (Chhattisgarh Rural Medical Core) has been fixed. Increase of MBBS seats is proposed after necessary expansion of medical college hospitals. Faculty recruitment is a big challenge for new medical colleges in remote areas. Even after offering higher salary, teaching faculty is unwilling to join medical colleges at

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

places like Jagdalpur. There is enough intake of paramedic staff, since Chhattisgarh has many paramedical training institutes. Vacancies in the GNTC and ANMTCs are being filled up after promotion of nursing cadre as tutors in these institutions. In the state there is an acute shortage of staff nurses, lab technicians, MPW male, LHVs, pharmacists, Ayush paramedics and cleaning staff. In all these categories many positions are vacant. Redeployment of EMOC and LSAS has been completed, and posting of RMAs is under progress for all the districts. Currently 1232 RMAs have been appointed of which 1048 RMAs are redeployed in different health facilities. The facility level HR on the web-site is a prerequisite for the mandatory disclosures. The state has been managing separate HR-MIS to provide staff position and vacancies in the state. The HR-MIS need simplification to provide facility level list of HR for both government and NRHM. A total picture of the serving /vacant positions designation wise is not available for the state as a whole. There is need of updation of this information on the web-portal. At Jashpur, an updated facility / designation wise list of existing manpower along with the vacancies is available. This needs to be updated on the HR-MIS. All 27 districts have prepared their District Health Action Plans. In all 27 districts, ROP has been issued and all districts have issued ROP for their respective blocks. Induction training for all new DPM, DTC, HC and BPM in the PMUs has been carried out. The state has prepared a training calendar for 2012-13. As per the training calendar 10/39 LSAS, 9/25 CEmONC, 44/223 BEmONC, 105/528 SBA 29/106 MTP, 142/386 RTI-STI persons have been trained in the state between April to September, 2012. Presently Durg District hospital is identified for SNCU training and Raipur medical college for training of trainers for FBNC. At Jashpur training planned for 2012-13 could not be initiated due to lack of training facilities. In Jashpur district this years training programme has yet to take off due to lack of infrastructure facilities for conducting the training. For routine training requirements of serving paramedic staffs, District Training Centres (DTC) are being revamped through a recent government directives. DTCs are now under the administrative control of SIHFW. District training coordinators (DTCs) are recruited recently. Review meeting of DTCs for their sensitization on health issues and their problems is being planned.

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

DH Jashpur, the only FRU in the district, has only 4 out of 12 posts of specialists filled up and 4 out of 16 posts of Medical Officers are vacant. A gynecologist is available but no pediatrician is in place. Out of the 58 posts of nursing staff and technicians 16 posts are vacant. In case of other supporting staff 15 out of 23 positions are vacant. In Jashpur about half of the sanctioned post of nursing and technician cadre is in position as on September2012. Procurement of equipments is being streamlined. All the civil surgeons have been asked to submit the list of equipments required for their hospitals by December2012 so as to process the demand for the next FY i.e. 2013-14 well in advance. No equipment audit has been conducted during the 2nd quarter. No MIS for logistics is implemented as of now. Whole procurement process is to be transferred to CGMSC. Commissioner (Health) has additional charges of MD, CGMSC. The state has planned the policy to provide uninterrupted supply of medicines free of cost to all OPD patients/Causality and Delivery cases. The latest EDL for DH, CH, CHC, PHC and SC has been formulated by the Directorate Health Services. The system of procurements of drugs, consumables for various health centres in the State is centralized and purchased through online tendering. District CMHO/CS of Jashpur is procuring the drugs as per requirement by tendering drugs as per EDL. In most of the facilities, shortage of essential medicines is reported. At the visited facilities it is observed that necessary medicines are purchased from untied grants. The state has also formulated an integrated policy for procurement of equipment. A state level committee is rationalizing the demands for different equipments received from the districts. The committee is also in the process of identifying suppliers to start the tendering process. The state has appointed 17 civil engineers for various districts. These engineers will be responsible for follow-up of execution, quality assurance, maintenance, planning new construction requirements etc. Various districts have provided inputs after need assessment. Based on Assam model an infrastructure wing is being planned for NRHM. Multi-agency dependency in carrying-out construction activities in the time-frame is creating hurdles for the task. The state has undertaken construction work by adding maternity wards, SNCUs, NBSU units, in different districts through state government and NRHM funds. Two consultancy agencies (HSCC and NBCC) have been contracted. To provide

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

security features and to save the space, duplex SHCs are being designed. One such duplex SHC is already constructed in Gidam block of Jagdalpur district. The state has identified 1044 functional delivery points 761 MCH L1, 214 MCH L2, MCH 69 L3 delivery points. Level 1 include SHCs and non 24*7 PHCs, level 2 include 24*7 PHCs and non FRU CHCs and the level 3 include FRU CHCs, CH and DH. However, full range of MCH services is available in identified delivery points i.e. 32 FRUs, 26 DH and 200 PHCs. Rationalization of functional delivery points are required to provide correct information on functional delivery points. In Jashpur, DH is the only MCH Level 3 facility, all the 8 CHCs are MCH Level 2, and about 59 SHCs and 27 PHCs as are functioning as MCH Level 1 delivery points. PHC-Paiku and PHC Sanna are 24x7 Level-1 delivery points. PHC-Paiku has been functioning from newly constructed building. PHC Sanna is functioning from old building. Logistics, infrastructure, manpower and referral linkages are insufficient at Sanna. JSSK a central scheme has been implemented by the state. Monitoring is done according to the currently prescribed monitoring and reporting formats on the basis of various JSSK components. District Jashpur has implemented free entitlements under JSSK. Drop-back facility is fully functional under JSSK. The district has contracted vehicles at the CHCs exclusively for JSSK. However, there is no call centre established for referral transport. Each vehicle under JSSK is running as stand alone transport facility. At CHC, Bagicha the vehicle is arranged from the public donation and running cost is borne by the JDS for poor patients. At CHC, Lodam the vehicle mainly provides drop-back service. There is a provision for free meals at the DH and CHCs. During field visits it was observed that both the CHCs have outsourced food arrangements. There is no fixed menu of meals under JSSK. At CHC Bagicha, the food arrangements are contracted to a restaurant. It was also observed during field visit that mothers are staying at the health facilities for less than 24 hours. The SHCs serving as delivery points do not provide free meals. As observed during field visit some delivery points especially the SHCs lack basic facilities like water, electricity and toilet. A referral transport system under PPP model GVK-EMRI is in place with 108 as toll free number in 172 facilities in the state. Three hundred mini ambulance have been sanctioned during 2012-13 as 102 Mahatari Express for referral transport from home to hospital and vice-versa. Request for proposal (RFP) for procurement of ambulance is

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

advertised. Currently 17 MMUs are functional in the state and 13 MMUs are expected to be deployed by 2nd week of November 2012. A total of 32 NBSUs are proposed of which 8 are planned for the year 2012-13 and 8 are functional. Out of a total of 285 proposed NBCCs in 2012-13, 71 are functional. The state has initiated the process of procurement of NBSU, NBCC equipments. It has circulated the guidelines and reporting formats of NBSU to districts. It has started collection of reports from functional facilities and has initiated feedback mechanism to districts based on analysis of data. Training on NSSK to staff posted at NBCCs has been initiated. SNCUs are in different stages of progress in 12 DHs. At present DH at Durg has a fully functional SNCU. In Jashpur, no SNCU has been established. District hospital and CHC Patthalgaon have NBSUs. All the other visited facilities are equipped with functional NBCC except PHC Sanna where NBCC is not functional due to limited space. The NSSK trained staffs is not placed in any of the visited facility except CHC Bagicha and PHC Sanna. A total of 39 Nutrition Rehabilitation Centers are operational in the state. Overall, 1822 SAM children received services between April-September 2012. The Sishu Surksha Mah is being implemented to improve coverage of child health services through an essential package including Vitamin A, deworming, IFA Supplementation and immunization. The main objective is to revitalize the health system through the periodic review of micro plans, coverage targets, achievements and line listing of beneficiaries and to engage communities in actively participating in child health activities. All 27 districts have completed two rounds of Immunization Weeks during the last week of August and September, 2012 targeting the low coverage areas. Twenty six persons have received FBNC training upto September, 2012 supported by UNICEF. Micro plans have been updated in all the districts. FBNC Observership. F-IMNCI, immunization, cold chain handlers, VHND ToT, IMNCI ToT and HMIS refresher training as proposed are yet to take place. Out of 157330 VHND sessions 146699 sessions have been conducted in the state. During visits to the SCs and VHNDs in Jashpur district it was observed that quality of immunization services for children and ANC services provided to the pregnant women is satisfactory. During the ANC check up, the pregnant woman is given TT, IFA tablets and weight is taken. District has initiated VHND linked alternate vaccine delivery system. Under the system a dedicated team of vaccine providers visit the VHND venue to deliver the vaccine as per the fixed route chart covering 5-6 VHNDs. These

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

providers also collect the vaccine usage reports and service reports from respective VHNDs. This enables effective monitoring of VHND services. There is no separate adolescent health unit at state level and therefore the ARSH program has not been initiated at the facility level. Adolescents are treated in routine OPD, but no separate record is maintained in OPD for ARSH services or adolescent health problems. Department of women and child development has initiated SABLA Scheme for Weekly Iron supplementation to the adolescent girls in five districts. The implementation of School Health Programme (SHP) during the year 2012-13 has been started since mid July 2012. This traditional implementation of School Health Programme will continue till the programme is outsourced by the state. A total of 66023 Mitanins have been selected at habitation level. Habitations without Mitanin or with inactive Mitanin have been identified and community has facilitated the selection of around 6000 new Mitanins. Sixteen rounds (50 days) of residential training has been completed for 90% Mitanins. Bridge Training has been given to 5059 new Mitanins. Block ToTs are in progress for 17th round training on revising essential life saving skills. Mitanin Support Structure of 3000 Mitanin Trainers, 290 Block Coordinators and 35 District Coordinators is in place. Mitanin Samman Diwas is initiated and Mitanins honoured by PRIs. District and Block Coordinators trained on supportive supervision for mitanins. The State Health Society is functional. The meeting of SHS was held in July2012 chaired by Secretary (Health) of the state. Issues related to the RoP like giving financial powers to RMAs where neither Allopathic nor Ayurvedic MOs are available are discussed. In the state out of 20308 villages, 19020 VHSNCs have been formed. This year more than 200 VHSNCs have been added. VHSNC meetings are facilitated by Mitanin Support Structure. Training module has been prepared for PRI members of VHSNCs. Community Based Monitoring activities has been initiated in the state. The state has initiated Chief Ministers Urban Health Programme (MMSSK) in the selected 11 major urban centres. There is a separate AYUSH directorate established in the state. A total of 399 AYUSH facilities are established in the state of which 319 are Ayurvedic, 60 Homeopathic and 20 from Unani stream. There is extra incentive of 4000 for contractual AYUSH doctors posted in tribal areas. An AYUSH Deep Samiti (ADS) has been constituted on lines of JDS. ADS

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

receive a grant of 25,000 per year for selected facilities. Six AYUSH hospitals funded by EUSSP gets 2.00 lakhs for maintenance. The state has formulated a PPP policy for effective implementation of PPP initiatives. During 2012-13, state has proposed medical colleges, Super Specialty Hospitals, Bio-waste management, establishment of PHCs, diagnostic services, Shav-Vahan etc. under PPP mode. MMUs under PPP mode is already rolled-out in the state. Quality Assurance at facility level is initiated since August2012. Process is initiated for accreditation of selected facilities through NABH on pilot basis. Strategies have been planned under Bio-Medical Waste management for infection control at labour room and OT at facilities. For bio-medical waste management 550 master trainers have been trained. As part for QAC nine hospitals (5 DHs and 4 CHCs) have been ISO certified. The sustainability of the ISO norms is to be ensured. State has proposed to set-up Health Equipment management cell, PPP cell and Bio-medical waste management cell under QAC. All the funds are grouped as NRHM and Non-NRHM accounts upto block level. State has received nearly 50 percent of the approved PIP budget. As on September 2012 state has utilized about 17 percent of the budget. District Jashpur has sanctioned PIP of 25.45 crores for 2012-13. During April-September2012 13.28 crores (52%) has been released to the district. Out of the total PIP budget 6.13 crores (24%) has been utilized by the district. The mandatory disclosures are yet to be fully implemented in the state. Facility Wise deployment of Contractual Staffs under NRHM with name and designation is displayed on web-site. Facility-wise separate list of GoCG health staffs and NRHM staffs is given on the website. State will initiate Mobile Medical Units (MMUs) from 15th August, 2012 but details are not disclosed on the website. Patient Transport Ambulance / Emergency Response Ambulance (108) are not disclosed. Procurement (Drugs and Equipments) are not disclosed completely on the website. EDL is available on the web-site. Building under construction / renovation is partially disclosed. Number of building under construction / renovation districtwise is on the web-site as assessed on 14.08.2012. Facility wise list of constructions / renovation is not placed on the web-site. The state has made progress on key conditionalities by following time-line set for its implementation. State has completed key conditionalities on redeployment of staff on delivery points, EmOC and LSAS, Web-based HR-MIS, HMIS facility level reporting and no user-fees for MCH services.

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Quality Monitoring of PIP in Chhattisgarh - Second Quarter (July-September2012)

1. Introduction Ministry of Health and Family Welfare, Government of India has approved the State Programme Implementation Plans (PIPs) under National Rural Health Mission (NRHM) for the year 2012-13 in May 2012. For the first time, States have been assigned mutually agreed goals and targets which states are expected to achieve, adhere to key conditionality and implement the road map provided in each of the sections of the approved PIP document. National Rural Health Mission has entered the 8th year of its implementation in 2012-13. Funds under the Mission are allocated to states on the basis of their State Programme Implementation Plans (SPIPs). For the year 2012-13, new framework has been developed for the preparation of annual PIP by the states. States are now focusing on outcome as given in Chapter 1 of the PIP documenting the state specific targets for the next five years and expenditure is seen as a means to achieve these goals. Along with the specific targets linked to the funds allocated to the states, a mutually agreed road map and key conditionality have been introduced in the SPIPs and these are seen as incentives as well as disincentives for the states in allocation of funds in the coming years. Monitor able targets for the states have been fixed for each quarter of 2012-13 PIP. Since the implementation of NRHM, review/action research is an ongoing process to assess the progress of the programmes of the states in terms of Rapid Assessment, Common Review Mission, analysis of HMIS and MCTS data etc. As a part of this process, MOHFW has involved the PRCs to monitor the progress made by the states in implementation of annual PIP and states adherence to the mutually agreed road map and conditionalities. With these objectives, all the PRCs have been asked to present a brief report on the implementation of the PIP for the respective state in which the PRC is located or working. Though, States were implementing the approved PIPs since the launch of NRHM, but there was hardly any mechanism in place to know how far these PIPs are implemented. Though some studies were undertaken to know the impact of NHM, but these studies are quantitative in nature, time consuming and do not reflect how the PIPs are implemented. It was in this background and in view of the enhanced allocations under NRHM, MOHFW entrusted the continuous qualitative monitoring of PIPs to the PRCs. It was decided that that all the PRCs would undertake qualitative monitoring of PIPs in the designated states. This
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

monitoring will be a continuous exercise and in each quarter PRC will cover a few districts to monitor the progress of PIP implementation in the state. PRC, Sagar has been assigned Chhattisgarh and Chhattisgarh states for monitoring. 2. Objectives To undertake qualitative monitoring of PIPs for the state of Chhattisgarh To visit health facilities in a high focus district for monitoring the implementation of PIP at the grassroots level

3. Methodology As emphasized during the meeting, a high focus district Jashpur in Chhattisgarh was selected in the second quarter. There are 18 existing districts in Chhattisgarh with 9 new districts carved out of the old ones. Jashpur is one of the high focus districts in the state. This district was selected after consultation with state officials. In Jashpur district we have selected District Hospital (DH), two Community Health Centre (CHC), 3 functional 24*7 PHCs, and 4 Sub-Centres all functioning as delivery points except SHC Aara. At each health facility we also decided to interview a maximum of 5 persons who might have come to avail the services and in case the beneficiaries were not available, efforts were made to contact a few persons who had availed MCH and other services from the health centres during the last few months by visiting their homes. For monitoring purpose, a set of 7 questionnaires were developed. These are (a) State Level Questionnaire, (b) Chief Medical Officer Questionnaire, (c) District Hospital Questionnaire, (d) Block Medical Officer Questionnaire, (e) Primary Health Centre Questionnaire, (f) Sub Centre Questionnaire, (g) ASHA, and (g) Beneficiary Questionnaire. 4. Data Collection In the month of October-November, state health officials in C.G. were visited by the PRC team to get the information about the progress made on implementation of various components of PIP. A meeting was held with the State Mission Director and discussions were held with the Nodal Person identified by the State. Meetings were held with other state level programme/nodal officers to get the information and relevant documents. At the district level CMO, BMO, DPM, DAM, DDO District Ayurvedic Officer, Pharmacist, and other officials were contacted to get the information. These officials were requested to provide information on the
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

structured questionnaires. Similar exercise was done at the CHC, PHC and SC level. These questionnaires contained questions on various aspects related to (a) Mandatory disclosures, (b) Key Conditionalitys and (c) Road Map for priority action. 5. Key Observations 5.1 Programme Management In Chhattisgarh, the state has established a full-fledged Programme Management Unit under the auspices of state NRHM office, headed by a full time, regular Mission Director who is supported by state level nodal officer for key technical areas of RCH and many other state level nodal officers for other components Maternal Health, Child Health, Immunization, ARSH, Family Planning and ASHA. There is Director Finance from State Finance Services who is in charge of finance/ accounts of both NRHM and the Directorate health Services of CG. In C.G. a functional Programme Management Unit is in place in the state as well as in district. There is full time Mission Director for NRHM and Director Finance who manages the finances of Directorate Health Services CG also. At state level new recruitments have taken place in the SPMU. State Training Coordinator, State Data Officer, 3 Sub-Engineers, 3 Programmers, and one Accountant have joined the SPMU. The SPMU has a total staff of 34 persons including Data Entry Operators and supporting staffs. Overall, 34 out of 100 posts in SPMU are filled, 229 posts out of 723 posts are filled in DPMU and 941 posts out of 1179 are filled in BPMU. Programme Management Units (PMU) has been established in all the districts. However, only few districts have fully staffed PMU. To strengthen and accelerate the recruitment process hiring of HR recruitment agencies is done and posts have been advertised. Online application system has been developed to reduce postal delays and manual compilation. Rationalization of salary to attract techno managerial post is done. The technical areas of RCH have a dedicated nodal officer at the district level. In all there are three nodal officers in the district in-charge of the different areas of NRHM as well as the national health programmes. Different components of RCH are being monitored by these 3 officers. A fully functional district progrmme management Unit (DPMU) is in place in the district. The DPMU unit has one DPM, DDO, DAM, DAA, DTC and 3 DEO. Meetings of the district health society are taking place regularly. The training requirements of Programme Management Units have been assessed at the district / block level.
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

The block programme management units (BPMU) have been established in all the development blocks of Jashpur. Out of 8 blocks all have BPM. BADA and DEO are posted in 7 and 6 blocks respectively. At PHC level 28 out of 32 PHCs have PADA in position. It was observed that there is high attrition among PMUs staffs. Out of 64 personnel in-position in PMUs in at the district / block level, 21 are appointed recently during second quarter. In DMPU, Jashpur out of 15 staffs in-position 6 have joined during second quarter. The state government reviews the training requirements of the PMUs at the district/block level. The district has also conducted training programmes for block level PADAs. Earlier DPM, DDO, BMPs, BADAs and PADAs have received training in HMIS and MCTS in 201112 at the state level. Another district level training programme is scheduled in October 2012. The training workshop for the programme management units for planning and use of HMIS data is planned and organized at the state level. Benchmarks have been set for monitoring the performance of staff of Programme Management Units at the district level. The financial powers to utilize NRHM funds are in accordance with the guidelines as laid out in the district action plan. HMIS/MCTS data is reported to be utilized for review of the performance. State has adopted monthly financial reporting using financial management software to maintain uniformity in the reporting physical and financial progress. District ranking is done based on the monthly reporting of physical and financial progress. The state has provided training to BPMs organized by PHRN at the state and orientations at the district level also. The BPMs have attended the training workshop for the PMUs in planning and use of DHIS, HMIS data, RSBY scheme software, organized at the state level. There are dates fixed for timely reporting of data, completing data entry of e-mahatari, and HMIS data. The block receives the funds in time in line with NRHM guidelines for different RCH programmes. This year the district action plan is yet to be approved although the district has prepared evidence based district action plan. The NRHM funds are utilized through a joint signature of BMO and BPM. HMIS/MCTS data is reported to be utilized for review of the performance at the district level but not at block level. Programme Managers from Directorate Health Services CG are coordinating with state NRHM office for ARSH, Child Health, Urban Health, AYUSH programmes. Progress of VHND and Mitanin programme is being coordinated by the SHRC.

Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

5.2 Planning State has taken various steps to increase the intake of medical graduate for government service. Incentivisation such as CRMC (Chhattisgarh Rural Medical Crop) has been fixed. Increase of MBBS seats is proposed after necessary expansion of medical college hospitals at Raipur, Jagdalpur and Bilaspur. New building for Jagdalpur medical college is under construction at a distance of 10 kms from the existing building. However, the state is facing difficulty in implementing its augmentation plan. Faculty recruitment is a big challenge for new medical colleges in remote areas. Even after offering higher salary, teaching faculty is unwilling to join medical colleges at places like Jagdalpur. There is enough intake of paramedic staff, since Chhattisgarh has many paramedical training institutes. Redeployment of EMOC and LSAS has been completed, and posting of RMAs is under progress for all the districts. Currently 1232 RMAs have been appointed of which 1048 RMAs are posted against the total requirement of deployment of 1248 positions in different health facilities. The total need to redeploy RMAs is highest in Rajnandgaon, Surajpur and Kanker. RMAs are being placed in the different health facilities where there is shortage of MOs especially in CHCs and PHCs. The high focus areas have been mapped at the block level, PHCs and SCs. Out of 146 blocks of CG only 14 blocks of Raipur are non high focus areas. The state has redefined high focus areas in various districts after creation of new districts in the state. Awareness and clarity regarding high focus (difficult and very difficult) and remote area was observed especially about demarcation of areas affected by left wing extremism. In Jashpur, there were 5 CHCs and 25 PHCs which have been defined as high-focus areas. As per the information provided by the DMPU a recent re-organization has increased this to 8 CHCs and 32 PHCs. The Chhattisgrah Rural Medical Crop (CRMC) has been created for posting of Medical Specialists, SNs, from Dept. of Health and Family Welfare to provide services in the identified high focus areas. The NRHM funds are received district downwards on the basis of submission of utilization certificates and equal division of funds for both untied and annual maintenance grants. The distribution of funds is also based on the submitted district action plans. 5.3 Supportive Supervision The state level the nodal officers for RCH, Maternal Health, Child Health, ASHA and JSY etc. are designated and they provide supportive supervision and monitor programme at their
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level. The State Health Society meeting is held regularly, during the second quarter two meetings were held. At the district level the program officer for RCH is a nodal person / monitoring officer responsible for monitoring and supportive supervision. The nodal officer is supported by two other programme managers for monitoring the health activities of the nine blocks. The CM&HO and DPM in general monitor all the NRHM programmes. The nodal officer stated that they prepare a schedule of visits and checklists for the monitoring. However, the action taken reports are not available. They share their findings in block and district review meetings. The nodal officers visit the remote/high focus areas in 2-3 months. BPM corroborated that RCH nodal officer and DPM visited the remote PHCs and SCs from time to time. District Health Society meetings are held regularly. In Jashpur at the district level special trainings have been planned for the field level sector supervisors and LHVs for effective supervision and to monitor performance of field staff in terms of service delivery and data management of HMIS or MCTS tracking. Training in monitoring and evaluation is proposed in month of October for ANMs, LHVs and BEEs. LHVs are to be trained also in NSSK and SBA. Monthly review meetings are held; meetings also take place on weekly basis and need based for special programmes are organized. Progress is monitored through weekly sector meeting and, monthly block level review meetings. 5.4 Human Resource The state is in the process of implementing a comprehensive HR policy under NRHM. Formulation of HR policy is under process. Chhattisgarh rural medical Crop (CRMC) has been implemented to strengthen HR in underserved areas. The recruitment of contractual staff which include data entry operator, PADA and staff of NRC under NRHM has been delegated to District Health Societies. These selections take place under the supervision of District Collector through open advertisements, skill tests and interviews. In the Jashpur district out of 1318 posts in different categories 668 posts are filled up. Out of the 141 sanctioned posts of Specialists and Medical Officers only 49 are in-position. Among 948 sanctioned posts of nursing and health staffs 467 are in-position. There are 109 contractual staffs posted under NRHM in Jashpur district which includes 18 RMAs, five ANMs, and 22 Staff Nurses apart from 64 BPMU staffs under NRHM. None of the block has regular BMO. The medical officer posted is the in-charge BMO. Out of 8 blocks, only
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

two blocks Patthalgaon and Pharasbahar have altogether 4 specialists in-position. District Hospital Jashpur has only four specialists in-position. Bagicha and Lodam blocks are short of sanctioned staff strength. Against the 7 regular posts of specialists and MOs, 5 are vacant in CHC Bagicha. In PHC Sanna apart from a MO, 1 RMA is posted. At CHC, Lodam one lady RMA provides ANC services on fixed days. Out of the 4 SHCs visited, three (Tatkela, Putri Choura and Neemgaon) are functioning as delivery point with single ANM. A monthly monitoring format (Format 1 to 5 respectively for SHC, PHC, CHC, CH and DH) for monitoring productivity of the contractual staff recruited under NRHM has been evolved in CG. The increment of contractual staff is linked to performance appraisal. Evaluation of performance is done on the basis of target setting and the goals achieved. Under the CRMC scheme health personnel serving in difficult areas are provided incentives. For minimizing the regular vacancies of doctors the state has adopted a system of direct recruitment through which 85 MOs have been appointed. The new system is taken out of the purview of the state public service commission. Recruitment of medical officers is being done on quarterly basis. As fresh batches of medical students pass out MBBS they are being encouraged to apply for the vacancies. However, due to a number of reasons like remote area postings, non-availability of residence, security and lack of proper transfer policy for medical doctors only few of them are joining public services. There is a paucity of medical specialists too in the state. State has taken various steps to increase the intake of medical graduate for government service. Incentivisation such as CRMC (Chhattisgarh Rural Medical Core) has been fixed. Increase of MBBS seats is proposed after necessary expansion of medical college hospitals at Raipur, Jagdalpur and Bilaspur. New building for Jagdalpur medical college is under construction at a distance of 10 kms from the existing building. However, the state is facing difficulty in implementing its augmentation plan. Faculty recruitment is a big challenge for new medical colleges in remote areas. Even after offering higher salary, teaching faculty is unwilling to join medical colleges at places like Jagdalpur. There is enough intake of paramedic staff, since Chhattisgarh has many paramedical training institutes. Redeployment of EMOC and LSAS has been completed, and posting of RMAs is under progress for all the districts. Currently 1232 RMAs have been appointed of which 1048 RMAs are posted against the total requirement of deployment of 1248 positions in different health facilities. The total need to redeploy RMAs is highest in Rajnandgaon, Surajpur and Kanker.
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

RMAs are being placed in the different health facilities where there is shortage of MOs especially in CHCs and PHCs. Under the redeployment process, in Jashpur, RMAs are posted at 11 SHC where ANMs positions are vacant. The facility level HR on the web-site is a mandatory disclosure. The state has been managing separate HR-MIS to provide staff position and vacancies in the state. The HR-MIS has been posted on the web-site http://health.cg.gov.in. A baseline data for HR including the current place of posting is being prepared and updated. The HR management information system (HR-MIS) reporting lacks facility wise details of HR at a single click. There is a listing of district and state level NRHM / Government officials under HR-MIS. These are mentioned in a separate whos who section on the web-site. The HR-MIS need simplification to provide facility level list of HR for both government and NRHM. A total picture of the serving /vacant positions designation wise is not available for the state as a whole. There is need of updation of this information on the web-portal. DMPU Jashpur has an updated list of facility / designation wise existing manpower along with the vacancies. This needs to be updated on the HR-MIS. The state has prepared a training calendar for 2012-13. As per the training calendar 10 out of 39 proposed LSAS training, 9 out of 25 CEmONC, 44 out of 223 BEmONC, 105 out of 528 SBA, 29 out of 106 MTP, 142 persons out of 386 for RTI-STI have been trained in the state between April to September, 2012. Presently Durg District hospital is identified for SNCU training and Raipur medical college for training of trainers for FBNC. Six batches of ARSH, 3 batches of Cold Chain Handlers, 4 batches of Quality ANC training, 1 batch of District Training Coordinators training has been conducted at SIHFW upto September 2012. At Jashpur training plan for 2012-13 includes 18 SBA, 90 NSSK, 240 ANC Care, 8 FP-IUD for MO, SN, LHV, 30 FP-IUD eacs for ANM, RMA, MO and 36 NVBDCP-Malaria for AYUSH MOs. However, none of the planned trainings could be initiated due to lack of training facilities and infrastructure facilities for conducting the training. District has master trainers available for NSSK, SBA, IUCD and Quality ANC training. Vacancies in the GNTC and ANMTCs are being filled up after promotion of nursing cedar as tutors in these institutions. Proposal for one time relaxation in recruitment norms has been sent for approval. Accordingly, 10% vacancies are being filled through direct recruitment and rest 90% may be filled by trained nursing graduates with 3-5 years of nursing experience in any hospital. For routine training requirements of serving paramedic staffs, District Training Centres (DTC) are being revamped through a recent GO. DTCs are now under control of SIHFW.
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Training calendar is under preparation. State training consultant is looking after HR issues. QAC of training institute being proposed in PIP 2013-14. For strengthening of training activities, micro-planning at district level is planned. Necessary approval of district collector for number of trainings to be conducted, date of training will be taken. District training coordinators (DTCs) are recruited recently. Review meeting of DTCs for their sensitization on health issues and their problems is being planned. Assessment of trainings imparted is also planned. In a recent review of SBA training it was observed that master trainers are not aware how to monitor SBA training. There was no pre-post training assessment done. A comprehensive training policy and training cell being proposed. Most of the times, training calendar is not followed due to lack of availability of master trainers and training sites. In the state there is an acute shortage of staff nurses, lab technicians, MPW male, LHVs, pharmacists, Ayush paramedics and cleaning staff. In all these categories many positions are vacant. DPC of nursing cadre is done, 20 new sister tutor have joined in government nursing schools. Ten percent vacancy for direct posting has been advertised. DH Jashpur, the only FRU in the district, has only 4 out of 12 posts of specialists filled up and 4 out of 16 posts of Medical Officers are vacant. A gynecologist is available; however, no pediatrician is in place for providing services to mothers and children. Out of the 58 posts of nursing staff and technicians 16 posts are vacant. In case of other supporting staff 15 out of 23 positions are vacant. In Jashpur about half of the sanctioned post of nursing and technician cadre is in position as on September2012.

5.5 Strengthening Services The state has implemented the policy to provide free and uninterrupted supply of medicines to all OPD patients/Causality and Delivery cases in all Govt. health institutions. State has developed essential drugs list for various health facilities. The EDL contains list of 635 generic drugs displayed on health website. State only purchases and provides drugs to the districts as per EDL list. The list is revised every 2 years. State calls for requirements from district as per EDL however last year the districts placed a demand for drugs amounting to Rs.300 crores where as the States budget is only between 40-50 crores. Drug testing report is essential with every supply. As per the revised guidelines drugs are accepted only after quality assurance report from NABL. Drug warehousing at district level is in process. Implementation of PROMIS system is required. Chhattisgarh Medical Services Corporation Limited (CGMSC) has
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

been established on the lines of TNMSC. Manpower recruitment is in the process at CGMSC. CG MSC has initiated its web-based services through http://cgmsc.in/ accessed on 20.11.2012. The EDL for DH contain drugs for MCH, safe abortion and RTI/STI. However, CHC and PHCs do not keep drugs for safe abortion and RTI /STI since no services are being provided. RTI/STI drugs are only available at the ICTC centres. The list of available drugs is not displayed in any of the visited health facilities. Supply of drugs to district and from the district to the health facilities is based on demand. The process of computerising the list of drugs and consumables has to be initiated in DH. Generic medicines are being mainly prescribed in the health facilities. The Civil Surgeon and BMOs did not report of prescription audit in their respective facilities.

5.6 Procurement of Drugs and Equipments The system of procurements of drugs, consumables and equipments for various health centres in the State is centralized and this procurement of drugs and equipments is through etendering process. Open tender is done one-time for all drugs and rates fixed for one year and put on website. Drug auditing through drug supply passbook is being initiated. The state has planned the policy to provide uninterrupted supply of medicines free of cost to all OPD patients/Causality and Delivery cases. The latest EDL for DH, CH, CHC, PHC and SC has been formulated by the Directorate Health Services. The system of procurements of drugs, consumables for various health centres in the State is centralized and purchased through online tendering. District CMHO/CS of Jashpur is procuring the drugs as per requirement by tendering drugs as per EDL. In most of the facilities, shortage of essential medicines is reported. At the visited facilities it is observed that necessary medicines are purchased from untied grants. Procurement of some essential drugs is also done locally at the district through tendering process. Generic medicines are being prescribed in the health facilities. The EDL were available at the respective facilities except for SHCs. The Civil Surgeon and BMOs did not report of prescription audit in their respective facilities. During field visits it was observed that all the required medicines were available at the SC level. The state has also formulated an integrated policy for procurement of equipment. A state level committee is rationalizing the demands for different equipments received from the districts. The committee is also in the process of identifying suppliers to start the tendering
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

process. Procurement of equipments is being streamlined. All the civil surgeons have been asked to submit the list of equipments required for their hospitals by December2012 so as to process the demand for the next FY i.e. 2013-14 well in advance. Online bidding system has some problems as some of the bidders could not submit all the documents online. This bidding process is being reviewed. No equipment audit has been conducted during the 2nd quarter. No MIS for logistics is implemented as of now. Whole procurement process is to be transferred to CGMSC. Commissioner (Health) is looking after the charges of MD, CGMSC. 5.7 Vehicles and Referral Transport A strong referral transport system has been put in place in the state. The GVK EMRI is in place with 108 as toll free number in 172 facilities. Three hundred mini ambulances have been sanctioned during 2012-13 as 102Mahatari Express for referral transport from home to hospital and vice-versa. Request for proposal for procurement of ambulance is advertised. Currently 17 MMUs are functional in the state and 13 MMUs are expected to be deployed by 2nd week of November 2012. 5.8 Mobile Medical Units Medical Mobile Units (MMUs) is going to be launched in the state from 15th August, 2012 in a phased manner. Most of the process is over regarding initiation of MMUs. However, due to some procedural issues, initiation of MMUs is planned during Otober-November2012. Currently 17 MMUs are functional in the state and 13 MMUs are expected to be deployed by 2nd week of November 2012. 5.9 New Infrastructure The state has appointed 17 civil engineers for various districts. These engineers will be responsible for follow-up of execution, quality assurance, maintenance and planning new construction requirements etc. Various districts have provided inputs after need assessment. Based on Assam model an infrastructure wing is being planned for NRHM in the state. At present, there is a uniform model for all the infrastructures being created in the state. In 27 districts labour room, OT, drug storage, store cum vaccine storage room & BSU are proposed for 2012-13. However, variation in the construction cost according to geography, location and other parameters restrict the construction activities. Activities planned for 2012-13 is in the tendering process. Jagdalpur medical college renovation is already begun. Multi-agency
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

dependency in carrying-out construction activities in the time-frame is creating hurdles for the task. For 2012-13 facility upgradation (DH/CHC and FRUs) to increasing bed strength is proposed for 35 facilities. Seven hundred residential quarters of F, G and H type are proposed for construction. Twenty Seven Drug warehouse and 100-50 bedded MCH clinics in all the districts are proposed for 2012-13 worth 800 crores of which 152 crore is sanctioned for current financial year. However, ongoing activities from previous year are being completed. The state has undertaken construction work by adding maternity wards, SNCUs, NBSU units, in different districts through state government and NRHM funds. It was observed that external agencies over-estimate the construction cost. Now every construction activity is being rationalized and re-planned. Two consultancy agencies (HSCC and NBCC) have been contracted. Training is also scheduled for newly joined engineers to acquaint them with health sector construction requirements. To provide security features and to save the space, duplex SHCs are being designed. One such duplex SHC is already constructed in Gidam block of Jagdalpur district. The information about new construction is not updated on the web-site. 5.10 AYUSH There is a separate AYUSH directorate established in the state. A total of 399 AYUSH facilities are established in the state of which 319 are Ayurvedic, 60 Homeopathic and 20 from Unani stream. They are posted at District Hospitals, CHC/PHCs. The state has a total of 505/567 AYUSH doctors of whom 15 are co-located in 15 DHs. Of these 70/97 is placed in CHCs, and 420/455 in PHCs. AYUSH OPD is monitored with IPD/OPD of the facility. AYUSH facilities are having AYUSH MOs and a pharmacist. There are 15 AYUSH wings in DH, 22 specialized therapy centres at the PHC level 24 specialty Clinics at the CHCs. Adequate supply of AYUSH medicine is provided. Priority is given to CHC and PHC for posting of AYUSH MOs. There is extra incentive of Rs.4000 for contractual AYUSH doctors posted in tribal areas. An AYUSH Deep Samiti has been constituted on lines of JDS where a grant of 25,000 is being provided to AYUSH facilities and Rs.2 lakhs for 6, 30 bedded hospitals funded by EUSSP. The District Ayurvedic Officer is the member of DHS in Jashpur district. AYUSH doctors are also members of JDS of the respective health facility. AYUSH MOs posted at the periphery in PHCs monitors JKS funds. A separate AYUSH wing has been established in the district hospital, Jashpur. AYUSH specialized therapy unit (ASTU) is collocated at CHC, Bagicha since July2012 in the newly constructed building in the CHC premises. ASTU is manned by an AMO, pharmacist
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

and an attandent. The IPD services are yet to start at the ASTU. Presently OPD services are being provided. Bagicha also has a separate Homeopathic dispensary. Under Bagicha, all the PHCs, except PHC Sanna have AYUSH MO. During 2nd quarter total 379 patients have availed AYUSH OPD services at ASTU. Apart from these stand alone AYUSH dispensaries are located at Roni, Sulesha and Saraipani. In spite of AYUSH co-location certain operational and functional problems persist.

5.11 ASHA / Mitanin The selection of ASHA or Mitanin is made on the basis of recommendations of the VHSC/PRI. A total of 66023 Mitanins have been selected at habitation level. Habitations without Mitanin or with inactive Mitanin have been identified and community has facilitated the selection of around 6000 new Mitanins. Sixteen rounds (50 days) of residential training have been completed for 90% Mitanins except Raigarh distt where it is in progress. Bridge Training has been given to 5059 new Mitanins. Block ToTs in Progress for 17th round training on revising essential life saving skills. Mitanin Support Structure of 3000 Mitanin Trainers, 290 Block Coordinators and 35 District Coordinators is in place. Mitanins have been provided a communication kit. Mitanin Programme MIS is in place for 16 indicators and grading of blocks done. Pilot undertaken for payment of incentives to Mitanins through Panchayats Mitanin Samman Diwas is initiated and Mitanins honoured by PRIs. Mitanin Helpline for Grievance Redressal has completed one year. Campaigns have been undertaken by Mitanins for reducing Child Malnutrition, Malaria Panch Prayas Mitanins led Joint teams of PRIs, students etc. to identify suspected cases of Cataract (50,840), TB (21,695) and Leprosy (3,168). Mitanins and support structure trained on home visits for Newborn, Pregnant women, Children upto 3 years of age District and Block Coordinators trained on supportive supervision radio programme Kahat he Mitanin Mitanin Newletter Mitanin Paati is being brought out quarterly. 5.12 Urban RCH The state has initiated Chief Ministers Urban Health Programme (MMSSK) in the selected 11 major urban centres. Rajnandgaon and Bilaspur are two of the identified districts for urban RCH programme for starting urban RCH. The state has issued necessary guidelines to districts for implementation of urban RCH programme in June2012. This programme will primarily focus on slum areas in these cities.
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Jashpur town has 18 wards in all. Identification of slum has been done in the Jashpur town. Initial assessment of service delivery load and location for setting up of health centre is being planned at the district level. District is mainly focusing upon strengthening MCH and immunization services under urban RCH. 5.13 Untied Funds VHNSCs have been constituted for majority of SCs. Out of total 19996 villages VHNSCs have been created in 19387 villages. Similarly, JDS have also been constituted for the DHs, CHCs and PHCs. The training of JDS members is proposed and VHNSC members have received training at the block level through Janpad Panchyats. At block level they have been briefed about their roles and responsibilities. Untied funds/JDS funds have been provided to all the VHNSCs uniformly and ASHAs maintain a joint account with Mahila Panch of their village. SCs functioning from government buildings have also received untied/ AMG funds, the joint account is operated with the MO of the concerned PHC. Cheque books are not provided to ASHAs and ANMs. Untied funds are also made available to all PHCs, CHCs and DHs uniformly. The JDS is established and functional in 17 districts, 141 CHCs and 693 PHCs. The number of JDS meetings held varies in different health facilities. At DH it was reported to be held monthly, at CHC quarterly and at the PHCs, biannually. There was problem of completing quorum in holding meetings at the PHCs. Although auditing of untied funds takes place regularly, the information regarding the amount of untied/AMG funds received and utilized last year was not displayed publicly in any of the health facilities in the district. Though all the health officials reported that they would appreciate/encourage public participation by way of donations from public but none has till date expressed a desire to donate to JDS. 5.14 Maternal Health The state has identified 1044 functional delivery points 761 MCH L1, 214 MCH L2, MCH 69 L3 delivery points. Level 1 include SHCs and non 24*7 PHCs, level 2 include 24*7 PHCs and non FRU CHCs and the level 3 include FRU CHCs, CH and DH. However, full range of MCH services are available in identified delivery points, 32 FRUs, 26 DH and 200 PHCs.

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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

Rationalization of functional delivery points are required to provide correct information on functional delivery points. In Jashpur, DH is the only MCH Level 3 facility and all the 8 CHCs are MCH Level 2, and about 59 SHCs and 27 PHCs as MCH Level 1 delivery points. PHC-Paiku and PHC Sanna are 24x7 level-1 delivery points. PHC-Paiku has been functioning from newly constructed building. PHC Sanna is functioning from old building. Logistics, infrastructure, manpower and referral linkages are insufficient at Sanna. 5.15 Janani Shishu Suraksha Karyakram (JSSK) JSSK has been implemented in the state on 15th August 2011 in the state. The JSSK has been implemented in all the District Hospitals and 75 FRUs or designated FRUs. The state has provided instructions for grievance redressal. JSSK a central scheme has been implemented by the state. Monitoring is done according to the currently prescribed monitoring and reporting formats. The state has issued various guidelines in July 2012 for implementation of JSSK components - sign-boards at all functional delivery points, provision of free diet supply of essential drugs, availability of functional labs and supplies for the labs, cashless services (No user fees for IPD/OPD/ ANC/PNC/ Diagnostics/ RKS or any other feed), free referral transport and functional grievance redressal mechanism instruction. JSSK services are available in All DH, 136 CHC and 27 PHCs in CG. Total number of pregnant women who availed the free entitlements free drugs and consumables to 55,336 pregnant women and 5551 children, free diet to 54,344 women, free diagnostics to 45,072 women and 1586 children and free blood to 1602 women and 3 children, free home to hospital transport to 38036 women, and 5,117 children, free hospital to home treatment to 36,605 women and 6912 children. District Jashpur has implemented free entitlements under JSSK. Drop-back facility is fully functional under JSSK. The district has contracted vehicles at the CHCs exclusively for JSSK. However, there is no call centre established for referral transport. Each vehicle under JSSK is running as stand alone transport facility. At CHC, Bagicha the vehicle is arranged from the public donation and running cost of born by the JSD for poor patients. At CHC, Lodam the vehicle is mainly provide drop back service. There is a provision for free meals at the DH and CHCs. During field visits it was observed that both the CHCs have outsourced food arrangements. There is no fixed menu of meals under JSSK. At CHC Bagicha, the food
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

arrangements are contracted to a restaurant. It was also observed during field visit that mothers are staying for less than 24 hours at the health facilities. The SHCs serving as delivery points do not provide free meals. Some delivery points especially the SHCs lack basic facilities like water, electricity and toilet. 5.16 Janani Suraksha Yojana The JSY guidelines are being followed in case of payments to beneficiaries who receive JSY payments at the time of discharge through a bearers cheque or cash in case of home delivery. The payments are made in a single installment at the time of discharge or within7days. There is a complaint box at DH for grievance redressal but other health facilities do not have a mechanism for redressal. Most of the beneficiaries leave the health facility before 48 hours. This raises questions about the quality of care received. District officials like nodal officer RCH, SDM, Tehsildar and MOs monitor payments are doing physical verification of payments in their respective areas. Redressal of JSY payments under Lok Seva Gaurantee 2011 is within 7 days as displayed in DH. 5.17 Family Planning State nodal officer for FP informed that supply of contraceptives are provided by GOI based on yearly achievement with ten percent increase provided directly to CMHO since 16th September, 2011. CMHO is directly responsible for implementation of all incentive schemes and achieving target. MD / Commissioner / Director (HFW) directly monitor program through video conferencing. Training of IUCD is provided as per GOI guidelines. The state also provides training on utilizing untied funds (for procurement of necessary items) for effective implementation of IUCD program. Majority, of the ANMs and staff nurses in the district are trained in IUCD 380A.There has been increase in the number of trained providers for IUCD. In 24*7 PHCs all ANMs and SNs are trained. Daily IUD services are being provided at the DH, CHC and fixed day services at the PHC and SCs. However, there is no quality assurance cell for monitoring the quality of FP services. Training for Cu-IUCD 375 Post Partum IUCD is proposed in the district. Post-partum sterilization (PPS) is encouraged through FP counselor posted at DH. District has a mechanism in place for quality assurance for FP services through a quality assurance committee under the chairmanship of District Collector. Chhattisgarh Lok Seva Gaurantee Act 2011 ensures
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

compensation under FP failure and service such as JSY/JSSK payments within stipulated time. Monitoring of FP cases is done by a team involving DC, CMHO, gynecologist, anesthetist, DHO, private doctors and legal advisor. 5.18 Child Health As per the state information SNCU is functional in 12 DH hospitals and 2 medical college hospitals of Raipur and Durg. NBSUs are functional in 38 facilities and NBCCs in 195 facilities including DH, CHC and PHCs. FBNC training has been received by 60 health personal including doctors and SNs. A total of 32 NBSUs are proposed of which 8 are planned for the year 2012-13 and 8 are functional. The state has initiated the process of procurement of NBSU equipments. It has circulated the guidelines and reporting formats of NBSU to districts. It has started collection of reports from functional facilities and has initiated feedback mechanism to districts based on analysis of data. Out of a total of 285 proposed NBCCs in 2012-13, 71 are functional. The state has initiated the process of procurement of NBCC equipments and circulated the guidelines and reporting formats of NBCC to districts. It has also started collection of reports from functional facilities and is providing feedback mechanism to districts based on analysis of data. Training on NSSK to staff posted at NBCCs has been initiated. SNCUs are in different stages of progress in 12 DHs. At present DH at Durg has a fully functional SNCU. In Jashpur, no SNCU has been established. District hospital and CHC Patthalgaon have NBSUs. All the other visited facilities are equipped and functional with NBCC only except PHC Sanna where NBCC is not functional due to limited space. The NSSK trained staffs is not placed in any of the visited facility except CHC Bagicha and PHC Sanna. The birth dose of immunisation is being ensured for all newborns delivered in the institutions, before discharge except for SHCs. Immunisation services are available in DH, on daily basis. In CHCs, PHCs and SHCs immunization services are being provided on fixed days. For SHCs without ANMs, an ANM/MPW from adjoining SHC is designated to provide these services. Due list of beneficiaries generated through MCTS was not observed during the field visit with some ANMs.

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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

5.19

Adolescent Reproductive and Sexual Health (ARHS) and MHS There is no separate adolescent health unit at state level and therefore the ARSH

program has not been initiated at the facility level. Adolescents are treated in routine OPD, but no separate record is maintained in OPD for ARSH services or adolescent health problems. Department of women and child development has initiated SABLA Scheme for Weekly Iron supplementation to the adolescent girls in five districts. The implementation of School Health Programme (SHP) during the year 2012-13 has been started since mid July 2012. At present School Health Programme (SHP) is being implemented as per traditional implementation framework. All the districts have been preparing the annual action plan for school health screening and as per the action plan the schools will be covered under SHP. This traditional implementation of School Health Programme will continue till the programme is outsourced to the 3rd Party from the State. 5.20 HMIS / MCTS The state has initiated HMIS facility level uploading. The facility level data is being monitored for timeliness, completion and validity. At Jashpur, district level training has been imparted to all the BMOs, BPMs, BADA and programme officers to monitor the facility level data. In this regard, BMO at Bagicha and Lodam have further reviewed HMIS at facility level in their respective block. A review and training is being conducted regularly to sensitize ANMs and other functionaries at periphery regarding quality of HMIS data. MCTS is functional for regular and effective monitoring for tracking service delivery. A call center has been sanctioned in the ROP 2012-13. Although, 75-100% pregnant mothers and children are registered in the MCTS for service delivery micro-birth planning for SAM is not being done, neither are LBW children being listed nor list for sick neonates is available with ANM as observed during field visit. Due lists for immunization and ANC services are only being generated. Operational difficulties reported are poor internet connectivity, mobility of data entry operators and electricity shortage. 5.21 Maternal Death Review / Infant Death Review There is a dual system for reporting of maternal deaths and MDR in the state. Facilities have to report maternal deaths within 24 hours of event. For the community based maternal deaths, ASHAs are given pre-printed Inland Cards, where they report name of the deceased
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

mother, her age, locality and date of death to the state NRHM office. From state NRHM office, this data is uploaded in the MDR portal. Respective districts then have to make necessary audit of the reported maternal deaths from community. Mitanins are given Rs. 50 incentive for every reported maternal death. State has issued MDR guidelines in May2010 and revised in July2012 (http://cghealth.nic.in/ehealth/MaternalDeathReview_NewInstruction.htm)

accessed on 18.08.2012. It was observed that facility level maternal deaths are not fully audited in the state. For community reporting of maternal deaths, Mitanins are not active in using the Inland Cards. During 2012-13, eight maternal deaths have been reported in Jashpur. However no maternal deaths are reported in HMIS during the two quarters. State nodal officer reported about lack of MDR training and paucity of medical personnel for MDR. System of IDR is not yet fully established in the state. 5.22 Coordination Adequate cooperation from the different departments is received. Special campaigns, against malnoursishment, sending SAM/LBW cases to NRCs are points of coordination with women and child development (WCD). There is participatory role of WCD at the village level where the VHNDs are organized in the AWCs. Immunization, pulse programme, fixed day immunization are conducted by support from WCD. PHE provides support in chlorination and epidemic prevention. Panchayats provide support in IEC of national programmes by making public announcements and RSYB listing. The education department is supportive in school health checkups, school rally, celebration of population fortnight and health and hygiene. The commissioner of Municipal Corporation is a member of DHS. 5.23 NGO/PPP/Civil Society/ Community Involvement The district has not initiated community monitoring process. There is suggestion and complaint box in DH but not in other health facility. Grievance Redressal is done through Jan Sunwai system at the Collectors office which addresses complaints from all departments including health on a selected day. Redressal under Lok Sewa Gaurantee Act, 2011 for JSY, FP and disability is being implemented. Various programmes under PPP model is proposed during 2012-13. These include medical colleges (Raigarh, Ambikapur and Bilaspur), Super Specialty Hospitals (Ambikapur, Bilaspur, Jagadalpur and New Raipur), Bio-waste management, PHCs with PPP mode,
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

diagnostic services, Shav-Vahan etc. MMUs under PPP mode is already rolled-out in the state. CG is the only state having its PPP policy. Although no PPP initiatives have been approved in the ROP but these are being conducted through alternate sources such as NHSRC / SHRC etc. Quality Assurance at facility level is initiated since August2012. In this regard, exposure visits is made to Gujarat. Process is initiated for accreditation of selected facilities through NABH on pilot basis. Strategies have been planned under Bio-Medical Waste management for infection control at labour room and OT at facilities. Till September2012 550 master trainers have been trained for bio-medical waste management. These trained personnel will disseminate information upto SHC level. For DH and CHC, 3 trainers per facility have been posted. For comprehensive QAC at facility protocol is being developed. Relevant RFP is to be issued for monitoring and training. As part for QAC 9 hospitals (5 DHs-Durg, Bilaspur, Ambikapur, Korba and Kanker and 4 CHCs-Khairagarh, Kurud, Manendragarh and Bilha) have been ISO certified. The sustainability of the ISO norms is to be ensured. For overall management of QAC, its composition and periodicity is being planned. For strengthening quality assurance formation of Health Equipment management cell, PPP cell and bio-medical waste management cell at state level is proposed. 6. Interaction with Beneficiaries During field visit exit and household interviews with beneficiaries were conducted at various facilities and at VHNDs to know their perception about the services received. It was found that beneficiaries at DH are satisfied with delivery care; however at other facilities services are limited. DH is not providing cesarean delivery services due to lack of blood-bank. Beneficiaries having normal delivery are not staying even for 24 hours after delivery at DH and CHC. This is also observed for the delivery at the SHC. Birth dose of immunization is provided at DH, CHC and PHCs. However, birth dose of immunization are not being given at SHCs for institutional or home deliveries since immunization at the SHCs is only on fixed days. Transportation from home to facilities are availed by beneficiaries however, drop back facilities are functional. Under JSSK / JSY, beneficiaries are not being provided adequate health advice during ANC and PNC, such as diet, pregnancy care, delivery care, newborn care and family planning. In all the facilities except SHCs, drop-back facility under JSSK is being provided with alternate source of transportation, however meals are provided only at DH and CHCs.

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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

7. Financial Outlay All the funds are grouped as NRHM and Non-NRHM accounts upto block level. SHS and DHS are transferring the funds to the receiving institutions as per the group banking system. Tally ERP 9.3 is used across the state up to block level (27 Districts & 122 blocks). It is plan to cover remain 24 blocks by end of December 2012. Guidelines on delegation of financial and administrative power are issued. District Jashpur has a sanctioned PIP of 25.45 crores for 2012-13. During April-September2012 13.28 crores (52%) has been released to the district. Out of the total PIP budget 6.13 crores (24%) has been utilized by the district. Nearly one fifth (5.61 crores) have been advanced to the blocks for their sanctioned PIP for 2012-13. 8. Mandatory Disclosures 8.1 Human Resource Disclosed a. http://cg.nic.in/healthhrmis/Reports/rptStaffPosition.aspx accessed on 20.11.2012 provides information regarding human resources available, sanctioned, in-position and vacant positions are placed in the HR-MIS. b. http://cg.nic.in/healthhrmis/Reports/NrhmEmplist.aspx accessed on 20.11.2012 provides facility wise list of NRHM staffs with their name, designation and other particulars. c. http://cg.nic.in/healthhrmis/Reports/rptEmppostwise.aspx accessed on 20.11.2012 provides post wise list of NRHM staffs available in the districts. Details of the staff can be seen by clicking link given with each district. 8.2 Mobile Medical Units Not disclosed a. The state has initiated MMUs in 14 LWE districts. MMU service has been names as National Mobile Medical Unit. Details information has not been disclosed on the website. In Jashpur, MMUs were inaugurated on 05.11.2012. A rout chart have been prepared for MMU services. b. State has not yet disclosed details of MMUs on the web portal. 8.3 Patient Transport Ambulance / Emergency Response Ambulance (108) Not disclosed 8.4 Procurement (Drugs and Equipments) a. Details of equipments procured Not disclosed b. Details of Drugs Procurements including EDL Disclosed 8.5 Building under construction / renovation Partial disclosure a. http://health.cg.gov.in/ehealth/Building.htm accessed on 20.11.2012 provide building estimates as per the PWD-CG designs for health facility (PHC, SHC), residential quarters (H,G,H type) and labour room b. State has created web-based infrastructure updation http://cg.nic.in/healthinfra/ on its portal. http://cg.nic.in/healthinfrablock/Login.aspx accessed on 20.11.2012
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Second Quarter Report on Qualitative Monitoring of PIP 2012-13 (C.G.)

c. Information regarding ongoing, completed and sanctioned construction work has been given on the web-site http://cg.nic.in/healthinfrablock/DistrictWiseReport.aspx accessed on 20.11.2012. However, this information is not updated. 9. Status of Key Conditionalities a. The state has made progress in achieving timeline to operationalize key conditionalities. Implementation of 27 key conditionalities are at various stages. b. The state has issued relevant orders to ensure range of services to be provided at designated delivery points. At present there are 1044 designated delivery points identified by the state. MCH services are made available in 32 FRUs, 200 PHCs and 26 DHs. However, the list of these facilities with details of service is not posted on webportal. Some definitional ambiguity is observed regarding designating a delivery point at the district level. During field visit in Bagicha block of Jashpur the district, the BPMUs pointed out discrepancies in the designated delivery point list provided by DPMU. As per DMPU list there were 29 designated delivery points, however, the BMPU informed that atleast 7 of these points does not have either own building or no ANM in-place. Reconciliation of information at district and block level is required. c. The state issued necessary guidelines for provision of various services under JSSK and has operationalized these services in 27 DHs. However, at Jashpur DH C-Section deliveries are not being provided due to operational difficulties of Blood Storage Unit.

10. Facilities visited in Jashpur District Facility Type District Hospital CHC PHC SHC Place Jashpur Bagicha and Lodam Sanna, (24*7), Paiku (24*7) and Aara Putrichoura, Tatkela, Neemgaon (Delivery Point) and Aara

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