Monitoring Report for the State of Uttar Pradesh: District Etah

Dr. Pradeep Mishra

Additional Director

Ajay Pandey
Assistant Director

Sukhdeo Prasad Tiwari

Filed Investigator

October 2013

Population Research Centre

Department of Economics
University of Lucknow
Lucknow, Uttar Pradesh

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 Table of Contents

1 Executive Summary ........................................................................................................ 4

2 Introduction ................................................................................................................... 8
3 State Profile and district profile ...................................................................................... 9
4 Key health and service delivery indicators ..................................................................... 11
5 Health Infrastructure: ................................................................................................... 14
6 Human Resources ......................................................................................................... 15
7 Other health System inputs .......................................................................................... 16
8 Maternal health............................................................................................................ 18
8.1 ANC and PNC ............................................................................................................................... 18
8.2 Institutional deliveries ................................................................................................................ 18
8.3 Maternal death Review............................................................................................................... 18
8.4 JSSK ............................................................................................................................................. 19
8.5 JSY ............................................................................................................................................... 19
9 Child health .................................................................................................................. 19
9.1 SNCU ........................................................................................................................................... 19
9.2 NRCs ............................................................................................................................................ 19
9.3 Immunization .............................................................................................................................. 19
9.4 RBSK ............................................................................................................................................ 20
10 Family planning ......................................................................................................... 21
11 ARSH ......................................................................................................................... 21
12 Quality in health services .......................................................................................... 21
12.1 Infection Control ......................................................................................................................... 21
12.2 Biomedical Waste Management ................................................................................................. 22
12.3 IEC ............................................................................................................................................... 22
13 Referral transport and MMUs .................................................................................... 23
14 Community processes ............................................................................................... 24
14.1 ASHA............................................................................................................................................ 24
14.2 Skill development........................................................................................................................ 24

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 14.3 Functionality of the ASHAs.......................................................................................................... 24
15 Disease control programmes ..................................................................................... 24
15.1 Malaria ........................................................................................................................................ 25
15.2 TB ................................................................................................................................................ 25
15.3 Other Communicable Disease..................................................................................................... 25
16 Non Communicable Diseases ..................................................................................... 25
17 Good Practices and Innovations................................................................................. 25
18 HMIS and MCTS......................................................................................................... 25
19 Key Conclusions and Recommendations .................................................................... 26
20 Annexure .................................................................................................................. 28

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1 Executive Summary

The NRHM PIP implementation monitoring in the District ETAH of Uttar Pradesh was
conducted in the month of October 2013. The two officers of the Population Research
Centre namely Ajay Pandey and Sukhdeo Prasad visited the identified district health
facilities besides interacting with the CMO of the District to assess the implementation
progress. Below is the snapshot of the monitoring visit.

STRENGTHS AND SHORT COMMINGS OF THE NRHM PROGRAMME IN ETAH DISTRCIT of

UTTAR PRADESH

Specific Strengths
• CMO ETAH is highly motivated and dedicated person. His personal emphasis on
maintenance and upkeep of records/data is commendable. Besides pushing innovative
implementation strategies for NRHM programs in the district he has used state budget
for NRHM programs, occasionally.
• CMO ETAH’s has started the process of providing digital BP measurement machine to all
ANMs.
• CMO had developed register/paper based due list generation technique for
immunization and ANC services to those due and this can be traced back and forward in
time.
• This is an alternative to what MCTS does. Due to various bottlenecks many a times MCTS
data are not complete and the due list generation is connectivity contingent, so this
alternative strategy works well.
• CMO with the help of NGO had submitted proposal to use innovation fund under NRHM
PIP so as to provide quality affordable diagnostic facility at the sub centre level but the
project was not commissioned
• Increasing numbers in service delivery reaching even remote areas via chain of
governmental health facilities and EMTS referrals.
• Subcentres functioning optimally inspite of several undocumented /unnoticed
challenges
• Frontline workers functioning well even in difficult conditions.
• Drug supply adequate even at peripheral facilities.
• NRHM has improved infrastructure - efforts to operationalize health facilities being
made.
• Cleanliness standards fairly good overall.
• JSY contributing to increasing number of institutional deliveries.
• JSY payments by and large prompt and transparent.
• ANM and ASHA valued by community, contributing to increased demand for MCH
services.
• Detailed micro planning for VHNDs - immunization being done in the community by
ANM with the help of AWWs and ASHAs

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Specific Shortcomings
• The recent decision of the Government to pay JSY beneficiaries via crossed check is
counterproductive to the very idea of speedy settlement of the JSY claims
• Banks in rural areas are reluctant opening accounts of the JSY Beneficiaries.
• There is no mechanism in place to redress non payment of JSY cheques due to it being
A/C payee.
• EMTS are not under the direct control/supervision of the CMS at District hospital or the
peripheral block facilities.
• The Data entry operators are agency recruited and are far less paid to what is envisaged
in the PIP budget. The process of selecting a lowest bid should be revisited if quality is
desired.
• Due to absence of diagnostic facilities at sub-centre level ANMs rely of their normative
skills for detection of severely anaemic women.
• ANM should regularly be provided with skills up-gradation training as even the best of
the ANM failed to correctly measure the BP using standard BP instrument.
• POL is not adequate/ proportionate to the power demands. Funds should be made
available on time.
• Huge shortfall in HR relating to all categories of doctors. DFH must have specialist such
as Gynaecologist and paediatricians besides surgeons for optimum service delivery.

Health Infrastructure: ETAH

• During the visit, it was found that the facilities which were planned to be operational as
FRU are still not fully functional. ETAH needs 3 CHC functioning as FRU. AYUSH facility is
not in place.
• ETAH district hospital does not have facility of SNCU, NRC, ICTC or BB/BSU at DFH.
• While residential accommodation has been provided in most facilities for the health
staff, their condition is poor or inhabitable. Example at BPHC Jaithra, Type 1 & 2
quarters are somewhat habitable but for type 2 & 3 quarters. At DFH hospital quarters
for MO are not available.
• More than three fourth of the RKS/UF/AMG funds are utilized m for minor works,
repairs for the facility at BPHCs/CHCs etc. DFH has only RKS funds of which more than 80
percent are utilized.
• Though the sub centre is running in a government building the approach to SC facility is
a task.
• System for maintenance of equipments at health facilities is not in place either at DFH or
at BPHC/CHC.
• Sub centre do not have 24 hour electricity and running water supply. Government hand
pump is used for water needs.
• Biomedical waste management systems are outsourced at DFH, BPHC/CHC while at SC
deep burial pit is used.
• The process of FRU operationalisation is slow as observed during the visit to BPHC
Jaithra , the facility is not fully functional with inadequate infrastructure to be
designated as FRU..

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• Only one functional Radiant Warmer is available at ETAH DFH against the demand of 6.
At-least 4 are required for fully functional NBSU.
• Due to ongoing CBI enquiry many of the OT equipments are locked in store so most of
them are in principle non functional.
• No provision for stay for ASHA or relatives/attendants accompanying the JSY patient at
health facility
Status of Human Resource: ETAH
• There is a huge shortfall of human resource in the ETAH district with respect to
specialists, doctors, and Staff Nurses. There is delay in recruiting and positioning of 2nd
ANMs and MPWs.
• There is no gynaecologist or paediatrician in position in the District.
• There is no cardiologist, ENT specialist or Eye specialist in position in the District.
• All categories NRHM contractual staff is in place in the District. BPMU are positioned.
• There are often delays in renewal of the contractual staff leading to drop-outs.
• No clear policy for career pathways for contractual staff.
• No clear guidelines on work policy relating contractual staff, leading to job role conflict
and burnouts.
• Training programmes have been stopped for the last two months throughout the state.
• Training of doctors in multi-skilling of doctors in EmOC, BeMOC and LSAS not yet
operationalised as no doctor got training in the district.
• There exits 4 SBA trainers in the DFH and out of 6 Staff Nurse 3 are SBA trained. No
mechanisms of Post training follow up.
Service Delivery: ETAH
• Increase in numbers of OPD, IPD, investigations, deliveries and other services over the
first two quarter period of the FY 2013-14 indicates better utilization of health care
services. This has also resulted in increasing workloads for the limited staff available at
the health facilities.
• No. of institutional deliveries conducted at DFH over the two quarter period is 969
against total of 1800 expected number of pregnancies. BPHC Jaithra conducted 1768
deliveries against the expected 3600 pregnancies.
• Due to non availability of surgeon no C section has been performed at DFH or at
CHC/BPHC.
• No provision of food or cooking for the patients and their attendants at the facility.
• All the newly born started breastfed within an hour of being born at health facility.
• Sizeable numbers of pregnant women seek ANC services at health facility.
• The number of sterilizations conducted at DFH in two quarters is 40 cases are grossly
inadequate. However large numbers of sterilizations seem to be conducted in camps. At
BPHC/CHC this facility is not there so no sterilization is reported. Minilaps are not being
performed. Male sterilizations are zero. Use of IUD needs to be promoted as in two
quarters only 64 cases were performed. While at BPHC/CHC the IUD insertion was 496.
Emergency contraceptive pills supply not available at the DFH or at BPHC/CHC.

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• 693 children were fully immunized in six month of the FY 2013-14 at DFH while 2876 got
fully immunized at BPHC/CHC Jaithra. Equal number of children received Vitamin A and
measles shot.
• 10 still births in six month were recorded at DFH while 5 at BPHC/CHC.
• Zero neonatal and infant deaths were recorded at health facilities. Reason only
institutional deaths are recorded and in six months no such deaths at institution took
place.
• Safe abortions services/MTPs are minimal across the District facilities. No evidence of
MVA or medical abortion seen.
• No data on SAM is reported as mechanism to record or address SAM is not in place in
the absence of NRC or the SNCU.
• No maternal deaths recorded at DFH however BPHC/CHC reported 5 maternal deaths in
six month. These deaths are audited.
• Maternal death audit initiated in the District Etah.
• Quality of delivery services not as per standards. No partograph present in the facilities
visited below DFH. Emergency drugs not adequately available below DFH.
• In District ETAH, laboratory service such as Haemoglogin, Urin Albumin and Sugar,
Malaria, and HIV testing are provided however No blood sugar/CBC/RPR/T.B./LFT test
are provided, hence optimal use of laboratories not being made.
• Privacy for patients in Health facilities inadequate due to overcrowding.
• Toilets for female health staff not present at facilities below DFH/BPHC/CHC.
• Proper signage and IEC materials are visible in health facilities upto CHC/BPHC level.
• The RKS funds at PHC/APHC are not optimally utilized as the RKS funds for PHC/APHC is
available with the BPHC/CHC.
• AYUSH doctors at PHCs/APHC providing allopathic services without any training.
Outreach Services: ETAH
• A total of 1203 ASHAs of the 1443 are in place.
• ASHA day is celebrated in the District and better performing ASHAs are rewarded. ASHA
uniforms are being worked upon and in the process to provide Uniforms.
• ASHA coordinators not in place in the District
• CMO-ETAH has provided each ASHA a unique block-wise code for their smooth
identification and performance monitoring.
• Every Thursday of the week one fourth of the Block ASHA come for meeting at Block. 50
ASHAs are present in a meeting. On an average 200 ASHAs per block in Etah.
• Detailed microplanning for VHNDs are available; however VHNDs sessions are mainly
used for immunization sessions and not for other purposes.
• Sub centers do not have second ANMs and MPWs for support to Outreach activities.
• ASHAs are provided with kits and are replenished regularly.
• MMUs are not operationalised in the District.
Nutrition Status: ETAH
• As per NFHS 3 Data, more than 48% children are malnourished, but growth monitoring
is not happening regularly in the visited districts.
• NRC is not established in the district ETAH.

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• Line listing of SAM is not done.
• Early and exclusive breastfeeding is observed widely in the field.
National Disease Control Programmes: ETAH
• The National Disease Control Programmes mainly NMCP, NLEP, RNTCP were looked in
detail at the DFH, and BPC/CHC visited. These programmes are operating under NRHM
at district level.
• During the Q2 quarter period of the 67 slides tested for malaria none were found
positive. While at BPH/CHC 771 slides were tested and 17 were malaria positive cases.
• There were no new cases of leprosy in Etah both at DFH and BPC/CHC.
• At DFH in Q2 quarter no cases of TB were tested as the testing is done mainly at Block.
At BPC/CHC Jaithra 333 cases in six months were tested for TB and 32 were positive.
• DOT medicine is available at Block. RNTCP staffs are paid salaries six monthly while the
DOT providers are paid in 3 to 4 years. Last payment to DOT providers was made in FY
2010-11
• Rapid diagnostic Kits for malaria testing are not available.
• Regarding tuberculosis, there is a need for improvement in supervision and monitoring
at district level.
• No separate NCD clinics established in Etah nor does an IEC relating to NCD are
displayed
• Only NCD drug available relates to treatment of Diabetics
JSY and JSSK Implementation: ETAH
• Beneficiaries of JSY are paid Account payee cheques on time. Few delays due to
document ion.
• Mandatory 48 hours stay is enforced to the extent possible
• EMTS (108) brings in the incoming delivery patient at the facility and the drop back is
provide using UP Ambulance Seva
• Meals are provided three times a day. Tender of Rs. 72/- per meal was approved in DHS
due to minimum bid. Rs. 100/- per meal protocol under JSSK is not adhered to.
• Total of 5660 beneficiaries were provided free meal in Etah District of Uttar Pradesh in
the first two Quarters and about 2648 were provided drop back facility
Institutional Mechanism and Programme Management: ETAH
• The Block Programme Management Unit has been established and Staffs are placed
• The role of District programme manager is to be more clearly defined.
• District is following facility based HMIS data reporting from all blocks.
• MCTS is not fully functional in the district and the MCTS data is not used for effective
monitoring of service delivery/SAM/LBW/Sick Neonates.

2 Introduction

The NRHM- PIP monitoring field work in District Etah of Uttar Pradesh was carried out in the
month of October 2014 by Ajay Pandey-Assistant Director and Sukhdeo Prasad-Field
Investigator at PRC Lucknow. Communication to visit district Etah was made by Additional

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 Director PRCis and a support letter addressing to CMO Etah from the Additional Mission
Director-NRHM GoUP was made available to my team. After reaching the district head
quarters the Chief Medical Officers was met and briefed upon the purpose of the field visit.
The detailed checklist was shared with the CMO Etah. The CMO in consultation with his
ACMOs and NRHM unit finalized the facilities to be visited for the PIP monitoring. Detailed
discussions were held with the CMO Etah at his office regarding PIP implementation and
various operational issues. Total 5 checklists were used to illicit responses. One each for
CMO office, District Female Hospital-Etah, Block Primary Health Centre/Community Health
Centre-Jaithra, Additional Primary Health Centre-Dhumri and peripheral Sub-centre
Dhumri. Apart from these health facilities 10 beneficiaries of JSY/JSSK were interacted upon
to know quality of services provided under the scheme and their concerns, if any.

3 State Profile and district profile

The district Etah is highlighted in the Map of Uttar Pradesh and is one of the 71 districts that
belong to State of Uttar Pradesh. As per Census 2011, district Etah of Uttar Pradesh
recorded a population of 1,774,480 consisting of 947,339 males and 827,141 females
compared to a population of 1,561,705 in 2001. Etah contributed to less than a percent
(0.89 percent) to total population of Uttar Pradesh. The percent share to State total has
declined since2001 which was 0.94 percent, due to bifurcation of the district. The decadal
growth for the decade 2001-11 was 15.1 percent compared to 20 percent growth for the
State. Etah consists of 8 blocks and 853 villages compared to 822 blocks and 97814 villages
in the State of Uttar Pradesh. Percentage of population in 0-6 age group is somewhat higher
in Etah (16 %) compared to the State average of 15.41 percent. Population density in 2011
of Etah district is 730 people per sq. km compared to 829 for the State of Uttar Pradesh. In
2001, Etah recorded density was at 636 people per sq. km. Schedule caste constituted 15.84
percent in Etah in 2011 compared to 20.70 in Uttar Pradesh. Schedule tribes are negligible
proportion in Etah while 0.57 percent tribes are in State of Uttar Pradesh. Literacy rate of
Etah in 2011 stood at 70.81 compared to 67.68 percent for the State. The gender gap in
literacy is higher in Etah compared to State. Male female gap in literacy in Etah is 22.5
percent compared to 20.1 percent in the State. This reflects low socio-economic status of
the females in Etah compared to the State. Overall Sex Ratio in Etah, stood at 873 females
per 1000 male compared State average of 912 as per 2011 Census. The overall sex ratio in
India is 940 females per 1000 males. The overall sex ratio of 873 females compared to 1000
males is alarming. A closer look at the sex ratio in 0-6 age group reveals 879 females per
1000 males compared to 902 for the State. Intervention programs in Etah should focus on
the importance of girl child to keep balance in the male to female ratio. Etah is less
urbanized compared to State of Uttar Pradesh. As per 2011 census only 15.11 percent lives

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in urban regions of district while the majority live in rural areas. Sex Ratio in urban region of
Etah district is 892 as per 2011 census data. The workforce participation rate in the district
Etah as per 2011 census is 31 percent compared to 33 percent in the State. The female
workforce participation rate is far below both in Etah as well as the State of Uttar Pradesh.
Workforce participation rate for female is only 13 percent in Etah compared to 17 percent
in the State. If one looks at category-wise employment data 24 percent of the workers are
employed as agricultural laborers compared to 30 percent for the State. Higher percentages
of female are employed as agricultural laborer in Uttar Pradesh compared to district Etah.

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 Table 1 Population and Socio-economic Indicators of Uttar Pradesh and district ETAH
Characteristics State District
(UP) (Etah)
No of Districts 71 NA
No of Tehsils 312 3
No of Blocks 822 8
No of inhabited Villages 97814 853
Population (2011) 199812341 1774480
Decadal Population Growth Rate (2001-2011) 19.85 15.08
Share to total Population 100 0.89
Share of 0-6 age group to total Population 15.41 16.02
Population Density ( per sq km) 2011 829 730
Urban Population (%) 2011 22.27 15.11
Schedule Caste Population (%) 2011 20.7 15.84
Schedule Tribe Population (%) 2011 0.57 0.01
Sex Ratio (overall) 912 873
Sex Ratio (0-6 age group) 902 879
Literacy (%) 2011
Males 77.28 81.28
Females 57.18 58.8
Total 67.68 70.81
Workforce Participation (%) 2011
Males 17.71 46.47
Females 16.75 12.78
Total 32.94 30.77
Workers as Agricultural Labourers (%) 2011
Males 27.69 24.39
Females 38.43 23.07
Total 30.3 24.14

4 Key health and service delivery indicators

Table 2 below provides the comparative picture of the key health and service delivery
indicators for Uttar Pradesh and the district Etah. According to Annual Health Survey of
2011-12 the Crude Birth Rate of district Etah is 27.9 births per 1000 population compared
to State average of 25 births per 1000 population. In contrast, the CDR in Etah is less than
the State average. The CDR in Etah is 7.8 deaths per 1000 population compared to 8.4
deaths per 1000 population in the State. Infant mortality rate is slightly higher in Etah at 71
infant deaths per 1000 live births compared to Uttar Pradesh at 70 deaths per 1000 live

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births. Neonatal mortality which approximately constitutes 2/3rd of all infant deaths is 51
per 1000 live birth in Etah compared to 50 per 1000 live births in the State. The Maternal
mortality rate estimates for the Aligarh division to which the district Etah belongs to stands
at 314 maternal deaths per 100000 live births against a state average of 300 maternal
deaths.

The unmet need or the latent demand for family planning services as per the AHS 2010-11 is
about 28 percent in the district Etah compared to around 30 percent unmet need for family
planning services in the State of Uttar Pradesh. The unmet demand for spacing
contraceptives is very high in Etah at 20 percent compared to 17 percent in Uttar Pradesh.
The demand for limiting contraception is higher in the State at 13 percent compared o the
demand in the district Etah at about 8 percent.

Health Management Information System data for the year 2013 provides detail on the
range of service delivery indicators. The information on HMIS has their own limitations as
many of the information are not complete on various parameters and not just that these
information are scanty but no appropriate justification is provided with against such
repetitive omissions. For example columns on death reporting are seldom complete. The
justification to this anomaly is that only the deaths that occurred at the facility (infant or the
maternal) are reported. Facility based deaths are rare. The deaths that occur in community
do not get updated/ reported on the portal. Now that the MDR and IDR are in place for
hospital as well as community based deaths and incentives are provided to ASHA to report,
the situation might improve. Another reason that works against the reporting is the lengthy
format on which the death information is to be sent/ reported by peripheral staff
discouraging reporting such events. Another classic case as is evident from the HMIS data
from Etah is zero reporting against the column on IPD or in-patients. No appropriate
response to such anomaly is received on probe. The information provided is that there is
pending official enquiry relating to such irregularities which is beyond the scope of this
report. About 7.3 lac OPD cases were registered in Etah district compared to 5.4 crores in
Uttar Pradesh in the year 2013. About 44 lac ANC cases were registered in the State of
Uttar Pradesh in 2013 as against 54 thousand ANC cases in district Etah. Roughly about 89
percent of the total ANC cases in Uttar Pradesh are registered on HMIS portal in-itself is
commendable. However, the ANC registration on HMIS portal for the year 2013 in case of
Etah is more than 100 percent. The detailed quality check should be carried out by the HMIS
handlers in the State as well as district. About 92 percent of the pregnant women got TT1
shots in Uttar Pradesh as against only 79 percent in Etah. Neonatal tetanus is the root cause
of deaths during first 28 days of birth. Coverage relating to TT injection should be increased
and made universal. Special campaign to increase T injections should be undertaken. Two
third of the deliveries are institutional in Uttar Pradesh while about 60 percent in Etah.

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 Table 2: Demographic and Service Delivery Indicator for Uttar Pradesh and District Etah
Characteristics State District
UP Etah
Demographic Indicators (AHS 2011-12)
CBR (per 1000 pop.) 25 27.9
CDR (per 1000 pop.) 8.4 7.8
IMR (per 1000 live births) 70 71
MMR (per 100000 live births) 50 51
MMR of the Mandal where district is located 300 314
Service delivery indicators (HMIS 2013)
OPD 54385402 733362
IPD 1040576 0
ANC
Women registering for ANC 4430018 54572
ANC registered with first trimester (%) 58.7 65.2
Percentage of women given TT-1 91.5 79.4
Percentage of women given 100+ IFA 93.9 75.2
Natal Care
SBA (percent to home delivery) 50.8 0
Percenatge of Institutional Delivery 67.7 60.4
Post Natal Care
Percentage 0f women receiving post partum check-up within 48 59.5 44.1
hours after delivery
Percentage of newborns visited within 24 hours of Home Delivery 59.9 49.6
Immunization
Immunization sessions planned 884360 8399
Percent of session held 92.5 97.4
Percentage of ASHAs present 79.9 85.9
Family Planning
No. of NSV/Conventional Vasectomy conducted 2049 0
No. of Female Sterilisations Conducted 31428 66
Number of New IUCD insertions 408244 4219
Number of Oral Pills cycles distributed 1104415 10837
Number of Condom pieces distributed 18299496 225280
Unmet need for Family Planning (AHS 2010-11)
Spacing 17.2 20
Limiting 12.6 7.6
Both 29.7 27.6
Source: Table provided by Additional Director PRC for the PIP report

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 The post partum checkup within 48 hours of delivery in Etah is only 44 percent compared to
State average of 60 percent. Similarly, about 50 percent of neonates born in at home in
Etah are attended by ASHAs within 24 hours of birth compared to State average of 60
percent. About 8399 immunization sessions were planned in Etah in 2013 of which 97.4
percent were met and ASHAs were present in about 86 percent of such sessions held.
Compare to this 88 lac immunization session were planned in Uttar Pradesh of which 93
percent were met and ASHAs were present in 80 percent of such session held in the year
2013. On family planning front Etah did not reported any case on NSV/Conventional
Vasectomy against 2047 NSV/CV in Uttar Pradesh. The Female Sterilization in Uttar Pradesh
in 2013 was recorded at 31428 while only 66 cases were reported from Etah. This is gross
underachievement compared to 7.5 percent unmet demand for family planning in Etah.
About 4 lac , IUCD were inserted in Uttar Pradesh as against 4 thousand in Etah. This again
is an underachievement considering 20 percent demand for spacing in Etah. 11.1 lac, cycles
of Oral pills were distributed in Uttar Pradesh while in Etah about 10 thousand cycles of Oral
Pills were distributed. 2.2 lac, condom pieces were distributed in 2013, while in Uttar
Pradesh 1.8 crore such pieces were distributed to those in want of them.

5 Health Infrastructure:

Etah with a population of 17 Lac has two district hospitals, 8 Block Primary Health Centres
/Community Health Centres, 29 Additional-PHC/New-PHC/PHC, 182 Sub-centres and one
Urban Family Welfare Centre/Urban Health Post. Of these 8 BPHCs 3 are to be
operationalised as CHC (FRU) while five are working as 24x7 BPHC. Of the 182 sub centre
building 45 are in rented buildings. 118 additional sub centres, 2 UFWC/UHP and one Ayush
hospital are required in Etah. There are 130 beds in the District hospital while 8 BPHCs have
80 beds @ of 10 each BPHC. The 29 NPHCs/APHC/PHC have together 116 beds @ 4 per
NPHC/APHC/PHC. Total of 326 inpatient beds are available in Etah through network of
Government Health Care Facilities.

Etah District Female Hospital (DFH) which has a catchment of 1.18 lac population has most
of the listed physical infrastructure facility in place except for SNCU, NRC, Separate ARSH
clinic, BB/BSU (facility at DMH), ICTC and functional help desk. PPTCT counselling is
provided at the DFH. Staff quarters for MOs are not available at DFH. Few quarters for Staff
Nurses are available at DFH. NBSU though there at DFH its non functional in the absences of
manpower and adequate number of equipments. Mostly cases are referred to Aligarh as
SNCU facility is available there. DFH has separate toilet facility for females. Wards were
clean; facility accessible by road has power facility 24x7 with running water. Labour rooms

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 are functional and are clean. 10x10 feet space available for each of the 4 labour tables at
DFH. Each quipped with foam mattress, sheet, pillow, mackintosh, kellys pad and stepping
stool. NBCC is equipped with radiant warmers and neonatal ambu bags, OT was under
repair and locked so the physical infrastructure relating to OT could not be verified. At DFH
there is no provision for spate male and female wards as male are admitted to DMH.

BPHC Jaithra which has a catchment population of 1.98 lacs covering 343 villages, among
the listed physical infrastructure over-and-above to those infrastructures that are not
available at DFH, hasn’t got functional NBCC. At BPHC spate Labour ward and Male wards
exist. BPHC Jaithra is 39 km away from District Head Quarters.

APHC/PHC Dhumri catering to population of 35000 covering 60-65 villages is 28 km from

District HQ. The facility was under renovation process and Staff Quarters for MOs and all
other category staff were built in.

Sub Centre Dhumri which is 11 km from BPHC/CHC and 1 KM from APHC/PHC had a
catchment of 11000 population covering 4 villages. SC was in the middle of the habitation
and get electricity for 12 hours each day, one week during day time and another week in
night. Toilet attached to labour room was not functional however; a separate toilet outside
the Labour room was functional. SC has proposed for NBCC to SPMU via CMO Etah.

Biomedical waste management systems are outsourced at DFH, BPHC/CHC while at SC deep
burial pit is used. Color coded bins are used for segregation of waste.

6 Human Resources

Human Resources relating to all categories of staff is grossly inadequate. There is a huge
shortfall of human resource in the ETAH district with respect to specialists, doctors, and
Staff Nurses. In the District there are 6 sanctioned post of Gynecologist and none are in-
position. Against 6 sanctioned post of pediatrician none are in position. Against 6
sanctioned post of anesthetist’s only one in place. Against sanctioned posts of 1
cardiologists, 1 ENT, 2 Eye Specialist no one is in position. Off the 3 sanctioned post of
Radiologist only 1 in position. Against 5 post of MD medicine, only 1 is in position. Against
the 95 posts of MOs only 35 are posted. Against the 6 pathologist 5 are in place. This
reflects grossly inadequate HR with regard to providing specialized quality care services in
the District. Due to lack of specialist/surgeon C-section deliveries are not conducted at the
DFH. In-spite of such a shortfall in HR, the volume of services provided is commendable.
Contractual staffs under NRHM are able to fill gaps in providing basis health care services
however they cannot be replacement to specialized care. UP government is trying its best
and should incentivize pay packages to attract specialist join government health care
system.

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7 Other health System inputs

Major listed equipments are available at the DFH. This includes BP Instrument and
Stethoscope; Sterilized delivery sets ; Neonatal, Paediatric and Adult Resuscitation kit;
Weighing Machine (Adult and child); Needle Cutter; Radiant Warmer; Suction apparatus;
Facility for Oxygen Administration; Foetal Doppler/CTG; Mobile light; Delivery Tables;
Autoclave; ILR and Deep Freezer; Emergency Tray with emergency injections ; MVA/ EVA
Equipment; ; O.T Equipment; O.T Tables; O.T Lights, ceiling (locked); O.T lights (locked),
mobile; Anesthesia machines;; Pulse-oximeters; Laparoscopes; Autoclaves (H or V);
Laboratory Equipment ; Microscope Hemoglobinometer; Centrifuge;; Reagents and Testing
Kits ; and Functional Ultrasound Scanners (locked for last 2 years).

The equipments that are not functional at DFH include phototherapy unit; C-arm units;
Ventilators; Multi-para monitors; Surgical Diathermies; Semi autoanalyzer; C.T Scanner;
X-ray units; and ECG machines

The Block-PHC/CHC Jaithra have all the listed equipments except for functional Neonatal,
Paediatric and Adult Resuscitation kit, Radiant Warmer; MVA/ EVA Equipment;
phototherapy unit; Semi autoanalyzer and Reagents and Testing Kits.

The APHC/PHC had none of the functional equipments listed except for functional BP
Instrument and Stethoscope; and Weighing Machine (Adult and child).

At Sub centre level Delivery equipments, neonatal ambu bag and color coded bins were
functional and available. Among those that were available but not functional included BP
machine and Needle & hub cutter. Equipments that were not available at SC includes
Haemoglobinometer, Blood sugar testing kits, Infant and New born weighing machine and
RBSK pictorial toolkit.

Ayush facilities are available in 4 BPHC/CHC while 5 APHC/PHC provide Ayush facility. In all
these facilities Ayush Pharmacist/compounders are posted along with the Ayush doctors.
The supply of Ayush medicines are erratic and most of the time the supply is not available.
Funds are available but the firms that supply medicines stop supply leading to un-
availability of Ayush medicines. Ayush doctors are involved in the monitoring and
implementation of NRHM programs in the field apart from their routine work.

The Essential Drug List is available and displayed ; IFA tablets,; IFA syrup with dispenser; Vit
A syrup; ORS packets; Zinc tablets; Inj Magnesium Sulphate; Inj Oxytocin; Misoprostol
tablets;; Availability of antibiotics; Labelled emergency tray ; common ailments drugs such
as PCM, metronidazole, anti-allergic drugs etc.; and Vaccine Stock are available at DFH.

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DFH does not have Computerized inventory management. Besides IFA tablets (blue);
Mifepristone tablets and Drugs for hypertension, Diabetes is not available. Wherever these
medicines are in short supply state budget is used to replenish them.

BPHC/CHC has all the listed medicines except for IFA (Blues), IFA syrup with dispenser, and
Mifepristone tablets.

While APHC/PHC has only IFA, IFA syrup with dispenser, ORS, Zinc, antibiotics, and
diabetes medicine. Sub-centre do not have most of the listed drugs such as IFA syrup with
dispenser, Inj. Magnesium sulpphate, Antibiotics, and misoprostol tablets.

To minimize the OOPS government provides essential supplies and lab testing facilities at
the health facilities.

DFH provides following essential supplies such as; Pregnancy testing kits, Urine albumin
and sugar testing kit, OCPs, IUCDs, Sanitary napkins and Gloves, Mckintosh, Pads,
bandages, and gauze etc. except for EC pills.

DFH provides laboratory service such as Haemoglogin, Urin Albumin and Sugar, Malaria,
and HIV testing are provided however No blood sugar/CBC/RPR/T.B./LFT test are provided,
hence optimal use of laboratories not being made. Similar is the case with BPHC/CHC,
APHC/PHC and SC

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8 Maternal health
8.1 ANC and PNC
Line listing of SAM is not done by any of the health facilities in Etah probably due to the
non availability of NRC in the district. At DFH total of 994 pregnant women were
registered for ANC 1 while 775 got registered for ANC 3. There is no data for the ANC 4.
Even doctors are not aware of ANC 4 protocol and were enquiring details on what
constitutes ANC 4. 16071 women were given IFA from the DFH.

At BPH/CHC Jaithra total of 2688 (75%) pregnant women got registered for ANC 1 and
2363 for ANC 2 (65%). Total of 2045 women in last six months at BPHC/CHC were given
IFA tablets. No such data was available from the PHC/APHC Dhumri. However, total of
200 ANC 1 and 192 ANC 2 cases were registered at SC Dhumri.

8.2 Institutional deliveries

Total number of deliveries in the first two quarters conducted at an institution is 969
against an expected number of 1800 pregnancies in the DFH covering the population of
about 1.18 lac. Approximately 60 percent of the births are institutional.

No C Section deliveries are conducted at DFH due to lack of specialist. Similarly no

emergency obstetric care facility is available at the DFH. Neither do DFH in last six month
managed obstetric complication nor have conducted any assisted delivery.

Block PHC/CHC Jaithra conducted 1768 deliveries against an expected number of

pregnancies 3600 pregnancies during the first two quarters. About half of the deliveries
are institutional. At BPHC/CHC level data is not maintained on number of assisted
deliveries due to lack of specialist. No Obstetric complications are handled at BPHC/CHC
they are referred to DFH.

No deliveries were conducted at APHC. At Subcentre in last six months total of 231
deliveries were conducted with an average of 38 deliveries per month.

8.3 Maternal death Review

The Maternal death review is initiated in Etah district and is now done at DHS meetings as
well as at Additional Director level in Aligarh. Regular meeting at the CMO level are also
carried out. MDR has gained impetus recently and health functionaries are sensitized and
trained to collected information on MDR on the form provided to each of the facility. Etah
has started the Facility as well as home based MDR. In Q2 alone about 11 maternal;
deaths were reviewed and cause of death was recorded. Based on MMR figures In Etah
roughly around 12 maternal deaths may occur. There by review just 11 death in 3 months

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 is an under achievement and process of review should be step up. The main casue of
death are Hemorrhage, and Hypertension.

8.4 JSSK
Total of 5660 JSSK deliveries were conducted upto September 2013 of which 2648 were
provided drop back. As per guideline drop is provided after 48 hours of mandatory stay at
the facility. Many a time patients rush back home within hours of delivery at the hospital
by their own vehicle. DFH conducted 239 JSSK deliveries while BPHC/CHA Jaithra 1048.
EMTS brings patients to Health facility and the UP ambulance seva provides drops back.
Though food @ of Rs. 100 to be provided the DHS Etah approved the lowest bid tender
offering food @ Rs. 72/-. Money on travel to facility incurred by some of the beneficiaries,
mainly as they were not aware free EMTS or in case of EMTS being out of order. Two of
the beneficiaries reported having paid money for delivery at the facility @300/-. This was
taken up with the hospital staff/facility doctor, which was denied. Under JSSK free
referral transport, medicines, diagnostics, meals, free blood and consumables are
provided. No user charge is collected for any of the services provided.

8.5 JSY
JSY beneficiaries are paid bearer cheque and payments are provided after verification of
documents on time. The data uploaded on portal is verified. JSY deliveries are back-
checked by the CMO and other health staff by conducting more than 5 % verification of
cases.

9 Child health
9.1 SNCU
SNCU is not established in Etah. Due to lack of equipments and staff even the NBSU is not
made functional in the District. Cases get referred to Aligarh.

9.2 NRCs
NRC is not established in Etah.

9.3 Immunization
During the last two quarters 693 children got fully immunized at DFH. While 663 got
vaccinated for measles and 693 children got vitamin A dose. At BPHC Jaithra 2876
children got fully vaccinated, received measles and vitamin A dose. No such data reported
from APHC/PHC. While at Subcentre-Dhumri168 got fully vaccinated and measles shot.
Only 118 children got Vitamin A dose. SC Dhumri had planned 28 sessions during Q2 and
all were held. Immunization schedule is displayed at SC.

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9.4 RBSK
Though the District has District nodal person identified for child health screening and
early intervention service being outlined and established no screening under RBSK is done

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 either at DFH or and BPHC Jaithra or at APHC Dhumri or Sub Centre Dhumri. This is even
after the district screening teams have been constituted.

10 Family planning
During the two quarters Q 1 & Q2 a total of 40 Tubectomy was carried out at DFH. Total of
64 IUCDs were inserted at DFH. Data relating to use of OCP and Condoms were not made
available. At BPHC Jaithra 496 IUCDs were inserted and the facility do not have means/staff
to conduct vasectomy or tubectomy. Mostly cases are referred to camps. No data from the
PHC/APHC Dhumri. While the Subcentre Dhumri reported 28 cases of IUCD insertion in first
six month of 2013

11 ARSH
ARSH clinics are not Functional in Etah district.

12 Quality in health services

12.1 Infection Control

Wards at the DFH and Block PHC Jaithra were clean and had a different look and feel in
comparison to the overall facility outlook. This was done due to personal initiative of the
CMO Etah. He was instrumental in using some of the State Budget resources for upkeep
and maintenance of JSY wards and Labour rooms. Regular fumigation is done at the DFH.
Regular Fumigation at BPHC is not carried out and is major challenge toward infection
prevention. Autoclaves are functioning both are DFH and BPHC. Laundry and washing
services available at Male hospital are used.

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12.2 Biomedical Waste Management
Bio medical waste is segregated in the color coded dustbins. Staffs are awareness and by
an large practice the waste disposal criterion. The BMW is outsourced at DFH and BPHC
while at SC level deep burial pit is used for disposal of BMW. There is no incinerator in the
Entire district of Etah.

12.3 IEC
IEC materials relating to MCH and FP are prominently displayed at DFH and BPHC/CHC
Jaithra. The display of IEC material is scanty at APHC/PHC and SC-Dhumri. At DFH and
BPHC the JSY entitlements and the JSSK entitlements are displayed. Various protocol
posters and EDL are displayed at DFH and BPHC/CHC. Citizen charter is also displayed at
the DFH and BPH/CHC. At DFH list of services available and the cost of such services such
as X-Ray, Ultrasound is also displayed. Timing of Health Facility is prominently painted/
displayed at DFH, BPHC and SC. Various protocol posters are also displayed at DFH. HIV
infection prevention message is also communicated at DFH.

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13 Referral transport and MMUs
As on September 30, 2013 total of 8 Ambulances from the Government of UP and 10 EMTS
are in use for referral and shipment of patients to facilities. One hired vehicle on contract
for JSSK drop back is also available at DFH.

Looking at the referral linkage data for the first two quarters from DFH we find that 1684
women were brought from Home to Facility by 108 during ANC/INC/PNC. While 806
women, were provided drop back home after delivery. These services are free of cost. 564
delivery cases were shipped to BPHC/CHC by EMTS-108. Drop back home were provided to
273 case during the first two quarters of 2013. 24 delivery cases were referred to DFH
using EMTS 108 services. During the six months period EMTS brought one case to SC
Dhumri for delivery. EMTS has revolutionized and brought speedy access to health care
services to the common person’s door step-up. This initiative needs to be applauded.

CMO himself monitors the use of Ambulances regularly. No Mobile Medical Unit is in place
in Etah. Control room for the EMTS is independent and health facility has no role in the
operation of linked EMTS. No call center or control room setup by the CMO for use of UP
ambulance seva. The facility in-charge acts as a facilitator.

There is however issues relating to the way these ambulances operate. At DFH it was
noticed that people themselves were searching JSSK vehicle driver for drop back home. On
asking CMS he said these vehicles are not under his supervision so he can’t do much. Some
time issues relating to power and authority in governing the vehicle mitigate the very
purpose for which these services are meant for.

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14 Community processes
14.1 ASHA
Total of 1443 ASHA are required in the Etah against which 1203 ASHAs are in place. ASHA
day is celebrated in the District and better performing ASHAs are rewarded. The First
prize consists of Rs. 5000/- second Rs. 3000/- and third prize of 1000 is provided to better
performing ASHAs. ASHA has been provided umbrella looking at their nature of job and
travel. ASHA uniforms are being worked upon and guidelines are formulated /in the
process to provide Uniforms. ASHA coordinators are not in place in the District.

14.2 Skill development

Every Thursday of the week one fourth of the Block ASHA come for meeting at Block. 50
ASHAs are present in a meeting. On an average 200 ASHAs per block in Etah. CMO-ETAH
has provided each ASHA a unique block-wise code for their smooth identification and
performance monitoring.

14.3 Functionality of the ASHAs

Detailed micro planning for VHNDs is available; however VHNDs sessions are mainly used
for immunization sessions and not for other purposes. ASHAs are provided with kits and
are replenished regularly.

15 Disease control programmes

The National Disease Control Programmes mainly NMCP, NLEP, RNTCP were looked in
detail at the DFH, and BPC/CHC visited. These programmes are operating under NRHM at
district level.

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15.1 Malaria
During the two quarter period of the 67 slides tested for malaria none were found
positive. While at BPH/CHC 771 slides were tested and 17 were malaria positive cases.
Rapid diagnostic Kits for malaria testing are not available. Usual slide based microscopes
are used for testing.

15.2 TB
At DFH in first two quarters no cases of TB were tested as the testing is done mainly at
Block. At BPC/CHC Jaithra 333 cases in six months were tested for TB and 32 were
positive. DOT medicine is available at Block. RNTCP staffs are paid salaries six monthly
while the DOT providers are paid in 3 to 4 years. Last payment to DOT providers was
made in FY 2010-11. Regarding tuberculosis, there is a need for improvement in
supervision and monitoring at district level.

15.3 Other Communicable Disease

There were no new cases of leprosy in Etah both at DFH and BPC/CHC.

16 Non Communicable Diseases

No separate NCD clinics established in neither Etah nor does an IEC relating to NCD are
displayed
Only NCD drug available relates to treatment of Diabetics

17 Good Practices and Innovations

CMO had developed register/paper based due list generation technique for
immunization and ANC services to those due and this can be traced back and forward in
time. So in effect CMO has created a paper based MCTS as an alternative to online MCTS
glitches and problems. Due to various bottlenecks many a times MCTS data are not
complete and the due list generation is connectivity contingent, so this alternative
strategy is working well. CMO has applauded for this initiative by health functionaries at
State.

CMO with the help of NGO had submitted proposal to use innovation fund under NRHM
PIP mainly to provide quality affordable diagnostic facility at the sub centre level but the
project was not commissioned. There is innovation fund in the PIP for Rs. 50 lac.

18 HMIS and MCTS

There is one staff for HMIS data handling at DFH and each of the BPHC/CHC. At block
level they are called Block Data Assistant or BDA. For MCTS data entry at Blocks DEO or
the Data entry operators are provided. Data operators are agency recruited and are far

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 less paid to what is budgeted in PIP. As told by the NRHM unit approximately Rs. 8000/-
is earmarked for Data Entry Operators. However, the lowest bid agency get recruited
and currently the agency provided approx. Rs. 2700/- per month to these operators.
This amount is a gross under payment and perhaps quality issues get on to backburner
while deciding the bids. How can a person getting Rs. 2700/- can keep self motivated to
provide error free key punching to the data that is handed to him/her.

District is reporting facility wise on HIMS and monthly review is taken by the DPM who is
Nodal for HMIS in the District. HMIS data is validated before uploading. MCTS data are
not complete and only about 30-35 percent of the data gets uploaded to the portal
compared to the volume of data for the given period. District authorities themselves do
not use MCTS data from the portal for Monitoring of service delivery or other activities.

19 Key Conclusions and Recommendations

• HR is grossly inadequate. A sustainable long term policy for human resource planning
needs to be developed including transfer and recruitment policies. Pending recruitment
of various positions, especially Specialist doctors 2nd ANM, MPW and BPMU staff should
be expedited. Temporary attachment of health staff needs to be discouraged.
• Time bound completion work for FRU up gradation, and facilities to be operationalized
as per the criteria laid down.
• FRUs need to be oprationalized as per guidelines at the earliest with special emphasis on
blood availability.
• Diagnostic facilities are not optimal and should be augmented/strengthened
• Maintenance of infrastructure and equipment need to be improved. Existing cold chain
mechanics at district level may be trained to provide regular maintenance of critical
MCH equipment
• Good practices should be encouraged and innovations should be taken up in positive
spirit.
• Capacity building of health staff needs to be initiated at the earliest. SBA trainings of
ANMs, multiskilling of doctors need to be given high priority. Training programmes need
to be resumed immediately.
• Recognition of meritorious staff may be considered to increase staff motivation levels.
Especially due to increased work load in the absence of range of health staffs.
• Subcentres need to be strengthened through provision of regular power and running
water supply. Sterilizers/autoclave need to be provided at subcentres. Drugs to manage
obstetric emergencies should be made available at subcentres on regular basis.
• Provision of 2nd ANM and male worker at subcentres should be expedited, especially in
Accredited Subcentres.

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• In service training for AYUSH doctors in provision of primary health care needs to be
provided.
• Involvement of ASHAs in implementation of National Disease Control Programmes
needs to be expanded and enforced.
• Accreditation of private hospitals for delivery and other services needs to be
encouraged.
• Maternal death audits need to be expedited and taken up rigorously..
• IEC activities at SC and APHC/PHC need to be strengthened.
• ASHA trainings for Modules 5,6,7 need to be completed.
• ASHAs when accompany cases to district they do not usually have place to sit and have
to be at bed side all the time. Some proper sitting place for ASHA at facilities may be
considered.
• VHSCs need to be strengthened. Civil society and Panchayat representation needs to b
ensured.
• Better utilization of RKS and VHSC funds to be ensured.
• Community monitoring to be initiated.
• The joint account of ANM with Pradhan needs to be revisited. ANM not feeling
conformable operating account alongside Pradhan due to trivial issues.

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20 Annexure

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ETAH DISTRICT in Uttar Pradesh

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