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Program Monitoring Report of Chattisgarh
District Narayanpur
First Quarter 2013-14
(April – June 2013)
By
National Health Systems Resource Center
Executive Summary
The report is based on monitoring visit to Narayanpur district of Chhattisgarh in June 2013.
A) Introduction:
The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district. Narayanpur is
one of the least developed district of India and of Chattisgarh. The district borders Chattisgarh
and Maharashtra. In the past, Narayanpur was part of the larger Bastar district of erstwhile
Madhya Pradesh and later Chattisgarh.
Almost 5 / 6th
of the district is the Abujhmarh, which is an extremely densely forested, hilly
area. It remain the only unsurveyed area of India. Currently, Abujhmarh is the stronghold of the
Left Wing Extremist groups. Narayanpur is tribal dominated, with Gond, Madia and Bada Madia
being the scheduled and primitive tribe. Abujhmarh is almost a sanctuary of the Madia tribe
without any access to roads, schools and health services. Parts of Abujhmarh are accessible by
roads, but invariably after a certain point roads disappear. The only way of commuting is on foot,
or vehicle like Tractor.
It is crucial to note that Narayanpur being one of the most heavily affected districts due to
LWE. Health, ICDS and school education are probably the only 3 programs signifying the
existence of Government in the district, especially, in the affected area (which is the majority of
the district).
B) Analysis of overall indicators of Narayanpur:
1) Availability of data: Lack of reliable data in general, and especially from the Abujhmarh part
of the district is a key problem. Any data needs to be evaluated in this context, with significant
underreporting possibly the norm. This may be a reason why Narayanpur could not figure in the
list of 183 High Priority Districts. Interestingly (and as a pointer to the significant
underreporting), the NMR, IMR and CMR of the district are lower than the State as a whole.
2) High Priority district: The exclusion of Narayanpur from the list of High Priority District
should be reconsidered as 5/6th
part of Narayanpur is Abujhmarh, which is probably the most
backward and inaccessible part of India. The planning of health system and priority should be
local with flexibility. Narayanpur should be included in the list of districts for the ‘Annual Health
Survey’. This is crucial to get the baseline data for the district.
C) Status of Facilities: Narayanpur has total 68 public health facilities out of these 30 are
designated delivery points. Private health care providers are few and public health care providers
are the only source of modern health care. The public health centers and personnel are
concentrated in mostly the north – east corner of the district. The area which is the primary
Abujhmarh, has negligible residential and functional health facility.
D) Human Resources:
1) Overall HR: The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant.
2) Rural Medical Assistant (RMA): The RMA cadre was the backbone of health services in
Narayanpur. Considering the remoteness, the difficulty in mobility and the conflict nature of the
district, it is crucial that this cadre is encouraged and strengthened.
3) MPW: Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant as there was only
1 MPW training institute in the entire division, which is in the adjoining district of Kanker
(Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate
considering the total requirement of MPW (44 vacancies in only 1 district). A combination of
MPW and ANM is an optimum combination in areas like Narayanpur, where instead of 2nd
ANM, a MPW can be considered. The MPW can provide the necessary support to the ANM
including mobility and security in difficult areas during difficult times, provide curative services
and work for National Disease Control Programs.
4) AYUSH: The involvement of AYUSH doctors in disease control programs as well as other
NRHM activities is minimal.
5) ANM: The ANM are involved in several other works other than primary health work, for
example preparing ration cards, which affected immunization coverage in the recent past and
several immunization sessions did not happen.
6) HR Supervisory cadre and Supervision: The nodal officers for various programs in
Narayanpur are appointed without any specific criteria with existing staff being given additional
charges. For example, the BMO of Orcha block is also the District Malaria Officer. For nursing
staff, there are only 2 LHV in the district. The reasons for significantly less number of LHV is
due to absence of promotions of ANM to LHV, which was not happening due to the inability of
the interested ANM to receive the 2 year training to become LHV as as there is not a single
training institution for LHV in Chhattisgarh.
7) Specialist training:
The selection of HR to be trained and the subsequent utilization of the training by appropriate
posting was severely lacking in the district.
E) Institutional Delivery
The district could report 84% of the expected deliveries, of which majority (52%) were home
deliveries.
1) C - Section and Complicated Deliveries: The C-Section rate is 2.3%, which is very low, and
would mean that several needy women are unable to reach emergency obstetric care center of not
receiving after reaching. This would also mean higher maternal mortality. Similarly, the
proportion of complicated pregnancies attended is also extremely low. This could be improved
by better training of ANM, RMA and PHC MO.
2) Stay in facility after delivery: Majority of the women were leaving the facility within 48
hours after delivery.
3) Management of Obstetric complications: The identification and management of obstetric
complications such as Eclampsia was negligible (0%) in Narayanpur. The detection of maternal
anemia is severely lacking. For ANC care there is lack of standard protocols and urine testing for
Albumin, nitrite, leukocyte esterase and blood was lacking, which would miss cases of pre
Eclampsia and UTI. The use of obstetric interventions as antibiotics, oxytocics was also severely
lacking in Narayanpur.
F) Janani Shishu Suraksha Karyakram (JSSK):
1) OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum
women and newborns in all the facilities visited.
2) Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to
pregnant women if the medicines are available. The system is centralized purchasing but the
supply was not regular and timely for several medicines. System of maintaining inventory
including regular watch of expiry date and timely replenishment is lacking. ANM and
Supervisors were not replenishing the drugs or proactively getting demands from the ASHA.
EDL was absent in the facilities visited and the records and stock were not computerized.
3) Diagnostics: Free Lab/diagnostics services were available at CHCs and DH. Exemptions for
diagnostic services are available for PW and Sick new born. What is missing is the overall
plan of maintenance including AMC, calibration of equipments, provisioning of diagnostics
reagents and regular laboratory technician.
4) Diet: Free diet was provided to pregnant and postpartum women. The food was generally
according to standard menu.
5) Referral transport: 4 Government and 3 Private Vehicles are available for JSSK transport.
If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or
using their own vehicle when the regular ambulances are not available on call or it is not
possible to connect with the facility due to lack of cellular connectivity. Drop back facility
was available in all the facilities visited though limited due to distances, limited number of
Ambulances with respect to the size of the district and extremely difficult terrain. The
referral transport mechanism was especially poor in case of newborns and (as per the data
provided by the district authorities) not a single newborn had received any referral transport
in the entire month of May.
6) Display of entitlement and awareness of community JSSK Entitlements were displayed in
only 1 of the all facilities visited (PHC Chotedongar). Boards in Local language (Gondi)
would be needed in the facilities in the tribal areas of the district.
7) Grievance Redressal / Nodal officer: No specific mechanism for redressal of grievances
exists in facilities visited. The district does not have a separate JSSK nodal officer for solving
grievances. There was lack of clarity on who is the specific point person for such is. There is
no specific accountability or responsibility for following up on complaints received has been
instituted.
8) Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that
when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be
arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying
that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the
ASHA expressed the inability, finally the mother was delivered in the DH itself.
9) Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free
referral transport but the cellular connectivity is almost absent especially in the Orchha block
of the district. This creates a major bottleneck in the optimum implementation of JSSK in the
district.
10) Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to
pregnant anemic women is very few. The blood bank has most of the infrastructure and is
waiting to get the License for operationalization.
G) JSY: The implementation of JSY in Narayanpur is significantly below mark, especially in
the case of home deliveries where only 15.56 % had received the payment. The key bottlenecks
are lack of banking network and unwillingness of Bankers to open ‘0’ balance account.
Considering the overall literacy and awareness level, there are also instances of cheque lying
with tribal for long time.
H) Neonatal and Child Health:
1) Vital rates: The current SBR is high, signifying high burden of birth asphyxia and lack of
emergency obstetric care, including LSCS. The high SBR could also be due to mis-classification
or reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth Asphyxia.
This creates an erroneous picture of less IMR preventing the possibility of corrective measures,
and hence must be audited. The Post neonatal mortality is also high, signifying lack of even ARI
and diarrhoea management services.
2) Timing of Childhood Mortality: The high Post Neonatal and Toddler Mortality is extremely
worrisome. It is indicative that Narayanpur is lagging far behind India as a whole where now
NMR is the key component of Childhood mortality. In Narayanpur, ARI and Diarrhea
managmenet programs are also possibly dysfunctional, with lack of training and supplies to
frontline workers, leading to high childhood mortality in these age groups.
3) Causes of Childhood Mortality: Causes of childhood mortality show great preponderance of
Pneumonia. This needs to be urgently addressed with training of ASHA and ANM in Childhood
ARI management and ensuring supplies.
4) Anganwadi Centers:
In Narayanpur, Anganwadi Centers are in functional in several remote villages and are the only
residential, functional facilities with several run by RK Mission. These Anganwadi offer unique
opportunity with an almost captive population of children for any intensive nutritional and health
intervention and are manned by educated and committed workers trained by RK Mission. The
children in these Anganwadi have several health problems, especially nutritional,
dermatological, ophthalmic and of ENT. Hence strengthening the Anganwadi with better drug
supplies, training and health interventions has possibility of rich dividends for child health.
I) SNCU: There was no SNCU at district hospital. Only a NBSU with average 31 admissions /
month. There were no outbound admission in NBSU in the entire year reflecting lack of referral
linkage or refusal to accept admission. Proportion of Still Births was 8.18% and very high. This
reflects lack of facility and training of asphyxia management and lack of timely emergency
obstetric intervention. Similarly, the proportion of newborn delivered in the hospital and being
admitted into the NBSU was 34% and very high. This reflects lack of proper labour room
management, and must be rectified.
J) Nutritional Rehabilitation Center:
There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It
was heartening to see patients in the NRC.
Areas of Concern:
• Keeping the mothers with the children for the required number of days is a major problem
despite the remunerative incentives to stay. This was due to family considerations.
• Follow up was poor and keeping up with follow up was a major problem.
• The weight gain was unsatisfactory. 15% weight gain was observed in < 50% cases.
• There were no remunerative incentives if the children were admitted again or for follow up.
The remunerative incentives for the first admission were only for a stay of 15 days, and not
more (even if the family wishes to stay for longer duration and the weight gain is
unsatisfactory). In places like Narayanpur, with high overall disease burden, poor outreach
services, recurrent communicable diseases and overall poor literacy and financial levels, it is
very much likely that a child who has once recovered from undernutrition would again fall
back due to the above mentioned reasons. It is also highly likely that the duration required for
a Madia / Gond child in Narayanpur for catch up weight gain would be significantly higher,
and a cut-off of 15 days would be inadequate.
• Hence all the financial remunerative incentives to the mother as well we the Mitanin must be
continued for follow up as well as subsequent admission. There should be no cap of 15 days
stay in the facility if the mother wishes to stay for more days with the child and there should
be commensurate remunerative incentive for this.
K) Outreach Services:
The key finding emerging from the district is that overall ANC registration and post partum
visits are significantly less. There was lack of availability of MCH registers. MCH Clinics are
not functional in Narayanpur, and as per the district health personnel, is not assigned to the
district as well.
L) Immunization:
1) Immunization coverage: The immunization rate for individual vaccines as well as the overall
full immunization coverage at 1 year is around 90%, and this is significant achievement. The
Cold Chain was difficult to maintain considering the lack of electricity.
2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring
the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA
including difficult terrain and inability to pass on information should be considered. If the
delivery is not institutional, the child is not given any dose of Hepatitis B vaccine.
3) Immunization system:
• There were only 8 BCG vials in the District Hospital. The rule of supply of the vials as per
the expected population of children and 1 vial per 4 children and to be used immediately after
opening is creating difficulties in Narayanpur. It is observed that the villages in Narayanpur
are very small (to the extent of 304 houses only) which means effectively the number of
children to be immunized would be quite less, in several cases, less than 4. At the same time,
the distances being large and terrain being difficult, generally visit to 1 or 2 such hamlets
would only take the entire day. Overall, this was resulting into wastage of vials where 1 vial
was being used for less than 4 children and then discarded. And finally less supply (based on
the norm of 1 vial for 4 children) compared to actual feasibility of use in Narayanpur.
• Hence the norm may be reconsidered in Narayanpur with more supply.
M) ASHA, VHSNC and NGO Partners:
1) The key problems identified were: Lack of HBNC kits, regular drug kits and system of drug
refilling, lack of adequate training d skill set of Mentor Facilitator and lack of Travel Allowance
for the Mitanin.
2) Conflict Situation and its effects: There are several instances of the Left Wing Extremists
asking for medicines to the health staff as well as the Mitanins. At the same time, the security
forces also question the Mitanin regarding the stock and supplies they carry from the block of
district HQ meeting to their villages with the doubt the medicines they carry would be for the
Maoists.
Overall, in places like Narayanpur where the formal health system is weak, it is extremely
crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system,
which is feasible locally, extend their training, provide them the necessary supplies and expand
the roles. They are the last connection with the people of the health system, especially in districts
like Narayanpur where the regular other health system is limited due to several reasons.
3) VHSNC: Gram Panchayat are not fully functional in Narayanpur as due to the opposition by
the Maoists to elections, Sarpanch and Gram Sevak hardly resides in villages. The method of
release of their payment through Panchayat is non functional and the concern was with the
implementation of the system of payment through Panchayat; the minimal incentives the Mitanin
were getting so far will also get stopped, reducing their involvement further. Considering the
unavailability of the Sarpanch and Gram Sevak, Bearer Cheque may be considered.
4) IEC: The orientation camps undertaken in the past with rigorous group discussions was a
better and more personalized model to communicate with tribal considering the culture and
literacy level in this area. The current method where the contents, IEC material are directly sent
from Raipur and are not in the local language (Gondi nor Madia) was not working.
5) NGO: Ramakrishna Mission is functional in Narayanpur district in the most interior parts,
providing extremely useful services. More convergence and involvement of the RK Mission with
health services will be useful.
N) Program Management:
1) Key issues emerging were: Induction training for NRHM staff and the DPM and establishing
block program management structure was desired in Narayanpur. The criteria of recruiting only
from the district was probably acting as a bottleneck in filling the vacancies as there is lack of the
trained HR for the respective positions in the district. Hence, can this rule be relaxed, probably
on a case basis, and / or allowing recruitment from adjoining districts such as Kanker,
Dantewada, Bijapur, Sukma, Kondagaon and Bastar?
2) PIP Planning and setting priorities: The process of setting priorities for Narayanpur should
consider local morbidity pattern. For example, it was observed that the BMO of Orcha (the only
MBBS doctors in the entire block), who is holding additional charge of District Malaria Officer,
had to go to Raipur to attend a meeting on ‘YAWS’, leading to his absence from the facility and
the block for 3 days, depriving the people of crucial health services. Is YAWS is a priority in
general and specifically for Narayanpur?
O) Quality of Services and supportive services:
1) Solar: The regular functionality of the solar back-up system is heartening and to maintain this,
there should be an integrated plan for regular maintenance and troubleshooting.
2) Mobility facilities: Roads are in poor condition and completely blocked in monsoon. No
regular 4-wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel but only Tractor (or
similar vehicles) or a Jeep with 4 Wheel gear system and motorcycle. Ambulances cannot travel
due to poor roads and less ground clearance of the vehicle severely affecting the availability of
emergency medical transport system preventing the health system of performing its crucial task
and eliminates the possibility of the representation of the State in a human form at the most
crucial and required hour. Lack of funds for the repair of vehicles including tires and battery in
Narayanpur where the life cycle of vehicles gets reduced from 10 to 5 years is concern.
3) Mobile and Internet connectivity: Lack of connectivity, which is already limited within a
radius of few kilometers of the district HQ, and further jammed when the security forces go for
patrolling to avoid information being spread about the whereabouts of the security personnel and
avoid an ambush. Internet connectivity is only in the district HQ, even where reliable network is
generally limited to the offices of Collector and CEO.
4) Infrastructure creation, maintenance and public works department:
• The work of the PWD was poor and maintenance was unsatisfactory in several of the
facilities visited. Uniformly water seepage, lack of staff quarters and delayed construction
were problems. The Maoists due to the possibility of the structures being used by security
forces to establish their bases oppose any structure with solid walls and flat roof.
• The district administration has proposed a novel structure of Bamboo, which is treated to be
fireproof, waterproof and anti termite with reasonable strength to last for up to 30 years.
These structures are being constructed in Bijapur and so far are unopposed by the Maoists.
5) HMIS / MCTS:
• It is extremely difficult to establish and operationalize internet-based systems such as MCTS
which assume reasonable speed and penetration of internet facilities in places like
Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur may be affecting
the regular functioning of the system.
• Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to
only the district HQ (not even block HQ) for such entry, as district HQ is the only place with
overall internet facility. For such, she would require to travel and spend 3 days considering
the lack of transport facilities in the district. At the same time, there is no assurance that the
internet would be functioning on that particular day when the ANM has reached the district
HQ.
• There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero
dose in the manual format but its inclusion in the software. Additionally there is the
persistence problem of villages of a certain PHC / block shown under different PHC / Block
resulting in more problems in reporting. Offline entry was not possible in MCTS.
P) Other health priorities / programs:
1) Mobile Medical Unit: 1 MMU is operational with average daily OPD of 52 patients and
average 14 lab tests. The average number of villages covered each month was 20 with 20
functional days per month. It will be useful to explore how to improve the diverse functionality
of the MMU, including services for NCD. A key problem was the large size and poor ground
clearance of the MMU which would lead to the vehicle getting stuck several times on the roads.
2) Surgical morbidities and tertiary care: The tribal from interior village were willing to
receive medical care for their morbidities, but unable to, due to lack of surgical care at the
district HQ, funds and support. Hence surgical care through camps and a special fund at the
district level to provide free advanced referral care to tribal including transport, a trained medical
social worker as accompanying person and the entire medical care would be useful.
Q) Disease Control Programs:
1) IDSP: The DPMU had recruited a person after significant efforts as IDSP I / c who was
functioning. Nevertheless, due to the recent change in the HR criteria, which makes it mandatory
to have 3 years of experience to be eligible for the post, the current IDSP manager would be
terminated. In places like Narayanpur, it may not be feasible to insist on 3 years of prior
experience and may effectively mean that the post would remain vacant. Instead, on job training
may be an alternative, if the candidate is committed and willing to learn and work.
2) Malaria: Narayanpur is endemic for malaria, especially falciparum. Though the commitment
of the outreach staff who are willing to work in a mission mode in cases of malaria epidemics is
remarkable, the key concerns are lack of integrated malaria prevention and management plan,
absent schedule of IRS and lack of supplies of LLIN or ACT and other antimalarials.
3) RNTCP: Considering that the burden of TB would be quite high in tribal district like
Narayanpur (as is the experience from other tribal districts), the suspected cases examined are
less, with a proportion of only 140 / 1,00,000. Screening and case detection can be increasing
through TB screening through the MMU, mass-selective screening of patients of cough through
ANM and ASHA, increasing the access to sputum collection through ANM and ASHA and
considering establishing advanced diagnostic method like DNA / PCR.
Detail Report
A) Introduction:
The first quarter (2013-14) visit in Chhattisgarh covered Narayanpur district, which is one of the
least developed district of India and of Chattisgarh, bordering Chattisgarh and Maharashtra. In
the past, Narayanpur was part of the larger Bastar district of erstwhile Madhya Pradesh and later
Chattisgarh.
Almost 5 / 6th
of the district is the Abujhmarh, which is an extremely densely forested, hilly area.
It is also the only unsurveyed area of India and currently the stronghold of the Left Wing
Extremist groups. Primarily Narayanpur is tribal dominated, with Gond, Madia and Bada Madia
being the scheduled and primitive tribe inhabiting Narayanpur. Abujhmarh is almost a sanctuary
of the Madia tribe without any access to roads, schools and health services.
It is crucial to note that Narayanpur being one of the most heavily affected districts due to LWE.
Health, ICDS and school education are probably the only 3 programs signifying the existence of
Government in the district, especially, in the affected area (which is the majority of the district).
Parts of Abujhmarh are accessible by roads, but invariably after a certain point beyond the
district HQ, roads become non-existent, leading to only forest. The only way of travel is on foot,
or vehicle like Tractor.
Table 1: Visit Schedule of first quarter visit was as follows
Dates Facility
Personnel
Type
Facility/places visited
22nd
,
23rd
and
24th
June
District Meeting with District Collector
Meeting with District CEO
District Hospital,
Civil Surgeon’s Office,
CHMO office,
DPMU
CHC Orchha
PHC Dhanora
PHC Chotedongar
RMA Sonpur
Mitanin
Trainer
Kurushnar
Mitanin Ader
ICDS Rohtad
B) Analysis of overall indicators of Narayanpur:
1) Key observations:
• Lack of reliable data in general, and especially from Abujhmarh is a key problem. Any data
needs to be evaluated in this context, with significant underreporting probably the norm. The
same underreporting may be a reason why Narayanpur could not figure in the list of 183
High Priority Districts. Interestingly (and as a pointer to the significant underreporting), the
NMR, IMR and CMR of the district are lower than the State as a whole!
• The MMR of Chhattisgarh as a State is 263; MMR of Narayanpur is 283. This could be due
to lesser availability of emergency obstetric facilities, inability to seek timely referral due to
unavailability of cellular network remote and being tribal and extremist-affected district.
• The district has 2 blocks, Narayanpur and Orcha (comprising the entire Abujhmarh area).
There were 60 Gram Panchayat for 413 villages (and even more hamlets, which are placed at
quite a distance), the average number of villages per VHSNC would be 6. Considering the
terrain and distance in Narayanpur, effectively this would mean non-functional VHSNC.
2) High Priority district:
• The exclusion of Narayanpur from the list of High Priority District should be reconsidered
urgently. In fact, a separate category may be considered of ‘Extremely High Priority
Districts’ for Narayanpur as almost 5/6th
part of Narayanpur is Abujhmarh, probably the most
backward and inaccessible part of India.
• The planning of health system and priority should be localized and there should be
significant flexibility. Additionally, Narayanpur district should be included in the list of
districts for the ‘Annual Health Survey’. This is crucial to get the baseline data for the district
and was voiced as a key demand by the district authorities.
Statistics Chattisgarh Narayanpur
Population - Census – 2011
Person 2,55,40,196 1,39,820
Male 1,28,27,915 70,104
Female 1,27,12,281 69,716
Sex Ratio ( No. of Females per1000
males) Census - 2011 991 995
Sex Ratio 0 - 6 years Census - 2011 964 946
MMR ( per 100,000 live births)
SRS - 2012
263 (HMIS) 281(HMIS)
CBR ( per 1000 population) 21.5 21.5
CDR ( per 1000 population) 7.9 7.9
IMR 48 (RHS 2012 ) 42 (HMIS)
Neo- natal Mortality Rate 35 (HMIS) 22.16 (HMIS)
Under Five Mortality Rate 66 (HMIS) 51 (HMIS)
Literacy Rate - Census – 2011 Person 71.04 40.49
Male 81.45 47.71
Female 60.59 33.23
% Decadal Growth Rate 22.59 28.74
Population Density per Sq.K.m 189 20
Blocks 02
Villages 413
Gram Panchayat 69
C) Status of Facilities:
• Narayanpur has total 68 public health facilities out of these 30 are designated delivery points,
the number and distribution as well as designated delivery points are as follows.
• In Narayanpur private health care provider are few and public health care providers are the
only source of modern health care. Crucially though, the public health centers and personnel
are concentrated in mostly the north – east corner of the district. The area in the west, and
bordering Maharashtra, which is the primary Abujhmarh, has negligible residential and
functional health facility. This situation is complicated further by overall the lack of roads,
and especially problematic conditions in Monsoon.
.
D) Human Resources:
1) Overall HR:
• The posts of RCHO, ACMO, DMO, DTO, DIO and DLO, all are vacant. In District Hospital,
of the sanctioned 26 Class 1 posts, only 1was filled. Of the sanctioned 22 Class II posts, only
7 are filled.
• It was desired by the contractual staff that considering the overall conflict situation of
Narayanpur, at least Life Insurance Policy should be considered for the staff. In fact
Total
number
Designated Delivery
points (%)
Level I facility
1 SHC 59 23 (39 %)
Level II facility
2 PHC 7 5 (71.4 %)
(100 %) 3 CHC 1 1
Level III facility
4 DH 1 1 (100 %)
Total 68 30 (44.11%)
No. of licensed blood banks (include pvt) 0
No. of licensed blood storage units/centers 0
considering that the health staff is the only other state staff apart from education and ICDS to
venture in interior and provide services, the distinction between contractual and permanent
may be reduced to possible extent.
• There is need of specific HR policy including clarification on promotions and
regularization and payment rules in an integrated manner, not fragmented. Similarly there is
need of retaining the staff to have institutional memory (the lack of which was sighted by the
district authorities as a major problem).
2) Rural Medical Assistant (RMA):
• The RMA cadre was the backbone of health services in Narayanpur. Considering the
remoteness, the difficulty in mobility and the conflict nature of the district, it is crucial that
this cadre is encouraged and strengthened. It is important to understand that the work of a
medical personnel in the conflict zone in districts like Narayanpur is not only providing
services but several others such as establishing access, communicating with people and doing
unexpected tasks as even rescuing a vehicle stuck in mud.
• Hence, increasing the number of RMA and their skill set by continuous training in CMC
Vellore should be increased. Additionally, new training should be planned as per the desired
skill set for RMA.
3) MPW:
• Of the total sanctioned 64 posts in Narayanpur, 44 posts were vacant. There was only 1
MPW training institute in the entire division, which is in the adjoining district of Kanker
(Pakhanjur). The capacity of that training institute is 50, which is extremely inadequate
considering the total requirement of MPW (44 vacancies in only 1 district).
• Considering this, ideally, an MPW training institute should be established for 2 districts and
all the posts should be filled at the earliest.
• It is important to note that a combination of MPW and ANM is the optimum combination in
areas like Narayanpur, where instead of 2nd
ANM, a MPW can be considered. The MPW can
provide the necessary support to the ANM including mobility and security in difficult areas
during difficult times, provide curative services and work for National Disease Control
Programs.
4) AYUSH:
• There was no integration of the regular NRHM activities with AYUSH with a parallel
structure not involving the regular CMHO. The involvement of AYUSH doctors in disease
control programs as well as other NRHM activities is minimal and should be increased to
optimally utilize them. An Ayurvedagram was observed in Orcha. It was reported that the
doctors remains present in the facility for 3-4 days in the week with OPD of 3-4 per day.
Generally, the cases are of URI and fever.
• Overall, the functionality, utilization and usefulness of AYUSH services and Ayurvedagram
were limited and can be reorganized catering to the immediate priorities of the people.
5) ANM:
• The ANM are involved in several other works other than health work, as preparing ration
cards. This affected immunization coverage in the recent past and several immunization
sessions did not happen. Overall, this was pointed as trend overloading the ANM.
• Recently a Government ANMTC was established in the district. A private ANMTC is
functioning since 2 years.
6) HR Supervisory cadre and Supervision:
• Overall supervision is extremely difficult in Narayanpur due to several reasons including lack
of HR, difficult terrains and lack of connectivity.
• The nodal officers for various programs in Narayanpur are appointed without any specific
criteria with existing staff being given additional charges. This adversely affects the
supervision. Example, the BMO of Orcha block is also the District Malaria Officer. Orcha
BMO being from an interior facility level, his additional charge requires him to stay at the
district HQ, affecting the regular work of providing medical services in the facility and in the
block. Finally, there is no overall comprehensive plan of supervision for doctors.
• Though there is plan for supervising ANM, only 2 LHV were present, affecting actual
supervision. The reasons for significantly less number of LHV is due to absence of
promotions of ANM to LHV, which was not happening due to the inability of the interested
ANM to receive the 2 year training to become LHV. The training could not be provided, as
there is not a single training institution for LHV in Chhattisgarh. The only one is in Jabalpur,
in Madhya Pradesh. This is leading to a situation where the ANM are retiring as ANM only
without any prospects of receiving additional training and promotion. There were examples
of staff in the service for 32 years (Orcha acting Sector Supervisor) without formal
promotion and the benefits.
• Hence a separate plan of supervision if required in such areas and establish a training
institution in Chhattisgarh at the earliest to provide the necessary cadre.
7) Specialist training: Overall, the selection of HR to be trained and the subsequent utilization
of the training by appropriate posting was severely lacking in the district. This is of great concern
considering that severe lack of trained HR in the district and unwillingness of HR to join in.
F) Deliveries: Overall
The district could report 84% of the expected deliveries, of which majority (52%) were home
deliveries. In addition to cultural reasons, the lack of transport and mobile services as well as the
absence of expedited channels of payments was key reasons for lack of institutional deliveries.
Narayanpur Deliveries
Total Population 1,39,820
Home SBA Home Non SBA
530 1,315
Home SBA % Home Non SBA%
15% 37%
G) Institutional Delivery
1) C - Section and Complicated
would mean that several needy women are unable to reach emergency obstetric care center o
receiving after reaching. This would also mean higher maternal mortality.
complicated pregnancies attended is also extremely low. This could be improved by better
training of ANM, RMA and PHC MO.
C sections & Complicated Deliveries
Deliveries (Public)
Total Deliveries
C Section (%)
Complicated Pregnancies
attended (%)
2) Stay in facility after delivery
hours after delivery.
Stay for more than 48 hrs
after delivery
8%
Chattisgarh-Naryanpur- Stay duration as percentage of Reported Institutional Deliveries
Narayanpur Deliveries - Apr'12 to Mar'13
1,39,820 Expected Deliveries 3,511
Home Non SBA Institutional (Pub & Pvt) Total Deliveries
Reported
1,315 1088 2,933
Home Non SBA% Institutional % Total Deliveries
Reported %
31% 84%
Section and Complicated Deliveries: The C-Section rate is 2.3%, which is
would mean that several needy women are unable to reach emergency obstetric care center o
receiving after reaching. This would also mean higher maternal mortality. The proportion of
cated pregnancies attended is also extremely low. This could be improved by better
training of ANM, RMA and PHC MO.
C sections & Complicated Deliveries 12 - 13
Institutional
Deliveries (Public)
Institutional
Deliveries (Pvt)
Total Institutional
deliveries
1088 NA
25 (2.3%) NA 25
26 (2.4%) NA 26
2) Stay in facility after delivery: Majority of the women were leaving the facility within 48
Stay for less than 48 hrs
after delivery
92%
Stay for more than 48 hrs
after delivery
Stay duration as percentage of Reported Institutional Deliveries - Apr'12 to Mar'13
3,511
Total Deliveries
Reported
2,933
Total Deliveries
Reported %
84%
Section rate is 2.3%, which is very low, and
would mean that several needy women are unable to reach emergency obstetric care center or not
he proportion of
cated pregnancies attended is also extremely low. This could be improved by better
Total Institutional
deliveries
1088
25 (2.3%)
26 (2.4%)
Majority of the women were leaving the facility within 48
Stay for less than 48 hrs
after delivery
Apr'12 to Mar'13
3) Management of Obstetric complications: The identification and management of obstetric
complications as Eclampsia was negligible (0%). The detection of maternal anemia was also
lacking. For ANC care there is lack of standard protocols. Similarly, urine testing for Albumin,
nitrite, leukocyte esterase and blood was absent missing cases of pre Eclampsia and UTI. The
use of obstetric interventions as antibiotics, oxytocics was also severely lacking in Narayanpur.
Overall, there is significant need for strengthening obstetric services and emergency care.
Management of Complications 12 - 13
Reported % against reported
ANC Registration
Hypertensive cases detected at institution 301 9.4%
Eclampsia cases managed during delivery 0 0%
ANC women having Hb level<11 377 11.7%
ANC women having severe anemia (Hb<7)
treated at institution 46 1.4%
Obstetric Interventions Cases
C - Section 25
PP Maternal Complications 1
Abortions 82
Still Births 90
Severe anemia cases treated 46
Blood Transfusion 2
IV antihypertensive / Magsulph injection 10
IV Oxytocin 23
IV Antibiotics 22
I) Janani Shishu Suraksha Karyakram (JSSK):
1. OPD and IPD services: Both OPD and IPD services were free for the pregnant, postpartum
women and newborns in all the facilities visited. The awareness of the new rule of extending
the benefit to 1 year may be focused upon.Nevertheless, there were informal reports from
Mitanin that Doctors in the District Hospital demand money (in the specific case recounted,
5000 INR) for services.
2. Drugs, consumables and Blood: The drugs for maternity cases were provided free of cost to
pregnant women if the medicines are available. The system is centralized purchasing and
probably in the process of being established as the supply was not regular and timely for
several medicines. The system of maintaining inventory including regular watch of expiry
date and timely replenishment is lacking. Several drugs were expired. ANM and Supervisors
were not proactively replenishing the drugs. EDL was absent in the facilities visited and the
records and stock were not computerized.
3. Diagnostics:
• Free Lab/diagnostics services were available at CHCs and DH. Exemptions for diagnostic
services are available for PW and Sick new born. What is missing is the overall plan of
maintenance including AMC and calibration. In both the CHC as well as the PHC the
facilities were poor with lack of regular provisioning of diagnostics and regular laboratory
technician. In such situation, the antenatal check up is devoid of any significant benefits.
Even basic laboratory reagents and kits were also lacking.
• In view of this, and in view of the significant investment in provision of modern and high end
equipments being provided and sanctioned in the budget, the provision of such a maintenance
plan, agency and personnel should be made integral part of the PIP. A separate wing like
IDW can be considered for the same. The full functionality of equipments is necessary for
optimum services and are as crucial as other civil infrastructure. Similarly, Point of Care
Tests should be considered to improve diagnostic facilities.
4. Diet: Free diet was provided to pregnant and postpartum women. The food was generally
according to standard menu.
5. Display of entitlement and awareness of community: JSSK Entitlements were displayed in
only 1 of the all facilities visited, which is the PHC Chotedongar. Nevertheless, similar
boards in Local language (Gondi) would be needed in the facilities in the tribal areas of the
district.
6. Informal payments: While discussing with the ASHA from Kurushnar, it was pointed that
when the ASHA took a pregnant woman for delivery (on cycle herself as no vehicle could be
arranged due to absent cellular connectivity), the obstetrician I / c demanded 5000 Rs saying
that the woman will need to be shifted to Jagadalpur Hospital. When the mother and the
ASHA expressed the inability, finally the mother delivered in the DH itself.
7. Referral transport
• Overall in the district, 4 Government and 3 Private Vehicles are available for JSSK transport.
If the pregnant woman has to come to facilities on their own by bus, by hiring vehicle or
using their own vehicle when the regular ambulances are not available on call or it is not
possible to connect with the facility due to lack of cellular connectivity
• Drop back facility was available in all the facilities visited though limited due to distances,
limited number of Ambulances with respect to the size of the district and extremely difficult
terrain.
• The referral transport mechanism was especially poor in case of newborns with as per the
data provided by the district authorities, not a single newborn receiving any kind of referral
transport in the entire month of May.
8. Grievance Redressal / Nodal officer
• No specific mechanism for redressal of grievances exists in facilities visited. The district
does not have a separate JSSK nodal officer for solving grievances. There was lack of clarity
on who is the specific point person for such is. There is no specific accountability or
responsibility for following up on complaints received has been instituted. No records of
registration of complaints, follow up actions, and post-resolution feedback related to JSSK
have been maintained with the primary reasons mostly being the lack of complaints.
• Hence, a grievance redressal mechanism needs to be put in place urgently at all levels of
health facilities, and records of the same maintained. Meaningful analysis can be done after
2-3 months of operationalizing the grievance redressal process and determining the
commonest complaints, actions taken and the response time. Considering the significant
tribal population of the district, for voicing any grievance in the district, a special mechanism
versed in the local language may be needed.
9. Blood Bank: The DH has a non-functional blood Storage Unit. Thus, blood transfusion to
pregnant anemic women is very few. The blood bank has most of the infrastructure and is
waiting to get the License for operationalization. This must be expedited urgently
considering the immense need of blood transfusion.
10. Toll Free Number: 108-toll free service was started in Narayanpur in May 2010 for free
referral transport but the cellular connectivity is almost absent especially in the Orchha block
of the district. This creates a major bottleneck in the optimum implementation of JSSK in the
district.
JSSK Referral Transport Service Report of Narayanpur:- MAY 2013
NAME OF
INSTITUTE
No. of
vehicles
No. of
deliveries
No. of Pregnant & Lactating
Mothers provided free
transport
no. of
sick
neonate
admitted
No. of Neonate Provided free
transport
Home
to
Institute
Institute
to
Institute
Drop
back
Home
Home
to
Institute
Institute
to
Institute
Drop
back
Home
monthly monthly monthly monthly monthly monthly monthly monthly
DISTRICT
NARAYANPUR
4+3 96 76 6 86 30 0 0 0
DH
NARAYANPUR
3+1 70 60 4 62 30 0 0 0
CHC ORCHHA 1+1 8 5 2 8 3 0 0 0
JSSK Referral Transport Service Report of Narayanpur: 2012 - 13
NAME OF
INSTITUTE
No. of
vehicles
no. of
deliveries
No. of Pregnant & Lactating
Mothers provided free
transport
no. of
sick
neonate
admitted
No. of Neonate Provided free
transport
Home
to
Institute
Institute
to
Institute
Drop
back
Home
Home
to
Institute
Institute
to
Institute
Drop back
Home
District
Hospital
4 771 81 43 662 377 - - -
Benoor PHC 0 33 3 0 27 0 4 - -
Chhotedongar
PHC
1 123 10 2 63 0 8 - 1
Orchha CHC 1 33 5 0 15 0 - - -
J) JSY:
• The implementation of JSY in Narayanpur is significantly below mark, especially in the case
of home deliveries where only 15.56 % had received the payment. One of the key bottlenecks
in payment is the lack of banking network and women find it extremely difficult to open
bank accounts. Considering the overall literacy and awareness level, there are instances of
cheque lying with tribal for long time. Unwillingness of Bankers to open ‘0’ balance account
despite clear instructions is a recurring problem. With accountant payee cheque in the
absence of bank accounts, the concern was raised that this may lead to further reduction of
JSY payments.
• It can be discussed as to why there is need of separate accounts for each scheme and why the
payment of JSY cannot be done through existing account such as of MGNREGA. Similarly,
the payment of JSY should be also allowed through BC, DCC and Urban Cooperative banks
as per the feasibility of the patients.
Naryanpur: JSY Paid to Mothers as % of reported deliveries 12 - 13
Deliveries JSY Paid
to mothers
% JSY paid against reported
deliveries
Home 1,845 287 15.56%
Institutional (Public) 1,088 1,060 97.43%
Total 2933 1347 45.93 %
K) Family planning:
1) Achievement:
It was heartening that the utilization of spacing methods was 89%. Overall, the priority of family
planning in Narayanpur should be considered in view of the small size of the Madia Community.
Narayanpur FP Methods 12 - 13
Reported % of All Reported
FP Methods
Total Reported FP Method (All types) Users 4,127 -
Sterilizations 453 11%
IUD 220 5%
Condom Users 1,939 47%
OCP Users 1,515 37%
Limiting Methods 453 11%
Spacing Methods 3,674 89%
2) Type of sterilization: Of the total procedures, majority were female sterilization and mostly
Laparoscopic. The district needs to undertake steps to increase NSV by especially by training
PHC MO in NSV and conducting more camps at PHC and CHC level.
Narayanpur Sterilizations 12 - 13
Reported % of Reported Sterilization
Total Sterilization 453
NSV 123 27%
Laparoscopic 328 72%
MiniLap 2 0%
Post Partum - 0%
Male Sterilization 123 27%
Female Sterilization 330 73%
3) Unmet need of family planning:
The total unmet need is 26.4% in the district, which is understandable considering the overall
picture of the district.
Naryanpur- Unmet need ( DLHSIII) met by reported FP Methods - Apr'12 to Mar'13
Estimated total
Eligible Couples
(17% of population)
24,329.89 Eligible Couples for
unmet need
Total reported
FP Users
Unmet need met
by Reported
Family Planning
Methods
Unmet Needs
Total 26.4 6,423 4,127 64%
Limiting 10.9 2,652 453 7%
Spacing 15.5 3,771 3,674 57%
L) Neonatal and Child Health: Overall:
1) Vital rates:
• There is lack of district specific data from SRS or AHS. There is also significant possibility
of underreporting. For example, the NMR is almost equivalent to Maharashtra! To rule out
this, an independent audit would be advisable, and the district should be included in AHS.
• The current SBR is high, signifying high burden of birth asphyxia and lack of emergency
obstetric care, including LSCS. The high SBR could also be due to mis-classification or
reporting of early neonatal deaths as Still Birth Deaths, especially the cases of Birth
Asphyxia. This creates an erroneous picture of less IMR preventing the possibility of
corrective measures, and hence must be audited.
• The Post neonatal mortality is also high, signifying lack of even ARI and diarrhoea
management services.
Narayanpur: Deaths 12 - 13
Live Births - Reported Live Births estimated Still Births Early Neonatal
deaths
2,843 3,420 90 60
Late Neonatal Deaths Infant Death Under 5
Deaths Maternal Deaths
3 118 145 8
Narayanpur Vital rates
Against Reported Live
Births (1000)
Against Estimated Live Births
(1000)
Reported Still Birth 31.66 26.31
Reported Perinatal Mortality 52.76 44
Reported Neonatal Mortality 22.16 18.42
Reported Infant Mortality 41.51 34.50
Reported Under 5 Child Deaths 51.0 42.39
2) Timing of Childhood Mortality:
• Early Neonatal, Post Neonatal and Toddler Mortality are significantly high in Narayanpur.
The provision of home based newborn care, timely referral, provisions of standard and
quality intensive care can prevent a significant proportion of these deaths. Hence it is crucial
to identify delays in identifying critical newborns, whether facility admissions are as per the
protocol and whether there has been adequate and quality roll out of HBNC.
• A postpartum visit by both the ANM and ASHA in case of home deliveries as well as in case
of institutional deliveries where the mother gets discharged early is hence crucial. There is
significant possibility of this not happening and hence the there is need of supervision of the
work of ANM.
• The high Post Neonatal and Toddler Mortality is extremely worrisome. It is indicative that
Narayanpur is lagging far behind India as a whole where now NMR is the key component of
Childhood mortality. In Narayanpur, ARI and Diarrhea management programs are also
possibly dysfunctional, with lack of training and supplies to frontline workers, leading to
high childhood mortality in these age groups.
3) Causes of Childhood Mortality:
The causes of childhood mortality show great preponderance of Pneumonia as overall cause of
childhood deaths. This needs to be urgently addressed (and can be easily done) with training of
ASHA and ANM in Childhood ARI management and ensuring supplies.
4) Anganwadi Centers:
In Narayanpur, Anganwadi Centers are in functional in several remote villages. In fact, they are
the only residential, functional facilities. Several of these Anganwadi are run by RK Mission.
These Anganwadi centers offer unique opportunity in that they have an almost captive
population of children for any intensive nutritional and health intervention and are manned by
educated and committed workers trained by RK Mission. On the other hand, the children in these
Anganwadi have several health problems, especially nutritional, dematological, ophthalmic and
of ENT.
Hence strengthening the Anganwadi with better drug supplies, training and health interventions
has possibility of rich dividends for child health.
M) SNCU:
There was no SNCU at district hospital. Only a NBSU is present with average 31 admissions per
month.
Areas of concern:
• No outbound admission was in NBSU in the entire year. This reflects severe lack of referral
linkage or refusal to accept admission, and must be explored and rectified.
• The proportion of Still Births was 8.18% and very high. This reflects lack of facility and
training of asphyxia management as well as lack of timely emergency obstetric intervention.
• The proportion of newborn delivered in the hospital and being admitted into the NBSU was
34% and very high. This reflects lack of proper labour room management, and must be
rectified.
• Overall, the maintenance of data was poor and need attention.
Name of District Narayanpur : 1 APRIL 2012 - 31 MARCH 2013
Total
Deliver
y
Admissions to
NBSU
Still
Birt
h
>
2500
gm
<
2000
-
2500
gm
150
0 -
200
0
gm
<
150
0
gm
Cure
d &
D / c
LAM
A
Referre
d
Deat
h
%
Deat
h Inbor
n
Out
bor
n
Tot
al
1099 377 0 377 90 Data not available
N) Nutritional Rehabilitation Center:
There are 2 NRC in Narayanpur district, 1 in the district hospital and the other in Orcha CHC. It
was heartening to see patients in the NRC.
Areas of Concern:
• Keeping the mothers with the children for the required number of days is a major problem
despite the remunerative incentives to stay. This was due to family considerations.
• Poor Follow up and difficulty in community based follow up.
• The weight gain was unsatisfactory. 15% weight gain was in less than 50% cases.
• Lack of remunerative incentives if the children are admitted again or for follow up. The
remunerative incentives for the first admission were only for a stay of 15 days, and not more
(even if the family wishes to stay for longer duration and the weight gain is unsatisfactory).
• In places like Narayanpur, with high overall disease burden, poor outreach services, recurrent
communicable diseases and overall poor literacy and financial levels, it is very much likely
that a child who has once recovered from undernutrition would again fall back due to the
above mentioned reasons. It is also highly likely that the duration required for a Madia /
Gond child in Narayanpur for catch up weight gain would be significantly higher, and a cut-
off of 15 days would be inadequate.
• Hence all the financial remunerative incentives to the mother as well we the Mitanin must be
continued for follow up as well as subsequent admission. There should be no cap of 15 days
stay in the facility if the mother wishes to stay for more days with the child and there should
be commensurate remunerative incentive for this.
NRC: April 2012 - March 2013
Total
admissions
Bed
Occupancy
Rate
Achieved
target weight
(15% weight
gain)
Discharge
from NRC
LAMA /
Defaulte
r
Non
Respond
ers
Death Still in
Ward
149 75.9 11.35% 128 14 2 1 0
NRC: April 2012 - March 2013
Children
due for
follow up
Children
followed
up
Defaulter for
follow up
Non
responder
after 4th
follow up
Death
during
follow
up
period
Relapse No. of
Children
completed
4th follow
up
Achieve
d
MUAC
>11.5
cm &
wet>2sd
142 67 71 2 0 2 4 22>91
O) Outreach Services:
Overall ANC registration and post partum visits are significantly less. There was lack of
availability of MCH registers. Despite repeated demands to the State HQ, there has been no
provision since 5 to 6 months. Ultimately, the district printed the MCH registers using the untied
funds. MCH Clinics are not functional in Narayanpur, and were not assigned to the district.
Performance Indicators of ANM Apr'12 to Mar'13
% ANC Registration in First Trimester
against Reported ANC registration 24%
% PNC visits within 48 hours and
14 days against total deliveries 42%
% Three ANC checkups against estimated
pregnancies. 69%
% Severe anemia (Hb<7) treated
against reported ANC registration 1.4%
ANC
ANC Check-up in first trimester 758
3 or more ANC Check-up 2,578
At least 1 TT received 2,091
100 IFA Tablets 3,311
P) Immunization:
1) Immunization coverage: The immunization rate for individual vaccines as well as the overall
full immunization coverage at 1 year is around 90%, and this is significant achievement. The
Cold Chain was difficult tp maintain considering the lack of electricity. Also, the staff had to
walk for several kilometers to ensure vaccination in the hamlets and villages.
2) Immunization sessions: The proportion of sessions held compared to plan as well as ensuring
the presence of ASHA at VHND requires special focus. The reasons of absence of ASHA
including difficult terrain and inability to pass on information should be considered.
Child Immunisation (0 to 11 months)
Measles given against Expected Live
Births 82%
Measles given against Reported Live Births 98%
Fully Immunised Children against
Reported Live Births 95%
Fully Immunised Children against
Expected Live Births 79%
Required numbers of VHNDs per
thousand population in 12 months
1,7
17
3) Hepatitis B Vaccination: If the delivery is not institutional, the child is not given any dose of
Hepatitis B vaccine. It was pointed out to the district officials that it is better to vaccinate late
than never. Considering the situation of Narayanpur where institutional delivery is difficult, the
opportunity to vaccinate a child for Hepatitis B should be utilized any time when possible
including when the ANM visits the village and encounters the child for the first time.
4) Alternate Vaccine Delivery System: The district health system officials pointed that instead
of sending the vaccines through another person, sending the vaccines through ANM with
additional incentive to the ANM would improve the efficiency of vaccine delivery pointed it.
5) Immunization system:
• There were only 8 BCG vials in the District Hospital.
• The rule of supply of the vials as per the expected population of children and 1 vial per 4
children and to be used immediately after opening is creating difficulties in Narayanpur. It is
observed that the villages in Narayanpur are very small (to the extent of 304 houses only)
which means effectively the number of children to be immunized would be quite less, in
several cases, less than 4. At the same time, the distances being large and terrain being
difficult, generally visit to 1 or 2 such hamlets would only take the entire day. Overall, this
was resulting into wastage of vials where 1 vial was being used for less than 4 children and
then discarded. And finally less supply (based on the norm of 1 vial for 4 children) compared
to actual feasibility of use in Narayanpur.
• Hence the norm should be reconsidered in Narayanpur and more supply should be provided
with more liberal norm.
Q) ASHA, VHSNC and NGO Partners:
1) Selection:
• In Narayanpur, of the approved 525ASHA, 508 were in place. Similarly the positions of 2
Block Community Mobilizers have been filled.
2) ASHA training:
No. of ASHAs trained in: 2012 - 13
• Module five 300
• Module six 305
• Module seven 305
3) Tasks ASHA is supposed to perform are as follows:
• JSY delivery in PHC or any recognized hospital (Tribal & Non-Tribal Areas)
• Motivation of BPL/SC/ST beneficiary for tubectomy
• Motivation of any beneficiary for vasectomy
• Completion of DOTS (RNTCP)
• Radical treatment of malaria Positive case
• Leprosy treatment
• Control of epidemic (outbreak)
• Escort of pregnant women for HIV testing in PPTCT centers, Admission of HIV +ve
mother for delivery in PPTCT center, Follow up of HIV positive mothers at 6 week, 6 and
18 months
• Immunization at Village Level
• Motivation of community for toilet construction
• Birth Information Registration of Birth
• Death Information of Age group 0 to 5,Information of women death for the age group
between 15 to 49 years
• For recording of Maternal death in the age group of 15 to 49 yrs, Yearly Immunization,
• Bringing critically ill child to hospital (for tribal areas only)
• Sickle Cell control program
4) The key problems identified were:
• Lack of HBNC kits.
• Lack of regular drug kits and antimalarials.
• Lack of system of drug refilling.
• Lack of supervisory visits.
• Lack of training of Mentor Facilitator.
• Lack of alternate system of payment in case the mother cannot avail the services of JSSK
(transport etc) due to poor connectivity, emergency and lack of vehicle.
• Lack of Travel Allowance for the Mitanin. A flexible system of travel allowance based on
distances to be travelled and transport facilities is extremely necessary.
5) Conflict Situation and its effects: There are several instances of the Left Wing Extremists
asking for medicines to the health staff as well as the Mitanins. At the same time, the security
forces also question the Mitanin regarding the stock and supplies they carry from the block of
district HQ meeting to their villages with the doubt the medicines they carry would be for the
Maoists. Considering this, it should be ensured that the Mitanin receive regular supplies inside
the village to escape from the questioning from security forces.
Overall, in places like Narayanpur where the formal health system is weak, it is extremely
crucial to strengthen the Mitanin, provide adequate remuneration, establish necessary system,
which is feasible locally, extend their training, provide them the necessary supplies and expand
the roles. They are the last connection with the people of the health system, especially in districts
like Narayanpur where the regular other health system is limited due to several reasons.
Similarly, the tasks of ASHA in Narayanpur need to revised and reviewed in view of the
local priorities. Accordingly, the ASHA incentive structure should be restructured.
5) VHSNC:
• Gram Panchayat are not fully functional and strengthened in Narayanpur. Due to the
opposition by the Maoists to elections, Sarpanch and Gram Sevak hardly reside in villages. It
was pointed that a Sarpanch gets elected by less than 10 votes, and immediately leaves the
village after election and generally stay in Narayanpur. This hampers functioning of VHSNC
and difficulty in expenditure of the funds. Sarpanch are also not aware of the funds.
• Mitanin find it difficult to work in-sync with the Sarpanch considering their consistent
unavailability. The method of release of their payment through Panchayat also does not
function. It was feared that with the implementation of the system of payment through
Panchayat; the minimal incentives the Mitanin were getting so far will also get stopped.
Hence due consideration must be given regarding the feasibility of implementation of this
mechanism in these areas where the Panchayat are dysfunctional.
• It was also suggested that in view of the unavailability of the Sarpanch and Gram Sevak,
Bearer Cheque may be considered for payments of Mitanin, or an alternative.
6) IEC: It was pointed out by the IEC officer that the orientation camps undertaken in the past
with rigorous group discussions was a better model to communicate with tribal and convince
them. This was a more personalized approach considering the culture and literacy level.
Compared to this the current program is more vertical where the contents, IEC material are all
directly sent from Raipur and are not in the local language (neither Gondi nor Madia). In fact
considering the overall literacy level, written material does not serve much purpose for IEC in
the areas like Narayanpur.
7) NGO: Ramkrishna Mission is functional in Narayanpur district in the most interior parts,
providing extremely useful services. In fact, at several places, the ICDS run by the mission are
the only functioning component of the system. Hence more convergence and involvement of the
RK Mission with health services will be useful.
S) Program Management:
1) Key issues emerging were:
• Can the several reporting systems be integrated and automated?
• Can there be dynamic rate for fuel? Considering that, increment is the trend. Can the distance
from district HQ be considered for calculating the budget for the facility?
• Can there be Induction training for NRHM staff and the DPM? There can be a bond for DPM
to continue after receiving the training.
• Can there be adequate block program management structure (which is currently almost
absent)?
• The criteria of allowing recruitment only from the district is probably acting as a bottleneck
in filling the vacancies as there is significant lack of the trained HR for the respective
positions in the district. Hence, can this rule be relaxed, probably on a case basis, and / or
allowing recruitment from adjoining districts such as Kanker, Dantewada, Bijapur, Sukma,
Kondagaon and Bastar?
• A review meeting at the block level generally requires travelling by the staff for 3 days due
to poor logistics and terrain. This affects the review as well as leads to waste of the working
days of the outreach staff. Can there be a solution to this?
2) PIP Planning and setting priorities:
The process of setting priorities for Narayanpur should rigorously take into consideration the
local morbidity pattern, and not enforce other priorities. For example, it was observed that the
BMO or Orcha, who is the only MBBS doctors in the entire block, and is holding the additional
charge of District Malaria Officer, had to go to Raipur to attend a meeting on ‘YAWS’. This
would lead to his absence from the facility and the block for almost 3 days, depriving the people
of crucial health services. It is also highly questionable whether YAWS is a priority in general
and specifically for the districts such as Narayanpur.
T) Quality of Services and supportive services:
1) Clinical care protocols and management AND Quality Assurance:
The key constrains were lack of:
• Proper case papers for patients and maintaining the case records.
• Standard guidelines for clinical management.
• Hand-over and signature when duties change, leading to lack of complete information of the
patients and accountability of clinical staff.
• Isolation wards.
• Firefighting facility
Other issues: Infection prevention practices were relatively inadequate in the facilities visited.
For example, the Ambu bag and baby warmer not sterilized. The Quality Assurance committee
and teams are absent, and there is no separate system or human resource. Overall, there is
significant need of quality measure to improve the quality of curative services in all the public
health facilities.
2) Solar: The regular functionality of the solar back-up system is a positive finding from
Narayanpur. Generally, the system was well functional, and was extremely crucial considering
the recurrent episodes of power failure. Hence, there should be an integrated plan for regular
maintenance and troubleshooting of solar system. Currently the complaints are lodged with
CREDA, but the response and troubleshooting is delayed and hence alternative should be
considered.
3) Biomedical waste disposal: Overall, there was lack of proper segregation and management of
biomedical waste and lack of knowledge. The color-coded bags were available at the DH, the
CHC visited, though the method, and protocols were not followed rigorously. A tender was
under process for incinerator at Jagadalpur where all the waste will be taken for disposal. Hence
establishing an Incinerator in Narayanpur should be considered for each of biomedical waste
management.
4) Mobility facilities:
• Logistics and mobility is a major problem in Narayanpur. Roads are already in poor
condition and are completely blocked in monsoon. In such conditions, no regular 4-
wheeler vehicle (ambulances, Tata Sumo Jeep, Buses) can travel. The only vehicles that can
pass are Tractor (or tractor like vehicles), a Jeep with 4 Wheel gear system and motorcycle.
• There is significant lack of public transport in these areas.
• Ambulances cannot travel due to poor roads and less ground clearance of the vehicle severely
affecting the availability of emergency medical transport system. This prevents the health
system of performing its crucial task and eliminates the possibility of the representation of
the State in a human form at the most crucial and required hour.
• The ANM, Mitanin Block Resource Persons, MPW, LHV need have to unfortunately travel
on cycle or feet, forcing them to walk large distances, affecting the outreach and timeliness
of services.
• A key constrain emerging was the absence of funds for the repair of vehicles including tires
and battery which limits the functioning of the vehicle.
• Though the general life cycle of vehicle in plain areas is considered 10 years, in the
extremely difficult terrain of Narayanpur, the life cycle of vehicles is not more than 5 years,
including recurrent and major expenditure on maintenance. This should be considered and
provided for in the PIP.
Possible solution:
• Can the field cadre be given Motorcycle considering the roads and distances? Similarly, the
facilities should have vehicles, which are Jeep with 4 Wheel gear system and / or a Tractor
which is actually the most all weather vehicle in such terrains. It has high ground clearance,
and is any ways used to free vehicles stuck up in mud and poor roads.
• Additionality it should be considered to provide POL for the outreach cadre in these areas.
5) Mobile and Internet connectivity:
• Lack of connectivity is one of the major problems in Narayanpur. Cell connectivity is limited
within a radius of few kilometers of the district HQ. Even that is absent when the security
forces go for patrolling to avoid information being spread about the whereabouts of the
security personnel and avoid an ambush.
• Internet connectivity is only in the district HQ, even where reliable network is generally
limited to the offices of Collector and CEO. On the day of visit, internet connection was
absent in the CMHO office since past 48 hours.
• In view of this, provision of VAST facility is crucial in Narayanpur. Additionally, the health
facilities and CMHO office should be included in the SWAN system.
6) Infrastructure creation, maintenance and public works department:
• The work of the PWD was poor and maintenance was unsatisfactory in several of the
facilities visited. Uniformly everywhere, water seepage, lack of staff quarters and delayed
construction were problems.
• Apart from other bottlenecks in constructing PHC and SHC in the interior, the opposition
from the Left Wing Extremists is a major additional problem in this area. Any structure,
which has solid walls with flat roof, is opposed by the Maoists due to the possibility of the
structures being used by security forces to establish their bases. This is one of the major
cause of the inability to do the necessary expenditures. In fact, the constructions from 2010 –
11 are still ongoing in Narayanpur, and lack of construction is a key constrain in the
utilization of health services.
• In view of this, the district administration has proposed a novel structure of Bamboo, which
is treated to be fireproof, waterproof and anti termite with reasonable strength to last for up to
30 years. These structures are being constructed in Bijapur and so far are unopposed by the
extremists. In view of this, the construction of these structures can be considered for support
in the PIP.
7) HMIS / MCTS:
The key observations were:
• It is extremely difficult to establish and operationalize internet-based systems such as MCTS
which assume reasonable speed and penetration of internet facilities in places like
Narayanpur. In fact, insistence on operationalizing MCTS in Narayanpur is probably
affecting the regular functioning of the system.
• Daily reporting of MCTS is impossible in Narayanpur. The ANM would need to come to
only the district HQ (not even block HQ) for such entry, as district HQ is the only place with
overall internet facility. For such, she would require to travel and spend 3 days considering
the lack of transport facilities in the district. At the same time, there is no assurance that the
internet would be functioning on that particular day when the ANM has reached the district
HQ.
• There was significant confusion in the minds of ANM regarding the HMIS and MCTS
reporting. This adds to even lesser enthusiasm about MCTS.
• There are other specific problems such as absence of reporting of Hepatitis B Vaccine Zero
dose in the manual format but its inclusion in the software.
• Additionally there is the persistence problem of villages of a certain PHC / block shown
under different PHC / Block resulting in more problems in reporting.
• Offline entry should be made possible in MCTS.
In view of this, it is extremely crucial to reconsider the reporting systems, which take into
considerations the peculiarity of these conflict areas. The systems should aid, not pose challenges
in providing regular clinical services, which are most necessary.
Other Health Priorities / programs in Narayanpur
1) Mobile Medical Unit:
In Narayanpur district 1 MMU is operational with average daily OPD of 52 patients. Daily on an
average 14 lab tests were conducted. The average number of villages covered each month was 20
with 20 functional days per month. It will be useful to explore how to improve the diverse
functionality of the MMU, including services for NCD. A key problem was the large size and
poor ground clearance of the MMU which would lead to the vehicle getting stuck several times
on the roads.
2) Surgical morbidities and referral Tertiary Care:
• Considering the surgical morbidities expected in the population but the lack of the surgical
human resource in the district, camp approach to provide surgical care should be actively
considered. This is especially important considering the experience from the monitoring visit
that tribal from quite interior village were willing to receive medical care for their
morbidities, but unable to due to several other reasons in addition to lack of surgical care at
the district HQ.
• It was observed in the monitoring visit that tribal from interior villages are willing to receive
benefits from the health system, especially in case of tertiary care. It is hence recommended
that a system and special fund covering the entire cost with the necessary provision of
support for referral care and tertiary care including transport, a trained medical social worker
as accompanying person should be established. This will also send a very positive message to
the tribal from the health system.
S) Disease Control Programs:
1) IDSP:The district program management unit had recruited a person after significant efforts as
IDSP I / c who was functioning. Nevertheless, due to the recent change in the HR criteria, which
makes it mandatory to have 3 years of experience to be eligible for the post, the current IDSP
manager would be terminated. It is important to understand that at places like Narayanpur, it may
not be feasible to insist on 3 years of prior experience. It may effectively mean that the post
would remain vacant. Instead, on job training can be considered as an alternative, if the person is
committed and willing to learn and work.
2) Malaria:
Narayanpur district, especially the tribal, remote and left wing extremist affected area are
endemic for malaria, especially falciparum. Though the commitment of the outreach staff who
are willing to work in a mission mode in cases of malaria epidemics is remarkable, following key
concerns and emerged:
• There was no integrated malaria prevention and management plan. Schedule of IRS was
absent. Similarly, LLIN or ACT and other antimalarials were not supplied.
• A repeated problem faced is the lack of Syrup of ACT (the recommended drug for
falciparum malaria in endemic zones like Narayanpur) for treating children. It is very
difficult to ensure compliance with tablets in children.
• There must be urgent provision of RDK, LLIN and IRS.
• There must be an annual timeline of distribution of LLIN and IRS.
3) RNTCP: Considering that the burden of TB would be quite high in tribal district like
Narayanpur (as is the experience from other tribal districts), the suspected cases examined are
less, with a proportion of only 140 / 1,00,000. Overall, the screening and case detection needs to
be increased. This is possible through:
- Ensuring TB screening through the MMU.
- Mass-selective screening of patients of cough through ANM and ASHA
- Increasing the access to sputum collection through ANM and ASHA
- Considering establishing advanced diagnostic method like DNA / PCR.
Indicator Narayanpur
Total population Covered (In Lakhs) 1.40
TB Suspects examined per lack of population per quarter 196
Total Patients registered for treatment 226
Total no smear positive patients diagnosed 100
Treatment outcomes, new smear positive rates (%) 54.21
Annexure:
Annexure 1:
Human resource status in Narayanpur under NRHM
Sr.
No.
Programme
Name
Sr.No
. Post Name
District Name :-
Narayanpur
Sanction
Post
Filled
Post
Vacant
Post
1 2 3 4 5 6 7
1 DPMU
1 Dist.Programme Manager 1 1 0
2 Dist.Account Manager 1 1 0
3 Data Entry Operator 2 1 1
4 Statstical Investigator 0 0 0
2 M&E 4 M&E Officer 0 0 0
5 Statstical Investigator 0 0 0
3 IPHS
6 IPHS Co-Ordinator 0 0 0
8 Programme Assistant / DEO 0 0 0
10 Lab.Technician 0 0 0
4 FMG 11 Accountant (C.S.) 0 0 00
12 Accountant (Z.P.) 0 0 0
5 ASHA
13 District Community Mobilizer 0 0 0
14 District Asha Assistant 0 0 0
15 Block Community Mobilizer 0 0 0
16 Asha 0 0 0
6 RKS 17 RKS Co-Ordinator 0 0 0
7 School
Health
18 Programme Supervisor 0 0 0
19 Programme Assistant 0 0 0
20 Medical Officer (Male) 0 0 0
21 Medical Officer (Female) 0 0 0
22 Pharmasist 0 0 0
8 AYUSH
23 Medical Officer (Aurved) 0 0 0
24 Medical Officer (Homeopathy) 0 0 0
25 Medical Officer (Unani) 0 0 0
26 Masajist (Male) 0 0 0
27 Masajist (Female) 0 0 0
28 Pharmasist 0 0 0
29 Ayush Nodal Officer 0 0 0
30 Data Entry Operator 0 0 0
9 Sickel cell 31 Sickelcell Co-Ordinator 0 0 0
32 Lab Technician 0 0 0
10 IDW
33 Deputy Engineer 0 0 0
34 Junior Engineer 0 0 0
35 Accountant Cum Operator 0 0 0
11 BPMU 36 Accountant 2 00 2
37 Programme Assistant 0 0 0
12 Procurement
/ Store 38 Pharmasist 0 0 0
13
Infrastruture
Human
Resorce
39 ANM (N.& T) 33 4 0
40 LHV (N.& T.) 11 1
41 Staff Nurse (N.& T.) 0 0 0
14 Urban RCH 42 ANM 0 0 0
15 Arsh 43 Arsh Supervisor 0 0 0
16 Telemedicine 44 Facility Manager 0 0 0
17 PCPDNT 45 Legal Advisor 0 0 0
18 Referral
Transport 46 Call Assistant 0 0 0
19
Rutine
Immunizatio
n
47 Data Entry Operator 0 0 0
20 IDSP 48 Epidemic Officer 0 0 0
49 Data Entry Operator 1 1 0
Annexure 2: Human Resources
Regular Contractual
Category /
type of
personnel
Sanctioned
posts
In
position
Sanctioned
posts
In
position
(through
state/other
sources)
(E)
In
position
from
NRHM
Total in
position
Vacancy
(%)
1st ANM 74 72 0 0 0 72 97.30%
2nd
ANM 0 0 33 0 4 4 12.12%
MPW/ Male
HW
66 25 0 0 0 25
37.89%
Staff Nurse
total
50 14 11 0 1 15
24.59%
DH 30 15 0 0 0 15 50%
Regular Contractual
Category /
type of
personnel
Sanctioned
posts
In
position
Sanctioned
posts
In
position
(through
state/other
sources)
(E)
In
position
from
NRHM
Total in
position
Vacancy
(%)
FRU 0 0 0 0 0 0 0%
24X7 PHCs 2 0 0 0 0 0 0%
Other
facilities (Pls.
specify)
18 0 0 0 0 0
0%
LTs 10 5 0 0 0 5 50%
DH 2 2 0 0 0 2 100%
FRU 0 0 0 0 0 0 0%
24X7 PHCs 2 1 0 0 0 1
50%
Other
facilities (Pls.
specify)
6 1 0 0 0 1
16.66%
Pharmacists 14 7 00 0 0 7 50%
MOs total 24 11 0 0 0 0 45.84%
AYUSH
MOs 0 0 0 0 0 0
0
DENTAL
MOs 1 0 0 0 0 0
0%
Specialists
total 26 1 0 0 0 0
3.84%
Obstetricians
&
Gynaecologist
1 1
(PGMO) 0 0 0 1
100%
Anaesthetist 1
1
(PGMO) 0 0 0 0
100%
Paediatrician
1 1
(PGMO)
0 0 0 0
100%