Program Monitoring Report of Chattisgarh

District Narayanpur

First Quarter 2013-14

(April – June 2013)

By

National Health Systems Resource Center

Executive Summary

The report is based on monitoring visit to Narayanpur district of Chhattisgarh in June 2013.

A) Introduction:

The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district. Narayanpur is

one of the least developed district of India and of Chattisgarh. The district borders Chattisgarh

and Maharashtra. In the past, Narayanpur was part of the larger Bastar district of erstwhile

Madhya Pradesh and later Chattisgarh.

Almost 5 / 6th

of the district is the Abujhmarh, which is an extremely densely forested, hilly

area. It remain the only unsurveyed area of India. Currently, Abujhmarh is the stronghold of the

Left Wing Extremist groups. Narayanpur is tribal dominated, with Gond, Madia and Bada Madia

being the scheduled and primitive tribe. Abujhmarh is almost a sanctuary of the Madia tribe

without any access to roads, schools and health services. Parts of Abujhmarh are accessible by

roads, but invariably after a certain point roads disappear. The only way of commuting is on foot,

or vehicle like Tractor.

It is crucial to note that Narayanpur being one of the most heavily affected districts due to

LWE. Health, ICDS and school education are probably the only 3 programs signifying the

existence of Government in the district, especially, in the affected area (which is the majority of

the district).

B) Analysis of overall indicators of Narayanpur:

1) Availability of data: Lack of reliable data in general, and especially from the Abujhmarh part

of the district is a key problem. Any data needs to be evaluated in this context, with significant

underreporting possibly the norm. This may be a reason why Narayanpur could not figure in the

list of 183 High Priority Districts. Interestingly (and as a pointer to the significant

underreporting), the NMR, IMR and CMR of the district are lower than the State as a whole.

2) High Priority district: The exclusion of Narayanpur from the list of High Priority District

should be reconsidered as 5/6th

part of Narayanpur is Abujhmarh, which is probably the most

backward and inaccessible part of India. The planning of health system and priority should be

local with flexibility. Narayanpur should be included in the list of districts for the ‘Annual Health

Survey’. This is crucial to get the baseline data for the district.

C) Status of Facilities: Narayanpur has total 68 public health facilities out of these 30 are

designated delivery points. Private health care providers are few and public health care providers

are the only source of modern health care. The public health centers and personnel are

concentrated in mostly the north – east corner of the district. The area which is the primary

Abujhmarh, has negligible residential and functional health facility.

D) Human Resources:

1) Overall HR: The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant.

2) Rural Medical Assistant (RMA): The RMA cadre was the backbone of health services in

Narayanpur. Considering the remoteness, the difficulty in mobility and the conflict nature of the

district, it is crucial that this cadre is encouraged and strengthened.

3) MPW: Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant as there was only

1 MPW training institute in the entire division, which is in the adjoining district of Kanker

(Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate

considering the total requirement of MPW (44 vacancies in only 1 district). A combination of

MPW and ANM is an optimum combination in areas like Narayanpur, where instead of 2nd

ANM, a MPW can be considered. The MPW can provide the necessary support to the ANM

including mobility and security in difficult areas during difficult times, provide curative services

and work for National Disease Control Programs.

4) AYUSH: The involvement of AYUSH doctors in disease control programs as well as other

NRHM activities is minimal.

5) ANM: The ANM are involved in several other works other than primary health work, for

example preparing ration cards, which affected immunization coverage in the recent past and

several immunization sessions did not happen.

6) HR Supervisory cadre and Supervision: The nodal officers for various programs in

Narayanpur are appointed without any specific criteria with existing staff being given additional

charges. For example, the BMO of Orcha block is also the District Malaria Officer. For nursing

staff, there are only 2 LHV in the district. The reasons for significantly less number of LHV is

due to absence of promotions of ANM to LHV, which was not happening due to the inability of

the interested ANM to receive the 2 year training to become LHV as as there is not a single

training institution for LHV in Chhattisgarh.

7) Specialist training:

The selection of HR to be trained and the subsequent utilization of the training by appropriate

posting was severely lacking in the district.

E) Institutional Delivery

The district could report 84% of the expected deliveries, of which majority (52%) were home

deliveries.

1) C - Section and Complicated Deliveries: The C-Section rate is 2.3%, which is very low, and

would mean that several needy women are unable to reach emergency obstetric care center of not

receiving after reaching. This would also mean higher maternal mortality. Similarly, the

proportion of complicated pregnancies attended is also extremely low. This could be improved

by better training of ANM, RMA and PHC MO.

2) Stay in facility after delivery: Majority of the women were leaving the facility within 48

hours after delivery.

3) Management of Obstetric complications: The identification and management of obstetric

complications such as Eclampsia was negligible (0%) in Narayanpur. The detection of maternal

anemia is severely lacking. For ANC care there is lack of standard protocols and urine testing for

Albumin, nitrite, leukocyte esterase and blood was lacking, which would miss cases of pre

Eclampsia and UTI. The use of obstetric interventions as antibiotics, oxytocics was also severely

lacking in Narayanpur.

F) Janani Shishu Suraksha Karyakram (JSSK):

1) OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum

women and newborns in all the facilities visited.

2) Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to

pregnant women if the medicines are available. The system is centralized purchasing but the

supply was not regular and timely for several medicines. System of maintaining inventory

including regular watch of expiry date and timely replenishment is lacking. ANM and

Supervisors were not replenishing the drugs or proactively getting demands from the ASHA.

EDL was absent in the facilities visited and the records and stock were not computerized.

3) Diagnostics: Free Lab/diagnostics services were available at CHCs and DH. Exemptions for

diagnostic services are available for PW and Sick new born. What is missing is the overall

plan of maintenance including AMC, calibration of equipments, provisioning of diagnostics

reagents and regular laboratory technician.

4) Diet: Free diet was provided to pregnant and postpartum women. The food was generally

according to standard menu.

5) Referral transport: 4 Government and 3 Private Vehicles are available for JSSK transport.

If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or

using their own vehicle when the regular ambulances are not available on call or it is not

possible to connect with the facility due to lack of cellular connectivity. Drop back facility

was available in all the facilities visited though limited due to distances, limited number of

Ambulances with respect to the size of the district and extremely difficult terrain. The

referral transport mechanism was especially poor in case of newborns and (as per the data

provided by the district authorities) not a single newborn had received any referral transport

in the entire month of May.

6) Display of entitlement and awareness of community JSSK Entitlements were displayed in

only 1 of the all facilities visited (PHC Chotedongar). Boards in Local language (Gondi)

would be needed in the facilities in the tribal areas of the district.

7) Grievance Redressal / Nodal officer: No specific mechanism for redressal of grievances

exists in facilities visited. The district does not have a separate JSSK nodal officer for solving

grievances. There was lack of clarity on who is the specific point person for such is. There is

no specific accountability or responsibility for following up on complaints received has been

instituted.

8) Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that

when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be

arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying

that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the

ASHA expressed the inability, finally the mother was delivered in the DH itself.

9) Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free

referral transport but the cellular connectivity is almost absent especially in the Orchha block

of the district. This creates a major bottleneck in the optimum implementation of JSSK in the

district.

10) Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to

pregnant anemic women is very few. The blood bank has most of the infrastructure and is

waiting to get the License for operationalization.

G) JSY: The implementation of JSY in Narayanpur is significantly below mark, especially in

the case of home deliveries where only 15.56 % had received the payment. The key bottlenecks

are lack of banking network and unwillingness of Bankers to open ‘0’ balance account.

Considering the overall literacy and awareness level, there are also instances of cheque lying

with tribal for long time.

H) Neonatal and Child Health:

1) Vital rates: The current SBR is high, signifying high burden of birth asphyxia and lack of

emergency obstetric care, including LSCS. The high SBR could also be due to mis-classification

or reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth Asphyxia.

This creates an erroneous picture of less IMR preventing the possibility of corrective measures,

and hence must be audited. The Post neonatal mortality is also high, signifying lack of even ARI

and diarrhoea management services.

2) Timing of Childhood Mortality: The high Post Neonatal and Toddler Mortality is extremely

worrisome. It is indicative that Narayanpur is lagging far behind India as a whole where now

NMR is the key component of Childhood mortality. In Narayanpur, ARI and Diarrhea

managmenet programs are also possibly dysfunctional, with lack of training and supplies to

frontline workers, leading to high childhood mortality in these age groups.

3) Causes of Childhood Mortality: Causes of childhood mortality show great preponderance of

Pneumonia. This needs to be urgently addressed with training of ASHA and ANM in Childhood

ARI management and ensuring supplies.

4) Anganwadi Centers:

In Narayanpur, Anganwadi Centers are in functional in several remote villages and are the only

residential, functional facilities with several run by RK Mission. These Anganwadi offer unique

opportunity with an almost captive population of children for any intensive nutritional and health

intervention and are manned by educated and committed workers trained by RK Mission. The

children in these Anganwadi have several health problems, especially nutritional,

dermatological, ophthalmic and of ENT. Hence strengthening the Anganwadi with better drug

supplies, training and health interventions has possibility of rich dividends for child health.

I) SNCU: There was no SNCU at district hospital. Only a NBSU with average 31 admissions /

month. There were no outbound admission in NBSU in the entire year reflecting lack of referral

linkage or refusal to accept admission. Proportion of Still Births was 8.18% and very high. This

reflects lack of facility and training of asphyxia management and lack of timely emergency

obstetric intervention. Similarly, the proportion of newborn delivered in the hospital and being

admitted into the NBSU was 34% and very high. This reflects lack of proper labour room

management, and must be rectified.

J) Nutritional Rehabilitation Center:

There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It

was heartening to see patients in the NRC.

Areas of Concern:

• Keeping the mothers with the children for the required number of days is a major problem

despite the remunerative incentives to stay. This was due to family considerations.

• Follow up was poor and keeping up with follow up was a major problem.

• The weight gain was unsatisfactory. 15% weight gain was observed in < 50% cases.

• There were no remunerative incentives if the children were admitted again or for follow up.

The remunerative incentives for the first admission were only for a stay of 15 days, and not

more (even if the family wishes to stay for longer duration and the weight gain is

unsatisfactory). In places like Narayanpur, with high overall disease burden, poor outreach

services, recurrent communicable diseases and overall poor literacy and financial levels, it is

very much likely that a child who has once recovered from undernutrition would again fall

back due to the above mentioned reasons. It is also highly likely that the duration required for

a Madia / Gond child in Narayanpur for catch up weight gain would be significantly higher,

and a cut-off of 15 days would be inadequate.

• Hence all the financial remunerative incentives to the mother as well we the Mitanin must be

continued for follow up as well as subsequent admission. There should be no cap of 15 days

stay in the facility if the mother wishes to stay for more days with the child and there should

be commensurate remunerative incentive for this.

K) Outreach Services:

The key finding emerging from the district is that overall ANC registration and post partum

visits are significantly less. There was lack of availability of MCH registers. MCH Clinics are

not functional in Narayanpur, and as per the district health personnel, is not assigned to the

district as well.

L) Immunization:

1) Immunization coverage: The immunization rate for individual vaccines as well as the overall

full immunization coverage at 1 year is around 90%, and this is significant achievement. The

Cold Chain was difficult to maintain considering the lack of electricity.

2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring

the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA

including difficult terrain and inability to pass on information should be considered. If the

delivery is not institutional, the child is not given any dose of Hepatitis B vaccine.

3) Immunization system:

• There were only 8 BCG vials in the District Hospital. The rule of supply of the vials as per

the expected population of children and 1 vial per 4 children and to be used immediately after

opening is creating difficulties in Narayanpur. It is observed that the villages in Narayanpur

are very small (to the extent of 304 houses only) which means effectively the number of

children to be immunized would be quite less, in several cases, less than 4. At the same time,

the distances being large and terrain being difficult, generally visit to 1 or 2 such hamlets

would only take the entire day. Overall, this was resulting into wastage of vials where 1 vial

was being used for less than 4 children and then discarded. And finally less supply (based on

the norm of 1 vial for 4 children) compared to actual feasibility of use in Narayanpur.

• Hence the norm may be reconsidered in Narayanpur with more supply.

M) ASHA, VHSNC and NGO Partners:

1) The key problems identified were: Lack of HBNC kits, regular drug kits and system of drug

refilling, lack of adequate training d skill set of Mentor Facilitator and lack of Travel Allowance

for the Mitanin.

2) Conflict Situation and its effects: There are several instances of the Left Wing Extremists

asking for medicines to the health staff as well as the Mitanins. At the same time, the security

forces also question the Mitanin regarding the stock and supplies they carry from the block of

district HQ meeting to their villages with the doubt the medicines they carry would be for the

Maoists.

Overall, in places like Narayanpur where the formal health system is weak, it is extremely

crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system,

which is feasible locally, extend their training, provide them the necessary supplies and expand

the roles. They are the last connection with the people of the health system, especially in districts

like Narayanpur where the regular other health system is limited due to several reasons.

3) VHSNC: Gram Panchayat are not fully functional in Narayanpur as due to the opposition by

the Maoists to elections, Sarpanch and Gram Sevak hardly resides in villages. The method of

release of their payment through Panchayat is non functional and the concern was with the

implementation of the system of payment through Panchayat; the minimal incentives the Mitanin

were getting so far will also get stopped, reducing their involvement further. Considering the

unavailability of the Sarpanch and Gram Sevak, Bearer Cheque may be considered.

4) IEC: The orientation camps undertaken in the past with rigorous group discussions was a

better and more personalized model to communicate with tribal considering the culture and

literacy level in this area. The current method where the contents, IEC material are directly sent

from Raipur and are not in the local language (Gondi nor Madia) was not working.

5) NGO: Ramakrishna Mission is functional in Narayanpur district in the most interior parts,

providing extremely useful services. More convergence and involvement of the RK Mission with

health services will be useful.

N) Program Management:

1) Key issues emerging were: Induction training for NRHM staff and the DPM and establishing

block program management structure was desired in Narayanpur. The criteria of recruiting only

from the district was probably acting as a bottleneck in filling the vacancies as there is lack of the

trained HR for the respective positions in the district. Hence, can this rule be relaxed, probably

on a case basis, and / or allowing recruitment from adjoining districts such as Kanker,

Dantewada, Bijapur, Sukma, Kondagaon and Bastar?

2) PIP Planning and setting priorities: The process of setting priorities for Narayanpur should

consider local morbidity pattern. For example, it was observed that the BMO of Orcha (the only

MBBS doctors in the entire block), who is holding additional charge of District Malaria Officer,

had to go to Raipur to attend a meeting on ‘YAWS’, leading to his absence from the facility and

the block for 3 days, depriving the people of crucial health services. Is YAWS is a priority in

general and specifically for Narayanpur?

O) Quality of Services and supportive services:

1) Solar: The regular functionality of the solar back-up system is heartening and to maintain this,

there should be an integrated plan for regular maintenance and troubleshooting.

2) Mobility facilities: Roads are in poor condition and completely blocked in monsoon. No

regular 4-wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel but only Tractor (or

similar vehicles) or a Jeep with 4 Wheel gear system and motorcycle. Ambulances cannot travel

due to poor roads and less ground clearance of the vehicle severely affecting the availability of

emergency medical transport system preventing the health system of performing its crucial task

and eliminates the possibility of the representation of the State in a human form at the most

crucial and required hour. Lack of funds for the repair of vehicles including tires and battery in

Narayanpur where the life cycle of vehicles gets reduced from 10 to 5 years is concern.

3) Mobile and Internet connectivity: Lack of connectivity, which is already limited within a

radius of few kilometers of the district HQ, and further jammed when the security forces go for

patrolling to avoid information being spread about the whereabouts of the security personnel and

avoid an ambush. Internet connectivity is only in the district HQ, even where reliable network is

generally limited to the offices of Collector and CEO.

4) Infrastructure creation, maintenance and public works department:

• The work of the PWD was poor and maintenance was unsatisfactory in several of the

facilities visited. Uniformly water seepage, lack of staff quarters and delayed construction

were problems. The Maoists due to the possibility of the structures being used by security

forces to establish their bases oppose any structure with solid walls and flat roof.

• The district administration has proposed a novel structure of Bamboo, which is treated to be

fireproof, waterproof and anti termite with reasonable strength to last for up to 30 years.

These structures are being constructed in Bijapur and so far are unopposed by the Maoists.

5) HMIS / MCTS:

• It is extremely difficult to establish and operationalize internet-based systems such as MCTS

which assume reasonable speed and penetration of internet facilities in places like

Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur may be affecting

the regular functioning of the system.

• Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to

only the district HQ (not even block HQ) for such entry, as district HQ is the only place with

overall internet facility. For such, she would require to travel and spend 3 days considering

the lack of transport facilities in the district. At the same time, there is no assurance that the

internet would be functioning on that particular day when the ANM has reached the district

HQ.

• There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero

dose in the manual format but its inclusion in the software. Additionally there is the

persistence problem of villages of a certain PHC / block shown under different PHC / Block

resulting in more problems in reporting. Offline entry was not possible in MCTS.

P) Other health priorities / programs:

1) Mobile Medical Unit: 1 MMU is operational with average daily OPD of 52 patients and

average 14 lab tests. The average number of villages covered each month was 20 with 20

functional days per month. It will be useful to explore how to improve the diverse functionality

of the MMU, including services for NCD. A key problem was the large size and poor ground

clearance of the MMU which would lead to the vehicle getting stuck several times on the roads.

2) Surgical morbidities and tertiary care: The tribal from interior village were willing to

receive medical care for their morbidities, but unable to, due to lack of surgical care at the

district HQ, funds and support. Hence surgical care through camps and a special fund at the

district level to provide free advanced referral care to tribal including transport, a trained medical

social worker as accompanying person and the entire medical care would be useful.

Q) Disease Control Programs:

1) IDSP: The DPMU had recruited a person after significant efforts as IDSP I / c who was

functioning. Nevertheless, due to the recent change in the HR criteria, which makes it mandatory

to have 3 years of experience to be eligible for the post, the current IDSP manager would be

terminated. In places like Narayanpur, it may not be feasible to insist on 3 years of prior

experience and may effectively mean that the post would remain vacant. Instead, on job training

may be an alternative, if the candidate is committed and willing to learn and work.

2) Malaria: Narayanpur is endemic for malaria, especially falciparum. Though the commitment

of the outreach staff who are willing to work in a mission mode in cases of malaria epidemics is

remarkable, the key concerns are lack of integrated malaria prevention and management plan,

absent schedule of IRS and lack of supplies of LLIN or ACT and other antimalarials.

3) RNTCP: Considering that the burden of TB would be quite high in tribal district like

Narayanpur (as is the experience from other tribal districts), the suspected cases examined are

less, with a proportion of only 140 / 1,00,000. Screening and case detection can be increasing

through TB screening through the MMU, mass-selective screening of patients of cough through

ANM and ASHA, increasing the access to sputum collection through ANM and ASHA and

considering establishing advanced diagnostic method like DNA / PCR.

Detail Report

A) Introduction:

The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district, which is one of the

least developed district of India and of Chattisgarh, bordering Chattisgarh and Maharashtra. In

the past, Narayanpur was part of the larger Bastar district of erstwhile Madhya Pradesh and later

Chattisgarh.

Almost 5 / 6th

of the district is the Abujhmarh, which is an extremely densely forested, hilly area.

It is also the only unsurveyed area of India and currently the stronghold of the Left Wing

Extremist groups. Primarily Narayanpur is tribal dominated, with Gond, Madia and Bada Madia

being the scheduled and primitive tribe inhabiting Narayanpur. Abujhmarh is almost a sanctuary

of the Madia tribe without any access to roads, schools and health services.

It is crucial to note that Narayanpur being one of the most heavily affected districts due to LWE.

Health, ICDS and school education are probably the only 3 programs signifying the existence of

Government in the district, especially, in the affected area (which is the majority of the district).

Parts of Abujhmarh are accessible by roads, but invariably after a certain point beyond the

district HQ, roads become non-existent, leading to only forest. The only way of travel is on foot,

or vehicle like Tractor.

Table 1: Visit Schedule of first quarter visit was as follows

Dates Facility

Personnel

Type

Facility/places visited

22nd

,

23rd

and

24th

June

District Meeting with District Collector

Meeting with District CEO

District Hospital,

Civil Surgeon’s Office,

CHMO office,

DPMU

CHC Orchha

PHC Dhanora

PHC Chotedongar

RMA Sonpur

Mitanin

Trainer

Kurushnar

Mitanin Ader

ICDS Rohtad

B) Analysis of overall indicators of Narayanpur:

1) Key observations:

• Lack of reliable data in general, and especially from Abujhmarh is a key problem. Any data

needs to be evaluated in this context, with significant underreporting probably the norm. The

same underreporting may be a reason why Narayanpur could not figure in the list of 183

High Priority Districts. Interestingly (and as a pointer to the significant underreporting), the

NMR, IMR and CMR of the district are lower than the State as a whole!

• The MMR of Chhattisgarh as a State is 263; MMR of Narayanpur is 283. This could be due

to lesser availability of emergency obstetric facilities, inability to seek timely referral due to

unavailability of cellular network remote and being tribal and extremist-affected district.

• The district has 2 blocks, Narayanpur and Orcha (comprising the entire Abujhmarh area).

There were 60 Gram Panchayat for 413 villages (and even more hamlets, which are placed at

quite a distance), the average number of villages per VHSNC would be 6. Considering the

terrain and distance in Narayanpur, effectively this would mean non-functional VHSNC.

2) High Priority district:

• The exclusion of Narayanpur from the list of High Priority District should be reconsidered

urgently. In fact, a separate category may be considered of ‘Extremely High Priority

Districts’ for Narayanpur as almost 5/6th

part of Narayanpur is Abujhmarh, probably the most

backward and inaccessible part of India.

• The planning of health system and priority should be localized and there should be

significant flexibility. Additionally, Narayanpur district should be included in the list of

districts for the ‘Annual Health Survey’. This is crucial to get the baseline data for the district

and was voiced as a key demand by the district authorities.

Statistics Chattisgarh Narayanpur

Population - Census – 2011

Person 2,55,40,196 1,39,820

Male 1,28,27,915 70,104

Female 1,27,12,281 69,716

Sex Ratio ( No. of Females per1000

males) Census - 2011 991 995

Sex Ratio 0 - 6 years Census - 2011 964 946

MMR ( per 100,000 live births)

SRS - 2012

263 (HMIS) 281(HMIS)

CBR ( per 1000 population) 21.5 21.5

CDR ( per 1000 population) 7.9 7.9

IMR 48 (RHS 2012 ) 42 (HMIS)

Neo- natal Mortality Rate 35 (HMIS) 22.16 (HMIS)

Under Five Mortality Rate 66 (HMIS) 51 (HMIS)

Literacy Rate - Census – 2011 Person 71.04 40.49

Male 81.45 47.71

Female 60.59 33.23

% Decadal Growth Rate 22.59 28.74

Population Density per Sq.K.m 189 20

Blocks 02

Villages 413

Gram Panchayat 69

C) Status of Facilities:

• Narayanpur has total 68 public health facilities out of these 30 are designated delivery points,

the number and distribution as well as designated delivery points are as follows.

• In Narayanpur private health care provider are few and public health care providers are the

only source of modern health care. Crucially though, the public health centers and personnel

are concentrated in mostly the north – east corner of the district. The area in the west, and

bordering Maharashtra, which is the primary Abujhmarh, has negligible residential and

functional health facility. This situation is complicated further by overall the lack of roads,

and especially problematic conditions in Monsoon.

.

D) Human Resources:

1) Overall HR:

• The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant. In District Hospital,

of the sanctioned 26 Class 1 posts, only 1was filled. Of the sanctioned 22 Class II posts, only

7 are filled.

• It was desired by the contractual staff that considering the overall conflict situation of

Narayanpur, at least Life Insurance Policy should be considered for the staff. In fact

Total

number

Designated Delivery

points (%)

Level I facility

1 SHC 59 23 (39 %)

Level II facility

2 PHC 7 5 (71.4 %)

(100 %) 3 CHC 1 1

Level III facility

4 DH 1 1 (100 %)

Total 68 30 (44.11%)

No. of licensed blood banks (include pvt) 0

No. of licensed blood storage units/centers 0

considering that the health staff is the only other state staff apart from education and ICDS to

venture in interior and provide services, the distinction between contractual and permanent

may be reduced to possible extent.

• There is need of specific HR policy including clarification on promotions and

regularization and payment rules in an integrated manner, not fragmented. Similarly there is

need of retaining the staff to have institutional memory (the lack of which was sighted by the

district authorities as a major problem).

2) Rural Medical Assistant (RMA):

• The RMA cadre was the backbone of health services in Narayanpur. Considering the

remoteness, the difficulty in mobility and the conflict nature of the district, it is crucial that

this cadre is encouraged and strengthened. It is important to understand that the work of a

medical personnel in the conflict zone in districts like Narayanpur is not only providing

services but several others such as establishing access, communicating with people and doing

unexpected tasks as even rescuing a vehicle stuck in mud.

• Hence, increasing the number of RMA and their skill set by continuous training in CMC

Vellore should be increased. Additionally, new training should be planned as per the desired

skill set for RMA.

3) MPW:

• Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant. There was only 1

MPW training institute in the entire division, which is in the adjoining district of Kanker

(Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate

considering the total requirement of MPW (44 vacancies in only 1 district).

• Considering this, ideally, an MPW training institute should be established for 2 districts and

all the posts should be filled at the earliest.

• It is important to note that a combination of MPW and ANM is the optimum combination in

areas like Narayanpur, where instead of 2nd

ANM, a MPW can be considered. The MPW can

provide the necessary support to the ANM including mobility and security in difficult areas

during difficult times, provide curative services and work for National Disease Control

Programs.

4) AYUSH:

• There was no integration of the regular NRHM activities with AYUSH with a parallel

structure not involving the regular CMHO. The involvement of AYUSH doctors in disease

control programs as well as other NRHM activities is minimal and should be increased to

optimally utilize them. An Ayurvedagram was observed in Orcha. It was reported that the

doctors remains present in the facility for 3-4 days in the week with OPD of 3-4 per day.

Generally, the cases are of URI and fever.

• Overall, the functionality, utilization and usefulness of AYUSH services and Ayurvedagram

were limited and can be reorganized catering to the immediate priorities of the people.

5) ANM:

• The ANM are involved in several other works other than health work, as preparing ration

cards. This affected immunization coverage in the recent past and several immunization

sessions did not happen. Overall, this was pointed as trend overloading the ANM.

• Recently a Government ANMTC was established in the district. A private ANMTC is

functioning since 2 years.

6) HR Supervisory cadre and Supervision:

• Overall supervision is extremely difficult in Narayanpur due to several reasons including lack

of HR, difficult terrains and lack of connectivity.

• The nodal officers for various programs in Narayanpur are appointed without any specific

criteria with existing staff being given additional charges. This adversely affects the

supervision. Example, the BMO of Orcha block is also the District Malaria Officer. Orcha

BMO being from an interior facility level, his additional charge requires him to stay at the

district HQ, affecting the regular work of providing medical services in the facility and in the

block. Finally, there is no overall comprehensive plan of supervision for doctors.

• Though there is plan for supervising ANM, only 2 LHV were present, affecting actual

supervision. The reasons for significantly less number of LHV is due to absence of

promotions of ANM to LHV, which was not happening due to the inability of the interested

ANM to receive the 2 year training to become LHV. The training could not be provided, as

there is not a single training institution for LHV in Chhattisgarh. The only one is in Jabalpur,

in Madhya Pradesh. This is leading to a situation where the ANM are retiring as ANM only

without any prospects of receiving additional training and promotion. There were examples

of staff in the service for 32 years (Orcha acting Sector Supervisor) without formal

promotion and the benefits.

• Hence a separate plan of supervision if required in such areas and establish a training

institution in Chhattisgarh at the earliest to provide the necessary cadre.

7) Specialist training: Overall, the selection of HR to be trained and the subsequent utilization

of the training by appropriate posting was severely lacking in the district. This is of great concern

considering that severe lack of trained HR in the district and unwillingness of HR to join in.

F) Deliveries: Overall

The district could report 84% of the expected deliveries, of which majority (52%) were home

deliveries. In addition to cultural reasons, the lack of transport and mobile services as well as the

absence of expedited channels of payments was key reasons for lack of institutional deliveries.

Narayanpur Deliveries

Total Population 1,39,820

Home SBA Home Non SBA

530 1,315

Home SBA % Home Non SBA%

15% 37%

G) Institutional Delivery

1) C - Section and Complicated

would mean that several needy women are unable to reach emergency obstetric care center o

receiving after reaching. This would also mean higher maternal mortality.

complicated pregnancies attended is also extremely low. This could be improved by better

training of ANM, RMA and PHC MO.

C sections & Complicated Deliveries

Deliveries (Public)

Total Deliveries

C Section (%)

Complicated Pregnancies

attended (%)

2) Stay in facility after delivery

hours after delivery.

Stay for more than 48 hrs

after delivery

8%

Chattisgarh-Naryanpur- Stay duration as percentage of Reported Institutional Deliveries

Narayanpur Deliveries - Apr'12 to Mar'13

1,39,820 Expected Deliveries 3,511

Home Non SBA Institutional (Pub & Pvt) Total Deliveries

Reported

1,315 1088 2,933

Home Non SBA% Institutional % Total Deliveries

Reported %

31% 84%

Section and Complicated Deliveries: The C-Section rate is 2.3%, which is

would mean that several needy women are unable to reach emergency obstetric care center o

receiving after reaching. This would also mean higher maternal mortality. The proportion of

cated pregnancies attended is also extremely low. This could be improved by better

training of ANM, RMA and PHC MO.

C sections & Complicated Deliveries 12 - 13

Institutional

Deliveries (Public)

Institutional

Deliveries (Pvt)

Total Institutional

deliveries

1088 NA

25 (2.3%) NA 25

26 (2.4%) NA 26

2) Stay in facility after delivery: Majority of the women were leaving the facility within 48

Stay for less than 48 hrs

after delivery

92%

Stay for more than 48 hrs

after delivery

Stay duration as percentage of Reported Institutional Deliveries - Apr'12 to Mar'13

3,511

Total Deliveries

Reported

2,933

Total Deliveries

Reported %

84%

Section rate is 2.3%, which is very low, and

would mean that several needy women are unable to reach emergency obstetric care center or not

he proportion of

cated pregnancies attended is also extremely low. This could be improved by better

Total Institutional

deliveries

1088

25 (2.3%)

26 (2.4%)

Majority of the women were leaving the facility within 48

Stay for less than 48 hrs

after delivery

Apr'12 to Mar'13

3) Management of Obstetric complications: The identification and management of obstetric

complications as Eclampsia was negligible (0%). The detection of maternal anemia was also

lacking. For ANC care there is lack of standard protocols. Similarly, urine testing for Albumin,

nitrite, leukocyte esterase and blood was absent missing cases of pre Eclampsia and UTI. The

use of obstetric interventions as antibiotics, oxytocics was also severely lacking in Narayanpur.

Overall, there is significant need for strengthening obstetric services and emergency care.

Management of Complications 12 - 13

Reported % against reported

ANC Registration

Hypertensive cases detected at institution 301 9.4%

Eclampsia cases managed during delivery 0 0%

ANC women having Hb level<11 377 11.7%

ANC women having severe anemia (Hb<7)

treated at institution 46 1.4%

Obstetric Interventions Cases

C - Section 25

PP Maternal Complications 1

Abortions 82

Still Births 90

Severe anemia cases treated 46

Blood Transfusion 2

IV antihypertensive / Magsulph injection 10

IV Oxytocin 23

IV Antibiotics 22

I) Janani Shishu Suraksha Karyakram (JSSK):

1. OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum

women and newborns in all the facilities visited. The awareness of the new rule of extending

the benefit to 1 year may be focused upon.Nevertheless, there were informal reports from

Mitanin that Doctors in the District Hospital demand money (in the specific case recounted,

5000 INR) for services.

2. Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to

pregnant women if the medicines are available. The system is centralized purchasing and

probably in the process of being established as the supply was not regular and timely for

several medicines. The system of maintaining inventory including regular watch of expiry

date and timely replenishment is lacking. Several drugs were expired. ANM and Supervisors

were not proactively replenishing the drugs. EDL was absent in the facilities visited and the

records and stock were not computerized.

3. Diagnostics:

• Free Lab/diagnostics services were available at CHCs and DH. Exemptions for diagnostic

services are available for PW and Sick new born. What is missing is the overall plan of

maintenance including AMC and calibration. In both the CHC as well as the PHC the

facilities were poor with lack of regular provisioning of diagnostics and regular laboratory

technician. In such situation, the antenatal check up is devoid of any significant benefits.

Even basic laboratory reagents and kits were also lacking.

• In view of this, and in view of the significant investment in provision of modern and high end

equipments being provided and sanctioned in the budget, the provision of such a maintenance

plan, agency and personnel should be made integral part of the PIP. A separate wing like

IDW can be considered for the same. The full functionality of equipments is necessary for

optimum services and are as crucial as other civil infrastructure. Similarly, Point of Care

Tests should be considered to improve diagnostic facilities.

4. Diet: Free diet was provided to pregnant and postpartum women. The food was generally

according to standard menu.

5. Display of entitlement and awareness of community: JSSK Entitlements were displayed in

only 1 of the all facilities visited, which is the PHC Chotedongar. Nevertheless, similar

boards in Local language (Gondi) would be needed in the facilities in the tribal areas of the

district.

6. Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that

when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be

arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying

that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the

ASHA expressed the inability, finally the mother delivered in the DH itself.

7. Referral transport

• Overall in the district, 4 Government and 3 Private Vehicles are available for JSSK transport.

If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or

using their own vehicle when the regular ambulances are not available on call or it is not

possible to connect with the facility due to lack of cellular connectivity

• Drop back facility was available in all the facilities visited though limited due to distances,

limited number of Ambulances with respect to the size of the district and extremely difficult

terrain.

• The referral transport mechanism was especially poor in case of newborns with as per the

data provided by the district authorities, not a single newborn receiving any kind of referral

transport in the entire month of May.

8. Grievance Redressal / Nodal officer

• No specific mechanism for redressal of grievances exists in facilities visited. The district

does not have a separate JSSK nodal officer for solving grievances. There was lack of clarity

on who is the specific point person for such is. There is no specific accountability or

responsibility for following up on complaints received has been instituted. No records of

registration of complaints, follow up actions, and post-resolution feedback related to JSSK

have been maintained with the primary reasons mostly being the lack of complaints.

• Hence, a grievance redressal mechanism needs to be put in place urgently at all levels of

health facilities, and records of the same maintained. Meaningful analysis can be done after

2-3 months of operationalizing the grievance redressal process and determining the

commonest complaints, actions taken and the response time. Considering the significant

tribal population of the district, for voicing any grievance in the district, a special mechanism

versed in the local language may be needed.

9. Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to

pregnant anemic women is very few. The blood bank has most of the infrastructure and is

waiting to get the License for operationalization. This must be expedited urgently

considering the immense need of blood transfusion.

10. Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free

referral transport but the cellular connectivity is almost absent especially in the Orchha block

of the district. This creates a major bottleneck in the optimum implementation of JSSK in the

district.

JSSK Referral Transport Service Report of Narayanpur:- MAY 2013

NAME OF

INSTITUTE

No. of

vehicles

No. of

deliveries

No. of Pregnant & Lactating

Mothers provided free

transport

no. of

sick

neonate

admitted

No. of Neonate Provided free

transport

Home

to

Institute

Institute

to

Institute

Drop

back

Home

Home

to

Institute

Institute

to

Institute

Drop

back

Home

monthly monthly monthly monthly monthly monthly monthly monthly

DISTRICT

NARAYANPUR

4+3 96 76 6 86 30 0 0 0

DH

NARAYANPUR

3+1 70 60 4 62 30 0 0 0

CHC ORCHHA 1+1 8 5 2 8 3 0 0 0

JSSK Referral Transport Service Report of Narayanpur: 2012 - 13

NAME OF

INSTITUTE

No. of

vehicles

no. of

deliveries

No. of Pregnant & Lactating

Mothers provided free

transport

no. of

sick

neonate

admitted

No. of Neonate Provided free

transport

Home

to

Institute

Institute

to

Institute

Drop

back

Home

Home

to

Institute

Institute

to

Institute

Drop back

Home

District

Hospital

4 771 81 43 662 377 - - -

Benoor PHC 0 33 3 0 27 0 4 - -

Chhotedongar

PHC

1 123 10 2 63 0 8 - 1

Orchha CHC 1 33 5 0 15 0 - - -

J) JSY:

• The implementation of JSY in Narayanpur is significantly below mark, especially in the case

of home deliveries where only 15.56 % had received the payment. One of the key bottlenecks

in payment is the lack of banking network and women find it extremely difficult to open

bank accounts. Considering the overall literacy and awareness level, there are instances of

cheque lying with tribal for long time. Unwillingness of Bankers to open ‘0’ balance account

despite clear instructions is a recurring problem. With accountant payee cheque in the

absence of bank accounts, the concern was raised that this may lead to further reduction of

JSY payments.

• It can be discussed as to why there is need of separate accounts for each scheme and why the

payment of JSY cannot be done through existing account such as of MGNREGA. Similarly,

the payment of JSY should be also allowed through BC, DCC and Urban Cooperative banks

as per the feasibility of the patients.

Naryanpur: JSY Paid to Mothers as % of reported deliveries 12 - 13

Deliveries JSY Paid

to mothers

% JSY paid against reported

deliveries

Home 1,845 287 15.56%

Institutional (Public) 1,088 1,060 97.43%

Total 2933 1347 45.93 %

K) Family planning:

1) Achievement:

It was heartening that the utilization of spacing methods was 89%. Overall, the priority of family

planning in Narayanpur should be considered in view of the small size of the Madia Community.

Narayanpur FP Methods 12 - 13

Reported % of All Reported

FP Methods

Total Reported FP Method (All types) Users 4,127 -

Sterilizations 453 11%

IUD 220 5%

Condom Users 1,939 47%

OCP Users 1,515 37%

Limiting Methods 453 11%

Spacing Methods 3,674 89%

2) Type of sterilization: Of the total procedures, majority were female sterilization and mostly

Laparoscopic. The district needs to undertake steps to increase NSV by especially by training

PHC MO in NSV and conducting more camps at PHC and CHC level.

Narayanpur Sterilizations 12 - 13

Reported % of Reported Sterilization

Total Sterilization 453

NSV 123 27%

Laparoscopic 328 72%

MiniLap 2 0%

Post Partum - 0%

Male Sterilization 123 27%

Female Sterilization 330 73%

3) Unmet need of family planning:

The total unmet need is 26.4% in the district, which is understandable considering the overall

picture of the district.

Naryanpur- Unmet need ( DLHSIII) met by reported FP Methods - Apr'12 to Mar'13

Estimated total

Eligible Couples

(17% of population)

24,329.89 Eligible Couples for

unmet need

Total reported

FP Users

Unmet need met

by Reported

Family Planning

Methods

Unmet Needs

Total 26.4 6,423 4,127 64%

Limiting 10.9 2,652 453 7%

Spacing 15.5 3,771 3,674 57%

L) Neonatal and Child Health: Overall:

1) Vital rates:

• There is lack of district specific data from SRS or AHS. There is also significant possibility

of underreporting. For example, the NMR is almost equivalent to Maharashtra! To rule out

this, an independent audit would be advisable, and the district should be included in AHS.

• The current SBR is high, signifying high burden of birth asphyxia and lack of emergency

obstetric care, including LSCS. The high SBR could also be due to mis-classification or

reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth

Asphyxia. This creates an erroneous picture of less IMR preventing the possibility of

corrective measures, and hence must be audited.

• The Post neonatal mortality is also high, signifying lack of even ARI and diarrhoea

management services.

Narayanpur: Deaths 12 - 13

Live Births - Reported Live Births estimated Still Births Early Neonatal

deaths

2,843 3,420 90 60

Late Neonatal Deaths Infant Death Under 5

Deaths Maternal Deaths

3 118 145 8

Narayanpur Vital rates

Against Reported Live

Births (1000)

Against Estimated Live Births

(1000)

Reported Still Birth 31.66 26.31

Reported Perinatal Mortality 52.76 44

Reported Neonatal Mortality 22.16 18.42

Reported Infant Mortality 41.51 34.50

Reported Under 5 Child Deaths 51.0 42.39

2) Timing of Childhood Mortality:

• Early Neonatal, Post Neonatal and Toddler Mortality are significantly high in Narayanpur.

The provision of home based newborn care, timely referral, provisions of standard and

quality intensive care can prevent a significant proportion of these deaths. Hence it is crucial

to identify delays in identifying critical newborns, whether facility admissions are as per the

protocol and whether there has been adequate and quality roll out of HBNC.

• A postpartum visit by both the ANM and ASHA in case of home deliveries as well as in case

of institutional deliveries where the mother gets discharged early is hence crucial. There is

significant possibility of this not happening and hence the there is need of supervision of the

work of ANM.

• The high Post Neonatal and Toddler Mortality is extremely worrisome. It is indicative that

Narayanpur is lagging far behind India as a whole where now NMR is the key component of

Childhood mortality. In Narayanpur, ARI and Diarrhea management programs are also

possibly dysfunctional, with lack of training and supplies to frontline workers, leading to

high childhood mortality in these age groups.

3) Causes of Childhood Mortality:

The causes of childhood mortality show great preponderance of Pneumonia as overall cause of

childhood deaths. This needs to be urgently addressed (and can be easily done) with training of

ASHA and ANM in Childhood ARI management and ensuring supplies.

4) Anganwadi Centers:

In Narayanpur, Anganwadi Centers are in functional in several remote villages. In fact, they are

the only residential, functional facilities. Several of these Anganwadi are run by RK Mission.

These Anganwadi centers offer unique opportunity in that they have an almost captive

population of children for any intensive nutritional and health intervention and are manned by

educated and committed workers trained by RK Mission. On the other hand, the children in these

Anganwadi have several health problems, especially nutritional, dematological, ophthalmic and

of ENT.

Hence strengthening the Anganwadi with better drug supplies, training and health interventions

has possibility of rich dividends for child health.

M) SNCU:

There was no SNCU at district hospital. Only a NBSU is present with average 31 admissions per

month.

Areas of concern:

• No outbound admission was in NBSU in the entire year. This reflects severe lack of referral

linkage or refusal to accept admission, and must be explored and rectified.

• The proportion of Still Births was 8.18% and very high. This reflects lack of facility and

training of asphyxia management as well as lack of timely emergency obstetric intervention.

• The proportion of newborn delivered in the hospital and being admitted into the NBSU was

34% and very high. This reflects lack of proper labour room management, and must be

rectified.

• Overall, the maintenance of data was poor and need attention.

Name of District Narayanpur : 1 APRIL 2012 - 31 MARCH 2013

Total

Deliver

y

Admissions to

NBSU

Still

Birt

h

>

2500

gm

<

2000

-

2500

gm

150

0 -

200

0

gm

<

150

0

gm

Cure

d &

D / c

LAM

A

Referre

d

Deat

h

%

Deat

h Inbor

n

Out

bor

n

Tot

al

1099 377 0 377 90 Data not available

N) Nutritional Rehabilitation Center:

There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It

was heartening to see patients in the NRC.

Areas of Concern:

• Keeping the mothers with the children for the required number of days is a major problem

despite the remunerative incentives to stay. This was due to family considerations.

• Poor Follow up and difficulty in community based follow up.

• The weight gain was unsatisfactory. 15% weight gain was in less than 50% cases.

• Lack of remunerative incentives if the children are admitted again or for follow up. The

remunerative incentives for the first admission were only for a stay of 15 days, and not more

(even if the family wishes to stay for longer duration and the weight gain is unsatisfactory).

• In places like Narayanpur, with high overall disease burden, poor outreach services, recurrent

communicable diseases and overall poor literacy and financial levels, it is very much likely

that a child who has once recovered from undernutrition would again fall back due to the

above mentioned reasons. It is also highly likely that the duration required for a Madia /

Gond child in Narayanpur for catch up weight gain would be significantly higher, and a cut-

off of 15 days would be inadequate.

• Hence all the financial remunerative incentives to the mother as well we the Mitanin must be

continued for follow up as well as subsequent admission. There should be no cap of 15 days

stay in the facility if the mother wishes to stay for more days with the child and there should

be commensurate remunerative incentive for this.

NRC: April 2012 - March 2013

Total

admissions

Bed

Occupancy

Rate

Achieved

target weight

(15% weight

gain)

Discharge

from NRC

LAMA /

Defaulte

r

Non

Respond

ers

Death Still in

Ward

149 75.9 11.35% 128 14 2 1 0

NRC: April 2012 - March 2013

Children

due for

follow up

Children

followed

up

Defaulter for

follow up

Non

responder

after 4th

follow up

Death

during

follow

up

period

Relapse No. of

Children

completed

4th follow

up

Achieve

d

MUAC

>11.5

cm &

wet>2sd

142 67 71 2 0 2 4 22>91

O) Outreach Services:

Overall ANC registration and post partum visits are significantly less. There was lack of

availability of MCH registers. Despite repeated demands to the State HQ, there has been no

provision since 5 to 6 months. Ultimately, the district printed the MCH registers using the untied

funds. MCH Clinics are not functional in Narayanpur, and were not assigned to the district.

Performance Indicators of ANM Apr'12 to Mar'13

% ANC Registration in First Trimester

against Reported ANC registration 24%

% PNC visits within 48 hours and

14 days against total deliveries 42%

% Three ANC checkups against estimated

pregnancies. 69%

% Severe anemia (Hb<7) treated

against reported ANC registration 1.4%

ANC

ANC Check-up in first trimester 758

3 or more ANC Check-up 2,578

At least 1 TT received 2,091

100 IFA Tablets 3,311

P) Immunization:

1) Immunization coverage: The immunization rate for individual vaccines as well as the overall

full immunization coverage at 1 year is around 90%, and this is significant achievement. The

Cold Chain was difficult tp maintain considering the lack of electricity. Also, the staff had to

walk for several kilometers to ensure vaccination in the hamlets and villages.

2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring

the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA

including difficult terrain and inability to pass on information should be considered.

Child Immunisation (0 to 11 months)

Measles given against Expected Live

Births 82%

Measles given against Reported Live Births 98%

Fully Immunised Children against

Reported Live Births 95%

Fully Immunised Children against

Expected Live Births 79%

Required numbers of VHNDs per

thousand population in 12 months

1,7

17

3) Hepatitis B Vaccination: If the delivery is not institutional, the child is not given any dose of

Hepatitis B vaccine. It was pointed out to the district officials that it is better to vaccinate late

than never. Considering the situation of Narayanpur where institutional delivery is difficult, the

opportunity to vaccinate a child for Hepatitis B should be utilized any time when possible

including when the ANM visits the village and encounters the child for the first time.

4) Alternate Vaccine Delivery System: The district health system officials pointed that instead

of sending the vaccines through another person, sending the vaccines through ANM with

additional incentive to the ANM would improve the efficiency of vaccine delivery pointed it.

5) Immunization system:

• There were only 8 BCG vials in the District Hospital.

• The rule of supply of the vials as per the expected population of children and 1 vial per 4

children and to be used immediately after opening is creating difficulties in Narayanpur. It is

observed that the villages in Narayanpur are very small (to the extent of 304 houses only)

which means effectively the number of children to be immunized would be quite less, in

several cases, less than 4. At the same time, the distances being large and terrain being

difficult, generally visit to 1 or 2 such hamlets would only take the entire day. Overall, this

was resulting into wastage of vials where 1 vial was being used for less than 4 children and

then discarded. And finally less supply (based on the norm of 1 vial for 4 children) compared

to actual feasibility of use in Narayanpur.

• Hence the norm should be reconsidered in Narayanpur and more supply should be provided

with more liberal norm.

Q) ASHA, VHSNC and NGO Partners:

1) Selection:

• In Narayanpur, of the approved 525ASHA, 508 were in place. Similarly the positions of 2

Block Community Mobilizers have been filled.

2) ASHA training:

No. of ASHAs trained in: 2012 - 13

• Module five 300

• Module six 305

• Module seven 305

3) Tasks ASHA is supposed to perform are as follows:

• JSY delivery in PHC or any recognized hospital (Tribal & Non-Tribal Areas)

• Motivation of BPL/SC/ST beneficiary for tubectomy

• Motivation of any beneficiary for vasectomy

• Completion of DOTS (RNTCP)

• Radical treatment of malaria Positive case

• Leprosy treatment

• Control of epidemic (outbreak)

• Escort of pregnant women for HIV testing in PPTCT centers, Admission of HIV +ve

mother for delivery in PPTCT center, Follow up of HIV positive mothers at 6 week, 6 and

18 months

• Immunization at Village Level

• Motivation of community for toilet construction

• Birth Information Registration of Birth

• Death Information of Age group 0 to 5,Information of women death for the age group

between 15 to 49 years

• For recording of Maternal death in the age group of 15 to 49 yrs, Yearly Immunization,

• Bringing critically ill child to hospital (for tribal areas only)

• Sickle Cell control program

4) The key problems identified were:

• Lack of HBNC kits.

• Lack of regular drug kits and antimalarials.

• Lack of system of drug refilling.

• Lack of supervisory visits.

• Lack of training of Mentor Facilitator.

• Lack of alternate system of payment in case the mother cannot avail the services of JSSK

(transport etc) due to poor connectivity, emergency and lack of vehicle.

• Lack of Travel Allowance for the Mitanin. A flexible system of travel allowance based on

distances to be travelled and transport facilities is extremely necessary.

5) Conflict Situation and its effects: There are several instances of the Left Wing Extremists

asking for medicines to the health staff as well as the Mitanins. At the same time, the security

forces also question the Mitanin regarding the stock and supplies they carry from the block of

district HQ meeting to their villages with the doubt the medicines they carry would be for the

Maoists. Considering this, it should be ensured that the Mitanin receive regular supplies inside

the village to escape from the questioning from security forces.

Overall, in places like Narayanpur where the formal health system is weak, it is extremely

crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system,

which is feasible locally, extend their training, provide them the necessary supplies and expand

the roles. They are the last connection with the people of the health system, especially in districts

like Narayanpur where the regular other health system is limited due to several reasons.

Similarly, the tasks of ASHA in Narayanpur need to revised and reviewed in view of the

local priorities. Accordingly, the ASHA incentive structure should be restructured.

5) VHSNC:

• Gram Panchayat are not fully functional and strengthened in Narayanpur. Due to the

opposition by the Maoists to elections, Sarpanch and Gram Sevak hardly reside in villages. It

was pointed that a Sarpanch gets elected by less than 10 votes, and immediately leaves the

village after election and generally stay in Narayanpur. This hampers functioning of VHSNC

and difficulty in expenditure of the funds. Sarpanch are also not aware of the funds.

• Mitanin find it difficult to work in-sync with the Sarpanch considering their consistent

unavailability. The method of release of their payment through Panchayat also does not

function. It was feared that with the implementation of the system of payment through

Panchayat; the minimal incentives the Mitanin were getting so far will also get stopped.

Hence due consideration must be given regarding the feasibility of implementation of this

mechanism in these areas where the Panchayat are dysfunctional.

• It was also suggested that in view of the unavailability of the Sarpanch and Gram Sevak,

Bearer Cheque may be considered for payments of Mitanin, or an alternative.

6) IEC: It was pointed out by the IEC officer that the orientation camps undertaken in the past

with rigorous group discussions was a better model to communicate with tribal and convince

them. This was a more personalized approach considering the culture and literacy level.

Compared to this the current program is more vertical where the contents, IEC material are all

directly sent from Raipur and are not in the local language (neither Gondi nor Madia). In fact

considering the overall literacy level, written material does not serve much purpose for IEC in

the areas like Narayanpur.

7) NGO: Ramkrishna Mission is functional in Narayanpur district in the most interior parts,

providing extremely useful services. In fact, at several places, the ICDS run by the mission are

the only functioning component of the system. Hence more convergence and involvement of the

RK Mission with health services will be useful.

S) Program Management:

1) Key issues emerging were:

• Can the several reporting systems be integrated and automated?

• Can there be dynamic rate for fuel? Considering that, increment is the trend. Can the distance

from district HQ be considered for calculating the budget for the facility?

• Can there be Induction training for NRHM staff and the DPM? There can be a bond for DPM

to continue after receiving the training.

• Can there be adequate block program management structure (which is currently almost

absent)?

• The criteria of allowing recruitment only from the district is probably acting as a bottleneck

in filling the vacancies as there is significant lack of the trained HR for the respective

positions in the district. Hence, can this rule be relaxed, probably on a case basis, and / or

allowing recruitment from adjoining districts such as Kanker, Dantewada, Bijapur, Sukma,

Kondagaon and Bastar?

• A review meeting at the block level generally requires travelling by the staff for 3 days due

to poor logistics and terrain. This affects the review as well as leads to waste of the working

days of the outreach staff. Can there be a solution to this?

2) PIP Planning and setting priorities:

The process of setting priorities for Narayanpur should rigorously take into consideration the

local morbidity pattern, and not enforce other priorities. For example, it was observed that the

BMO or Orcha, who is the only MBBS doctors in the entire block, and is holding the additional

charge of District Malaria Officer, had to go to Raipur to attend a meeting on ‘YAWS’. This

would lead to his absence from the facility and the block for almost 3 days, depriving the people

of crucial health services. It is also highly questionable whether YAWS is a priority in general

and specifically for the districts such as Narayanpur.

T) Quality of Services and supportive services:

1) Clinical care protocols and management AND Quality Assurance:

The key constrains were lack of:

• Proper case papers for patients and maintaining the case records.

• Standard guidelines for clinical management.

• Hand-over and signature when duties change, leading to lack of complete information of the

patients and accountability of clinical staff.

• Isolation wards.

• Firefighting facility

Other issues: Infection prevention practices were relatively inadequate in the facilities visited.

For example, the Ambu bag and baby warmer not sterilized. The Quality Assurance committee

and teams are absent, and there is no separate system or human resource. Overall, there is

significant need of quality measure to improve the quality of curative services in all the public

health facilities.

2) Solar: The regular functionality of the solar back-up system is a positive finding from

Narayanpur. Generally, the system was well functional, and was extremely crucial considering

the recurrent episodes of power failure. Hence, there should be an integrated plan for regular

maintenance and troubleshooting of solar system. Currently the complaints are lodged with

CREDA, but the response and troubleshooting is delayed and hence alternative should be

considered.

3) Biomedical waste disposal: Overall, there was lack of proper segregation and management of

biomedical waste and lack of knowledge. The color-coded bags were available at the DH, the

CHC visited, though the method, and protocols were not followed rigorously. A tender was

under process for incinerator at Jagadalpur where all the waste will be taken for disposal. Hence

establishing an Incinerator in Narayanpur should be considered for each of biomedical waste

management.

4) Mobility facilities:

• Logistics and mobility is a major problem in Narayanpur. Roads are already in poor

condition and are completely blocked in monsoon. In such conditions, no regular 4-

wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel. The only vehicles that can

pass are Tractor (or tractor like vehicles), a Jeep with 4 Wheel gear system and motorcycle.

• There is significant lack of public transport in these areas.

• Ambulances cannot travel due to poor roads and less ground clearance of the vehicle severely

affecting the availability of emergency medical transport system. This prevents the health

system of performing its crucial task and eliminates the possibility of the representation of

the State in a human form at the most crucial and required hour.

• The ANM, Mitanin Block Resource Persons, MPW, LHV need have to unfortunately travel

on cycle or feet, forcing them to walk large distances, affecting the outreach and timeliness

of services.

• A key constrain emerging was the absence of funds for the repair of vehicles including tires

and battery which limits the functioning of the vehicle.

• Though the general life cycle of vehicle in plain areas is considered 10 years, in the

extremely difficult terrain of Narayanpur, the life cycle of vehicles is not more than 5 years,

including recurrent and major expenditure on maintenance. This should be considered and

provided for in the PIP.

Possible solution:

• Can the field cadre be given Motorcycle considering the roads and distances? Similarly, the

facilities should have vehicles, which are Jeep with 4 Wheel gear system and / or a Tractor

which is actually the most all weather vehicle in such terrains. It has high ground clearance,

and is any ways used to free vehicles stuck up in mud and poor roads.

• Additionality it should be considered to provide POL for the outreach cadre in these areas.

5) Mobile and Internet connectivity:

• Lack of connectivity is one of the major problems in Narayanpur. Cell connectivity is limited

within a radius of few kilometers of the district HQ. Even that is absent when the security

forces go for patrolling to avoid information being spread about the whereabouts of the

security personnel and avoid an ambush.

• Internet connectivity is only in the district HQ, even where reliable network is generally

limited to the offices of Collector and CEO. On the day of visit, internet connection was

absent in the CMHO office since past 48 hours.

• In view of this, provision of VAST facility is crucial in Narayanpur. Additionally, the health

facilities and CMHO office should be included in the SWAN system.

6) Infrastructure creation, maintenance and public works department:

• The work of the PWD was poor and maintenance was unsatisfactory in several of the

facilities visited. Uniformly everywhere, water seepage, lack of staff quarters and delayed

construction were problems.

• Apart from other bottlenecks in constructing PHC and SHC in the interior, the opposition

from the Left Wing Extremists is a major additional problem in this area. Any structure,

which has solid walls with flat roof, is opposed by the Maoists due to the possibility of the

structures being used by security forces to establish their bases. This is one of the major

cause of the inability to do the necessary expenditures. In fact, the constructions from 2010 –

11 are still ongoing in Narayanpur, and lack of construction is a key constrain in the

utilization of health services.

• In view of this, the district administration has proposed a novel structure of Bamboo, which

is treated to be fireproof, waterproof and anti termite with reasonable strength to last for up to

30 years. These structures are being constructed in Bijapur and so far are unopposed by the

extremists. In view of this, the construction of these structures can be considered for support

in the PIP.

7) HMIS / MCTS:

The key observations were:

• It is extremely difficult to establish and operationalize internet-based systems such as MCTS

which assume reasonable speed and penetration of internet facilities in places like

Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur is probably

affecting the regular functioning of the system.

• Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to

only the district HQ (not even block HQ) for such entry, as district HQ is the only place with

overall internet facility. For such, she would require to travel and spend 3 days considering

the lack of transport facilities in the district. At the same time, there is no assurance that the

internet would be functioning on that particular day when the ANM has reached the district

HQ.

• There was significant confusion in the minds of ANM regarding the HMIS and MCTS

reporting. This adds to even lesser enthusiasm about MCTS.

• There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero

dose in the manual format but its inclusion in the software.

• Additionally there is the persistence problem of villages of a certain PHC / block shown

under different PHC / Block resulting in more problems in reporting.

• Offline entry should be made possible in MCTS.

In view of this, it is extremely crucial to reconsider the reporting systems, which take into

considerations the peculiarity of these conflict areas. The systems should aid, not pose challenges

in providing regular clinical services, which are most necessary.

Other Health Priorities / programs in Narayanpur

1) Mobile Medical Unit:

In Narayanpur district 1 MMU is operational with average daily OPD of 52 patients. Daily on an

average 14 lab tests were conducted. The average number of villages covered each month was 20

with 20 functional days per month. It will be useful to explore how to improve the diverse

functionality of the MMU, including services for NCD. A key problem was the large size and

poor ground clearance of the MMU which would lead to the vehicle getting stuck several times

on the roads.

2) Surgical morbidities and referral Tertiary Care:

• Considering the surgical morbidities expected in the population but the lack of the surgical

human resource in the district, camp approach to provide surgical care should be actively

considered. This is especially important considering the experience from the monitoring visit

that tribal from quite interior village were willing to receive medical care for their

morbidities, but unable to due to several other reasons in addition to lack of surgical care at

the district HQ.

• It was observed in the monitoring visit that tribal from interior villages are willing to receive

benefits from the health system, especially in case of tertiary care. It is hence recommended

that a system and special fund covering the entire cost with the necessary provision of

support for referral care and tertiary care including transport, a trained medical social worker

as accompanying person should be established. This will also send a very positive message to

the tribal from the health system.

S) Disease Control Programs:

1) IDSP:The district program management unit had recruited a person after significant efforts as

IDSP I / c who was functioning. Nevertheless, due to the recent change in the HR criteria, which

makes it mandatory to have 3 years of experience to be eligible for the post, the current IDSP

manager would be terminated. It is important to understand that at places like Narayanpur, it may

not be feasible to insist on 3 years of prior experience. It may effectively mean that the post

would remain vacant. Instead, on job training can be considered as an alternative, if the person is

committed and willing to learn and work.

2) Malaria:

Narayanpur district, especially the tribal, remote and left wing extremist affected area are

endemic for malaria, especially falciparum. Though the commitment of the outreach staff who

are willing to work in a mission mode in cases of malaria epidemics is remarkable, following key

concerns and emerged:

• There was no integrated malaria prevention and management plan. Schedule of IRS was

absent. Similarly, LLIN or ACT and other antimalarials were not supplied.

• A repeated problem faced is the lack of Syrup of ACT (the recommended drug for

falciparum malaria in endemic zones like Narayanpur) for treating children. It is very

difficult to ensure compliance with tablets in children.

• There must be urgent provision of RDK, LLIN and IRS.

• There must be an annual timeline of distribution of LLIN and IRS.

3) RNTCP: Considering that the burden of TB would be quite high in tribal district like

Narayanpur (as is the experience from other tribal districts), the suspected cases examined are

less, with a proportion of only 140 / 1,00,000. Overall, the screening and case detection needs to

be increased. This is possible through:

- Ensuring TB screening through the MMU.

- Mass-selective screening of patients of cough through ANM and ASHA

- Increasing the access to sputum collection through ANM and ASHA

- Considering establishing advanced diagnostic method like DNA / PCR.

Indicator Narayanpur

Total population Covered (In Lakhs) 1.40

TB Suspects examined per lack of population per quarter 196

Total Patients registered for treatment 226

Total no smear positive patients diagnosed 100

Treatment outcomes, new smear positive rates (%) 54.21

Annexure:

Annexure 1:

Human resource status in Narayanpur under NRHM

Sr.

No.

Programme

Name

Sr.No

. Post Name

District Name :-

Narayanpur

Sanction

Post

Filled

Post

Vacant

Post

1 2 3 4 5 6 7

1 DPMU

1 Dist.Programme Manager 1 1 0

2 Dist.Account Manager 1 1 0

3 Data Entry Operator 2 1 1

4 Statstical Investigator 0 0 0

2 M&E 4 M&E Officer 0 0 0

5 Statstical Investigator 0 0 0

3 IPHS

6 IPHS Co-Ordinator 0 0 0

8 Programme Assistant / DEO 0 0 0

10 Lab.Technician 0 0 0

4 FMG 11 Accountant (C.S.) 0 0 00

12 Accountant (Z.P.) 0 0 0

5 ASHA

13 District Community Mobilizer 0 0 0

14 District Asha Assistant 0 0 0

15 Block Community Mobilizer 0 0 0

16 Asha 0 0 0

6 RKS 17 RKS Co-Ordinator 0 0 0

7 School

Health

18 Programme Supervisor 0 0 0

19 Programme Assistant 0 0 0

20 Medical Officer (Male) 0 0 0

21 Medical Officer (Female) 0 0 0

22 Pharmasist 0 0 0

8 AYUSH

23 Medical Officer (Aurved) 0 0 0

24 Medical Officer (Homeopathy) 0 0 0

25 Medical Officer (Unani) 0 0 0

26 Masajist (Male) 0 0 0

27 Masajist (Female) 0 0 0

28 Pharmasist 0 0 0

29 Ayush Nodal Officer 0 0 0

30 Data Entry Operator 0 0 0

9 Sickel cell 31 Sickelcell Co-Ordinator 0 0 0

32 Lab Technician 0 0 0

10 IDW

33 Deputy Engineer 0 0 0

34 Junior Engineer 0 0 0

35 Accountant Cum Operator 0 0 0

11 BPMU 36 Accountant 2 00 2

37 Programme Assistant 0 0 0

12 Procurement

/ Store 38 Pharmasist 0 0 0

13

Infrastruture

Human

Resorce

39 ANM (N.& T) 33 4 0

40 LHV (N.& T.) 11 1

41 Staff Nurse (N.& T.) 0 0 0

14 Urban RCH 42 ANM 0 0 0

15 Arsh 43 Arsh Supervisor 0 0 0

16 Telemedicine 44 Facility Manager 0 0 0

17 PCPDNT 45 Legal Advisor 0 0 0

18 Referral

Transport 46 Call Assistant 0 0 0

19

Rutine

Immunizatio

n

47 Data Entry Operator 0 0 0

20 IDSP 48 Epidemic Officer 0 0 0

49 Data Entry Operator 1 1 0

Annexure 2: Human Resources

Regular Contractual

Category /

type of

personnel

Sanctioned

posts

In

position

Sanctioned

posts

In

position

(through

state/other

sources)

(E)

In

position

from

NRHM

Total in

position

Vacancy

(%)

1st ANM 74 72 0 0 0 72 97.30%

2nd

ANM 0 0 33 0 4 4 12.12%

MPW/ Male

HW

66 25 0 0 0 25

37.89%

Staff Nurse

total

50 14 11 0 1 15

24.59%

DH 30 15 0 0 0 15 50%

Regular Contractual

Category /

type of

personnel

Sanctioned

posts

In

position

Sanctioned

posts

In

position

(through

state/other

sources)

(E)

In

position

from

NRHM

Total in

position

Vacancy

(%)

FRU 0 0 0 0 0 0 0%

24X7 PHCs 2 0 0 0 0 0 0%

Other

facilities (Pls.

specify)

18 0 0 0 0 0

0%

LTs 10 5 0 0 0 5 50%

DH 2 2 0 0 0 2 100%

FRU 0 0 0 0 0 0 0%

24X7 PHCs 2 1 0 0 0 1

50%

Other

facilities (Pls.

specify)

6 1 0 0 0 1

16.66%

Pharmacists 14 7 00 0 0 7 50%

MOs total 24 11 0 0 0 0 45.84%

AYUSH

MOs 0 0 0 0 0 0

0

DENTAL

MOs 1 0 0 0 0 0

0%

Specialists

total 26 1 0 0 0 0

3.84%

Obstetricians

&

Gynaecologist

1 1

(PGMO) 0 0 0 1

100%

Anaesthetist 1

1

(PGMO) 0 0 0 0

100%

Paediatrician

1 1

(PGMO)

0 0 0 0

100%