Regional Resource Centre for NE Statesrrcnes.gov.in/study_report/Boat Clinic Evaluation, Assam...

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EVALUATION OF BOAT CLINICS OF ASSAM

RRC NE

ACRONYMS

ANM Auxiliary Nurse Midwife

ANC Ante-Natal Care

ASHA Accredited Social Health Activist

BCC Behavioral Change Communication

BCG Bacillus Calmette–Guérin

Conducted by

Regional Resource Centre for NE States Ministry of Health & Family Welfare, Govt. of India

Guwahati – 781 022, ASSAM

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ACKNOWLEGEMENT

The Evaluation of Boat Clinics in Assam was conducted by Regional Resource Centre for North

Eastern States (RRC, NE) during June-July 2013 in all the 15 units of Boat Clinics in 13 districts of

Assam. During the course of the study, the concerned officials at Centre for North East Studies

and Policy Research (C-NES) at Guwahati, entire team of the Boat Clinics and beneficiaries were

interviewed.

We would take this opportunity to thank Mr.Prateek Hajela IAS, Mission Director, National

Rural Health Mission, Assam for supporting the RRC-NE team for conducting the Boat Clinic

Evaluation Study in the State. We would also like to acknowledge the support and cooperation

extended by the Management and officials of C-NES, Guwahati and District units of the Boat

Clinics throughout the study. Our heartiest thanks to all the staff members of Boat Clinics who

spent their valuable time with us and provided all the necessary information, which helped the

RRC-NE team to accomplish the task assigned on time successfully.

(Dr. A.C. Baishya)

Director, RRC-NE

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RESEARCH TEAM FOR THE STUDY

Name Designation

Dr. A.C. Baishya

Director, RRC-NE

Dr. Joydeep Das Advisor Public Health, RRC-NE

Dr. Hitesh Deka Advisor Public Health, RRC-NE

Ms. Rita Pradhan Coordinator, Capacity Building

Dr. Ramkesh Prasad Consultant, Public Health, RRC-NE

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CONTENTS

Page No.

1 Executive Summary

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2 Introduction

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3 Boat Clinics In Assam

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4 Assam At A Glance

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5 Key Findings Of The Study

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6 District Wise Analysis Of Services Provided By Boat Clinics In The Year 2012-2013

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7 Manpower At State Program Management Unit, Guwahati, 54

8 Budget

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9 Findings And Conclusion

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10 Recommendations

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11 Annexure

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12 Photo Gallery

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ACRONYMS

ANM Auxiliary Nurse Midwife

ANC Ante-Natal Care

ASHA Accredited Social Health Activist

AWW Anganwadi Worker

BCC Behavioural Change Communication

BCG Bacillus Calmette–Guérin

C-NES Centre for North East Studies & Policy Research

CC Coordination Committee

CW Community Worker

DPO District Programme Officer

DPT Diphtheria-Pertussis-Tetanus vaccine

GNM General Nurse Midwife

GoA Government of Assam

GoI Government of India

Hb Haemoglobin

Hep BV Hepatitis B Vaccine

HMIS Health Management Information System

IEC Information, Education, and Communication

IFA Iron and Folic Acid

IMR Infant Mortality Rate

IMNCI Integrated Management of Neonatal and Childhood Illnesses

IUD Intra Uterine Device

IPPI Intensified Pulse Polio Programme

JE Japanese Encephalitis

MMR Maternal Mortality Rate

MO Medical Officer

MOU Memorandum of Understanding

NRHM National Rural Health Mission

OCP Oral Contraceptive Pills

OPV Oral Polio Vaccine

ORS Oral Rehydration Solution

PHC Primary Health Centre

PNC Post-Natal Check up

PPP Public Private Partnership

RI Routine Immunization

PMU Programme Management Unit

RBSK Rashtriya Bal Swasthya Karyakram

NPCDCS National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular

Diseases and Stroke

ToR Term of Reference

TT Tetanus Toxoid

VDRL Venereal Disease Research Laboratory

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EXECUTIVE SUMMARY

National Rural Health Mission has been launched with the objective to provide accessible,

affordable and accountable quality health services to the poorest households in the remotest

parts of the country. In Assam 87% of the population resides in rural areas and about 1-2% i.e.

about 3 million live in the riverine islands of the Brahmaputra. People residing in these

outreached areas lack basic health facilities and it is difficult for them to travel to reach the

health centre seeking for health care services.

The boat clinic initiative of C-NES started in 2005 with AKHA – the ship of Hope with aid from

UNICEF. Encouraged by its success NRHM entered into an agreement with C-NES to provide

health service to the island communities of the state. C-NES came forward to spread the

initiative to other parts of the State. With this partnership NRHM has been able provide

preventive and curative services to these communities in 13 districts of the State with funding

from NRHM.

These units not only provide access to basic services of health care but also provide essential

knowledge and information on the kind of services under the umbrella of NRHM to the

residents in the island who have no access to health care.

Regional Resource Centre for NE States conducted an evaluation of the services provided by

Boat Clinics in Assam through their 15 units in 13 districts.

The study is a cross sectional study with qualitative and quantitative data. Data collection of the

study was done in the month of June-July 2013. The respondent for the study were the District

and State Unit Team. This report is based on the functioning status of Boat Clinics, its diagnostic

facilities and immunisation services. The second major head, that is for the beneficiaries will be

carried out in the second phase of the study.

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There are total 15 units of Boat clinics function in 13 district Assam namely – Dibrugarh,

Tinsukia, Dhemaji, Lakhimpur, Sonitpur, Jorhat, Kamrup, Barpeta (2 units), Dhubri (2 units),

Nalbari, Morigaon, Goalpara and Bongaigaon. The health facilities provided by all the boat

clinics are similar. The manpower composition is also similar in all the units except for vacancies

in some.

It was observed that availability of manpower in Boat Clinics for Medical officer 1 was 100%

whereas it was only 53% for Medical Officer 2; similarly for staff nurse it was for 53%.

Laboratory technician was available in all the units, whereas the post of Pharmacist was vacant

in one district, ANM 1 was available in all units, ANM 2 were present in 13 units. Community

workers were also available in all units. No induction training has been provided to any Medical

Officer of the Boat clinics.

As per the MoU with NRHM, Assam, the State Programme Management Unit has been

approved 15 staff viz. 1 (one) Project Director, 1(one) Programme Manager, 1(one) Associate

Programme Manager, 2(two) Assistant Programme Manager, 1(one) Accounts Manager, 2(two)

Accounts Assistant, 1(one) Data analyst, 1(one) Communication Officer, 2(two) Office Assistants

and 3(three) Multi-tasking Office Helper. The manpower at the State level unit increased from 5

nos. in 2008 to 13 nos. in 2013. However it was of concern that there is duplication of role &

responsibilities starting from Project Director/CEO, Programme Manager, Associate Programme

Manager and Assistant Programme Manager. Similar duplication was seen in the roles of the

Accounts manager and 2 Accounts Assistant. The Data Analyst has been stationed at New Delhi.

The role of the Communication Officer has been found to be of limited significance as no IEC

material has been developed by her. Monitoring and supervision by the PMU was found to be

totally lacking.

It was observed on an average 15-18 camps were conducted by each unit every month. The

average OPD attendance was found to be 55 -100 per camp. The services offered by the Boat

clinics are OPD services, ANC and PNC services, immunization, laboratory services, family

planning services like distribution of OCP and condoms and IUCD insertion in a few districts.

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Most of the cases who attended the OPD had respiratory infections, musculoskeletal pain, pain

abdomen, leucorrhoea, fungal and bacterial skin diseases. In few of the units delivery has been

conducted.

The following laboratory test i.e. Haemoglobin estimation, Peripheral Blood smear for malaria

parasite, Rapid Diagnostic kit test for malaria, Urine for Albumin and sugar, Random blood

sugar, Urine pregnancy test , ABO & Rh were done in all the units. Recently VDRL and HIV

testing has been introduced in all units, and technicians have been trained.

It was observed that availability of drugs and consumables limited the service delivery. Boat

clinic drug kits were provided once a year and subsequent replenishment is being done from

District Drug Store which is irregular and inadequate. Moreover in Kamrup district there was no

supply of Iron and Folic acid tablets. Zinc sulphate which is an essential component in

diarrhoea management was not supplied in Goalpara.

During the exit interview it was observed that 78.3% of the beneficiaries attending health

camps were females. Beneficiaries received information about camps from ASHAs and the

community workers. 76.4% of the beneficiaries received the required medicines and 91.2% of

the beneficiaries were fully satisfied with the services of Boat Clinics. About 4.3% patients were

referred for specialised treatment to higher facilities.

Total expenditure incurred in the functioning of Boat Clinics in 2012-13 was ₹ 5,46,94,714.

Expenditure incurred on district units ranged from ₹ 28,83,899 in Dhemaji to ₹ 38,32,583 in

Jorhat. Expenditure on Boat/Logistics ranged from ₹ 5,57,463 in Dibrugarh to ₹ 12,97,986. Total

OPD registration ranged from 6,639 in Lakhimpur to 22,552 in Nalbari. Expenditure per patient

consulted ranged from ₹ 158.44 in Nalbari to ₹ 480.03 in Jorhat. Average cost per patient was

found to be ₹ 292. The average cost per patient has increased from ₹ 169 in 2010-11 to ₹ 292 in

2012-13.

The MoU between NRHM, Assam and C-NES needs to be amended. There needs specific

mention about the mechanism of fund release from the State. It should also mention clearly

about mechanism of drug supply to Boat Clinics. MoU also needs specific mention on

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monitoring activities by Boat Clinic PMU personals. The number of camps to be organised by

every district in a month needs to be specified.

Based on the current evaluation there appears scope for improvement in the service delivery by

the Boat Clinics in Assam. A technical guideline should be designed for the proper functioning of

the Boat Clinics. Teams should be stationed at the sub district level (as close to the ghats as

feasible) to increase the time for patient care and should follow uniform timing with respect to

start of the journey to reach the islands. A backup boat is required to provide uninterrupted

service when any district unit boat is under repair. All units must have adequate life jackets. All

pharmacists must be trained for inventory management and record keeping. Non

communicable disease screening should be added. Family planning services should be extended

with more emphasis on IUCD insertion. There should be monitoring from the district as well as

State level.

The output of the Boat Clinics may be reviewed monthly and reporting of performance should

be submitted monthly through HMIS. District Health Society should make quarterly review of

Boat Clinic activities for strengthening services and quality improvement.

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1 INTRODUCTION

The International Conference on Primary Health Care, meeting in Alma-Ata on 12th September

1978 expressed the need for urgent action by all Governments, all Health and Development

Workers, and the World Community to protect and promote the health of all the people of the

world. It stated that the existing gross inequality in the health status of the people particularly

between developed and developing countries as well as within countries is politically, socially

and economically unacceptable and is, therefore, of common concern to all countries.

In the Alma Ata Declaration the concept of primary health care includes at least: education

concerning prevailing health problems and the methods of preventing and controlling them;

promotion of food supply and proper nutrition; an adequate supply of safe water and basic

sanitation; maternal and child health care, including family planning; immunization against the

major infectious diseases; prevention and control of locally endemic diseases; appropriate

treatment of common diseases and injuries; and provision of essential drugs.

In Assam, for the river-dependents particularly on the islands of the Brahmaputra and other

major rivers as well as those living close to the river on its banks, the presence of government

planning and development interventions is limited or, at times, altogether missing.

The misery is compounded by floods which pose a major challenge and devastate livestock and

property, including standing crops. Although the number of those who are killed by high water

has decreased, lakhs are affected by water borne diseases. More than five lakh are rendered

homeless and take shelter in temporary relief camps where families huddle together for weeks

without proper facilities for sanitation. Many fall ill during this period and a major problem is the

transportation storage and distribution of food and medicines.

People with poor health and nutrition levels, affected by high morbidity, are extremely vulnerable

and more so, despite the best efforts of district administrations, medical care is not accessible to

stranded groups and marooned communities.

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About 3 million live in over 2,500 islands of the Brahmaputra, of which the largest river island is

Majuli, in Jorhat district. There are some 2,300 villages at last count on the islands - at times,

these may comprise of a few huts, at times of several settlements dispersed over a large area

where connectivity is on foot or by country boat (usually dug outs, pulled by oars and not engine-

propelled).

Most of these islands, lack all basic infrastructure and services: from health to schools, from

power to, not surprisingly, roads and water supply not to speak of sanitation.

Extensive travels in the region sensitized one to local needs in thinking about designing a basic

strategy that would reach the unreached, the most vulnerable groups in the Assam, Valley - the

island people. Detailed discussions with villagers, officials, NGOs, scholars and stakeholders over

many journeys also helped clarify the design of interventions that could be people-friendly,

efficient, be done locally and delivered fast, as well as meet existing gaps.

One of the conclusions that was arrived on was the river itself could be used to respond to and

answer some of the very problems and challenges caused by the river. Thus, more boats and

better ships could improve connectivity. Indeed, rural water transport has the potential to

eliminate poverty and reduce isolation. This led to the concept of Boat Clinics in Assam.

The one gap that was narrowed was that of health which was non-existent barring ad hoc

relief at times of floods, never sustained beyond the high water period. Improvement of health

indicators, it was felt, could have a multiple impact on other areas of the lives of the island

people.

The proposal for the innovative programme was placed at the World Bank's India

Development Marketplace 2004 competition in New Delhi. The concept was lauded by the judges

and C-NES was chosen as one of the 20 winners. C-NES’s design won an award of prize money of

US$ 20,000 in competition; judges said it represented a unique innovation that could transform

the lives of rural communities. With the funds from that award, the ship took shape at Maijan

ghat, Dibrugarh with carpenters from Dholla, Tinsukia, and under the supervision of a local boat

builder. The boat was christened AKHA – Assamese for hope

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The boat, completed in June 2005, is 22 meters long and over 4 meters wide, has an OPD,

cabins for medical staff, medicine chest, kitchen, toilets, crew quarters and a general store.

Equipped with a generator set and a 200 litres water tank, it is powered by a 120 HP engine.

In 2005, the organization launched the Boat Clinic initiative to deliver health services to people

living on the islands of Dibrugarh district. C-NES started with one boat and seven staff in

Dibrugarh district in 2005. Public Private Partnership was developed with the local administration

in Dibrugarh, signing a MoU which defined responsibilities of the two parties and made the state

government a major stakeholder. In addition, five crews were hired and efficient community

organizers were selected who could develop the programmes and ensure that the impact was

substantial and effective and would maintain good contacts with government. For smooth

conduct, a community organizer was appointed in 2005 to run the programme for Dibrugarh.

For proper monitoring of the activities of the health camps, flood and post flood relief measures a

Coordination Committee (CC) was set up in May 2005. The CC members comprised of

representatives of district administration, district health department, Assam Medical College,

District Rural Development Agency, Inland Water Transport Department, entrepreneurs, civil

society groups, and representatives of C-NES with the Deputy Commissioner as the Chairperson.

The programme was launched in conjugation with the National Immunization Day i.e., on May 25,

2005. Priority was given to immunization of children and health check-up of pregnant mothers as

well as general check-up (curative and preventive approach). Immunization campaigns have

been part of a national drive and have also included the critical Japanese Encephalitis (JE)

vaccination campaign.

AKHA goals included the following in Dibrugarh

80% immunization coverage to children

80% of pregnant women to receive two doses of TT & IFA

Maintain growth chart of all children

Exclusive breastfeeding to be ensured.

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In 2006 UNICEF recognizing the programme’s potential gave it a push with training and some

funding in Dibrugarh. UNICEF also supports the programme in Dibrugarh and Lakhimpur

districts where it works with C-NES on health training and skill up gradation as well as a school

outreach programme to cover children who have dropped out of school or have never been to

school.

Encouraged by the success NRHM, Assam signed a memorandum of agreement in February

2008 with Centre for North East Studies and Policy Research to provide health service to the

island communities of the state through Boat Clinics. It started in the state in phased manner

and is now operating 15 units in 13 districts of the state.

AKHA –Ship of Hope

In the first phase of partnership with NRHM, the Boat clinic programme was implemented in 5

districts of Assam - Dibrugarh, Tinsukia, Dhemaji, Morigaon and Dhubri. In the second phase,

from March 2009, 5 more districts Lakhimpur, Jorhat, Sonitpur, Nalbari and Barpeta were

added. From August 2010, 3 more districts- Kamrup, Goalpara, and Bongaigaon along with one

more unit each in Barpeta and Dhubri have been brought under the Boat Clinic health initiative.

Currently 15 units of Boat Clinics are operating in 13 districts of the state.

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Boat clinic in Assam are working in conjunction with the concept of primary health care and are

moving toward the goal of Universal Coverage and providing quality health care to the

remotest corner of India most of which are unknown to the rest of the world.

The 12th Five Years Plan document states the concept of the National Health Mission which

incorporates the core principle of universal coverage and achieving quality standards and has

recognized boat clinic as a medium for ensuring access to health care among under-served

populations, boat clinics of C-NES in Assam provide curative and emergency care for the

population residing in islands and flood plains of the State.

RATIONALE OF THE STUDY

The existing Boat Clinics are serving to the unreached char areas of Assam since 2008. After 5

years of implementation, it was required to study the effectiveness and efficacy of the

functionality of Boat Clinics in the region. Thus it became imperative to assess the performance

of the programme against the expected outcomes. The assessment has focused on outcomes of

investment being on Boat Clinic. The findings of the study and recommendations would also

help to further strengthen the operations of the Boat Clinics.

OBJECTIVE OF THE STUDY

General Objective

To assess the functionality of Boat Clinics, quality of healthcare services provided, issues,

challenges and overall satisfaction of the clients accessing Boat Clinic services.

Specific Objectives

To assess the functional status of Boat Clinic in terms of:

availability and functionality of boats;

availability and functionality of equipments /diagnostic equipments;

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availability of drugs;

To assess availability & composition of human resources & training status and their

outcome.

To assess the operational plan of Boat Clinic which includes coverage area - whether the

Boat Clinic is covering areas as per the route plan or not.

To assess the type of services provided in terms of

Curative services Reproductive and child health services

Family planning services

Diagnostics

Specialised facilities and services

Emergency services

To assess the IEC activities conducted by Boat Clinics.

To assess the level of awareness amongst the beneficiaries about the services provided.

To assess the client satisfaction accessing the services of Boat Clinics Units

To assess the financial implications of Boat Clinic.

METHODOLOGY OF THE STUDY

The proposed study design is descriptive cross-sectional. Both quantitative and qualitative data

will be collected to assess the effectiveness and efficiency of the boat clinic programme. The

study area will comprise of three major heads:

i. Functional status of Boat Clinics including the status of boats, drugs, diagnostic and

manpower

ii. Assess the knowledge and skills of the service providers

iii. Exit interview of the boat clinic beneficiaries.

iv. Household Survey

v. Review of MoU with the State Nodal Agency and review of ToR of the Programme

Management Staff and their output.

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Sampling procedure:

For category i. (1st Phase) Functional status of Boat Clinics including the status of boats, drugs,

diagnostic and manpower will be taken up for the entire fleet of boat.

For category ii. (1st Phase) The core service provider of each of the 15 boat clinic unit will be

interviewed. The core service provider team will include Medical Officer, GNM,

Pharmacist and Lab Technician, who are directly involved in providing health

care service to the people of the char areas.

For category iii. (1st Phase) Exit interview of the beneficiaries:

The OPD cases per camp on an average were reported to be 80

beneficiaries. Therefore based on the minimum numbers of OPD

beneficiaries, sampling interval 3 will be taken to get 25 nos. of

beneficiaries per camp for exit interview.

Therefore, 25 beneficiaries will be interviewed in each of the boat clinic

camp on an interval of 3 beneficiaries.

For category iv. (2nd phase) Household survey:

Household survey will be carried out in 25% of the boat clinic unit. Total

functional boat clinic = 15. Of these 15 boat clinic unit, 25% of them will

be covered. Therefore 4 boat clinic unit will be taken up for the study.

These boat clinic units will be taken up one each in one zone randomly.

On an average 15 camps are organized per month by each of the boat

clinic unit covering 15 villages each. Also each of the villages are covered

monthly once by each of the boat clinic unit. Therefore for the study

purpose the villages covered during preceding month of the survey

period will be covered.

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Further for the study purpose 20% of the 15 covered villages by the Boat

Clinic unit will be taken which comes to 3 villages per district. These

villages will be selected randomly.

20% of the household of each of these 3 selected villages will be taken up

as primary sampling unit for the study.

For category v: (1st Phase) Nodal Agency & the Programme Management Staff

The MoU signed by Nodal Agency (C-NES) with NRHM, Assam will be

reviewed along with their service delivery output.

The TOR of the each of the Programme Management Staff vis-a vis their

individual output will be reviewed thoroughly.

Study Tools:

The study tool will comprise of the following:

Interview Schedule for State Nodal Agency (C-NES) and its Programme Management

Staff.

Structured questionnaire to assess the

functional status of the boats,

necessary equipments & medicines

manpower availability and training status

the types of services provided in Boat Clinic Unit

awareness & IEC activities and

operational plan and frequency of visits by Boat Clinic.

financial involvement in running the boats

Interview Schedule for the service providers (1st Phase)

Interview Schedule for exit interview of the beneficiaries (1st Phase)

Interview schedule for household survey (2nd Phase)

Focus Group Discussions with the beneficiaries/community ( 2nd Phase)

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Study duration

1st Phase: 4 months.

2nd Phase: 2 months

Total Duration: 6 months

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BOAT CLINICS IN ASSAM

In 2005, the Centre for North East Studies & Policy Research launched the Boat Clinic initiative

to deliver health services to people living on the islands of Dibrugarh district. C-NES started with

one boat and seven staff in Dibrugarh district in 2005. Public Private Partnership was developed

with the local administration in Dibrugarh, signing a MoU which defined responsibilities of the

two parties and made the state government a major stakeholder.

Encouraged by success in Dibrugarh, the Boat Clinic project was extended to two more districts

– Dhemaji and Tinsukia, with more ships being added through funds from a private Indian

donor. The Boat Clinic journey really took off when National Rural Health Mission (NRHM) was

launched in 2005. The NRHM contacted C-NES and urged a partnership to extend the

programme rapidly. That partnership has been cemented with a Memorandum of Agreement

signed in February 2008 which defines responsibilities of each partner.

The responsibility for construction of boats and their insurances has been vested on C-NES and

the expenditure on the recurring cost (i.e. manpower, medicines, maintenance of the boat and

camp organizing cost etc.) is borne by Government of Assam under NRHM.

In the first phase of partnership with NRHM, the Boat clinic programme was implemented in 5

districts of Assam - Dibrugarh, Tinsukia, Dhemaji, Morigaon and Dhubri. In the second phase,

from March 2009, 5 more districts Lakhimpur, Jorhat, Sonitpur, Nalbari and Barpeta were

added. From August 2010, 3 more districts- Kamrup, Goalpara, and Bongaigaon along with one

more unit each in Barpeta and Dhubri have been brought under the Boat Clinic health initiative.

Currently 15 units of Boat Clinics are operating in 13 districts of the state. The public health

programme was recognized by Government of India as well as the state government as a model

of ‘inclusive health care’ and the Planning commission has cited it in the 11th and 12th Five Years

plans for India.

The NRHM funds the Boat Clinic programme fully- staff salaries, transportation costs, IEC,

equipment and also provide medicines. The health teams, led by District Programme Officers

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(DPOs), work extensively on delivering basic health services with priority given to delivery of

national immunization programme for children as well as pre and post–natal check-ups for

women. A series of camps to deliver these services are organized by developing work plans for

each district to cover the islands in association with NRHM, the Joint Directors of Health as

well as C-NES’ teams of District Programme Officers (DPOs) and Community Workers.

These Boat Clinics operate on two systems. The units where specially designed boats like the

“AKHA” model are present (Dibrugarh, Tinsukia, Jorhat, Dhemaji, Sonitpur and Dhubri unit I),

the teams go on trips of 4-6 days (includes night halts) at a stretch conducting 1 or 2 camps per

day. Where the bigger boats are not available country boats are hired and modified to provide

the basic provisions including an OPD and a cabin for ANC check-up. Each unit has a district

office which is headed by the District Programme Officer (DPO). The DPO coordinates with the

District Health Society and the targeted communities for smooth implementation of the

programme along with the Medical Officers and supporting clinical staff and is guided by the

programme management unit (PMU) at Guwahati & Delhi. There are 3 community worker who

work at the field level and helps in mobilizing communities. The ASHA worker and the AWW

worker are actively involved in the programme. Village Health & Sanitation Communities

(VHSC) where ever active are also involved in the programme. Yearly target and monthly plan

of action is prepared in consultation with the District Health Department taking care that the

immunization schedule is not disturbed. Micro plan targets are set at the beginning of the

financial year in consultation with the Block PHC. Medicines and vaccines are supplied from the

District Drugs Store as per the indent. Close coordination is maintained with the different

government departments and district NRHM unit, including the state police.

The boat clinic manpower comprises of technical manpower providing health care services who

are supported by the crew staff for delivering the health care services.

Service Delivery

To provide health care services to the marginalized community of the char areas monthly

health camps are being organized in these areas. It is to be mentioned here that for smooth

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functioning of the camps, a monthly work plan is developed by district programme officer of C-

NES in consultation with the district health authority.

As per the work plan the team visits the char areas with prior intimation to the community

residing there with the help of ASHAs and Community workers.

Salient features of The MoU between NRHM & C-NES with regards to services to be provided by

the Boat Clinics

1. Curative and preventive Care

Referral of complicated cases- child survival-IMNCI services

Early detection of TB, Malaria, Leprosy, Kala-azar etc. and other epidemic prone

diseases including locally endemic communicable diseases and non-communicable

diseases such as CVD, Hypertension, diabetes, blood dyscrasias etc.

Minor surgical procedure and preliminary care of injuries etc.

Arranging Special camps for Deafness, Eye, Paediatrics, O&G. Elderly, etc.

Counselling for Psychiatry & Alcohol Dependent Syndrome

Early detection of disabilities and other congenital disorders

Implementation of National Health programmes

Palliative care for chronic diseases

Reproductive and Child Care

Ante-natal check-up and related services e.g. routine immunization like tetanus

toxoid etc. , iron and folic acid tablets administration, counseling etc.

Referral for complicated pregnancies

Promotion of institutional deliveries

Post-natal check-up and counseling

Immunization clinics for mother and child

Treatment of common childhood illness such as diarrhoea, ARI / Pneumonia etc.

Treatment of RTI/ STI

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2. Family Planning Services

Counseling for spacing and permanent method for sterilization

Distribution of Condoms, Oral Contraceptives, Emergency Contraceptives

IUD Insertion like Cu ‘T’ insertion.

3. Basic Laboratory Services

Haemoglobin for ANC / PNC, Urine for sugar and albumin and Malaria – RDK and

other biochemical tests etc.

4. Emergency services & care in times of disaster / epidemic / public health emergency /

accidents etc.

Roles of Partners:

Activities

Provision of services

Remarks

NRHM C- NES

1. Infrastructure

Construction of boats √ √

Medicines and equipments as per the PHC kit of IPHS standard

√ The medicines will be provided by Jt. Director. It may also be provided from NRHM and other various NDCP

Instruments/ Equipments √

2. Manpower (a) – (For each boat)

Medical Officer (2) √ The team will work in close coordination with the First Party

Staff Nurse(1) √

Lab. Technician (1) √

Pharmacist (1) √

ANM (2) √

Community Workers (3)

√ Community workers will be appointed for each district to facilitate the organization, mobilization, smooth running and conduct of the health services in all aspects including liaising with local community leaders etc.

District Programme Officer (1) for each unit

√ The DPO will be responsible for smooth running of the program in the district and will co-

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Activities

Provision of services

Remarks

ordinate with the communities and the district authorities. He will be under the direct supervision of the PMU.

Boat Crew (4) √

Referral Boat Crew (2) √

2.(b) Project Management Unit (PMU)

Programme Manager (1) √ The Programme Manager will be based at Guwahati and will coordinate with the Project Director. NRHM & District and State officials as and when required

Associate Programme Manager (1)

√ The Associate Programme Manager will be based at Guwahati and will coordinate with the Project Director, Programme Manager in all aspects of Program.

Assistant Programme Manager (2) √ The Asstt. Programme Manager will be based at Guwahati and will coordinate with the Programme Manager and Associate Program Manager in all aspects of Program.

Communication Officer (1) √ Communication and Dissemination, editing reports

Data Analyst (1) √ Data entry and analysis

Accounts Manager (1) √ Maintaining books of account

Assistant Accountant (2) √

Office Assistant (2) √

Multi-Tasking Office Helper (3) √

3. Additional role

IEC/BCC √ √ IEC/BCC will be done in coordination by both the parties

Maintenance of the Boats Biannually as per actual

Necessary renovations repair and maintenance as and when required.

15

3 ASSAM AT A GLANCE

Set squarely between the countries of Bangladesh, Myanmar, China, and Bhutan and connected

to the rest of India by a narrow 20 km strip of land, Assam is truly a unique location. Tea

production, petroleum, coal, and natural gas are Assam’s major economic drivers, whilst it is

also known for beautiful golden silks, unique wildlife, and as an untouched tourist destination.

Assam also has much to offer in terms of its rich mosaic of culture, history, and industry;

however, seven out of eight residents live in a rural setting without necessary infrastructure

and basic services

The total geographical area covered by Assam is 78,438 sq. km. The mighty river Brahmaputra

passes through Assam with a stress of 800 km starting from Sadia in the North East till Dhubri in

the Western part and then turns south to enter the plains of Bangladesh. Another river Barak

passes through southern districts of Assam. After the name of these two rivers Assam is divided

into “Brahmaputra valley” and “Barak valley” with Borail Mountain Range in between the two.

Map of Assam

3

16

Table 3.1: Demographic profile of Assam and India

Parameters Census 2011

(Assam)

Census 2011

(India)

Population Urban 14 % 37.7 crore (31.15%)

Population Rural 86% 83.3 crore (68.8%)

Population (0-6 yrs) – Total 4511307 (14.47%) 158789287 (13.12%)

Population (0-6 yrs) – Male 2305088 (14.45 %) 82952135 (13.3%)

Population (0-6 yrs) – Female 2206219 (14.5%) 75837152 (12.93%)

Sex Ratio 954 940

SC Population (Census 2001) 1,825,949 (6.85%) 16.2%

ST Population (Census 2001) 3,308,570 (12.41%) 8.2%

Male Population 15954927 (50.22%) 51.48%

Female Population 15214345 (48.81%) 48.42%

Decadal Growth Rate 16.93 17.64

Population density per km2 339 382

Literacy rate (total) 73.18 74.04

Male 78.81 82.14

Female 67.27 65.46

Source: Census 2011, GoI

As per 2011 census, the population of Assam is 31.17 million and the population is scattered

across 27 districts and 26395 villages. Assam acquires 2.5 % of the total population of India as

per census 2011. Out of the total population of Assam, 50.22% is male population and 48.81% is

female population. The sex ratio of all age group of Assam is 954 which are higher than the

national. The decadal growth rate of Assam is 16.93. 68.8% of population inhabits in rural area

and 31.15% inhabits in urban area of Assam (Table 3.1).

17

HEALTH INDICATOR OF ASSAM

The health indicators like Infant Mortality Rate (IMR) and Maternal Mortality Rate (MMR) in

Assam is 55 and 347 (Table 3.2) respectively. To provide better health care to the people there

are many training sections under NRHM to the grass root level workers like the ASHAs, ANMs

and Multipurpose Health Worker Male/female. Assam Government has initiated a three years

rural health education which is known as Rural Health practitioners, who are trained for three

years and are posted in the Primary health centre, CHCs and sub-centres to provide health care.

These initiatives are taken to reduce Maternal and Infant mortality rate and provide proper

MCH in the remote area. There are also facilities initiated like the Mobile Medical Units and

Boat Clinics to reach the remote area of the State where health facilities are not available.

Table 3.2: Health Indicators of Assam

Sl. No. Indicator Assam

1 Maternal Mortality Rate 347

2 Infant Mortality Rate (SRS Oct. ‘12) 55

3 Crude Birth Rate 21.3

4 Crude Death Rate 7.1

5 Natural Growth Rate 14.2

6 Total Fertility Rate 2.4

Source: Annual Health Survey 2011-2012

18

Performance of the Boat Clinics

The service delivery output of this intervention under NRHM is shown in the table below

(comparative from 2008 to 2013) which shows array of services provided by the Boat clinics and

number of people benefitted by the same.

Table 3.3 Performance of the Boat Clinics (2008-2013)

Sl. Activity 2008-09 2009-10 2010-11 2011-12 2012-13

1 No. of Camps organized 1,038 1,867 2,159 2,776 2,582

2

No. of patients treated

under General Health

Check-up

91,839 1,41,413 1,77,300 2,25,141 2,00,679

3 Routine Immunization 8,994 20,389 22,468 24,817 21,971

4 Ante Natal Care (ANC) 3,201 6,064 9,020 14,679 11,576

5 Post Natal Care (PNC) 993 1,202 2,422 3,499 3,355

6 Vitamin A

supplementation 1,463 7,170 8,088 11,037 11,407

7 Special Immunisation

Activities 1,343 1,330 2,656 6,201 669

8 IPPI 4,281 1,684 105 56 708

9 Family Planning 2,533 14,030 38,728 88,913 72,069

19

4 KEY FINDINGS OF THE STUDY

The boat clinic unit provides services to the island communities in the district where there is

lack of medical facilities. The yearly micro plan is prepared by the District Programme Officer in

consultation with Medical Officers and district health authorities. The list of selected chars is

approved by the Joint Director of the District. The operational plan is prepared monthly in all of

the districts and the criteria of selection of the camps are done by the District Programme

Officers and Medical Officers. The monthly plan is then submitted to the district in the

beginning of each month.

A total of 15 units of boat clinics are operating in 13 districts of the state (Table. 4.1). Boats of

Dibrugarh & Dhubri unit 1 are under repair. Dhubri unit 1 has hired a local boat and modified

their needs. Dibrugarh uses the boat of Tinsukia and Dhemaji units alternatively when these

units do not have their camps.

Table 4.1 Distribution of Boat clinic with functional status

S. No. District/Unit Functional status

1 Barpeta Unit I YES

2 Barpeta Unit II YES

3 Bongaigaon YES

4 Dhubri Unit I YES

5 Dhubri Unit II YES

6 Dhemaji YES

7 Dibrugarh YES

8 Goalpara YES

9 Jorhat YES

10 Kamrup YES

11 Lakhimpur YES

12 Morigaon YES

13 Nalbari YES

14 Sonitpur YES

15 Tinsukia YES

4

20

COVERAGE BY BOAT CLINICS

Table 4.2 shows Jorhat boat clinic covered the maximum of 33 islands (saporis) followed by

Dhubri units of the boat clinics covered the maximum number of chars (32 chars by each unit).

Tinsukia unit covers 4 saporis but it has 39 villages with a population of 18,858 to be covered.

On an average 26 chars are covered by each unit.

Table 4.2 No. of char/sapori covered by Districts/Units of Boat Clinic in 2012-13

S. No. District/Unit Char/Sapori covered

1 Barpeta Unit I 30

2 Barpeta Unit II 30

3 Bongaigaon 20

6 Dhemaji 20

4 Dhubri Unit I 32

5 Dhubri Unit II 32

7 Dibrugarh 17

8 Goalpara 30

9 Jorhat 33

10 Kamrup 26

11 Lakhimpur 21

12 Morigaon 36

13 Nalbari 30

14 Sonitpur 26

15 Tinsukia 4

TOTAL 387

Average* 26

*rounded off

Table 4.3 and 4.4 shows the coverage of districts and number of camps held in the year 2012-

2013. The districts like Nalbari, Goalpara, Kamrup, Barpeta Unit II, Dhubri Unit II, Bongaigaon

were better performing districts and the district like Dibrugarh, Dhubri Unit I, Tinsukia had less

number of camps. In Dibrugarh unit the boat is under repair for many months so it has been

hampering the camp schedules. It was found that the funding to all the district units were

irregular from May 2012 till date which hampered holding camps as scheduled.

21

The frequency of coverage of particular mapped areas in a year varies between 6- 24 times. The

average time taken to reach the camp sites from the ghats varied from 30 minutes in some

areas of Goalpara to 16 hours in Dhemaji. On an average each unit covers a population of

20,963

Table 4.3 Population covered under each unit of Boat Clinics (2012-2013)

District/Unit Population

Barpeta I 29,203

Barpeta II 28,006

Bongaigaon 12,953

Dhemaji 11,882

Dhubri I 24,450

Dhubri II 38,795

Dibrugarh 13,010

Goalpara 20,702

Jorhat 16,966

Kamrup 23,031

Lakhimpur 12,922

Morigaon 21,534

Nalbari 33,046

Sonitpur 12,085

Tinsukia 18,858

TOTAL 3,14,443

Average 20,963

Table 4.4: District wise No. of camps planned and held during the year 2012-2013

District No of Camps

planned No of camps

held Total Percentage

Barpeta Unit I 189 153 80.95

Barpeta Unit II 217 184 84.79

Bongaigaon 210 182 86.67

Dhubri Unit I 178 133 74.71

Dhubri Unit II 213 183 85.92

Dhemaji 212 160 75.47

Dibrugarh 192 116 60.42

Goalpara 208 192 92.31

22

District No of Camps

planned No of camps

held Total Percentage

Jorhat 190 158 83.16

Kamrup 224 186 83.03

Lakhimpur 200 151 75.50

Morigaon 202 179 88.61

Nalbari 204 202 99.02

Sonitpur 180 174 96.67

Tinsukia 185 145 78.38

Total 3004 2498 83.15

Average* 200 167 83.50

*Rounded off

Table 4.4 shows number of camps planned and held during the year 2012-2013. A total of 3004

camps were planned and 2498 (83.15%) were actually held. On average each unit planned 200

camps and organised 167 (83.50%) camps.

Equipments and Instruments:

The boat clinic is equipped with facilities to provide diagnostic tests. Table 4.5 describes about

the equipment availability and its utility in all the evaluated units. Among the basic equipment

and instruments, BP apparatus and stethoscope were present 100% and their utility was also

100%. The equipments like microscope, centrifuge, autoclave/steriliser and semi auto analyser

were present in all the boat clinics but most of these equipments were not utilised even though

they were functioning. Only in 13% of the total units the microscope were utilised i.e. is in

Dibrugarh and Dhemaji district which were used occasionally and the rest of the units did not

use the equipments and the reason was lack of training facilities and space in space in smaller

boats.

SERVICE DELIVERY BY BOAT CLINICS

As per the work plan the team visits the char areas with prior intimation to the community

residing there with the help of ASHAs and Community workers. The team provides the

following services including emergency preparedness and response in case of flood, relief

measures etc. (when required):

23

Antenatal and Postnatal Check up

Immunization of children in which JE vaccine campaign is also included


General check-ups for preventive and curative care

Along with the above mentioned services the boat clinic has a referral boat for

transporting the cases which needs immediate health care services.

Table 4.5: Availability of equipments in the districts in percentage

Equipment Availability in the District Utility of the equipment

Microscope 100% 13%

Centrifuge 87% 0

Autoclave/sterilizer 100% 13%

Semi auto analyzer 47% 0

TV 100% 100%

DVD 87% 87%

Generator 100% 100%

BP Apparatus 100% 100%

Stethoscope 100% 100%

BP apparatus and stethoscope were present 100% and their utility was also 100%. The

equipments like microscope, centrifuge, autoclave/steriliser and semi auto analyser were

present in all the boat clinics but most of these equipments were not utilised even though they

were functioning. Only in 13% of the total units the microscope were utilised (Table 4.5)

24

Table 4.6 Service delivered by Boat Clinics (2012-2013)

Sl. No.

UNITS OPD Laboratory Facilities

Family Planning Services

Immunisation IEC Activities

Health Awarenes

s

1 Barpeta I YES YES YES YES YES YES

2 Barpeta II YES YES YES YES YES YES

3 Bongaigaon YES YES YES YES YES YES

4 Dhubri I YES YES YES YES YES YES

5 Dhubri II YES YES YES YES YES YES

6 Dhemaji YES YES YES YES YES YES

7 Dibrugarh YES YES YES YES YES YES

8 Goalpara YES YES YES YES YES YES

9 Jorhat YES YES YES YES YES YES

10 Kamrup YES YES YES YES YES YES

11 Lakhimpur YES YES YES YES YES YES

12 Morigaon YES YES YES YES YES YES

13 Nalbari YES YES YES YES YES YES

14 Sonitpur YES YES YES YES YES YES

15 Tinsukia YES YES YES YES YES YES

Total 100 100 100 100 100 100

OPD LaboratoryTest

FamilyPlanningServices

Immunisation HealthAwareness

100% 100% 100% 100% 100%

Service Delivery by Boat Clinics in 2012-13

25

Table 4.7 District wise OPD Registration of Boat Clinics (2012-2013)

S. No.

DISTRICTS OPD cases

1 Barpeta 8,784

2 Barpeta II 14,948

3 Bongaigaon 14,483

4 Dhemaji 8,384

5 Dhubri 18,021

6 Dhubri II 14,388

7 Dibrugarh 6,784

8 Goalpara 13,004

9 Jorhat 7,984

10 Kamrup 15,321

11 Lakhimpur 6,639

12 Morigaon 17,804

13 Nalbari 22,552

14 Sonitpur 14,426

15 Tinsukia 9,818

TOTAL 1,93,340

Average 12,890

Table 4.7 shows OPD registration of all district units. A total of 1,93,340 patients were

registered in 2012-13 and the average OPD attendance was 12,890

Health awareness is an indispensable component of Boat Clinics services. It was observed that

health awareness and IEC activities were done in every camp which mostly concentrated on

family planning, antenatal check-up and postnatal check-up. Other health topics that were

discussed were awareness on malaria, Japanese encephalitis clean drinking water, hand

washing, personal hygiene etc. Television and DVD player has been supplied to all units of Boat

clinic but are less often used. Six of the Boat Clinic teams go for trips of 4-6 days which include

night halts. In the evening after the health camps audio-visual materials on Immunisation,

Family planning etc. are shown to the people of the chars.

LABORATORY TESTS DONE IN BOAT CLINICS

1. Haemoglobin (Sahli’s method / Colour scale method)

26

2. Random Blood Sugar (Glucometer)

3. Urine – Sugar & Protein (Dip stick)

4. Peripheral Blood Smear for Malaria parasite

5. Rapid Diagnostic Kit test for Malaria

6. Β-HCG kit test (Urine test for Pregnancy )

7. VDRL

8. HIV

All the 15 units of Boat Clinics provide essential laboratory services mentioned above.

Whenever there is shortage of reagents or testing kits, it is purchase locally by an approved

fund. Stool test is never done.

Table 4.8: Laboratory Tests done in Boat clinics (%)

DISTRICT Hb% RBS Urine Sugar

Urine Albumin

PBS for MP

RDK for Malaria

HCG/ Pregnancy

test

Blood Grouping

VDRL* HIV*

Barpeta I YES YES YES YES YES YES YES YES YES YES

Barpeta II YES YES YES YES YES YES YES YES YES YES

Bongaigaon YES YES YES YES YES YES YES YES YES YES

Dhubri I YES YES YES YES YES YES YES YES YES YES

Dhubri II YES YES YES YES YES YES YES YES YES YES

Dhemaji YES YES YES YES YES YES YES YES YES YES

Dibrugarh YES YES YES YES YES YES YES YES YES YES

Goalpara YES YES YES YES YES YES YES YES YES YES

Jorhat YES YES YES YES YES YES YES YES YES YES

Kamrup YES YES YES YES YES YES YES YES YES YES

Lakhimpur YES YES YES YES YES YES YES YES YES YES

Morigaon YES YES YES YES YES YES YES YES YES YES

Nalbari YES YES YES YES YES YES YES YES YES YES

Sonitpur YES YES YES YES YES YES YES YES YES YES

Tinsukia YES YES YES YES YES YES YES YES YES YES

TOTAL 100 100 100 100 100 100 100 100 100 100

*VDRL and HIV have been newly introduced.

27

Table 4.9: Laboratory Tests done in Boat clinics during 2012-13

Sl.

No. District Unit Hb% RBS Urine Sugar

Urine Albumin

PBS for MP

RDK for MP

HCG kit test

ABO / Rh

1 Barpeta I 462 476 409 409 0 122 135 402

2 Barpeta II 939 710 475 475 134 68 282 479

3 Bongaigaon 1287 1276 329 329 599 308 604 356

4 Dhubri I 216 165 90 90 52 52 112 96

5 Dhubri II 119 119 239 235 0 205 75 119

6 Dhemaji 281 284 283 283 12 0 444 274

7 Dibrugarh 281 46 225 225 75 57 69 107

8 Goalpara 1037 682 681 682 323 335 362 721

9 Jorhat 912 556 572 572 126 126 214 210

10 Kamrup 1451 726 1145 1145 133 110 568 639

11 Lakhimpur 316 247 213 213 4 4 117 236

12 Morigaon 1447 439 1418 1418 97 81 380 210

13 Nalbari 818 342 338 319 35 111 159 345

14 Sonitpur 482 127 507 507 19 82 393 329

15 Tinsukia 627 463 224 224 229 229 394 627

TOTAL 10675 6658 7148 7126 183

8 1890 3914 5150

Average* 712 444 477 476 123 126 261 344

*Figures have been rounded

28

All the 15 units of Boat Clinics provide essential laboratory services mentioned above.

Whenever there is shortage of reagents or testing kits, it is purchased locally by an approved

fund. Stool test is never done.

DRUGS AVAILABILITY IN BOAT CLINICS

Drugs to the Boat Clinics were supplied through Boat Clinic & MMU Drug kits and from the

District Drug store. The mechanisms of indent of the drug were done monthly or according to

the requirements. The Boat Clinic & MMU Drug kit provided the essential drugs which are

supplied during the beginning of the financial year.

Table 4.10 Availability of Drugs in Boat Clinics (%)

Y – Yes, NA- Not available, PCM - Paracetamol

DISTRICT IFA (L)

IFA (S)

PCMl Antacid Cough syrup

Antibiotics ORS Zinc Sulphate

Vitamin B complex

Anti-inflammatory

Barpeta I YES YES YES YES YES YES YES YES YES YES

Barpeta II YES YES YES YES YES YES YES YES YES YES

Bongaigaon YES YES YES YES YES YES YES YES YES YES

Dhubri I YES YES YES YES YES YES YES YES YES YES

Dhubri II YES YES YES YES YES YES YES YES YES YES

Dhemaji YES YES YES YES YES YES YES YES YES YES

Dibrugarh YES YES YES YES YES YES YES YES YES YES

Goalpara YES YES YES YES YES YES YES NA YES YES

Jorhat YES YES YES YES YES YES YES YES YES YES

Kamrup YES YES YES NA YES YES YES YES YES YES

Lakhimpur YES YES YES YES YES YES YES YES YES YES

Morigaon YES YES YES YES YES YES YES YES YES YES

Nalbari YES YES YES YES YES YES YES YES YES YES

Sonitpur NA YES YES YES YES YES YES YES YES YES

Tinsukia YES YES YES YES YES YES YES YES YES YES

TOTAL 93 100 100 93 100 100 100 93 100 100

29

Table 4.11 Immunisation Coverage

S.No.

District Units BCG OPV1 OPV2 OPV3 DPT1 DPT2 DPT3 Hep B1

Hep B2

Hep B3

Measles Vitamin

A

Fully Immunis

ed

1 Barpeta Unit

I 282 269 274 199 291 294 213 284 229 118 222 1223 154

2 Barpeta Unit

II 373 394 428 394 373 394 428 373 494 428 294 705 294

3 Bongaigaon 302 335 339 324 335 339 324 317 494 268 293 1612 245

6 Dhemaji 217 228 198 195 228 198 195 228 494 195 203 339 217

4 Dhubri Unit I 186 224 142 121 224 142 121 127 494 44 132 237 106

5 Dhubri Unit II 309 382 290 201 387 273 196 355 494 143 157 335 57

7 Dibrugarh 95 116 112 96 116 112 96 107 494 9 57 201 68

8 Goalpara 504 548 573 482 534 637 608 490 494 486 460 1794 205

9 Jorhat 65 78 68 62 78 68 62 72 494 62 81 75 60

10 Kamrup 406 469 428 370 469 428 370 376 494 163 308 490 283

11 Lakhimpur 230 235 204 200 235 204 200 230 494 186 202 225 110

12 Morigaon 674 499 451 437 499 451 437 478 494 402 524 4237 519

13 Nalbari 479 448 430 412 448 430 412 288 494 9 355 603 138

14 Sonitpur 285 272 286 304 272 286 304 288 494 9 355 603 138

15 Tinsukia 59 59 63 47 59 63 47 7 494 9 49 254 47

Total 4466 4556 4286 3844 4548 4319 4013 4020 7145 2531 3692 12933 2641

Average* 298 304 286 257 304 288 268 268 477 169 247 863 177

30

Table 4.10 shows availability of drugs in all Boat clinics. There was huge shortage of & Folic acid (IFA)

tablets (large). The availability of tablets Paracetamol, anti-inflammatory like Diclofenac sodium, and

antibiotics were 100% but were inadequate for distribution to the patient. In 2012-13 Zinc

sulphate was not supplied to Goalpara unit and IFA tablets were not supplied to Kamrup unit.

During the evaluation process it was observed that most of the adult patients presented with

musculoskeletal pain for which anti-inflammatory drugs like tablet Paracetamol, and injection

Diclofenac sodium, and Diclofenac gel were prescribed. The supplied quantity did not meet the

demand.

MANPOWER AND TRAINING

Table 4.12 Manpower at District Unit

S. No. Post No.

1 District Programme Officer 1

2 Medical Officer 2

3 General Nurse Midwife 1

4 Auxiliary Nurse Midwife 2

5 Pharmacist 1

6 Laboratory Technician 1

7 Community Workers 3

8 Boat Crew (Driver, Master, Cook & Helper) 4

Total 15

The District Unit is manned by a District Programme Officer, two Medical Officers, one GNM,

two ANM, one Laboratory Technicians, one Pharmacist, three Community Workers and four

Boat crew which include a cook and a helper.

Medical officers provide OPD services, ANC and PNC, minor surgical procedures and advice for

family planning. They are also often involved in health awareness lectures. There was no

training given to the medical officers prior to the joining of Boat Clinic. Medical Officers have

been trained in Routine Immunization, Neonatal Resuscitation and RCH & Health logistics.

ANMs and GNM provide immunization services, ANC & PNC services and maintenance of

records. In all of the districts nursing staffs have been trained in routine immunization,

Neonatal Resuscitation and HIV counseling. Medical officer aided with nursing staff have

31

conducted few deliveries in the chars notably 6 deliveries have been conducted till date in

Dibrugarh Boat clinic. In 2012-13 one delivery was conducted in Barpeta unit 2 and two

deliveries in Jorhat unit. . All the boat clinic units have a laboratory technician. The services

provided by the technician were Hb test, RBS, Urine Albumin & Sugar, PBS for MP, RDK for MP,

Urine pregnancy test and ABO/Rh grouping. Recently additional tests have been added like

VDRL, HBsAg and HIV. Proper training has not been given to Laboratory Technicians prior to

induction in boat clinics. After addition of HIV testing technicians were trained in HIV testing

and counseling at Gauhati Medical College. Equipments like microscope, semi-auto analyser&

centrifuge are rarely used. Most of the tests done were kit tests except for Haemoglobin

estimation which is done by Sahli’s Haemometer. The use of the centrifuge and semi auto

analyser has been found to be very limited.

Table 4.13 District wise availability of manpower in 2012-2013.

District Medical Officer

1

Medical Officer

2 GNM

ANM 1

ANM

2

Laboratory Technician

Pharmacist District

Programme Officer

Community worker

Barpeta I YES NA NA YES YES YES YES YES YES

Barpeta II YES YES NA YES YES YES YES YES YES

Bongaigaon YES NA NA YES YES YES YES YES YES

Dhubri I YES NA NA YES YES YES YES YES YES

Dhubri II YES YES NA YES YES YES NA YES YES

Dhemaji YES YES YES YES YES YES YES YES YES

Dibrugarh YES NA YES YES YES YES YES YES YES

Goalpara YES NA NA YES YES YES YES YES YES

Jorhat YES NA YES YES NA YES YES YES YES

Kamrup YES YES YES YES YES YES YES YES YES

Lakhimpur YES NA YES YES YES YES YES YES YES

Morigaon YES YES YES YES NA YES YES YES YES

Nalbari YES YES YES YES YES YES YES YES YES

Sonitpur YES YES YES YES YES YES YES YES YES

Tinsukia YES YES NA YES YES YES YES YES YES

NA- Not available

Table 4.12 shows manpower position in Boat Clinics. There is no second Medical Officer in 7

units. In 7 of the boat clinics there are no GNMs and 2 of them do not have second ANM.

32

Dhubri Unit II does not have a Pharmacist; drugs are dispensed by community worker under

supervision of a Medical Officer.

Table 4.14 Training program for Boat Clinic staff from 2012-13

Year Training MO GNM ANM CW ASHA

2012-13

Routine Immunisation * *

Community mobilization for awareness *

IMNCI * *

Neonatal resuscitation * *

FICTC refreshers training module *

There has been no training of pharmacists since induction. Record maintenance varied among

them. It was observed that batch no. and expiry dates were not entered in the Stock Registers

All boat clinic units have Community workers from the chars in which service is provided.

Community workers liaise between the medical team and the char population. They inform

people about the date, time and place of camp in advance. They work in cooperation with the

ASHA for the smooth functioning of the health camps. Community workers are engaged yearly

in doing actual head count of the char population to which the boat clinic cater. This census

serves as baseline data for micro plan preparation for the next financial year. Community

workers form an integral part of the boat clinic unit team.

100%

53% 53%

100% 87% 93% 100% 100% 100%

Manpower Availabilty

33

Table 4.15 Programme Management Staff at State

S.No. Post No. (as per MoU) In Position

1 Project Director 1 1

2 Programme Manage 1 1

3 Associate Programme

Manager

1 1

4 Assistant Programme

Manager

2 0

5 Accounts Manager 1 0

6 Account Assistants 2 2

7 Communication Officer 1 1

8 Data Analyst 1 1

9 Office Assistant 2 1

10 Multi-tasking Office Helper 3 2

11. Driver 0 1

Total 15 11

The State office of Boat clinic is current manned by a Chief Executive Officer, a Programme

Manager, a Associate Programme, a Communication Officer, two Accounts Assistants, an Office

Assistants, two Peons and a Driver. The Data Analyst is stationed in New Delhi office of C-NES.

It has been observed that there is gradual increase in manpower at the state office of C-NES

with 5 staff in 2008-09 to 13 staffs in 2012-13

KEY OBSERVATION OF ToR OF STATE NODAL AGENCY (C-NES, GUWAHATI) STAFF

Most of the ToR were prepared after the evaluation process had started and were

signed on 17-07-2013

It was observed that there has been gradual increase in manpower in the State office of

the Boat Clinic. In 2008-09 the office was manned by 5 staffs, 2009-10 by 9 staffs, 2010-

11 and 2011-12 by 10 and 2012-13 by 13 staffs.

There is no mention of employing a driver, in the MoU signed for 2012-13.

34

The job responsibility of Project Director, Programme Manager, Associate Programme

Manager and Assistant Programme Manager is quiet similar and has overlapping of

responsibilities.

Most of the job responsibilities of Associate Program Manager relates to liaison with

UNICEF, PFI etc.

The post of Data Analyst is held at the New Delhi office of the organization which is not

mentioned in the MoU document.

There are two post of Accounts Assistant, both have similar responsibilities and are

under the Accounts Manager.

There are two posts of Peon in the office who have similar job responsibilities.

It was also observed that there are no records of any monitoring activities done till date by any

management staff. The evaluation team was informed that all communication are done

through emails.

MAINTENANCE OF BOATS

C-NES own six boats namely in Dibrugarh, Dhemaji, Sonitpur, Jorhat, Tinsukia and Dhubri. A

boat for Morigaon is being built at Dibrugarh. The remaining units have hired and modified

boats according to their convenience. According to the MoU between C-NES and NRHM the

responsibility of boat maintenance and repair is vested upon C-NES. The rented boat are

repaired and maintained by their respective owners.

During the evaluation process it was observed that the Dhemaji Boat (SB Swaminathan) is in a

critical condition. Most of the visible wooden structures has worn out, water leaks over the

couch made for Medical Officers to sleep and most of it window glasses were broken. The boat

needs a major repair urgently. The Dibrugarh and Dhubri boats are already on repair.

It was also observed that none of the boats had adequate number of life jackets moreover

many life jackets were non-usable. It was learnt that every boat clinic units have informed the

35

State Office of C-NES to supply them with adequate life jackets since last year but nothing has

been done yet. It has been negligence on the part of the C-NES Guwahati for not supplying the

life jackets and putting the life of the boat clinic teams in danger who serve for the cause of the

State.

KEY OBSERVATIONS OF EXIT INTERVIEWS WITH BENEFICIARIES

25 beneficiaries were randomly interview at each camps site in each district. A total of 375

beneficiaries were interviewed. The key findings of the interviews are cited below

1. 78.3% (293) of the beneficiaries were females, of which most of them had come for

antenatal check up and vaccination of their children (Table 4.16)

2. Beneficiaries received information about camps from the ASHAs and the Community

Workers

3. Seeking treatment was the most common reason for attending the health camps (Table

4.16)

4. 91.2% (342) of the beneficiaries were fully satisfied with the service of the boat clinics.

5. 6.7% (25) were partially satisfied reasons being - waiting in queue for long, all medicines

were not available 2.1% (8) (Table 4.16) were not satisfied because they did not receive

the desired medicine (most commonly Syrups of vitamin and liver support)

6. 76.4% (286) of the beneficiaries received the required medicine, 23.6% (89) of the

beneficiaries were prescribed medicine which was not in supply (Table 4.16).

7. 4.3% (16) patients were referred for specialised treatment to higher health facilities

8. It was observed that services were provided on first come – first serve basis, however

priority was given to pregnant mothers, children and elderly.

9. The health camps were organized inside tents with provision of privacy to female

patients.

36

Table 4.16 Observations of Exit Interviews with Beneficiaries

Parameters No. %

Patients Registered

Male 82 21.7

Female 293 78.3

Seeking Treatment for

Self 369 98.4

Relatives 6 1.6

Level of Satisfaction

Fully Satisfied 342 91.2

Partially Satisfied 25 6.7

Not Satisfied 8 2.1

Availability of prescribe

medicines

Yes 286 76.3

No 89 23.7

Waiting time (In minutes)

<30 321 85.6

30-60 33 8.8

>60 21 5.6

Purpose of visit to health camp

For Treatment 373 99.5

Information on Health Issue 2 0.5

10. IEC materials were displayed in all the camps. IEC materials most comprised of leaflets

and flyers of Iodised salt, family planning, IPPI, Janani Suraksha Yojna etc

11. Discussion on health issues were done in all the units of Boat Clinic, however it was

learnt that these discussion are held less frequently.

12. There was no sitting arrangement in any of the health camps.

Table 4.17 show the common illnesses and symptoms presented at the Boat Clinics. Anemia,

Gastritis/Peptic Ulcer Syndrome, Body ache, generalized weakness were some of the common

symptoms and illnesses of patient presenting to Boat Clinics

37

Table 4.17 Common ailments presented by patients in Exit Interview

Type of Illness / Purpose of visit No.

Generalised weakness 156

Headache 89

Bodyache 142

Lower backache 201

Leucorrhea 47

Gastritis/Peptic Ulcer Syndrome 213

Anemia 246

Antenatal Check up 192

Post Natal Check up 32

Fungal skin infection 98

Local Bacterial Infection 49

Injury 12

It was observed that generalised body ache, weakness, fungal and bacterial skin infection,

anaemia, vitamin deficiency were the common ailments found among the OPD attendees of

Boat Clinics.

38

DISTRICT WISE ANALYSIS OF SERVICES PROVIDED BY BOAT CLINICS IN THE YEAR 2012-13

5

39

BARPETA UNIT I

Barpeta unit I started functioning from January 2009 and started organizing its health and

immunization camps from 16th March of 2009. It had been covering 71 char villages of 34 char

islands, the total targeted population was 81,055. As the unit was catering to a huge

population, a need for another unit for Barpeta was felt. In October 2010 Barpeta Unit II started

functioning and the areas were divided between the units and new chars were added. Currently

unit I caters to 30 chars in the district which covers a population of 29,203 under Chenga BPHC .

A total of 146 camps were held in the 2012-13. The team goes for day camps and on an average

each char was visited once in 2 months. The average OPD attendance was found to be 58

patients per camp.

Parameters No. Immunisation

Population covered 29,203 BCG 282

Camps planned 189 OPV1 269

Camps held 153 OPV2 274

OPD attendance 8784 OPV3 199

No. of Pregnant women Registered

393 DPT1 291

No. of 3 ANC 137 DPT2 294

TT1 365 DPT3 213

TT2/Booster 245 Hep B1 284

Laboratory Tests Hep B2 229

Hb% 462 Hep B3 118

RBS 476 Measles 222

Urine Sugar 409 Vitamin A 1223

Urine Albumin 409 Fully Immunised 154

PBS for MP 0

Total Positive 0

RDK for MP 122

Total Positive 0

HCG kit test 135

ABO/Rh 402

40

The boat is harboured at Bahari, which is about 30 kms from Barpeta town. It takes about an

hour to reach the ghat. The time taken to reach camp site ranges between 30 minutes to 3

hours. The team starts from Barpeta town by 9:00 – 9:30 AM. The team reaches at the camp

site at about 12:00 pm and returns by 2:30 – 3:00 pm. The unit should find out alternatives to

decrease the fuel expenditure and time spent in travel.

BARPETA UNIT II

Barpeta unit II started functioning from 28th October 2010. It caters to a population of 28,006 in

30 chars under Mandia BPHC.

Key Observations: A total of 184 camps were held in the 2012-13. The team goes for day camps

and each char is visited once in 2 months. The average OPD attendance was found to be 82

patients per camp.







433 DPT1 373


TT1 333 DPT3 428



Hb% 939 Hep B3 428

RBS 710 Measles 294



PBS for MP 134

Total Positive 0

RDK for MP 68

Total Positive 0

HCG kit test 282

ABO/Rh 479

41

The ghat where the boat stands is situated at Mandia ghat, which is takes about an hour to

reach from Barpeta town due to bad road conditions. The team reaches at the camp site by

12:00 pm and returns by 2:30 – 3:00 pm. The effective time used for patient care can be

increased by starting an hour early for duty.

BONGAIGAON

Bongaigaon Boat Clinic started function on 21st October 2010. Bongaigaon district there are

about 52 chars. And out of these 20 char villages are covered by the Boat Clinic under the two

BPHC named Boitamari and Srijangram.

Key Observations: It covers a population of 12,953 in 20 chars. 182 camps were held in 2012-

13. The team goes for day camps and on an average each char is visited every one and half

month. The average OPD attendance was found to be 80 patients per camp.





OPD attendance 14,483 OPV3 324


319 DPT1 335


TT1 217 DPT3 324



Hb% 1287 Hep B3 268

RBS 1276 Measles 293



PBS for MP 599

Total Positive 0

RDK for MP 308

Total Positive 0

HCG kit test 604

ABO/Rh 356

42

DHEMAJI

Dhemaji unit of Boat clinic started functioning from December 2006. It covers a population of

11,882 in 20 saporis under Sissiborgaon and Jonai.

Key Observations: 133 camps were held in 2012-13. The average OPD attendance was found to

be 63 patients per camp. The team visits a sapori every 1-1 ½ months.

The Dhemaji unit usually carries out 5-6 trips of 3-4 days camps in the saporis which includes

night halts. Frequently the team arranges for audio-visual awareness camps in the sapori with

the help of television, DVD players and Projectors in the evenings.







72 DPT1

228


TT1 60 DPT3 195



Hb% 216 Hep B3 195

RBS 165 Measles 203



PBS for MP 52

Total Positive 0

RDK for MP 52

Total Positive 0

HCG kit test 112

ABO/Rh 96

43

DHUBRI UNIT I

Dhubri Boat Clinic started operating from 16th February 2008. Dhubri district has 480 chars in 12

different community development blocks, 59 chars had been covered where at least 3

continuous visits were being ensured to follow up the routine immunization round. Owing to

the huge number of chars and the population to be covered it was decided to start the second

unit of Dhubri Boat Clinic and the areas were divided among the two units with inclusion of new

areas. Currently Dhubri Unit I cater to 32 chars covering a population of 24,450 under South

Salmara block.

Key Observations: A total of 183 camps were held in 2012-13. The average OPD attendance

was 99 patients per camp. The unit goes for only day camps and visits each char every 2

months.





OPD attendance 18,021 OPV3 121


151 DPT1 224


TT1 129 DPT3 121



Hb% 119 Hep B3 44

RBS 119 Measles 132



PBS for MP 0

Total Positive 0

RDK for MP 205

Total Positive 0

HCG kit test 75

ABO/Rh 119

44

DHUBRI II

The Dhubri Unit II started functioning from 30th October 2010. It caters to 32 chars covering a

population of 38, 795.


was 99 patients per camp. The unit goes for only day camps and visits each char every 2

months.

The team does not have a pharmacist. Drugs are dispensed by community workers and DPO

under the supervision of the MO.


Population covered 38795 BCG 309





247 DPT1 387


TT1 208 DPT3 196



Hb% 281 Hep B3 143

RBS 284 Measles 157



PBS for MP 12

Total Positive 0

RDK for MP 0

Total Positive 0

HCG kit test 444

ABO/Rh 274

45

DIBRUGARH

The Dibrugarh boat clinic was the first to be launched by C-NES for the health program in

Assam. It was launched on 25th May 2005. It caters to a population of 13,010 in 17 saporis

under Lahoal and Panitola BPHC.


was found to be 59 patients per camp. The team visits each sapori twice in a month.

The team goes on 5-6 trips of 3-4 days which include night halts. Frequently the team arranges

for audio-visual awareness camps in the sapori with the help of television, DVD players and

Projectors in the evenings.







131 DPT1 116


TT1 118 DPT3 96



Hb% 281 Hep B3 9

RBS 46 Measles 57



PBS for MP 75

Total Positive 0

RDK for MP 57

Total Positive 0

HCG kit test 69

ABO/Rh 107

46

GOALPARA

Goalpara Boat clinic was launched on 27th October 2010. The boat clinic operates from Chunari

ghat. It caters to 30 chars covering a population of 20,702 under.

Key Observations: 192 camps were held in 2012-13. No camps were held in the month of

September due to ethnic violence. The average OPD attendance was 68 patients per camp. The

team goes for day camps and visits each char every 2 months.







392 DPT1 534


TT1 306 DPT3 608



Hb% 1037 Hep B3 486

RBS 682 Measles 460



PBS for MP 323

Total Positive 1

RDK for MP 335

Total Positive 1

HCG kit test 362

ABO/Rh 721

47

JORHAT

Jorhat boat clinic was started in 2009. The unit has its own boat. It caters to 33 saporis covering

a population of 16,966 under Kamalabari BPHC and Majuli.

Key Observations: 190 camps were held in 2012-13. The average OPD attendance was 43

patients per camp. The team visits each char every 1-1 ½ months. The team goes on trips of 4-5

days which includes night halts.

The team arranges for audio-visual awareness camps in the sapori with the help of television,

DVD players and Projectors in the evenings.







502 DPT1 78


TT1 86 DPT3 62



Hb% 912 Hep B3 62

RBS 556 Measles 81



PBS for MP 126

Total Positive 0

RDK for MP 126

Total Positive 0

HCG kit test 214

ABO/Rh 210

48

KAMRUP

The Kamrup unit of Boat Clinic started functioning from 25th October 2010. It covers a

population of 23,031 in 26 chars under Chaygaon BPHC.

Key Observations: 186 camps were held in 2012-13. The average OPD attendance was 83

patients per camp. The team goes for day camps and visits each char every 2 months.







585 DPT1 469


TT1 436 DPT3 370



Hb% 1451 Hep B3 163

RBS 726 Measles 308



PBS for MP 133

Total Positive 0

RDK for MP 110

Total Positive 0

HCG kit test 568

ABO/Rh 639

49

LAKHIMPUR

Lakhimpur unit has been functioning since 16th March 2009. It covers a population of 12,922 in

21 saporis under Bihpuria, Nowboicha and Boginadi BPHC.

Key Observations: A total of 151 camps were held in 2012-13. The average number of patients

attending OPD was 44 per camp. The team goes on day camps and visits each sapori every 1-1

½ months.

The boat clinic operates from two ghats. One is at Bihpuria and other at Khabolu. It is about 52

kms from Lakhimpur town to Bihpuria and 29 kms to Khabolu. Considerable amount of time

and fuel is spent to reach the ghats. The district unit should find out alternatives to decrease

the fuel expenditure and time spent in travel. Time spent in travel to reach the ghats decreases

the actual time spent in camp activities.







196 DPT1 235


TT1 158 DPT3 200



Hb% 316 Hep B3 186

RBS 247 Measles 202



PBS for MP 4

Total Positive 0

RDK for MP 4

Total Positive 0

HCG kit test 117

ABO/Rh 236

50

MORIGAON

Morigaon Boat Clinic has been functioning since February 2008. . It covers a population of

21,534 in 36 chars under 4 blocks.

Key Observations: The total number of camps held in 2012-13 was 179. The average number of

patients attending OPD was 99 per camp. The team goes on day camps and visits each chars

every 2 months.

The team is stationed at Morigaon town. The ghat is at Lahorighat, it takes about an hour to

reach the ghat. The team reaches the ghat by 10:00 – 10:30 am. More time is spent on travel

and less on actual services provided. The district unit should find out alternatives to decrease

the fuel expenditure and time spent in travel. The team should take steps to increase the time

spent on patient care. It was also observed that the prescription written was too shortcut.







610 DPT1 499


TT1 238 DPT3 437



Hb% 1447 Hep B3 402

RBS 439 Measles 524



PBS for MP 97

Total Positive 0

RDK for MP 81

Total Positive 0

HCG kit test 380

ABO/Rh 210

51

NALBARI

Nalbari unit of boat clinic was launched in 2008. It caters to a population of 33,046 in 30 chars.

Key Observations: A total of 202 camps were held in 2012-13 which also included relief camps

during floods. Average OPD attendance was found to be 112 per camp. The team goes for day

camps and visits each char in 1-1 ½ month.

The ghat where the boat stands is situated at Mukalmua, which is about 30 kms from Nalbari

town. It takes about an hour to reach the ghat. The team reaches at the camp site at about

12:00 pm and returns by 2:30 – 3:00 pm. The district unit should find out alternatives to

decrease the fuel expenditure and time spent in travel. The team should take steps to increase

the time spent on patient care.







417 DPT1 448


TT1 371 DPT3 412



Hb% 818 Hep B3 9

RBS 342 Measles 355



PBS for MP 35

Total Positive 1

RDK for MP 111

Total Positive 1

HCG kit test 159

ABO/Rh 345

52

SONITPUR

Sonitpur unit of boat clinic was launched on 1st January 2009. It caters to a population of 12,085

in 26 chars.

Key Observations: A total of 174 camps were held in 2012-13. Average OPD attendance was

found to be 81 patients per camp. The team goes for day camps as well as on trip of 3-4 days

which includes night halts and visits each char once in 1-1 ½ month.

The team arranges for audio-visual awareness camps in the sapori with the help of television,

DVD players and Projectors in the evenings.







336 DPT1 272


TT1 293 DPT3 304



Hb% 482 Hep B3 9

RBS 127 Measles 355



PBS for MP 19

Total Positive 1

RDK for MP 82

Total Positive 1

HCG kit test 393

ABO/Rh 329

53

TINSUKIA

The Tinsukia unit of boat clinic was launched in 2008. It caters to a population of 18,858 in 4

saporis consisting of 39 villages under Guijan and Sadiya blocks. 145 camps were held in 2012-

13. The average OPD attendance was found to be 68 patients per camp. The team goes for trips

of 4-5 days which includes night halts. The team visits each sapori once in 1-1 ½ month.

Frequently the team arranges for audio-visual awareness camps in the sapori with the help of

television, DVD players and Projectors in the evenings.







164 DPT1

59


TT1 67 DPT3 47



Hb% 627 Hep B3 09

RBS 463 Measles 49



PBS for MP 229

Total Positive 01

RDK for MP 229

Total Positive 01

HCG kit test 394

ABO/Rh 627

54

MANPOWER AT STATE PROGRAM MANAGEMENT UNIT (C-NES), GUWAHATI, ASSAM

It was observed that the manpower at the PMU has increased gradually over the years from 5

(2008-09) to 13 (2012-13). During the evaluation of the PMU it was found that 11 staff were in

position against 15 as per the MoU between NRHM, Assam and C-NES. It was also observed

that ToR of staff at the PMU was prepared in the month of July 2013.

Table 6.1 Programme Management Staff at State

S.No. Post No. (as per MoU) In Position

1 Project Director 1 1

2 Programme Manage 1 1

3 Associate Programme

Manager

1 1

4 Assistant Programme

Manager

2 0

5 Accounts Manager 1 0

6 Account Assistants 2 2

7 Communication Officer 1 1

8 Data Analyst 1 1

9 Office Assistant 2 1

10 Multi-tasking Office Helper 3 2

11. Driver 0 1

Total 15 11

Table 6.2 Core Activities as per Term of Reference

S.No. Post Key Deliverables as per ToR Activities done

1 Project Director He is the overall in charge of the C-

NES Boat Clinics, staff and

Accounts in the PMU of the

program.

No record of monitoring

activities at the field level

2 Programme

Manage

Compilation of monthly reports

received from Districts, Advising on

implementation of all programs of C-

NES, Analysis of performance of



6

55


staffs, Logistic Management,

Coordination with NRHM,

Supporting CEO, Overseeing

Accounts

3 Associate

Programme

Manager

Registration and Insurance of Boat,

Agreement with hired Boat owners,

Logistic Management, Compilation

of monthly report, Repairing and

maintenance of Boat, Collection of

action plan from the districts, HMIS

validation and sharing with State,



4 Assistant

Programme

Manager

Posts vacant

5 Accounts

Manager

Post vacant

6 Account

Assistants

Maintain cash book entry, data

entry under the allotted expenditure

head, maintain pending bill file after

duly verifying the suppliers/party's

bill/invoice, maintain cheque issue

register , maintain salary register of

all staff under the programs,

maintain file of PF,TDS, PT and

deposit the deducted amount in

time. Maintain data of individual

employees with up to date

7 Communication

Officer

Compiling narrative reports of activities received from DPOs of Boat clinics and are shared with State office, she looks after the C-NES website, Quarterly E-newsletter by C-NES, documentation and publication, social networking, aids in fund raising for the organisation, publicizing the activities of Boat

Her role at the field level could not be elicited. No IEC/BCC material for field level activities has been designed yet.

56


Clinics & C-NES in electronic and national print media.

8 Data Analyst To works directly under the supervision of the Managing Trustee and function according to his instructions on issues relating to the office and to the organization. To compile and analyze all the data relating to Boat Clinics He manages the C-NES office at New Delhi.

No record of any activities

at the PMU

9 Office Assistant Assisting in maintaining the day to

day working of the State office,

maintaining the attendance records,

maintaining records of all vacancies,

resignations, appointments,

termination, maintaining records of

all incoming and outgoing dak.

As per ToR

10 Multi-tasking

Office Helper

Day to day activities of the office,

dispatch of letter, cheque deposit to

banks, maintaining the office

stationeries

As per ToR

11. Driver No mention about Driver in the MoU Drives the office vehicles

Benefits to employees

1. Accidental insurance for all district level staff.

2. Mediclaim for all staffs including State office staffs who joined till 2011. It has not been

renewed since 2013.

3. CPF for staff whose salary is less than ₹6,500 (Community Worker, Cook, Boat Helper &

ANM)

4. All staffs at State Office avail payment of mobile bills through C-NES except one peon and

driver.

57

5. Salary increment is subject to budget approval from NRHM (Pay revision and arrear

were paid from 2010 and was approved in 2011-12)

6. Set rules of rates of Daily allowance on tour for C-NES staff were prepared and came into

effect after the commencement of this evaluation that is from July 2013. Prior to this

there were no set rules on TA/DA.

Key Observations of Evaluation of PMU

1. It was observed that there has been gradual increase in manpower in the State office

of the Boat Clinic. In 2008-09 the office was manned by 5 staffs, 2009-10 by 9 staffs,

2010-11 and 2011-12 by 10 and 2012-13 by 13 staffs.

2. There is duplication of roles and responsibilities of the CEO, Program Manager and

the Associate Program Manager.

3. Most of the job responsibilities of Associate Program Manager relates to liaison with

UNICEF, PFI etc.

4. The post of Data Analyst is held at the New Delhi office of the organization which is

not mentioned in the MoU document and his role is under question.

5. There are two post of Accounts Assistant, both have similar responsibilities and are

under the Accounts Manager.

6. There are two posts of Peon in the office who have similar job responsibilities.

7. There is no mention of employing a driver, in the MoU signed for 2012-13.

8. There was no ToR for employees of the PMU till the commencement of this

evaluation.

9. Roles and responsibilities of the Communication officer could not be elicited at the

field level and there was no documentation of any field visits by her.

10. The Data Analyst has been stationed at New Delhi

58

11. Monitoring and supervision activities are totally lacking

12. No technical guidelines on the functioning of the Boat Clinics have been designed yet.

13. Monitoring checklist has been designed recently to monitor works of District units.

59

BUDGET

Table: 7.1 Funds received from NRHM, ASSAM

YEAR FUND RECEIVED (₹) FUND EXPENDED (₹)

2008-09 1,66,81,231 1,48,81,196

2009-10 2,81,58,431 2,65,64,095

2010-11 3,65,58,956 4,16,71,125

2011-12 5,49,45,000 5,43,18,178

2012-13 6,03,10,664 5,46,94,713

ANALYSIS OF EXPENDITURE INCURRED BY BOAT CLINICS (District wise)

Table: 7.2 Expenditure (2012-13)

Districts Manpower

(₹) Boat/Logistics

(₹) Total (₹) OPD cases

Cost per patient (₹)

Barpeta 2128898 919814 3048712 8784 347.08

Barpeta II 2196246 1175968 3372214 14948 225.6

Bongaigaon

2128320 1118011 3246331 14483 224.15

Dhemaji 2304868 579031 2883899 8384 343.98

Dhubri 2257565 830400 3087965 18021 171.35

Dhubri II 2173835 918419 3092254 14388 214.92

Dibrugarh# 2547074 557463 3104537 6784 457.63

Goalpara 2063198 933452 2996650 13004 230.44

Jorhat 2534597 1297986 3832583 7984 480.03

Kamrup 2362899 1199537 3562436 15321 232.52

Lakhimpur 1878424 1121156 2999580 6639 451.81

Morigaon 2424606 1262088 3686694 17804 207.07

Nalbari 2438397 1134837 3573234 22552 158.44

Sonitpur 2732897 1095798 3828695 14426 265.4

Tinsukia 2451516 1130568 3582084 9818 364.85

Total 34623340 15274528 49897868 193340 4375.27

Average* 2308223 1018302 3326525 12889 292

*Rounded off

7

60

It was observed that during 2012-13, total expenditure incurred on district units ranged from

28,83,899 in Dhemaji to 38,32,583 in Jorhat. Expenditure on Boat/Logistics ranged from ₹

5,57,463 in Dibrugarh to ₹ 12,97,986. Total OPD registration ranged from 6,639 in Lakhimpur to

22,552 in Nalbari. Expenditure per patient consulted ranged from ₹158.44 in Nalbari to ₹

480.03 in Jorhat. Average cost per patient was found to be ₹292. The average cost per patient

has risen from ₹169 in 2010-11 to ₹ 292 (Table 7.2, 7.3 & 7.4)


Districts Manpower (₹) Boat/Logistics (₹) Total (₹) OPD cases Cost per patient (₹)

Barpeta 2102748 1265277 3368025 15785 213.37

Barpeta II 2147828 1333148 3480976 5908 589.2

Bongaigaon 2106000 1066496 3172496 8734 363.24

Dhemaji 2275080 772524 3047604 12392 245.93

Dhubri 2070226 965564 3035790 20199 150.29

Dhubri II 2241966 1038968 3280934 9041 362.9

Dibrugarh # 1857923 125342 1983265 8338 237.86

Goalpara 1817315 1054026 2871341 7776 369.26

Jorhat 2246716 1186492 3433208 9164 374.64

Kamrup 2027698 1236418 3264116 6208 525.79

Lakhimpur 2029784 1260700 3290484 10144 324.38

Morigaon 2183760 1337286 3521046 18292 192.49

Nalbari 1917465 1365143 3282608 17997 182.4

Sonitpur 2287417 1395217 3682634 11298 325.95

Tinsukia 2407199 1207972 3615171 12884 280.59

Total 31719125 16610573 48329698 174160 4738.29

Average* 2114608 1107372 3221980 11611 316

*Rounded off



Barpeta 1646600 1084629 2731229 16448 166.05

Barpeta II 942135 677295 1619430 17197 94.16

Bongaigaon 883834 477417 1361251 15197 89.57

61


Dhemaji 1666167 867228 2533395 10656 237.74

Dhubri 1594875 848255 2443130 19176 127.41

Dhubri II 931966 442531 1374497 22328 61.56

Dibrugarh 1422500# 158979 1581479 10703 147.76

Goalpara 846841 512548 1359389 12479 108.93

Jorhat 1685500 1140887 2826387 9233 306.12

Kamrup 897966 592373 1490339 17854 83.47

Lakhimpur 1642466 1221641 2864107 9014 317.74

Morigaon 1626634 1321006 2947640 22387 131.67

Nalbari 1636800 1323409 2960209 18876 156.82

Sonitpur 1512632 1440307 2952939 10708 275.77

Tinsukia 1779500 1106636 2886136 12885 223.99

Total 20716416 13215141 33931557 225141 2528.78

Average* 1381094 881009 2262104 15009 169

*Rounded off, # Boat crew paid by UNICEF fund

Table: 7.5 Expenditure on Boat/Logistics

Districts 2010-11 (₹) 2011-12 (₹) 2012-13 (₹)

Barpeta 1084629 1265277 919814

Barpeta II 677295 1333148 1175968

Bongaigaon 477417 1066496 1118011

Dhemaji 867228 772524 579031

Dhubri 848255 965564 830400

Dhubri II 442531 1038968 918419

Dibrugarh * 158979 125342 557463

Goalpara 512548 1054026 933452

Jorhat 1140887 1186492 1297986

Kamrup 592373 1236418 1199537

Lakhimpur 1221641 1260700 1121156

Morigaon 1321006 1337286 1262088

Nalbari 1323409 1365143 1134837

Sonitpur 1440307 1395217 1095798

Tinsukia 1106636 1207972 1130568

Total 13215141 16610573 15274528

Average (rounded off) 881009 1107372 1018302

62

Boat/Logistics includes cost of equipments, POL, Lubricants, Food, Boat repair, Boat hiring

incentive to ASHA, camp organising cost, contingencies, monitoring, awareness camps and

administrative expenses.

*operational cost of Dibrugarh Boat was funded by UNICEF till March ‘12

Boat/Logistics expenditure has increased over the year ranging from ₹ 8,81,009 in 2010-11 to

₹ 10,18,302 in 2012-13

Figure showing expenditure on Boat/Logistics

Table: 7.6 Expenditure on Manpower (Salary)

Districts 2010-11 (₹) 2011-12 (₹) 2012-13 (₹)

Barpeta 1646600 2102748 2128898

Barpeta II 942135 2147828 2196246

Bongaigaon 883834 2106000 2128320

Dhemaji 1666167 2275080 2304868

Dhubri 1594875 2070226 2257565

Dhubri II 931966 2241966 2173835

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

2010-11

2011-12

2012-13

in ₹

63

Districts 2010-11 (₹) 2011-12 (₹) 2012-13 (₹)

Dibrugarh# 1422500# 1857923# 2547074

Goalpara 846841 1817315 2063198

Jorhat 1685500 2246716 2534597

Kamrup 897966 2027698 2362899

Lakhimpur 1642466 2029784 1878424

Morigaon 1626634 2183760 2424606

Nalbari 1636800 1917465 2438397

Sonitpur 1512632 2287417 2732897

Tinsukia 1779500 2407199 2451516

# Boat crew and DPO were paid by UNICEF fund

Expenditure on manpower has increased over the years from ₹17,79,500 in 2010-11 to

₹24,51,516 in 2012-13

Figure showing expenditure on Manpower

0

500000

1000000

1500000

2000000

2500000

3000000

2010-11

2011-12

2012-13

in ₹

64

Table: 7.7 Total Expenditure District wise

Districts 2010-11 (₹) 2011-12 (₹) 2012-13 (₹)

Barpeta 2731229 3368025 3048712

Barpeta II 1619430 3480976 3372214

Bongaigaon 1361251 3172496 3246331

Dhemaji 2533395 3047604 2883899

Dhubri 2443130 3035790 3087965

Dhubri II 1374497 3280934 3092254

Dibrugarh * 1581479 1983265 3104537

Goalpara 1359389 2871341 2996650

Jorhat 2826387 3433208 3832583

Kamrup 1490339 3264116 3562436

Lakhimpur 2864107 3290484 2999580

Morigaon 2947640 3521046 3686694

Nalbari 2960209 3282608 3573234

Sonitpur 2952939 3682634 3828695

Tinsukia 2886136 3615171 3582084

Total 33931557 48329698 49897868

Average 2262104 3221980 3326525

Figure showing total expenditure District wise

The total expenditure for running of the Boat clinics have increased over the years ranging from

₹ 3,39,31,557 in 2010-11 to ₹4,98,97,868 in 2012-13

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

2010-11

2011-12

2012-13

in ₹

65

Table: 7.8 OPD Registrations

Districts 2010-11 2011-12 2012-13

Barpeta 16448 15785 8784

Barpeta II 17197 5908 14948

Bongaigaon 15197 8734 14483

Dhemaji 10656 12392 8384

Dhubri 19176 20199 18021

Dhubri II 22328 9041 14388

Dibrugarh 10703 8338 6784

Goalpara 12479 7776 13004

Jorhat 9233 9164 7984

Kamrup 17854 6208 15321

Lakhimpur 9014 10144 6639

Morigaon 22387 18292 17804

Nalbari 18876 17997 22552

Sonitpur 10708 11298 14426

Tinsukia 12885 12884 9818

Total 225141 174160 193340

Average (rounded off) 15010 11611 12890

Figure showing total number of OPD Registrations

The average and total OPD registration has decreased in 2012-13 as compared to 2010-11

0

5000

10000

15000

20000

25000

2010-11

2011-12

2012-13

Tota

l OP

D R

egis

tere

d P

atie

nts

66

Table: 7.9 Expenditure per Patient with respect to OPD Registration

Districts 2010-11 (₹) 2011-12 (₹) 2012-13 (₹)

Barpeta 166.05 213.37 347.08

Barpeta II 94.17 589.20 225.60

Bongaigaon 89.57 363.24 224.15

Dhemaji 237.74 245.93 343.98

Dhubri 127.41 150.29 171.35

Dhubri II 61.56 362.90 214.92

Dibrugarh * 147.76 237.86 457.63

Goalpara 108.93 369.26 230.44

Jorhat 306.12 374.64 480.03

Kamrup 83.47 525.79 232.52

Lakhimpur 317.74 324.38 451.81

Morigaon 131.67 192.49 207.07

Nalbari 156.82 182.40 158.44

Sonitpur 275.77 325.95 265.40

Tinsukia 223.99 280.59 364.85

Average 169.00 316.00 292.00

₹0

₹50

₹100

₹150

₹200

₹250

₹300

₹350

2010-11 2011-12 2012-13

₹169

₹316 ₹292

Cost per patient

67

Figure showing expenditure per patient with respect to OPD registration

Table: 7.10 Budgets Spent on Monitoring Activities

Year Amount (₹)

2008-09 4,96,567

2009-10 5,78,500

2010-11 6,35,489

2011-12 6,80,660

2012-13 2,82,329

No data or reports are available with the PMU or district units regarding monitoring of any

boat clinic

Table: 7.11 Funds Received From UNICEF for Dibrugarh Boat Clinic

Year Fund Received (₹)

2008-09 15.58 lakhs

2009-10 22.11 lakhs

2010-11 27.48 lakhs

2011-12 28.60 lakhs

2012-13 10.39 lakhs

UNICEF funds were used for salary of District Program Manager and boat crew and operational

cost in Dibrugarh District till March 2012.

0

100

200

300

400

500

600

2010-11

2011-12

2012-13

In ₹

68

5KEY FINDINGS AND CONCLUSION

The Boat Clinics initiative in partnership with NRHM, Assam was launched in February 2008 to

provide health care to the underserved island population if the State. The evaluation study on

Boat Clinics in Assam was carried out by RRC-NE in the month of June-July 2013 for the year

April 2012 to May 2013.

The findings were divided into the assessment of the functional, availability and services

provided by 15 units of Boat Clinics in 13 districts of Assam.

ASSESSMENT OF FUNCTIONAL STATUS OF BOAT CLINICS:

The study revealed that functional status of boat used were good except for Dhemaji district

where the condition of the boat is worrisome. It needs to be immediately repaired. Boat of

Dibrugarh and Dhubri Unit 1 are on repair. Dhubri unit 1 is using hired boat and Dibrugarh is

using Tinsukia’s and Dhemaji’s boat alternatively when the boats are lying idle..

The equipments like microscope, semi-auto analyser, centrifuge and autoclave were

functioning in all the districts but these instruments were never utilised. Only the portable

investigations like Haemoglobin Colour scale method and in some district Sahli’s method of

Hemoglobin estimation is used. Glucometer for RBS and Urine strip methods for Urine Albumin,

Sugar and pregnancy test were used. Blood smears for malaria parasite and RDK for malaria

was also done. Recently VDRL and HIV testing and counseling has also been introduced in all

the units.

The drugs to the boat clinics were supplied through NRHM Boat Clinic & MMU drug kits and

from the District Drug store. There is a huge shortage of drugs especially for IFA, anti-

inflammatory and paediatric drugs mainly salbutamol syrup. Each unit has a separate store

room for drug storage. The process of indent is done monthly or according to the requirement.

ASSESSMENT OF MANPOWER AND TRAINING:

The study revealed the availability of the following manpower: Medical officer I (100%),

Medical officer II (53%), GNM (53%), ANM 1 (100%) and ANM 2 (87%), Laboratory Technician

8

69

(100%), and Pharmacist (93%). Out of two medical officers in the Boat Clinic, there were 100%

availability of MO-1 in all the units and availability of MO-2 was 53%

The Medical officers were not given induction training. Training on routine immunisation and

neonatal resuscitation was given to Medical Officers and nursing staffs

In the office of the State Nodal Agency (C-NES) it was observed that most of the staffs had no

ToR, fresh ToR were prepared after the current evaluation process had started and were

signed on 17-07-2013. There has been gradual increase in manpower in the State office of the

Boat Clinic. In 2008-09 the office was manned by 5 staffs, 2009-10 by 9 staffs, 2010-11 and

2011-12 by 10 and 2012-13 by 13 staffs.

At the PMU it was observed that there is duplication of roles and responsibilities of the CEO,

Program Manager and the Associate Program Manager. Roles and responsibilities of the

Communication officer could not be elicited at the field level and there was no documentation

of any field visits by her. The Data Analyst has been stationed at New Delhi and his role is under

question. Monitoring and supervision activities are totally lacking. Till date no technical

guidelines on the functioning of the Boat Clinics have been designed yet.

ASSESSMENT IN SERVICES PROVIDED BY BOAT CLINICS

The study revealed that no or few camps were organized in the month of May 2012; the reason

cited by district unit was lack of funds. Units received funds in June 2012 and the camp

activities resumed. It was also observed that no camps were organized in Goalpara in the

month of September 2012 the reason being cited was ethnic violence in the district.

The study revealed that most of the OPD cases were seen during the month of November-

January 2012-13. During these months the water level is adequate for smooth sailing of boats.

The common OPD cases that were been treated by the doctors were mostly Respiratory tract

infection, fungal skin and nail infection, bacterial skin infection, diarrhoea, musculoskeletal

pains, dysmenorrhea, leucorrhoea, conjunctivitis cases. Rarely cases of tuberculosis were

treated. Cataract cases were referred to the nearby CHCs, PHCs or to Medical Colleges.

70

Antenatal cases were seen in all the units by medical officer and nursing staffs. Every ANC case

is registered and all the basic investigations are done including abdominal examination. The

privacy of the patients was always taken care.

All laboratory test mentioned in this report were done were uniformly done in all the units.

3 normal deliveries had been conducted, 2 in Barpeta unit 2 and 1 in Jorhat unit of the boat

clinics in 2012-13. Till date 6 deliveries have been conducted in Dibrugarh unit.

The family planning services were done by the nursing staff. All units provided Oral

Contraceptive and condoms. Some unit arranged for Laparoscopic sterilization and NSV camps

with the help of district health authorities. In many of the units nurses were trained in IUCD

insertion were successful in making ladies accept the method.

It was found that the funding to all the district units were irregular from May 2012 till date

which hampered holding camps as scheduled.

EXPENDITURE ON BOAT CLINICS IN THE DISTRICTS

It was observed that during 2012-13, total expenditure incurred on district units ranged from

28,83,899 in Dhemaji to 38,32,583 in Jorhat. Expenditure on Boat/Logistics ranged from ₹

5,57,463 in Dibrugarh to ₹ 12,97,986. Total OPD registration ranged from 6,639 in Lakhimpur to

22,552 in Nalbari. Expenditure per patient consulted ranged from ₹158.44 in Nalbari to ₹

480.03 in Jorhat. The expenditures were dependent on remoteness of the camp sites from the

ghats which adds to the fuel cost, boats own by C-NES or hired boats

OBSERVATION OF THE MoU

The earlier MoUs signed between C-NES and NRHM, Assam has been a generic one. There

appears need for amendment in the MoU. The MoU does not mention clearly on certain issues

like:

71

Physical performance in terms of number of camps by each boat clinic per month must be

mentioned.

The mechanism of drug supply to Boat Clinics with respect to replenishment of the drugs has

not been mentioned. There is no clear guideline when and from where drug supply to Boat

Clinics will be done and at what interval such supply will be done.

There is no specific mention of advance release of fund from the State which hampers

sustainability of services.

The MoU mentions about the monitoring process of the Boat Clinics’ performance however this

has not been institutionalised.

Provision for incorporation of new schemes by NRHM and delivery through Boat Clinics has not

been mentioned.

72

RECOMMENDATION

Based on the assessment of the functionality of the Boat Clinics, there appears scope for

improvement in the service delivery by the Boat Clinics in Assam. The following measures are

suggested to improve the service delivery.

1. There should be technical guideline designed for the proper functioning of the Boat

Clinics and uniform targets viz. number of camps per boat clinic, should be fixed.

2. There should be uniform timing with respect to start of the journey to reach the islands

(char) which will in turn help to start health camps early and increase the time on

patient care for all the districts.

3. The repairing of the damaged boats must be taken up on urgent basis.

4. There should be a backup boat to provide uninterrupted service when any district unit

boat is under repair.

5. All the staff and crew members of the boat must be insured and provided with life

jackets.

6. Teams should be stationed at the sub district level (as close to the ghats as feasible) to

increase the time for patient care as many Boat Clinic units were providing only 2-2.5

camp hours of service. This will also curtail the time taken to reach the camp site and

fuel expenditure on hired vehicles.

7. There should training of pharmacist to with respect to inventory management and

record keeping.

8. Separate drug kit should be provided by State NRHM in respect to the morbidity

pattern. Drug replenishment should be timely so that services are not affected.

9. Non communicable disease screening should be added in service package.

10. Laboratory services needs to be further strengthened by utilising the supplied

instruments and equipment. Test reports should be delivered on the same day before

departure from the camp site.

11. IEC should be further strengthened to increase the coverage of the clinics.

9

73

12. Family planning services should be extended with more emphasis on IUCD insertion.

13. There has been no review of performance of Boat Clinics either from the district or from

the State. There should be joint review meetings with the district health administration

and the State.

14. The MoU between NRHM, Assam and C-NES needs to be amended in context of

responsibilities and monitoring mechanism.

15. There should be specific mention of advance release of fund from the State in the MoU.

First instalment should be paid in advance to C-NES in the first quarter of the year. After

utilization of 75% of the available funds, the party can apply for subsequent release of

next instalment subject to submission of Statement of Expenditure and verification of

the same.

16. The MoU should mention clearly about mechanism of drug supply to Boat Clinics with

respect to replenishment of the drugs. There should be clear guideline when and from

where drug supply to Boat Clinics will be done and at what interval such supply will be

done.

17. There also needs specific mention on monitoring activities in the MoU with respect to

Boat Clinic PMU personals responsible to carry out such monitoring activities to be

carried out regularly.

18. There is duplication of roles and responsibilities of the PMU staff. to curtail the extra

expenditure incurred due to excess man power at the State level, and considering the

present workload the following staffing pattern at the PMU is recommended.

1. Overall in charge of the Boat Clinic Program 1

2. Program Manager 1

3. Associate/Assistant Program Manager 1

4. Office Assistant 1

5. Accounts Manager 1

74

6. Accounts Assistant 1

7. Peon 1

8. Driver 1

19. Considering the effectiveness of Boat Clinics to reach the remote areas, the service

coverage in terms of more content of promotive and preventive care needs to be

included at the camp sites.

20. Newer health programmes like RBSK, NPCDCS etc. should be included in the gamut of

services of Boat Clinics in phased manner. Referral care of screened persons should also

be ensured.

21. The operational cost of the Boat clinics should be reviewed in terms of optimization

and improving the quality of services provided.

75

ANNEXURE - I

Memorandum of Understanding

This Memorandum of Understanding herein after referred to as MoU, between. Centre for North East Studies and Policy Research (C-NES) here after known as the First Party and the National Rural Health Mission (NRHM) Guwahati of the Government of Assam, hereby referred to as the Second Party.

Article 1: Effective Date:

1.1 The agreement shall be in force for a period of 12 (Twelve) months or until otherwise terminated as provided for in this MoU, with effect from 1st April 2012.

Article 2: Duties and Responsibilities of the First Party

2.1 That this MoU refers to providing health services to the communities residing in the remote river islands (Char/Saporis) on the River Brahmaputra in 13 (Thirteen) Districts of the State of Assam through 15 (Fifteen) Boat Clinic units. These fifteen (15) Boat Clinics units are operational in the districts of Dhubri, Barpeta, Nalbari, Morigaon, Sonitpur, Lakhimpur, Dhemaji, Dibrugarh, Tinsukia, Jorhat, Goalpara, Bongaigaon and Kamrup with one additional units each in Dhubri and Barpeta District.

2.2 That the First Party has built 6 (six) vessels / boats from its own resources as an innovative health outreach project and operating in the districts of Dibrugarh, Dhemaji, Tinsukia, Dhubri, Jorhat and Sonitpur with support from NRHM, Assam, for undertaking health care services i.e. providing Medical Officers, specialists, nursing staffs and allied health staffs along with medicines, laboratory services and health awareness campaign as necessitated for such services through these vessels/boats in the saporis / char / island areas of the selected districts which are otherwise inaccessible and thereby lacking medical facilities

2.3 That the first party is presently building one more boat at its own expense for its Morigaon unit.

The boat would undertake health care activities as indicated in clause 2.2 of the MoU.

2.4

The boats built by either party would be registered and insured under the name of the respective Party as the sole owner of the boats and will not be sold nor shall its primary purpose (health, nutrition and awareness campaign) be changed or otherwise used unless mutually agreed to.

2.5 That the First Party will be responsible for the upkeep of these vessels/boats ensuring their insurance, safety and river-worthiness and its running by responsible and trained crews

76

2.6 That the First Party will be a part of the District Health Society in each of the above mentioned 13 district as specified in clause 2.1 through nominated representative of the First party in the district.

2.7 That the First Party will set targets, plan programs in consultation with the District Health Society on activities for the 15 boats clinics in all these 13 districts and accordingly submit the action plan to the respective districts and State NRHM office at the beginning of each month

2.8

2.9

That as a mechanism for development of prototype and training for implementation of the boat health services the existing partnership with NRHM and C-NES will continue.

That as an emergency measure during disasters the boat may be utilized for supporting post disaster health management.

2.10 That a sub-committee of 4 (four) persons from both the First and Second parties (two from the First Party and two from the Second Party) will work out emergent issues and will meet as and when required.

2.11 That this MOU and work plan becomes functional with the boats operated / hired by First Party as and when they are placed for service and such boats built with funds from either Party becomes functional under this MoU as and when the boats are commissioned and ready for service.

2.12

That in the interim period the First Party may appropriately hire local ferries etc for the purpose of providing health care services in the districts in case of non-availability of bigger boats for which the running expenses of these hired boats including staffing cost will be fully met by the Second Party by means of a lump sum payment in advance based on the appropriate cost of running such boats, till such time the new dedicated boats are commissioned. However, such boats will be hired only on condition that they are certified as safe and river-worthy

2.13. The said ferries shall be insured and the costs of the insurance debited to the Second Party when these ferries are contracted for conducting health services under the direction of the First Party

2.14 That these said hired ferries shall be equipped with lifesaving equipment like life jackets for crew and passengers and medical first aid kit. That after the services of these hired ferries are dispensed with following the construction and commissioning of the new dedicated ships, the said life-saving equipment and kits will become the property of these new dedicated ships which will be operated by the First Party

2.15 That a separate MOU will be signed between the First Party and the owners/operators of these hired ferries covering all the above clauses and issues

77

2.16 (i) That the operations of the said boats/vessels will be flexible depending on the situation prevailing in the area such as bad weather, natural calamity like cyclones and floods, law and order situation, relief measures on the advice of District Program Officer and the respective District Administration on these matters

(ii) That country boats equipped with appropriate engine capacity built/ to be built as per the budget funded by the second party will be used for quick navigation and evacuation of complicated cases requiring urgent admission, treatment at district hospitals etc., and will be attached to the larger vessel during camp days.

(iii) That in case of medical urgency the arrangement of referral transport would be the responsibility of the second party for arranging the vendor, while the first party will be responsible for informing the vendor (third party) for taking the patients from the ghat to the nearest referral hospital / PHC. The 108 ambulance service of NRHM or other referral road transport may be utilized for referral transport from Ghat to Health institution.

2.17 That there shall be 1 (one) Project Director, 1(one) Program Manager, 1(one) Associate Program Manager, 2(two) Assistant Program Manager, 1(one) Accounts Manager, 2(two) Accounts Assistant, 1(one) Data analyst, 1(one)Communication Officer, 2(two) Office Assistants and 3(three) Multi-tasking Office Helper for its Project Management Unit (PMU) based at Guwahati under the direct guidance of the First Party

2.18 That the Provision of Services (Article – 4) mean remuneration of staff members will be provided by the Second Party and the staffs would be appointed and supervised by the First Party in consultation with the Second Party

2.19 That in each Boat clinic unit the services of 2 (two) Medical Officers and paramedical health staff consisting of 1 (One) Staff Nurse, 1 (one) Pharmacist, 1 (one) Laboratory Technician, and 2 (two) ANM will be utilized by the first party on the basis of interviews conducted by the First Party in consultation with the Second Party . The Second Party shall be responsible for the remuneration and all other requirements of the health team provided in the boats as per approved budget. The Human Resources of the First Party comprise of staff of the Program Management Unit (PMU), District Program Officers, Community Workers and the Boat crew for each of the 15 (fifteen) units as indicated in Article – 4 of this MOU. Selection and appointment including supervision of the above staffs will be the responsibility of the First Party in consultation with the Second Party as and when the needs arise.

2.20

That the monthly schedule of each unit will be prepared in consultation with the District Health Authority and in case of emergency the vessels may be utilized for special health programs and health relief activity during natural disasters like floods with the agreement of the First Party

Maintenance of the vessels, future proper utilization will be handled by the First Party

78

2.21 and debited to the account of the Second Party

2.22 That the First Party will provide the following services through its medical teams on board the boats in the above mentioned 13 ( thirteen) districts through its 15 units as on clause 2.1

(a) Curative and Preventive Care

Referral of complicated cases- Child survival-IMNCI services

Early detection of TB, Malaria, Leprosy, Kala-azar etc and other epidemic prone diseases including locally endemic communicable diseases and non-communicable diseases such as CVD, Hypertension, diabetes, blood dyscrasia etc

Minor surgical procedure and preliminary care of injuries etc.

Arranging Special camps for Deafness, Eye, Pediatrics, O&G. Elderly etc.

Counseling for Psychiatry & Alcohol Dependent Syndrome

Early detection of disabilities and other congenital disorders

Implementation of National Health programs

Palliative care for chronic diseases (b) Reproductive and Child Care

Ante-natal check-up and related services e.g. routine immunization like tetanus toxoid etc , iron and folic acid tablets administration, counseling etc


Promotion of institutional deliveries

Post-natal check-up and counseling

Immunization clinics for mother and child

Treatment of common childhood illness such as diarrhoea, ARI / Pneumonia etc

Treatment of RTI/ STI (c) Family Planning Services

Counseling for spacing and permanent method for sterilisation

Distribution of Condoms, Oral Contraceptives, Emergency Contraceptives

IUD Insertion like Cu ‘T’ insertion. (d) Basic Laboratory Services

Haemoglobin for ANC / PNC Urine for sugar and albumin and Malaria – RDK and other biochemical tests etc.

(e) Emergency services & care in times of disaster / epidemic / public health emergency / accidents etc

(f) Public health awareness campaigns through IEC on health including personal hygiene,

79

proper nutrition, water and sanitation etc. as well as multimedia presentation and

screening of health documentaries for awareness building

2.23 Training and Technical support will also be taken in collaboration with other partners like UNICEF, PFI etc.

2.24 Monthly reporting and submission of physical performance for all the services as per format devised by the first party in consonance with second party as mentioned above to the Authorities in State NRHM and District Health Authority

2.25 Submission of expenditure statement with utilization certificate on quarterly basis and the yearly audited accounts by the appointed Chartered Accountant of the First Party and verified by the Auditor of the Second party for March ending with utilization certificate to be submitted by 30th June each year

2.26 Production of records of services and the statement of Expenditure (SOE) for verification by officials of Govt. of Assam, Health Department / Govt. of India from time to time or as and when asked for

2.27 Maintenance of records of all the movable assets acquired and created from the Second Party’s Fund.

2.28 Any other duties as may be mutually agreed upon

Article 3: Duties and Responsibilities of the Second Party

3.1 The Second Party will at its level organize the District Health Society of the districts and include at least three members from the Boat Clinic team as representatives for smooth conduct of the health out-reach initiative

3.2 The expenditure for the activities performed for rendering services as mentioned in clause 2.1 shall be borne as per State Action Plan.

3.3 Funds shall be released in advance as mentioned in this MoU (2.1 to 2.28 all clause inclusive)

3.4 Release of advance shall be made within two weeks after submission of fund requirement request from the First Party.

3.5 Vaccines, contraceptives and other RCH and Curative drugs and equipment shall be supplied as per requirement of the Boat Clinic from the office of the DHS and NRHM state and respective district offices. Supply of medicines, vaccines etc for Boat Clinic should be made available throughout the year and given priority. .

3.6 NRHM shall provide support for the items as provided in the annexure.( Article 4)

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Article 4: Roles of Partners:

Activities Provision of services

Remarks

NRHM C- NES

1. Infrastructure

Construction of boats √ √

Medicines and equipments as per the PHC kit of IPHS standard

√ The medicines will be provided by Jt. Director. It may also be provided from NRHM and other various NDCP

Instruments/ Equipments √

2. Manpower (a) – (For each boat)

Medical Officer (2) √ The team will work in close coordination with the First Party

Staff Nurse(1) √

Lab. Technician (1) √

Pharmacist (1) √

ANM (2) √

Community Workers (3)

√ Community workers will be appointed for each district to facilitate the organization, mobilization, smooth running and conduct of the health services in all aspects including liaising with local community leaders etc.

District Programme Officer (1) for each unit

√ The DPO will be responsible for smooth running of the program in the district and will co-ordinate with the communities and the district authorities. He will be under the direct supervision of the PMU.

Boat Crew (4) √

Referral Boat Crew (2) √

2.(b) Project Management Unit (PMU)

Project Director (1)

√ The PD will be overall in-charge of the programme and will be based at Guwahati.

Programme Manager (1) √ The Programme Manager will be based at Guwahati and will coordinate with the Project Director. NRHM & District and State officials as and when required

Associate Programme Manager (1)

√ The Associate Programme Manager will be based at Guwahati and will coordinate with the Project Director, Programme Manager in all aspects of Program.

Assistant Programme Manager (2)

√ The Asstt. Programme Manager will be based at Guwahati and will coordinate with the Programme Manager and Associate Program Manager in all aspects of Program.

81

Communication Officer (1) √ Communication and Dissemination, editing reports

Data Analyst (1) √ Data entry and analysis

Accounts Manager (1) √ Maintaining books of account

Assistant Accountant (2) √

Office Assistant (2) √

Multi-Tasking Office Helper (3) √

3. Additional role

IEC/BCC √ √ IEC/BCC will be done in coordination by both the parties

Maintenance of the Boats √ Biannually as per actual

Necessary renovations repair and maintenance as and when required.

4.1 All the assets acquired and created from NRHM fund will be the property of GOVERNMENT OF ASSAM Article 5: Termination 5.1 Any deficiency in service by the First Party under Public Private Partnership will be looked

into by the NRHM Directorate and unless rectified within an appropriate time frame as mutually agreed, the agreement will be terminated after giving one month’s notice

5.2 Delays in releasing funds, deficiencies in PPP and other necessary support services by the Second Party shall be looked into by the First Party and unless rectified within an appropriate time frame as mutually agreed, C-NES will terminate the agreement after giving one month’s notice.

These terms of contract shall remain in force for a period from …………… to ………. The agreement shall be reviewed after …………… and may be extended to further period with or without modification on approval of the State Health Society. In case of any dispute between interpretations of any clause/clauses of this agreement the decision of the Health & Family Welfare Department, Govt. of Assam will be binding on both parties.

IN WITNESS WHEREOF both the parties of the FIRST AND SECOND PARTY have signed this agreement on the date, month and year mentioned above. Second Party First Party Mission Director Managing Trustee NRHM, Christian Basti, Guwahati (C-NES), Guwahati

82

ANNEXURE - II

INTERVIEW SCHEDULE FOR ASSESMENT OF BOAT CLINIC FOR STATE NODAL AGENCY

1. Total No. of Units Functional in the State:

2. Total No. of Districts covered by Boat Clinic:

3. Year of inception of Boat Clinics:

Year No. of Boat Clinics Operational

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

4. Fund received from NRHM and Other Sources for Boat Clinic

Year Fund received from NRHM (Rs. in lakhs)

Fund expended (Rs. in lakhs) (audited figure)

Fund received from other sources (Rs. in lakhs)

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

5. Manpower at State / District Level with salary structure since inception for Boat Clinic

Year Manpower (State)

Nos. Salary (pm)

Incentive (pm)

Manpower (District)

Nos. Salary (pm)

Incentive (pm)

2007-08

2008-09

83

Year Manpower (State)

Nos. Salary (pm)

Incentive (pm)

Manpower (District)

Nos. Salary (pm)

Incentive (pm)

2009-10

2010-11

2011-12

2012-13

84

Other areas of expenditure from NRHM Funding

Year

Construction of Boat

Equipments

POL / Lubricants

Food

Repairing cost

Incentive for ASHA

Awareness camp

Vehicle hiring

Office contingency

Monitoring & supervision

Drugs /consumables

Others

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

85

6. Availability of drugs in the Boat Clinic: What are the drugs available provided to the patient

during the camp? Please provide the list.

SN Name of the drugs Drugs available

on the day of

visit

Drugs received

during 2012-13

Drugs distributed

during 2012-13

1 Tab. Paracetamol 500 mg

2 Syp. Paracetamol 125mg/5ml

3 Tab. IFA (L)

4 Tab. Anatcid

5 Tab. Ranitidine/Omerprazole

6 Tab. Nifedipine 5mg

7 Cough syrup

8 Tab. Salbutamol 2/4 mg

9 Tab. Vitamin B Complex

10 ORS

11 Tab. Zinc Sulphate 10mg

12 Cap Amplicillin / Amoxycillin

500mg

13 Syp. Ampicillin / Amoxycillin

250mg/5ml

14 Tab. Trimethoprin

+Sulphadoxine(20+100) Ped

15 Tab. Trimethoprin

+Sulphadoxine(80+400)

16 Gloves

17 Laboratory reagents

7. What is the re-placement system of the drugs in the boat clinic? Please provide the details.

a. Source of drug provided to the Boat Clinic:

b. What is the mechanism of indent:

c. What is the frequency of replenishment: monthly/bi-monthly/quarterly/ half yearly

d. Where are the drugs stored:

e. Do you purchase drugs from NRHM fund: Yes / No

f. Is yes, pls specify:

8. What are the gamut of services provided:

86

Gamut of services Available (yes/ No)

OPD

Laboratory facility , please specify


IEC activities

Others (please specify below)

9. Is the operational plan of Boat Clinic prepared? (Yes/ No)

10. If yes, for what duration the plan is prepared, pls specify:

11. What is the criteria for selection of camp areas:

Camp areas Criteria for selection Average no. Of camps Average distance from nearest PHC/CHC

CHC area

PHC area

SC area

Outreach areas

Pls attach the annual work plan for the year 2012-13:

12. Frequency of coverage of mapped areas in a year:

13. If no work plan, please specify the process of functioning of Boat Clinic

14. Service delivery by the Boat Clinics during 12-13

Services

Ap

ril’1

2

May

’12

Jun

e’1

2

July

’12

Au

g’1

2

Sep

’12

Oct

’12

No

v’1

2

Dec

’12

Jan

’13

Feb

’13

Mar

’13

No. Of camps planned

87

No. Of camps held

No. Of villages covered

No. Of OPD

No. Of ANC

No. Of referral

No. Hb test

No. Of MP test

No. Of urine test

No. Of stool test

Others

Others

15. Training conducted for Doctors / para-medical staff

Year Trainings conducted

MO GNM ANM Pharmacists Lab.

Technician

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

88

NNEXURE - III

INTERVIEW SCHEDULE FOR ASSESMENT OF BOAT CLINIC – DISTRICT LEVEL

16. District:

17. Total No. of Units functional in the District:

18. Year of inception of Boat Clinic:

Year No. of Boat Clinics Operational

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

19. Population covered:

20. Total number of char/sapori covered:

21. Average no. of char/sapori visited per month

22. Fund received from NRHM and Other Sources for Boat Clinic

Year Fund received from

NRHM (Rs. in lakhs)

Fund expended

(Rs. in lakhs)

(audited figure)

Fund received from other

sources (Rs. in lakhs)

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

23. Manpower at District Level with salary structure since inception for Boat Clinic

Year Manpower (District) Nos. Salary (pm) Incentive (pm)

89


2007-08

2008-09

2009-10

90


2010-11

2011-12

2012-13

91


24. Other areas of expenditure from NRHM Funding

Year Constr

uction

of

Boat

Equipm

ents

POL /

Lubric

ants

Fo

od

Repai

ring

cost

Incen

tive

for

ASHA

Aware

ness

camp

Vehi

cle

hirin

g

Office

conting

ency

Monito

ring &

supervi

sion

Drugs/

consum

ables

Oth

ers

20

07-

08

20

08-

09

20

09

-

10

20

10

-

11

20

11-

12

20

12

-

13

25. Availability of drugs in the Boat Clinic:What are the drugs available provided to the patient

during the camp? Please provide the list.


on the day of

visit

Drugs received

during 2012-13

Drugs

distributed

during 2012-13

1 Tab. Paracetamol 500 mg

2 Syp. Paracetamol 125mg/5ml

3 Tab. IFA (L)

92


on the day of

visit

Drugs received

during 2012-13

Drugs

distributed

during 2012-13

4 Tab. Anatcid

5 Tab. Ranitidine/Omerprazole

6 Tab. Nifedipine 5mg

7 Cough syrup

8 Tab. Salbutamol 2/4 mg

9 Tab. Vitamin B Complex

10 ORS

11 Tab. Zinc Sulphate 10mg

12 Cap Amplicillin / Amoxycillin 500mg

13 Syp. Ampicillin / Amoxycillin

250mg/5ml

14 Tab.

Trimethoprin+Sulphadoxine(20+100)

Ped

15 Tab.

Trimethoprin+Sulphadoxine(80+400)

16 Gloves

17 Laboratory reagents

26. What is the replenishment system of the drugs in the boat clinic? Please provide the details.

g. Source of drug provided to the Boat Clinic:

h. What is the mechanism of indent:

i. What is the frequency of replenishment: Monthly /Bi-monthly /Quarterly/ Half yearly

j. Where are the drugs stored:

k. Do you purchase drugs from NRHM fund: Yes / No

93

l. If yes, pls specify:

27. What are the gamut of services provided:

Gamut of services Available (Yes/ No)

OPD

Laboratory facility , please specify

Immunisation


IEC activities

Others (please specify below)

28. Is the operational plan of Boat Clinic prepared? (Yes/ No)

29. If yes, for what duration the plan is prepared, pls specify:

30. What is the criteria for selection of camp areas:

Camp areas Criteria for selection Average no. Of camps Average time taken to reach

nearest PHC/CHC

CHC area

PHC area

SC area

Outreach areas

Please attach the annual work plan for the year 2012-13:

31. Frequency of coverage of mapped areas in a year:

32. If no work plan, please specify the process of functioning of Boat Clinic

33. Service delivery by the Boat Clinics during 12-13

94

Services

Ap

ril’

12

May

’12

Jun

e’1

2

July

’12

Au

g’1

2

Sep

’12

Oct

’12

No

v’1

2

De

c’1

2

Jan

’13

Feb

’13

Mar

’13

No. Of camps

planned

No. Of camps

held

No. Of

villages

covered

No. Of OPD

No. of PW

registered

No. of ANC

No. of 3 ANC

received

TT1

TT2/Booster

No. of PW

given 100 IFA

No. of

referral

Others

Remarks if any on service delivery;

34. Antenatal and Post Natal Check ups

Services 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

No. of PW

registered

No. of ANC

No. Of 3 ANC

received

95

TT1

TT2/Booster

No. of PW given

100 IFA

No. of Deliveries

conducted

No. of referrals

Others

35. Immunisation

Vaccine

Coverage (%)

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

BCG

OPV1

OPV2

OPV3

DPT1

DPT2

DPT3

Hep B1

Hep B2

Hep B3

Measles

Vitamin A

MCV2

JE

Fully Immunised

96

36. Cold Chain:

Cold chain

equipments

Available Functional Remarks if any

ILR

Cold box

37. Who supervises the immunization session, pls specify:

38. Family Planning

Methods 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

OCP

Condoms

IUD

LTO

NSV

Remarks (on FP services) if any;

39. Laboratory Services

Test 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

Hb%

RBS

Urine Sugar

Urine Albumin

PBS for MP

Total Positive

RDK for MP

Total Positive

97

HCG kit test

Others

40. IEC Activities

IEC 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13

Planned

Conducted

41. Training conducted for Doctors / Para-medical staff

Year Trainings conducted

MO GNM ANM Pharmacists Lab. Technician

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

42. Equipment available

Equipment Available Functional

Weighing scale

Delivery Set

98

Nebuliser

Generator

Semi Auto Analyser

ILR

Microspcope

Centrifuge

Sterilizer

TV

DVD

Projector

Others

99

ANNEXURE - IV

INTERVIEW SCHEDULE (FOR SERVICE PROVIDERS) FOR ASSESMENT OF BOAT

CLINICS IN ASSAM

Name of the District:

Medical

Officer

GNM ANM Laboratory

Technician

Pharmacists

Training

received

Place of

residence

Language

spoken

Medical Officer

1. Do you follow any operational plan - Yes / No

2. Who prepares the operational Plan for Boat Clinic camp:

3. Are you a part of the operational planning process:

4. How many days in advance you get the operational plan before the actual camp date:

5. Is there any deviation from route plan: Yes / No

6. If yes, please specify the reason

7. Do you face any difficulty during visit, if yes please specify

8. How do you intimate the villagers about the Boat Clinc camps:

9. What is the additional allowance that you get per camp (DA/ Food, etc):

10. What do you do when the camps are not organized

11. Suggestion/ recommendation if any:

Laboratory Technician

12. Name of the respondent:

13. What are the different tests done in Boat Clinc, pls specify:

100

14. From where do you get the consumables / reagents for laboratory:

15. What is the additional allowance that you get per camp (DA/ Food, etc):

16. What do you do when the camps are not organized


Pharmacists


19. From which source is the drug provided to the Boat Clincs:

20. What is the mechanism of indent:

21. What is the frequency of replenishment:

22. Where are the drugs stored:


GNM/ANM


25. What are your responsibilities in the boat clinic?

26. Problems faced during service delivery.

27. Suggestions, if any.

101

ANNEXURE - V

EXIT INTERVIEW FOR BOAT CLINC BENEFICIARIES

1. Name of the respondent:.....................................................................

2. How did you come to know about the camps ( Multiple option):

1. ASHA

2. Service provider

3. Relatives / Villagers / Neighbour

4. Miking

5. Banner / Leaflet

6. Others (specify)....................................................

3. How many times was the Boat Clinc camp organized during 12-13 :

1 / 2 / 3 / 4 / More than 4 / Does not Know

4. What was the reason for going to the camp:

1. For treatment

2. Seeking information on Health Issues

3. To know about Boat Clinc

4. Others (specify)....................................................

5. If for seeking treatment, who was suffering from illness :

1. Self

2. Relatives (specify) :

6. Age of the patient :

7. Sex of the patient: Male/ Female

8. What was the type of illness (Specify) :

9. Was complete treatment provided at Boat Clinic camp : Yes / No

10. If No, were you referred to hospital: : Yes / No

Name of the District

Name of the Block

Name of the village

Distance /Time taken to reach the nearest health facility/ (Name and Type of health facility to be mentioned)

102

11. Reasons for referral (Specify):

12. If Yes, what services did you receive:

1. OPD:

2. Immunization

3. Diagnostic services:

4. Family Planning:

13. If any Lab. Test done at the camp, which was it:

1. Hb % estimation

2. Urine

3. Blood for MP

4. Others (specify)................................................

14. Did you get the required medicine: Yes/ No

15. How long did you wait to get the services:

1. Less than 30 minutes

2. 30 minutes to 1 Hour

3. More than 1 Hour

16. Was there any sitting arrangement for the patients : Yes / No

17. Was IEC material displayed: Yes / No

18. If Yes, can you recall them (Specify):

19. Was there any discussion on health related issues : Yes / No

20. Overall were you satisfied with the services provided at Boat Clinic Camp:

1. Fully satisfied

2. Partially satisfied

3. Not satisfied

Date Signature of the investigator

103

PHOTO GALLERY

104

A health camp at Dhubri

A health camp at Dibrugarh

105

Immunisation session at Kamrup Boat Clinic

Deworming campaign

106

Vitamin A prophylaxis campaign

Vaccination and antenatal clinic

107

Antenatal Check up by Medical Officer

Medical team in a small country towards narrow channels

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