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Report of 5th Common Review Mission

Bihar

November 2011

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REPORT OF THE FIFTH COMMON REVIEW MISSION - BIHAR

November 9 to November 15, 2011

The Common Review Mission (CRM) visited the state of Bihar between November 9 and November 15. The state has been included in all past CRMs except the third. After a state level briefing, the team divided into two – one for the district of Begusarai, and the other for Kishanganj. The Begusarai team consisted of: Mr. Deep Shekhar, Dr. B.K. Tiwari, Dr. P.C. Bhatnagar, Ms. Medha Gandhi, Dr. Sarita Sinha, and Mr. Ravi Sawlani. Mr. Ranjit Samiyar from the State Health Society acted as facilitator. The Kishnaganj team consisted on Dr. S.I. Amir, Dr. Sher Singh Kashotiya, Dr. Rajani Ved, Mr. Billy Stewart, Mr. Sunil Kumar Babu, and Mr. Ajit Singh. Mr. Ram Rattan from the State Health Society facilitated the district visit. Details of the tema are at Annexure 1. A state level briefing was held on November 9, and the tema was provided with state and district level data on several of the Terms of Reference in the CRM. The teams then spent from November 10 to November 13 in the districts, returning to Patna on December 14; visiting facilities and sites. (Annexure 2) On December 15, a presentation of key findings and recommendations was presented to the Principal Secretary, the Mission Director; members of the State Health Society and other stakeholders. .

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II. INTRODUCTION

Bihar is located in the eastern part of the country (between 8 3°-30' to 88°-00' longitude). It is an entirely land–locked state, lies mid-way between the humid West Bengal in the east and th e sub humid Uttar Pradesh in the west which provides it with a transitional position in respect of climate, economy and culture. It is bounded by Nepal in the north and by Jharkhand in the south. The Bihar plain is divided into two unequal halves by the river Ganga which flows through the middle from west to east. With a total population of 103 million, it ranks as the third most populous state in the country. It has a decadal growth rate of 25.07, and a population density of 880/sq km. The state has nine sub divisions; 38 districts, 534 blocks and 8471 panchayats. About 40% of the population is below the official poverty line and the state is characterized by high out migration in search of employment, seasonal and otherwise. The tables below depict the demographic and health profiles of the state and a comparison with the national averages.

Profile of Kishanganj and Begu Sarai

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BEGUSARAI KISHANGUNJ BIHAR STATE

Profile The district lies on the

northern bank of river

Ganga.

Kishangunj district is

in Purnea division of

Bihar state, but

geographically and

culturally it is part of

the north Bengal. It is

part of the chicken

neck of Indian map.

Bihar lies mid-way

between West Bengal in

the east and Uttar

Pradesh in the west. It is

bounded by the country

of Nepal to the north and

by Jharkhand to the

south. The Bihar plain is

divided into two parts by

the river Ganges which

flows through the middle

from west to east.

Demography

Total population 29,54,367 16,90,948 103,804,367

Growth rate 25.75 30.44 25.07

Population

density

1540/square km 898/square km 1,102/square km

: R: U:

Sex Ratio: total

population

894/1000 down by 18 946/1000 up by 10 916 down by 3

Sex Ratio- 0 to 6- 911 down from last

decade by 35 points

966/1000 up by 19

points

933 down by 9

Literacy Female literacy- 57.10

Male literacy -74.36

Female literacy-

47.98

Male literacy - 65.56

Female literacy- 53.33

Male literacy – 73.39

IMR 46* 61* 52***

Neonatal

Mortality Rate

25* 47* 31***

Under Five 65* 90* 70***

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Mortality

Mothers who

had at least

three ANC visits

before delivery

(%)

29.4** 27.7** 26.3**

Institutional

Deliveries (%)

26.9** 17.9** 27.5**

Children fully

immunized (12-

23 months of

age) for BCG,3

doses of DPT,

Polio and

Measles (%)

41.4** 23.6** 41**

*as per AHS 2011

** as per DLHS -3

***as per SRS 2009

Demographic Profile

Indicator BIHAR India

Total population (Census 2011) (In Crore) 10.38 121.01 Decadal Growth (Census 2011) (%) 25.07 17.64 Crude Birth Rate (SRS 2009) 28.5 22.5 Crude Death Rate (SRS 2009) 7 7.3 Natural Growth Rate (SRS 2009) 21.5 15.2 Sex Ratio (Census 2011) 916 940 Child Sex Ratio (Census 2011) 933 914 Schedule Caste population (In Crore) 1.3 16.6 Schedule Tribe population (In Crore) 0.076 8.43 Total Literacy Rate (Census 2011) (%) 63.82 74.04 Male Literacy Rate (Census 2011) (%) 73.39 82.14 Female Literacy Rate (Census 2011) (%) 53.33 65.46

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Status of Health Indicators:

Indicators Bihar India

Infant Mortality Rate (SRS- 2009) 52 50

Maternal Mortality Rate (SRS 2007-09) 261 212

Total Fertility Rate (SRS- 2009) 3.9 2.6

Crude Birth Rate (per 1000 population) (SRS 2009) 28.5

Institutional Deliveries (In Lakhs) 2011-12 (Upto June)(HMIS)

2.56 32.98

Full immunization (In thousands) 2011-12 (Upto June)(HMIS)

534 4651

(b) Baseline of Public Health System in the State:

Rural Population (In lakhs) Census 2011 920.75

Number of Districts (RHS 2010) 38 Number of Sub Division/ Talukas 101 Number of Blocks 534 Number of Villages (RHS 2010) 45098 Number of Medical Colleges 6 Number of District Hospitals 36 Number of Community Health Centres (RHS 2010)

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Number of Primary Health Centres (RHS 2010) 1863 Number of Sub Centres (RHS 2010) 9696

Table 4: List of Facilities visited

Begusarai

S.No. Name Location Level (SC / PHC

/ CHC/other) 1. Sadar Hospital Begusarai District Hospital 2. PHC Bakhari Bakhari PHC 3. Mohanpur HSC Mohanpur SC

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4. Anganwadi Centre Chanhakat Mohanpur AWC 5. PHC Naokothi Naokothi PHC 6. HSC Maheshwara Maheshwara SC 7. RH Manjhaul Manjhaul RH 8. APHC Banwaripur Banwaripur APHC 9. HSC Chandrapur Chandrapur SC 10. HSC Atarwa Atrwa SC 11. APHC Sokhra Sokhra APHC 12. HSC Baramuri Baramuri SC 13. PHC Teghra Teghra PHC 14. HSC Kasavarain Kasavarain SC 15. APHC Simaria Simaria APHC 16. PHC Barauni Barauni PHC 17. APHC Phulwaris Phulwaria APHC 18. SDH Balia Balia SDH 19. HSC Barbighi Barbighi SC 20. HSC Bagatpur Bagatpur HSC 2 Kishanganj DH Kishanganj DH

HSC Maheshbathna HSC (Delivery

point)

AWC Maheshbathna Anganwadi

Center PHC Terhagachh Block PHC HSC Gamarhia Sub Center HSC Jhala Sub Center

AWC Jhala Anganwadi

Center

AWC Gamarhia Anganwadi

Center PHC Pothia Block PHC HSC Chhatargachh HSC HSC Mirzapur Sub Center

AWC Mirzapur Anganwadi

Center PHC Bahadurganj Block PHC HSC Mahadev Dighi Sub Center AWC Khajurwadi Anganwadi

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III. KEY FINDINGS

1. Infrastructure Development

Number of Facilities

functioning

As on

01.04.2005 As on 31.03.2011

Total No of

Facilities

Total No of

Facilities

Functioning

as per IPHS

DH 25 36 36

SDH* 22 46 29

CHC/RH 84 70 70

PHC 399 534 533

APHC 1243 2787 1330

Sub centre 8858 16576 9696

1. Health Infrastructure:

As can be seen from the table above, since the beginning of NRHM, the strengthening of infrastructure in District Hospitals, Referral Hospitals, PHCs and Sub Centres has

Center HSC Bargarhiya Sub Center

M.G. Medical College Kishanganj Private Medical

College

ANMTC Kishanganj ANM Training

School

Surya Clinic Kishnaganj Private clinic –for FP/MTP;

Janani

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expanded greatly, and contributed to increased access to health services from the existing baseline in 2005. . At present the state has 9696 HSCs, which is about 60% of the total required. For other facilities the existing against required is as follows: APHC: 50%; PHC 100%; Referral Hospitals: 11%‟. The lack of iinfrastructure for service delivery is a limiting problem in the state. In addition to a mismatch between required, sanctioned, and those in place; the quality and completeness of facilities is also a major challenge. There are major physical infrastructure constraints at the field level. The pace of civil works is very slow. Most of the HSCs are situated in either at rented building or having no buildings. The load on the BPHC is high in comparison to availability of resources and adequate infrastructure, hence there is urgent requirement of up gradation of BPHCs into CHC to reduce the load and enhance the quality of care. Running water, electricity and toilet facilities are missing at most APHCs and SCs. Non availability of residential accommodation is a major lacuna since no new additions of staff quarters between 2005 and now. Construction of health facilities is not as per IPHS standard. Currently there is no infrastructure and finance wing both at state and district level. With a view to bring about improvement in the existing health facilities by bridging the gaps between the required as per GoI norms and the existing, several steps have been initiated. The Bihar state Health Infrastructure Corporation has been established, but not operationalized. An amount of approximately Rs. 1100 crore is pending with the building and construction dept, (since 2006) which has hampered the completion of previous ongoing construction work. However districts have used other sources (MDSP, SamVikas Yojana, Intl. Charities) to enable construction.

Status of Health Facilities in the State:

Type of Facility Present Required Shortfall MCH 7 20 13 DH 36 38 2 SDH 46 55 9 CHC/RH 70 604 534 PHC 534 534 0 APHC 1330 2787 1544 HSC 9696* 16576 7718

*4875 without own building

New constructions and renovation:

NRHM has enabled new constructions; and much is also currently ongoing.

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Facility No. of New buildings

Completed in NRHM period

No. of Ongoing Works No. of buildings with Quality certification

SC 767 1583 1 DH only, 46 units for ISO certification, 100+ for Family Friendly Hospital Initiative

APHC 1 216 PHC 94 41

CHCs 0 201

DH 10 2

1. Health Sub-Centres:

Out of 9696 sub centres in the State, about 4875 are operating without building. State government has taken up construction of 2291 from own fund and loan from R.I .D.F. As per the norms of a Health Sub center for every 5000 population, Bihar requires 16576 sub centers; translating into a requirement of 7718 additional HSCs. Currently most HSCs in the state cover twice the IPHS norm at about 10705. The state had proposed to create 1553 HSCs every year to meet the requirement which could not be achieved. Only a few sub centres in the state serve as delivery points. Out of 9696 SCs, 6903 have a second ANM in place, but a majority do not stay at the sub centre given a lack of residential facility. Running water, electricity and toilet facility is not available in most of the sub centers.

Status of Health Sub Centres:

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2. Primary Health Centres:

There are 534 block PHCs and 1330 additional PHCs in the state. The state plans to upgrade block PHCs to CHCs in a phased manner. The requirement of 2787 APHCs as per IPHS, therefore 1457 APHCs are required to be set up, by 2012 . The Govt of Bihar plans to upgrade all its PHCs and Referral Hospitals to CHC as per IPHS standard. Of a total of 534 PHC s which 40 operate from rented building. The construction work for up gradation of 201 PHCs into CHCs is in process since last two years.480 BPHCs out of 533 are functional as 24x7 bases. Functional APHCs providing only Out patient services. In some BPHCs strengthening of the building has been done during last two years including minor repairs, electricity , water supply and equipments.

Status of APHC:

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Status of PHC:

3. Community Health Centre/ Referral Hospital:

There are 70 CHC/RH is present in the state. At present Block PHCs are working as CHC in the state as BPHCs caters an approximate population of around 2 lakhs. The up gradation of 201 BPHCs into CHCs is in process.

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* 14 Number of Referral Hospitals (CHC) under up gradation to S.D.H

4. Sub Divisional Hospitals:

5.District Hospital:

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6. First Referral Units:

Begusarai District:

Health Infrastructure of the districts

Type of Facilities Begusarai Kishanganj

District Hospital 1 1

Referral Hospital including SDH

3 1

Primary Health Center (PHC)

18 7

Additional Primary Health Center (APHC)

22 44

Health Sub Center 288 259

Blood Bank 1 1

Blood storage units 2 1

Anganwadi Center (AWC)

2308 1295

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Gap in Infrastructure: Begusarai

Observation:

Pace of civil works is slow in the district No dedicated infrastructure and finance wing is established in the district Newly constructed OPD at DH Begusarai working well with blood bank, USG,(PPP) and

free diet District does not include a plan for infrastructure; there is no prioritization of construction

of infrastructure based on backward areas, land availability and need where in those areas where services are being provided and high caseloads.

Two SDH designated in Ballia and Manjhaul, construction underway, but currently functioning as PHC.

24x7 electricity ensured by using generators Electricity and running water facility is completely missing at HSC level Adequate Telephone and internet facilities up to BPHC level All facilities readily accessible by good roads except Samhoo block Facilities expanded incrementally often on existing buildings requiring frequent repairs,

this is a constraint to planning to meet IPHS No ICU and SNCU in the district Nutritional Rehabilitations is not present in the district Due to lack of storage space, the procured drugs were found to be kept at the corridor of

the district hospital Begusarai.

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Limitation of land availability for APHC and SC Many APHCs functioning in HSC building Dentist in position in many facilities but no dental chair No accommodation and sitting arrangements for patient attendants or ASHA in the IPD Delays in handover of newly constructed/ renovated building Lack of engagement with demolition committee at district Residential accommodation is a major constraint in delivering quality health care services

at all level. APHC Phulwaria functioning for the last three years in old building but more than 80%

of the building was occupied by the Police Station officials. In the district some of the APHC is situated in the building of HSC eg. APHC

Banwaripur Sitting arrangements for patient attendants and ASHAs were not available in the IPDs Construction quality were found very poor in the referral hospital Manjhaul likely to fall

any time, inspite of sanctioned bed strength of 30 but the actual numbers of beds were only 10.

Kishanganj District:

In Kishanganj, although funding was adequate, (from sources beyond NRHM, the MSDP and Sam Vikas Yojana, Damien Foundation) the creation and maintenance of infrastructure remains a challenge and affects access and quality of services. Till 2010 funds have been received from NRHM, and diagnostic centers built but not yet utilized. There has been some building work and renovations. Some construction has been undertaken using funds from MSDP.

Given the delays and constraints in creating new infrastructure, the district has opted to renovate old structures, demolish parts of older buildings and construct thereon. Thus they are not able to meet IPHS standards. Although the district does include a plan for infrastructure, there is no prioritization of construction of infrastructure based on backward areas, land availability and need where in those areas where services are being provided and high caseloads. There needs to be a dedicated infrastructure team. Land is available upto the PHC, at the level of the APHC and SC, land availability is not so easy. Part of the problem is that there are no human resources to provide support to the DHS to develop such plans nor is there an agency to execute such plans as exist. Despite this the nine facilities that currently provide institutional deliveries and other services.

Several of the HSC visited although complete in terms of concrete structures did not have the finishing touches- latches, minor works are pending, but this affects that the functionality of the HSC. Handover of facilities is delayed; resulting in unfinished works which affects the services being provided at the facility. HSC Kamati, Gamariya, Water and electricity have not been provided in several sites. A case in point is Pothia, There has been no building construction after 2010.

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There are no residential quarters almost anywhere, although there is sufficient space. Even where very few staff have got residential quarters, they are in a dilapidated condition.

HSC buildings mostly completed but are not yet in a shape from which the services can be provided. In some others, there is a building to run the outreach activity, but no residential facility.

Infrastructure planning: Damlwadi APHC and HSC run from the same renovated facility, testifying lack of planning.

The district has not yet approached the demolition committee of the PWD to undertake demolition of old structures.

Despite the large caseloads in the nine facilities there are no arrangements for patient attendants or for ASHA leading to overcrowding in the wards.

Water supply in all PHCs is through tube wells and overhead tanks. In occasional HSC there are hand pumps but many that the teams visited had no running water supply. Water chlorination was not being conducted in the facilities visited. There is no provision for testing for residual chlorine in drinking water in the health facility. The PHED was not able to meet the team.

There is regular electric supply in all PHCs except in Theragacch, where even the ILR is run on a generator but ensured for 24 hours. In Pothia and Bahadurgunj the electric supply is through the regular supply for eight to nine years. In sum all facilities at the level of PHC and above have ensured 24 hour supply.

Telephone and internet connectivity in all facilities is adequate. All PHCS are readily accessible by good roads, except Teragachch and its sub center, where road access is difficult.

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2. Health and Human Resources

i. Availability of Human Resources and Gap analysis

.Regular Doctors 2519/4867

Contractual Doctors 1632/2375

AYUSH Doctors 1385/1694

Specialist 197/604

Nurse Grade A (Contractual) 1476/3395

Regular Nurse Grade A 440/1004

ANM-R (Contractual) 7521/11433

Regular ANM 9676/11808

Regular LHV 497/1171

MPW (Regular) 808/1700

Lab. Tech 331/680

OT Assistant 67/122

Physiotherapist/Occupational Therapist in process/132

Epidemiologist 22/38

KTS Supervisor 163/183

VBD Consultant 20/31

Senior DOTS cum TB-HIV Supervisor 38

ASHA 80967/87135

MAMTA 4174/4434

Para Medical Ophthalmic Assistants : 20/20

Eye Surgeons : 3/10

Dental Surgeons

The overall availability of human resources is shown in Table 1. While the position has improved considerably since 2005, on account of hiring of contractual staff, and beginning to implement progressive HR policies, there is still substantial ground to cover. Several policies are still in the formulation phase and some have been rolled out. The state has been able to meet the HR gap in districts where there is easy access, good living conditions, and economic prosperity. The challenge in hard to reach, poorer districts is the next frontier where the state has to break new ground.

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In terms of overall distribution there is still much to be concerned about. Difficult living conditions in some areas, are certainly an issue, since in Begusarai district, the shortages are less acute. In Begusarai district, there are few vacancies among ANMS with some HSC even having two ANMs. OF 8858 HSCs, in the state, 3640 have two ANMs, and 138 have more three or more ANMs. Only 254 of the 8858 HSCs have Male health workers. Of all 38 districts, there is only one district in which the state reports demonstrate that there are no HSC without ANM. In Begusarai, it appeared that the second ANM was serving more as an aide to the first ANM. On the whole the number of no ANMs or single ANMs in the HSC is higher in the poorer performing districts. The number of HSC without ANMs ranges from one in Sheikhpura to 143 in Purnea. In hard to reach areas such as Kishanganj district, there are high vacancies. The staff shortages span not just doctors, but also paramedicals and managerial staff. Thus for example the gap in Kishanganj is as follows: Specialists: (75%), Doctors (regular): (66%) , , contractual doctors (31%), ANMs (rural) (25%): and, ANMs (contractual): (78%), Grade A nurses (56%). This cannot all be attributed to infrastructure shortages. Adjacent Purnea district has a better availability of doctors and specialists. One of the reasons that has been postulated is that because the doctors are allowed private practice. In Kishnaganj with high levels of poverty, the possibility of private practice is limited. Part of the problem with staff shortages is also due to delays in the recruitment policies. Despite the decentralization of recruitment of certain categories of staff, the districts have not yet been able to put in place the required numbers. Reasons are: the delayed approval of reservation rosters, difficult living conditions, delays in recruitment (for instance there is little proactive action for campus selection (despite there being an active ANMTC in the Kishanganj district. The faculty reported that over 80% of the last two batches have sought employment in the private sector or do not have jobs). Even within the district, there is no plan for staff rotation- In Kishanganj, 80% of all AYUSH positions are filled and are posted in the APHCs, and in the sub centers. The state has instituted the following measure to recruit, post and retain staff » Walk-in Interviews every Monday (Vacancies advertised on official website) » Online application facility » Re-organizing and Rationalising the existing trained manpower » Power to transfer doctors delegated to Civil Surgeons » AYUSH posted doctors in APHC (and in HSC OPDs under process) » Web enabled system to capture district level cadre information and recruitment » Provision of three dynamic ACP at interval of 6, 12 & 24 years » Cadre rules notified for paramedics and health educator » Revision of pay-scales

» General Duty Medical Officers (from Rs.20,000 to 30,000), » Specialists (from Rs.25,000 to 35,000), » Contract Staff Nurses (from Rs.7500 to 20,000),

» Contract ANMs (Rs.6000 to 12000)

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» Paramedics like Lab. Technician, X-ray Technician, OT Assistant) from Rs.4000 to 6500)

» Dentist at PHC – From 2 days to 6 days and finally to be appointed on contract at Rs.30,000 pm for general and Rs.35,000 pm for specialists

» Rational deployment of LSAS and EmOC trained medical doctors is being ensured esp. in FRUs to operationalise FRUs and for optimal utilization of HR. Similarly SNCUs and NBCCs are being made functional with deployment of nurses trained in newborn care

» IT enabled HR database being created for medical and non medical staff. » Cadre Review for Medical and Non-Medical Technical Staff » Campus selection for MBBS students in last quarter of internship- 210 selected so

far. In terms of support staff in the wards, outsourcing services has been beneficial. The district has outsourced services but payment is centralized and thus the block does not have direct authority over the agency, affecting the quality of services. In remote areas, such as Teragachch, private agencies are unwilling to undertake the task.

(ii) Pre-service Training capacity

There is a purposive effort to build in service training capacity by expanding the numbers of medical colleges and nursing schools in the state. This is a long term effort and a good beginning has been made. Sustaining and building on this effort requires undiluted attention.

Substantial initiatives have been taken in reviving state run ANM training schools. The state has There are also private nursing colleges that could potentially add to the pool. In the public sector, the shortage in nursing faculty is being addressed by recruiting faculty from outside the state. There is currently an approximate student capacity of 1455 in 21 ANM schools and 376 in GNM schools. The present medical college intake of 600 students is being revised to …. The state also has … private medical colleges. High capitation fees are a deterrent to aspirants from poorer families, but the recent court decision on setting ceilings on capitation fees may make medical careers more accessible to such candidates. Four ANM colleges and Four GNM colleges have been prosped and ..new medical colleges.

Category Institutions and Annual Intake capacity

Govt. (Sept 2011)

Govt. (added during Mission Period) Private (Sept 2011)

Private if any - (added during Mission Period)

No Intake No Intake No Intake No Intake

ANM 21 1490 34 1740

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Schools

LHV Schools

GNM Schools

6 376 5

MPHW Schools

Post Basic B.Sc (Nursing)- College

2 40

B.Sc. (Nursing)- College

2 40

M.Sc. (Nursing)-College

The state has initiated several measures to augment pre service training capacity. A sum of Rs. Two lakhs has been allocated to each GNM & ANM schools in the state for up-gradation. Active faculty recruitment is underway. The training cell of the SHSB has submitted a proposal to strengthen the RHFWTC, Patna to undertake a range of training programmes. SHSB has also taken steps to strengthen the SIHFW, Patna for starting Health Management Course for Public Health professionals, and has actively sought proposals from PHFI and IIHMR. Both Kishanganj and Begusarai district have effectively revived the ANMTC. In the Kishanganj ANMTC, so far one batch of 19 has graduated, and another batch of 31 will pass out early next year. This year‟s batch has 44 candidates. Student enthusiasm needs to be matched with improvements in physical conditions and teaching quality. There is a shortage of faculty and the school itself needs renovation and some additional space to create a skill lab. There appears to be a shortage of teaching learning material. Hostel facilities also need expansion and up-gradation. Currently there are six students to a room. In Begusarai, the Faculty are in place, with anatomical models and a demonstration lab.

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(iii) Plan for Augmentation of Health Human Resources

The state is contemplating active measures to augment the existing human resources. As has been discussed earlier, the state plans to establish medical colleges, and at least one ANM or GNM training school in every district. So far the state graduates 600 medical students every year, through nine medical colleges and a major expansion is planned. These are as yet in the pipeline. The state has partnerships with private sector institutions for training. One Nursing school has been added during this period. (Any ANMTCs?? The present capacity is approximately 1455 student in 21 ANM schools and 376 in GNM schools. In Kishanganj, ANMs provide significant levels of OP, delivery and FP services. The state has entered into private sector partnerships in Kishanganj for enhancing training and service delivery – Janani, MG Medical College

iv. Building Skills In Available Health Human Resources

A annual training calendar for skill upgradation is developed at the state level and sent to the districts. Training does not always according to plan. Reasons appear to be on account of local issues (festivals, elections), and due to non or delayed release of funds. It appears that there is no shortage of training venues. There is a high reliance on existing officers (DIO, CS, DPM) to serve as trainers. Lack of a dedicated training cadre is likely to impact the pace and quality of training.

One innovation that the state can be justifiably proud of is the skill lab that has been set up in the Guru Gobind Singh Hospital in Patna city. Plans to establish such skill labs in four more districts namely Vaishali, Bhagalpur, Purnea and Darbhanga are underway, and the labs are expected to be functional in 20 days time. No skill labs are in existence in either place or planned in Kishanganj and Begusarai. The skill lab established in the Guru Gobind Singh Hospital needs to be scaled up rapidly across the state, since the team in both districts observed skill deficiencies, particularly among the para medical staff.

The main role of SIHFW is in developing the Master Trainers for SBA trainings. SIHFW is also responsible for organizing different types of trainings on continuous basis. There appears to be a team for assessment and follow-up of various trainings such as SBA, LSAS, and EMOC. The team is expected to regularly visit the districts to mentor the trainees. The RHFWTC conducts a range of trainings but there are few nominees from Bihar. The pace of training is slow, although it is picking up. Given the large numbers to be trained, the pace will need to be quickened significantly to enable any observable changes in coverage and quality of service delivery. . For F-IMNCI, of a target of 77 doctors in 10-11, about 44 were trained. This year of a target of 36, only eight have been trained. In trainign ANM in IMNCI however, the coverage has been better, - in 09-10 the state trained 427 out of 940, but in 10-11,

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863 of 940 were trained. In SBA training, 0f the total of 16901 ANMs/Staff Nurses, only 2320 were trained from 09-11. This fiscal year however, there is a small but steady increase in numbers. In 18 of 38 districts no SBA training has been undertaken. For MTP training, of a target of 240 MOs last year, 212 were trained. 49 MOs have been trained this year. The higher achievement in MTP appears to the additional training capacity provided by agencies such as IPAS which are focused on expanding access to safe abortion services. The higher achievement of MTP training also demonstrates that there is also the likelihood of realization of targets when there is a dedicated training agency and trainers. IUCD training is focused on ANMs with 577 being trained so far. Anecdotal evidence from Kishnaganj demonstrates that IUCD as a method of contraception is gaining acceptance. It is often the lack of space or training that limits the provision of this service at the HSC level, thus putting this method of choice out of the reach of women. In areas such as BEmONC, CEmONC, and LSAS, the numbers trained are low. Observation of ANM skills in the field attest to the need for training in skill building. While the BP apparatus was available few ANMs were able to take the blood pressure. AYUSH doctors have been oriented to NRHM, and trained in IMNCI, HMIS, and family planning. (numbers) The state also enables nursing staff and nursing faculty to participate in conferences, workshops, seminars at the state, national and international levels. This year 33 nurses were selected and sponsored by SHSB for the post-basic nursing course at Noida and Dehradun. Doctors have also been are sponsored for the PGDFM course at CMC Vellore and the PGDPHM course from IIPH, Delhi every year.

3. Health care service delivery- facility based- quantity and quality.

Table: State Level data

Total Annual OPD in the State

Percentage increase of OPD over previous year

Total annual In-Patient admissions in the State

Percentage increase of IPD over previous year

2005-06 - - - -

2006-07 105.44 lakhs - - -

2007-08 152.90 lakhs 45.01% 7.98 lakhs -

2008-09 159.51 lakhs 04.32% 14.01 lakhs 75.56%

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2009-10 296 lakhs 85.56% 20.37 lakhs 45.39%

2010-11 407.37 lakhs 37.50% 24 lakhs 17.82%

(Please note that all these findings pertain to Kishanganj. Please insert those pertaining to Begusarai and any addl. Findings for Kishanganj). The increases seen in the state were also seen in the districts visited. (Annexure 2 has facility wise data for OPD, IPD, FP, RI, ID and C-sections in Kishanganj district. Pothia PHC, handles more than the district hospital, likely because the staff are resident, and because there are no private facilities in the area. Annexure 1 also provides the bed strength, bed occupancy rates, and HR status. There is no ICU in either district. The quality of the OT in Begusarai needs improvement. , Table 2: Status of staff and services

No of subcentres with Second ANM 3640

No. of sub-centres with MPW 254

No. of PHCs with 3 Staff Nurses 281

No of CHCs with 9 Staff Nurses

% of 24x7 facilities where 24X7 lab services are available 33% (209/641)

No of facilities providing safe abortion services In process

No of RTI/ STI Clinics in State 42

Bed Occupancy Rate 62

The state has entered into PPP arrangements for provision of laboratory services. Routine blood and urine, tests for malaria and AfB, and ICTC. The lab services in Kishanganj are both free and costed. In Begusarai district, it was apparent that asepsis and quality protocols were not being adhered to. In the DH, Begusarai, only the most basic investigations were available. There were Lab techs in place in Kishanganj. (more in section on NVBDCP). In Kishanganj there was a semi autoanalyser only in the DH. The supply of reagents supply is erratic, but no effort is being made to use RKS funds to procure this.

Drugs are available in all facilities visited in Kishanganj, although there were complaints of stock-outs a few weeks ago. Kit A and Kit B have not yet reached sub centers. In some facilities cases the drugs listed in the essential drug list were not available. Drug inventory management systems were not in place in any facility, including tracking of expiry drugs. HSC ANMs saw on a average at least ten outpatients per clinic day. A review of the records and interviews demonstrate that the ANSM need training in rational drug use. Doctors and ANMs need training in the use of standard treatment protocols. In Begusarai district drugs were stored

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in one of the wards which had been converted into a store room. There were no reports of out of pocket expenses incurred on drugs from the beneficiaries that the team met.

Outsourcing of housekeeping, laundry and diet is working well and the overall impression of the DH and PHCs is one of relatively clean facilities. . However the contracts and payments are made from the district level, leaving the blocks with little monitoring authority. Diet is being supplied to all, tasted by team, and was found to be of good quality and taste.

Transport is an issue- ambulances are available in eight of the nine facilities, and at the DH. There is one private ambulance (102) and one 108. This service is not provided free of cost except to those that are able to demonstrate that they are BPL and produce a BPL card. Just being on the BPL list is not sufficient. Transport for pregnant women is free but only upto the first facility. In case of onward referral they are required to pay. Generally patients pay the transporter for a drop back facility.

Infection control procedures are generally in place,(such as three coloured dustbins), and disposal pits – however the biomedical waste management need to be instituted soon. The service guarantee lists are displayed on most facilities including HSC, visited by the team. Issues of privacy were generally well considered- separate toilets for women, curtains, etc were in place in all facilities visited. The state has instituted the following for grievance redressal:

– Call 1911 – Online Grievance Redressal Form – SMS # 9711981981

• A Grievance box is expected to be provided in health facilities under the responsibility of Medical Officer In-Charge.

In Kishanganj, although phone numbers of key service providers are displayed, the CMO is the de facto nodal officer for grievance redressal.

The RKS has been set up at all levels. In the DH meetings the RKS meetings take place, and members have been drawn from PRI, NGOs, beneficiaries. At least one third of the representatives are women. There is an increasing confidence in making expenditures although more systematic planning and comprehensive understanding of possible investments of RKS funds. The fund inflow is from blood banks, OPD registration, ambulance. Most expenditure is on repair and maintenance, have appointed a plumber and electrician for services to the DH. Audits of RKS are not taking place at any level. RKS at APHC have been formed, and accounts have been opened, but members need orientation. An evaluation of the RKS is required at this stage to understanding key constraints in operation and enabling more effective use of the funds.

There are no accreditation or quality improvement processes being undertaken in Kishanganj district .

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A more enhanced system of record maintenance has begun but is still in its infancy. Referral registers are not being maintained. Delivery registers well maintained, but there are no records of complications.

Infrastructure As on 01.04.2005

As on 31.03.2011

Blood Storage Units 0 09

Blood Banks 21 28

SNCUs 0 9

NBSU 0

0(40 NBSU Planned in 2011-12)

NBCC 0 452 ASHA Ghars 0 0 (Proposed)

Total Number of Beds - 11271

Bed population Ratio (No. of beds per thousand population)

- 0.108/1000

4. Outreach services

A majority of the HSC in Kishangnaj district cover a population greater than 10,000, essentially covering the work of four ANMs. Where accommodation is available (as in Maheshbathna and Natwapada) the ANM is resident. The ANMs provide out patient services thrice a week, conduct VHSND in their coverage areas, and in some cases they also provide back up the PHC in which are deliveries are taking place. They also are required to attend a weekly meeting on Tuesdays. In Begusarai, there are two ANMs in the HSC. Untied funds to the sub centers were reported by ANMs in both districts. In Mahesh bethna HSC in Kishnanganj block, the ANM conducts upto 63 deliveries a month. Microplanning for the immunization sessions is taking place in Kishanganj. The ANM is also involved in pulse polio programme and Vitamin A prophylaxis. Of the total of 14, 520 sessions to be held, for the year 11-12, (mid year point) 5698 have been held as of October 31, 2011. The major services provided at the VHND include: immunization of mothers and children, weighing of the mother, taking the BP of pregnant mothers (in some sub centers in Kishanganj), Vitamin A for the children and dispensing IFA. In most cases there is no space to conduct

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antenatal checkup, HB and urine is not examined and the ANM does not have a Hb meter, or reagent for urine exam or dipsticks. Similar findings were observed in Begusarai. Route chart of MMU was made for the month, and this provides services in remote villages. (need state data on MMU)

5. ASHA Programme:

Outputs so far:

(i) Selection and Training of ASHA: The state has a target of 87,135 ASHA (based on a one per 1000 population norm, as of Census 2011). So far 80, 967 (93%) ASHAs have been selected. Status of training is as follows:

Module 1: 69,402 (86%) Module 2, 3 and 4: (integrated): 52,859 (65%).

(ii) Training Institutions: In October 2011, the state signed a tripartite MOU with four

state level agencies to train a team of ASHA trainers in each district. The state has identified 18 district training organizations to undertake the training of the ASHA. The MOUs have yet to be signed.

(iii) Programme Support Structures: The State ASHA Resource Center (SARC) was

established in 2010, and registered as a separate society, with a sanctioned staff of seven, against which only three were appointed. Currently there is a team leader and one consultant in the ARC. In 2010, NHSRC facilitated the recruitment of the District Community Mobilisers, (DCM) Block Community Mobilisers, (BCM) and District Data Assistants.(DDA). Current status is as follows:

Required Selected (2010) In place (October

2011) DCM 38 37 23 DDA 38 38 30 BCM 534 497 404

The selection of ASHA facilitators has recently been initiated and 3137 of 4150 ASHA facilitators have been appointed. Recruitment of the remaining is underway. The state is selecting the ASHA facilitators from among the ASHAs themselves.

(iv) Other support mechanisms: The ASHA receive incentives for JSY, VHND, RNTCP,

for family planning and for Kala Azar. They are also compensated for participation

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in the monthly ASHA Diwas. They have been provided with saris, umbrella, and a drug kit with a one time drug supply. A monthly meeting for all ASHAs (ASHA Diwas) is conducted at the block level. The two modules have been distributed to the ASHA at the time of training.

(v) The state has printed 22,000 copies of Modules 6 and 7, and plans to print the rest as soon as the training is initiated. There are no communication or equipment kits, and the sate has no plans for issuing tenders, despite the fact that lists and prototypes were supplied to them in June this year.

Observations: These observations are based on the visits of the CRM team to the districts of Begusarai (better performing) and Kishanganj (poor performing). .

In the three – four years since the ASHAs have been appointed, they have acquired both visibility and stature. In both districts the ASHAs have credibility in the community and are seen as a resource that has close links with the health system. She is viewed by the ANM as a valuable outreach arm. Where the ANM has a population of over 10,000 to cover, this function enables children and mothers from marginalized communities to reach the VHND and other services. The ASHAs role as a facilitator of services is firmly established.

Most of the ASHA met were enthusiastic about their work and seem to spend about two to three hours doing the rounds of the village and in the case of the HSC village and nearby villages, being in the sub center. Some ASHA demanded more training and skills. Only a few ASAH asked if they would be regularized in government jobs.

The ASHA conduct home visits for mothers and newborns, consistently for institutional deliveries, less so for home deliveries. The primary function is to enquire after the health of the mother and newborn and in case of any complications, refer them to the PHC. While escort to the institution was seen quite commonly, escort in cases of sick newborns, children or post partum mothers is not reported. Even the ASHA reported that they are not able to reach marginalized households because of distance, and socio cultural barriers. .

The ASHA, the ANM and AWW appear to enjoy good rapport and the teams did not hear any reports of conflicts. Part of this is due to the fact that the incentives are clearly divided. Part of it also has to do with the fact that the ANM is highly reliant on the ASHA and less so on the AWW for providing information o pregnancies, children for whom immunization is due, and for those women who are willing to accept family planning, mostly terminal methods. In Kishanganj, IUCD is gaining credence and ASHA also seem to be referring such cases to the ANM. The JSY incentive is firmly that of the ASHA, the FP for the ANM (in some instances the ASHA also gets it). The AWW also gets an incentive of Rs, 100 per VHND

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However the ASHA is not equipped with the skills to undertake social mobilization and/or service provision. The ASHA have not received any training inputs for over 18 months. The nodal agency that was nominated for training in 2007 was PRANJAL, but no training has been held for over 18 months Last year 22 state trainers were trained at the national training sites in Modules 5, 6 and 7. While the State training agencies have been selected, funds are yet to be released. District training agencies have been identified, but no formal arrangements have been made as yet. One agency the Infrastructure Leasing and Finance Corporation (ILFS) has been given responsibility for 19 districts, although there is little evidence of grassroots presence.

The state has provided a drug kit, two sarees, and an umbrella for the ASHAs, which the team was able to see. Drug kits were given once, but not replenished. In Kishanganj district only two blocks had a Block Community Mobiliser of whom one is on leave. Thus there is only one mobilizer in the seven blocks and no district community mobilizer. There is a high turnover in this cadre. The ASHA Diwas meetings are held once a month at the level of the Block PHC. Since each block has over 200 ASHA, and even if 50% of them attend there is little space for any discussion beyond a lecture by the Medical Officer in charge. One ASHA said: Prabhari meeting lehe hain, aur who hame bathathe hain kya karma hain, kaise karma hai, hamari sunwai tho hoti nahin”. Another ASHA said that while she was happy doing her work, “aur trainign milege tho hum jyada kush kar sakte hain” . The ASHA does not conduct village level meetings, she does do home visits.

Two of the twelve ASHAs we met were non literate but were able to perform the functions that her counterparts did and were just as active and informed.

Data base of ASHA was being maintained at block levels, bank accounts have been opened, for most, and payments have been streamlined, as per state guidelines. We heard no complaints of non payments, but there were reports of delayed payments (upto three months). The data base needs updating

There is some attrition but the significant part seems to be on account of notification of “urban” areas. ASHAs in these newly notified areas are dropped from the programme. The state has not yet been able to find a solution tot his, and despite letters to the MOHFW has not heard back.

The ASHA were not aware of the VHSNC, and do not conduct village level meetings. In Kishanganj district there were hardly any community based organizations and so there were few groups with whom the ASHA could forge relationships. There is no NGO involvement in either district.

Conclusions: The ASHA programme in the state is an “orphan” programme. The support structures have not been able to reach the ASHAs to enable them to function more effectively. The lack of training inputs and reach is clearly visible- the ASHA are seeing themselves as agents of the system, and relate far less to the community. Unless the state activates the training

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programme and revitalizes the support structures rapidly, the potential of the ASHA will not be realized.

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6. RCH II (Maternal Health, Child Health & Family Planning Activities)

There are 143 private accredited centers for provision of family planning centers, none have been accredited as yet to provide safe delivery or safe abortion services.

Findings for Kishangani:

Antenatal care: Rise in 3 ANC has risen according to both DLHS and HMIS. High ANC registration (70% IN 2009/10 according to MIS) but full ANC only 29% at DLHS-3. Services were available in facilities seen, sub-centres had IFA. However outreach services through VHNDs were not equipped to provide ANC, with no haemoglobin or urine testing. Asha is in some cases helping to mobilize for ANC but more follow up needed to ensure 3 ANC checks. This could be part of Asha support.

Micro-birth plans: This did not seem to be happening in any of the communities visited. Decisions on care seeking for delivery were made on the basis of distance, cost, and perceptions of quality of care in public facilities.

Institutional delivery: Institutional deliveries rose from 10 to 18% between DLHS 2 and DLHS 3. According to MIS data it rose still further to around 37% in 2009/10, though this data needs to be further validated. In any case, over 60% of deliveries by any measure are occurring at home. APHCs and sub-centres are mostly not able to provide institutional delivery. Only one sub-centre is able to provide, although the caseload here is quite high (60 deliveries a month).

Partograph: Although some effort has been made to roll this out, with charts visible in most delivery rooms, implementation was patchy. Some centres were filling in the partograph but most were not. ANMs at sub-centres providing delivery were not fully trained on filling the partograph.

48 hour stay: On the while women are staying around 24 hours post delivery. PHCs, with new infrastructure made in the last years have greater capacity to provide institutional delivery but are still stretched, especially if a 48 hr post delivery stay were to be ensured. This could be because Food is provided but room for stay for family members and Asha workers not ensured. Delays in JSY payments mean that this is not acting as an incentive for 48 hour stay.

Essential newborn care/safe newborn corners: PHCs have recently been provided with some newborn care equipment, including baby warmers and phototherapy units, though it was not clear these were being used. Staff have been trained at the Sadar district hospital. APHCs and sub-centres have no newborn corner.

Postnatal follow-up: This seemed to be a gap. The ANM does not have time for postnatal visits due to other work including the VHND. Instead postnatal visits are made

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by the Asha, but she is mainly not clear on what to ask and check for during these visits. Although there is an incentive payment for postnatal visits, this does not seem to be being provided.

Family planning services: The team saw examples of strengthened implementation of family planning. PHCs were providing fixed day services for tubectomy. There is also a growing acceptance of IUD, with ANMs aware and referring women for IUD services at the PHC. Emergency contraception pills were available in sub-centres, although knowledge of NMAs on emergency contraception was weak (i.e. when to take EC). A PPP with Janani was providing a range of FP services, though uptake of methods such as injectable contraceptives was low. In many communities visited family size of 4-6 was common, and there seem to be particular cultural barriers to improving birth spacing or limiting. More outreach and behaviour change, enlisting the religious and community leaders, is required.

MTP: Other than the (private) medical college, and the Janani PPP clinic, no facilities were providing MTP. At Janani, MTPs were only provided to acceptors of sterilization or IUD.

Are ASHAs creating demand for RCH services: To some extent the Asha is helping to mobilize demand for some services, but only those which have been incentivised (institutional delivery, sterilization). In some of the marginalized communities visited, lack of knowledge or distrust of public services has created a barrier to demand which the ASHA finds it hard to overcome. ASHA monitoring and support structures are very week. Monthly meetings are held, but not all ASHAs attend, and these mainly focus on institutional delivery. Quality of care is seen as a major barrier by some communities, who complained of poor services and attitudes on the part of clinical staff. MOICs could be given more orientation and sensitization on aspects of quality of care.

JSY: There seemed to be a near uniform delays in JSY payments, usually of around 1-2 months. It was difficult to find the precise reasons for this – in some PHCs it did not seem to be related to lack of funds or cheque books. Rather there seems to be a lack of commitment in the system to make the payments more regular. A regular „catch-up‟ day for payments could help to reduce the delays being experienced. Informal payments seemed to be a regular feature in many facilities, mainly for transport (around 500 rupees was common). Cross checking of JSY beneficiaries was not being made.

MCH centres: There is a document which the team was shown which had an identification of facilities by MCH levels 1,2 and 3. However, this does not seem to have been internalized at the district level, nor is it used for planning for service upgradation and service quality improvements. For example, although the district – like the state – has made strong efforts to operationalise the block PHC facility, there has not been an identification of which block PHCs would be prioritised for provision of emergency obstetric care including caesarian section.

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Maternal death review: This is currently not being done. There is a budget for maternal death review in the allocations to PHCs. However no PHC visited had plans to implement this. A guideline has been issued from the state level and a district committee has been established, but there remains an implementation gap.

Private facilities: The team visited a facility run by the Janani social marketing network. This was providing mini-lap services, as well as MTP and othe forms of family planning. There were half a dozen women staying overnight at the time the team visited, waiting for sterilization services the next day. The facility is being reimbursed by the public sector for sterilization services. The motivator is paid Rs. 400, and for women who are self referred Rs. 200 is paid. No wage loss compensation is paid to the women. Janani charges Rs. 500 for MTPs conducted in the center. The center is a busy one (fill in numbers)

Adolescent health: No implementation of specific services for adolescents, or of adolescent friendly health services.

School Health Programme: The school health programme has been closed from 31 March 2011. In its place a new scheme – the Nayee Pidhi Swasthya Guarantee Karyakram – to provide health screening of all children from 0-14 years and of adolescent girls from 14 and 18 years. The team visited a school where children did have health cards under the scheme. However, the cards were not filled out properly and many girls had been given the wrong card. The school teacher was not clear on all details of the scheme.

Role and functioning of the quality assurance committees: The quality assurance committee has not been established. Although the team saw plenty of examples of frontline staff providing exceptional effort in difficult circumstances, there remain many quality improvements that could help communities to have more acceptance of public facilities.

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7. Preventive & Promotive health services including Nutrition and Inter-Sectoral

Convergence.

Institutional mechanisms for inter-sectoral convergence under the NRHM were established with representation from departments of social welfare (nutrition) and public health engineering (water and sanitation) at the state and district level bodies. The team observed functional coordination between the ANM, ASHA and the AWWs at the community level mainly in the areas of routine immunization, polio and biannual Vitamin A supplementation rounds. Day to day coordination between the managerial staff of NRHM and ICDS at the block and district levels seems to be a missing link. This may be the case with the PHED too. Convergence appears to be most effective at the community level between AWW and ANM/ ASHA. However, it is important to strengthen the same at other levels to ensure coordination among frontline workers could be optimized for advancing health interventions beyond routine immunization and polio in a sustained manner. . Although NFHS 3 found fewer children in Bihar to be stunted than NFHS 2, (percentage of children under three years, below 2 standard-deviations for height for age declined from 58.4 percent to 50.1 percent), the wasting has increased substantially between the same surveys (percentage of children under three years, below 2 standard-deviations for weight for height increased from 25.4 to 32.6 percent). The weight for age for children under 3 has remained more or less constant between NFHS 2 and 3 (with about 55 percent of children less than 2 SD and a quarter of children less than 3 SD). Infant and young child feeding behaviors substantially contribute to this picture of under nutrition, wasting and stunting: pre-lacteal feeds and delayed feeding (by at least one hour) are almost universal at 91% and 96% respectively and about a third of infants less than six months are fed exclusively breast milk. Complementary feeding is also poor, with about 58 percent of infants receiving complementary foods at six months, and only about a quarter of children eating optimally. The quantity, frequency, variety of food groups as well as energy density of complimentary foods needs to be improved significantly. The percentage of children (6 to 35 months) with moderate level of anemia has also increased from 49.7 to 59 between NFHS 2 and 3. During the same survey only about 6.4 percent of children (6 to 35 months age) were found to have consumed iron-rich foods in 24 hours prior to the survey. Nearly half the children in the same age group were found to have consumed foods-rich in Vitamin A and the biannual Vitamin A supplementation in the state has been recording very high coverage against the estimated targets among children under 5 years of age. Nearly 66 percent of households covered in NFHS 3 were found to be using iodized salt with very high disparity between rural/ urban and wealth quintiles.

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These trends in poor nutrition persist into adulthood as shown in NFHS 3 data. Nearly half of the rural women in Bihar fall in the category of being thin (Body Mass Index of less than 18.5 kg/m2) and about 20 percent are in the category of moderately or severely thin (BMI less than 17kg/m2). Nearly half of the ever-married women in 15-49 age group have a prevalence of mild anemia (Hemoglobin 10 to 11.9 g/dl) and this has worsened since NFHS 2. Moderate anemia (Hemoglobin 7 to 9.9 g/dl) has remained stagnant at 16.5 percent between NFHS 2 and 3. While most of the above observations pertain to the state of Bihar, the field interactions and DLHS 3 data indicate similar situation in Kishanganj district. Some observations include: Early initiation of Breast Feeding: With JSY there have been significant increases in this indicator. Our interactions with Mamtas indicate that they ensure initiation of breast feeding for all institutional deliveries and proportion of deliveries are increasing in Kishanganj (HMIS data shows XX% of newborns born in institutions were initiated breastfeeding within one hour). Mamtas were present in all PHCs visited. Their communication skills can be sharpened through structured trainings and communication tools.

Feeding behaviors: As reported by the mothers, exclusive breastfeeding was practiced upto six months. In some cases the team observed exclusive breastfeeding beyond six months. Pregnant women and mothers of young infants mentioned that they didn‟t receive any information from AWWs or other frontline workers about infant feeding practices. There is an urgent need to improve focus of AWWs and ASHAs on quantity and frequency of complementary feeding. There are no systems in place for planning and executing home visits by AWWs. It appears to be an area that is not focused during the supervisory visits.

Supplementary feeding program of ICDS: Supplies for supplementary feeding program were found at all AWCs visited. Cooking and feeding of children (3-6 years) were observed on both the working days. Conflict among community members due to norms around capping on number of beneficiaries to be covered was reported in all AWCs visited in Kishanganj. With the continuation of the capping the number of beneficiaries for food supplementation leveraging ICDS platform for universal reach of health services appears a challenge.

Coverage of population: AWWs s reported that there has been a recent delimitation of their areas, and they were concerned that this leaves out a substantial number of households. This was evident from the fact that were a number of households and few habitations not reflected in the in the survey register of AWWs and the workers are aware of this issue. Except for pulse polio and routine immunization sessions (by ANMs only) services don‟t appear to reach all women and children

Identification and management of severely malnourished: In Kishanganj, only one out of six AWWs visited reported having two different weighing scales in working condition (Badapaka

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mana of Mirajpur sub-center in Pothia block). Nutrition Rehabilitation Centre was reported to be the main a strategy for managing severely malnourished in the district. However, the implementation of NRC strategy appears to be more like a service provision scheme than a need based response.

No salt testing kits found at the VHSND visited. However, the medical officer Incharge informed that the salt testing happens twice a year (probably as part of the bi-annual Vitamin A rounds).

NGO involvement: An NGO was involved in managing nutrition rehabilitation center (NRC) at the district hospital. Other than this one example, there doesn‟t seem to be engagement of NGOs in the district. .

The NRC was functional in the district hospital in Kishanganj. NRC was found in the district hospital. 40 children were receiving services. NGO is managing the NRC and all mothers at the NRC expressed satisfaction with the arrangements. While evidence of linkage with AWCs was found in one of the AWC visited, there is a programming disconnect between the batch-wise admissions at the NRC and management of severely malnourished children. In Begusarai the NRC is just being established.

In one of the AWCs the team was informed that the AWW was asked to take 4 severely malnourished children for admission into the NRC. Two out of the four were found to be severely malnourished but could not be admitted for treatment as the number of admissions was capped at 40 per month and the families were asked to come back after a month. They were given some multi-vitamin syrup, and the mother of one of the children selected mentioned that it will not work for her to stay at NRC for 3 weeks.

The VHSC was renamed as VHNSC and health staff up to block level were aware of it. However, while VHNSCs were constituted in the GP level, very few people were aware of their existence. Due to recent PRI elections there is a turn over of PRI members involved in VHNSCs. In order to enhance the involvement of VHNSCs in NRHM it is important to carry out joint orientations to PRIs with ANM and ASHAs and ensure ongoing communication. Mechanisms for convergence and sharing responsibility in monitoring VHNSC functioning may be useful. The level of convergence in district planning appears to be good. The functionality of convergence with PRIs/ RD can be enhanced significantly jointly with the state RD department.

All the relevant departments are formally part of the state and district level bodies and their representatives attend key decision making forums from time to time. Review of district health plan indicates that there is a need for greater detail in convergent planning. The convergence between ICDS and RCH is at the highest level in the delivery of RI, polio and bi-annual Vitamin A rounds and coordinated plans exist for these components. For implementation of the state initiative of Nayi peedi Swasth Gaurantee scheme there are coordinated plans with the education department.

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In all the villages visited, for the RI sessions the ANMs and ASHAs work closely with the AWWs and they use common due lists. The role of AWWs in mobilizing kids for immunization was limited but they help the ANM for session at the AWC. While none of the community members could recall about the incentives for construction of individual sanitary latrines (under TSC) in one of the village large wall writing about TSC was seen. Many of them expressed interest to have one for their family. 8. Gender issues & PCPNDT The 2011 census data on sex ratio provides disquieting information on the sex ratios at birth (2011: 919 (AHS) and in the age group 0-6 years (2011: 2001: 953, 1991: 942). The sex ratio at birth ranges from 989 in Buxar to 869 in Sitamarhi. Kishangani district has a relatively better sex ratio at 968 ranking sixt best in the state against 954 for Begusarai, which ranks ninth. Sex ratio in the age group 0-4 years is also adverse; likely reflecting discrimination against the female child. At the state level it is 931; both Begusarai and Kishanganj at 948 and 968 respectively rank better than the state average. Overall sex ratio is the highest in Kishanganj at 1056 (against a state average of 950), and this is likely because of the high outmigration of men. This also accounts for a high prevalence of HIV/AIDS in the district. The state has established PC&PNDT Department/ cell that looks into issues of constitution and meetings of the advisory committees at district level. At the state level, the Director in chief/SPO, at the District, the civil Surgeon, and at the Sub-divisional Hospital, the Dy Superintendent are in charge. The number of registered USG centres in the public sector – in the state is 1090, of which the state reports that 48 facilities where PCPNDT is not being implemented. There is no state level data on private sector clinics. The state reports that IEC activities including radio spots have been aired across the state. There is no report of specific local planning and action for the issue. In district Begusarai, no PC-PNDT Committee has been constituted yet. The Civil Surgeon informed that there are 47 machines including one PPP machine in Sadar hospital. However, no registrations have been done yet and neither the Sadar USG or any of the private facilities offering USG services reportedly filling Form F. The Civil Surgeon assured the team that he will ensure that the PC-PNDT committee will be constituted and the process of implementation of the Act will be ensured in the district. In Kishanganj district, the PCPNDT Committee has been constituted and the nodal officer appointed. Twelve clinics have been registered, and Monthly inspections have just begun. One registration was recently cancelled because of non compliance. There is no Form F in place. The budget sanctioned for the committee is Rs. 25000. From the funds available from registration fees and renewal of registration, the committee now has Rs. 33139. There is

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however no district plan for PC PNDT activities. Block level workshops to implement PCPNDT are being conducted. Access to safe delivery and access to family planning services for women have increased. However the focus of the family planning programme is predominantly on women although NSV are being reported from some districts; and the state reports an overall increase in the numbers of NSV performed. Access to safe abortion services in the states is limited. Although the state reports that about 844 medical officers have been trained in MVA, given the lack of rationalizing the postings, there is a mismatch of providers with facilities, especially in the more remote areas. In Kishanganj MTPs are provided at the district hospital and in the Surya Clinic managed by Janani at a cost of Rs. 500. The state has recently initiated a scheme called the Yukti Yojana in order to expand the service delivery centers in the private sector and offer safe abortion services free of cost. The scheme is just being operationalized. The continuing expansion of HSC with ANM enables the provision of a basic service package at that level, which is potentially more accessible to women given the poor mobility. In addition the posting of Mamta in the labour wards, increased attention to issues of privacy and comfort in the female wards, albeit with a focus on the maternity section all indicate improvement in providing gender sensitive services. Despite this however there is a pervasive gender neutrality in programming, service provision and among service providers at all levels. For example, there are high anaemia levels among women but Hb testing was not being done except at the level of block facilities and above; because of the lack of availability of haemoglobinometers. The state does not provide gender disaggregated data on out patient registration making it difficult to comment on whether there in an increase in the numbers of women accessing other services. A review of the ANMs OP registers show that higher numbers of male children are brought for illness management. The state has not yet established ARSH clinics nor outreach interventions for adolescents. Bihar has ten districts under the Menstrual Hygiene scheme. The state has not yet undertaken training of ASHA or printing of manuals and flip books. A workshop was held recently with the district officers to plan for storage and distribution of sanitary napkins which are to reach the state soon. Gender sensitization of programme officers and service providers is urgently needed.

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9. National Disease Control Programmes

A. National Vector Borne Disease Control Programme (NVDCP): Six diseases namely Malaria, Kala-azar, Dengue, Filaria, Japanese Encephalitis (JE) are monitored in the programme.

1. Kala-azar: The state has the country‟s highest burden of Kala Azar with 32 of

the 38 districts having endemic foci. IRS is being done by Hot Spot Selection of the villages having even a single case of Kala-azar since last three years. No plan for Vector Control was available. It has informed that the District PIP including VC Plan will be completed in about two weeks. It was informed that the Kala-azar was at verge of elimination in 2003 (59 cases) and 2004 (47 cases). But the cases have been increased sinc with a peak in 2008 (214). The cases reduced to 128 in 2009 were again increased in 2010 (167) and 2011 (193) probably due to increased surveillance. The VBD consultant is posted at the district. Only two KTSs have been recruited out of 6 sanctioned posts. Further, one KTS is posted at low burden area PHC Teragachchh (<1API) whereas highly burden area Dighalbank (API>3) is without KTS. The incentive for Kala-azar treatment is being paid to the patients @ Rs 50/ day for 30 days but for ASHAs it is paid @ Rs 100/day instead of Rs 200/ day ( Rs 50 for referal case and Rs 150 for completion of treatment).

2. Malaria: National Drug policy on Malaria, 2010 was neither available nor in knowledge of Health system. The presumptive treatment is still continuing in the district. The treatment is given on clinical basis and the effort for lab confirmation is not in practice. A copy of the policy for implementation was downloaded and handed over to the health facility visited and the same was communicated to the district authorities. A balance of 9591 Kg of DDT remains at the district. LLN and Incentives for Malaria is not introduced to the district. Nil BSC were reported in 2007, 2010 & 2011 till date. 135 blood slides in 2008 and 73 in 2009 were reported as collected for Malaria microscopy and none was found positive. It was informed that the district is not prone for Malaria. However during the visit, the different picture was found. 6 cases were found positive for Pf Malaria out of 75 blood slide collected during June to October, 2011 at PHC Teragachchh. MO I/c Bahadurganj informed plenty of positive cases tested outside (PP). 176 suspected malaria cases were treated at PHC with CHQ. Other health facilities also confirmed of suspected malaria cases. ACT is not available at district.

The reagent for Malaria microscopy and RDT was not available at the district government health facility. Central Diagnostic, the agency out sourced by

40

district authorities is charging Rs 60 for microscopy and Rs 200 for RDT. The RDT is not done at site resulting the delayed reporting by 3 days. Ten LTs against 22 sanctioned posts are in position. In addition 6 LTs of ICTC are doing only HIV test and 8 LTs of RNTCP are doing only AFB test. Further there are usually good spacious separate labs. for ICTC and RNTCP, but a small and congested labs for remaining tests including blood slide examination for malaria. None of LT is trained in malarial microscopy or lab diagnosis for VBDS. The district authority was suggested for training for malaria microscopy to all LTs. Sr RD Patana agreed for imparting the same at Patna if proposed by state/ district.

3. Dengue & Chikungunya: No case is reported from the district. The team was

told that No diagnostic centre/ NIV Kits is available at district, however this facilty is available at nearby district Purnia.

4. Japanese Encephalitis: No case is reported from the district. Not reported by the district. The team was told that Diagnostic is available at nearby district Purnia. NO Vaccinationfor JE done.

5. Filaria: 94.8% MDA coverage is done till Oct 2011. Status of treatment of lymphedema and hydocoele

The posts for District Disease Control Programme Officer have not been sanctioned. The Civil Surgeon and ACMO is overburdened.

B. Revised National Tuberculosis Control Programme (RNTCP): a. 8 LTs are conducting quality diagnostic sputum smear activities at the Designated

Microscopy Centers. b. Funds are getting released for programme from SHS in time. Financial

Management guidelines of NRHM shared with programme officers. RNTCP officers are called for review meetings.

C. Integrated Disease Surveillance Program (IDSP) : Has been marked mostly by improvements in reporting. The state reports 100% reporting on „P‟ form during currently(40th week) compared to 58% last year. There is 95% reporting on „L‟ form in currently(40th week) which was 48% last year. Reporting on the „S‟ form has just begun. Started. EWS being issued and monitored on regular basis. A total of 257 outbreaks have been detected during last 40 weeks (2011). Out of these outbreaks in Muzaffarpur and Gaya were epidemic which led to death of 55 and 73 children respectively till date. Under IDSP regular line listing based on epidemiological information was ensured which was key to facilitating control action

D. National Leprosy Elimination Program (NLEP)

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10. Programme Management

Structure of Mission programme management in place at State, District and Block level and its integration with the Department of Health and Family Welfare at various levels

Program management units are established at state, regional, district and block levels across the state. Managers and accountants at district and block level were found in place in all the districts and block visited during the CRM. However a number of positions of district and block community mobilizer were vacant and only few positions at the ASHA resource center were filled.

At the state level XX contractual and XX government officers are posted in the SHS for managing different components of NRHM. A list of state program officers and coordinators engaged at the SHS and their areas of responsibility is provided in annex of the report. Program management units are established at regional level, district and block levels. Following is the current staffing pattern in the district and block level PMUs in the state.

District Programme Manager : 36/38 District Accounts Manager : 35/38 M & E Officer : 36/38 District Planning Coordinator : 29/38 District Coordinator Mobiliser (ASHA) 24/38 District Data Assistant (ASHA) 31/38 Junior Child Health Managers 13/38 Hospital Managers : 63/76 Block Health Managers : 459/518 Block Accounts Manager : 457/518 Block Coordinator Mobiliser (ASHA) : 401/533

Integration of department and PMU: The State has initiated a review of the relationship between the directorate and the SHS. While integration of program management units with the functionaries of department of HFW is clearer at block and district levels it appears weak at the state level. As per discussions with state and district level officials of health society, the directorate is mainly involved in managing the administrative affairs like leaves, transfers, deputations etc of the permanent cadre of health staff at all levels. There is a general feeling among the officers working with SHS (some of them were earlier with the directorate) that the officers at the directorate are more bureaucratic and decisions are severely delayed at their level. Though there was no scope to get the perspective of directorate level officials about the SHS and integration, the team feels that there is an immediate need to increase efficiencies of the departmental units and to reduce redundancies in the current system at the state level.

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Vacancies and capacities of staff in PMUs

As discussed in the earlier sections of the report, most of the manager and accountant positions at all levels are filled and there are a number of vacancies in the community mobilizer positions in district and block PMUs. While decentralized efforts are being made on a weekly basis to recruit staff for different positions, there is a high turn over among contractual staff posted at difficult block and district situations. It was also reported by some of the existing PMU staff that due to increasing demand for development and management professionals with community and government system level experience from other developmental initiatives of government as well as donor supported programs, there is a high turnover of PMU staff. Better remuneration packages and perks from other agencies are attracting a number of experienced staff from the NRHM PMUs in district and block level.

Many of the contractual staff in state and district PMUs and some block health managers were found to have adequate capacities to handle their responsibilities. It was found that the Program Officers/ Health Managers are also sent to the institutions such as NIHFW, IIHMR, PHFI for various short duration courses. Accountants at the district and block levels had adequate skills in basic accounting practices. While many of the PMU staff at state and district level, especially the ones with social-work academic background or experience of working with communities were found to have good facilitation and persuasive communication skills, some others lacked this skill and it appears essential to provide targeted capacity building for such individuals. All of the accountants and most of the managerial staff reported that they have not received any formal training about their work as part of PMU. They all have learnt things on the job and through their interactions with seniors and by referring to available literature. Considering that all the PMU staff are well qualified academically, are young and have keen interest to learn and grow in their careers and all most all of them are computer savvy, there is immense scope to provide structured online capacity building courses and to build capacities in an ongoing manner. Some of the human resource development inputs for the contractual staff may be useful for increasing the retention.

Infrastructure and logistics of the Programme Management Units at various levels

While the state PMU is housed in a building as part of the state health society with adequate space and facilities and one of the districts (Kishanganj) had well furnished adequate space for PMU housed within the DM‟s office campus, the PMU space in Begusarai was not up to the expected standard. In all the blocks visited, the block health managers are co-located in the PHC and appear to have adequate space and infrastructure for functioning. Adequate numbers of support staff for handling office requirements were found to be in place in Kishanganj and at the state level.

While the district management units are provided with hired four-wheelers for transportation the state management unit staff appears to have access to adequate resources for logistic

44

arrangements. Considering that the extent of travel for program monitoring that should be undertaken by block and district PMU staff, especially the community mobilizers adequate resources and systems for travel may need to be ensured.

Coordination between State and District Programme Management Units

As informed by the district PMU staff and the state PMU staff who were part of the CRM field visits, there is excellent coordination between the state and district PMUs. As each district has an assigned nodal officer at the state PMU, a number of coordination issues are addressed in timely manner through the nodal officers. The relationship between the district PMU staff, district health officials and the state PMU point person were found to be good in both the districts visited. However the district PMU members in Kishanganj, including the accountant expressed need for more program content based engagement and guidance from the state PMU to the district and block PMU staff. While the coordination support was appreciated more program content leadership from state PMU needs to be increased. However the state point persons appear to have limited skills in understanding the breadth of programme to provide effective support to the district. The capacities of state PMU point persons in program content other than their own domain area appear to be limited and this may require alternate arrangements like drawing other program officers for issue specific support.

Supervision and monitoring activities taken up by the management units at all levels

As reported by the DPMU staff, the point person for the district from the SPMU undertakes monitoring visits to the districts. One such visit to the field locations was undertaken during the current year in Kishnganj district. While no formal report of observations and feedback was provided for the visit, the point person had shared the observations through a de-briefing session at the district level.

While the DPMU staff undertakes a number of visits to the blocks and often to the sub-center and community levels, there is no structured monitoring process adopted. There appears an immense scope for introducing a structured monitoring of prioritized thematic areas through involvement of a multi-disciplinary team with a specific ToR and validated data collection tools at each level. Adapting from the approaches of CRM and JRMs, the state and district PMUs could evolve more ongoing internal monitoring mechanisms that can enhance timely course corrections of program implementation.

Institutions providing technical assistance- SHSRCs, SIHFWs, TAST

The state health society is being supported through the NHSRC and the TAST established under Bihar Health Sector Reforms Project supported by DFID resources. An increasing number of external donors are seen to be providing support to the state and districts.

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Ongoing support from NHSRC is recognized by the state health society. SIHFW provides training support however quality monitoring and follow up continues to be a challenge. In Begusarai, CARE through its project supported by Bill and Melinda Gates Foundation was found working closely with the district administration - focus seems to be on improving service delivery, community mobilization and demand creation through innovative approaches.

- SPMU functional- has programme officers for a range of areas, in touch with

district counterparts. - Nodal officers have joint responsibility for thematic areas as well for district –

limited skills in understanding breadth of programme to provide effective support to the district

- At the district level vacancies in DPMU, thus overburdening existing staff/neglect of programmes

- ARC has only two staff against a sanctioned strength of seven. - Unfilled posts amongst DCM and BCM - Selection of ASHA facilitator not yet complete - Program Officers/Health Managers are also sent to the National Institutions such

as NIHFW, IIHMR, PHFI for various short duration courses. - State has initiated a review of the relationship between the Directorate and the

SHS - DHS office spaces and infrastructure is a challenge - Decentralized appointments of DPMU staff occasionally results in limited

accountability to state - Ongoing support from NHSRC is recognized - A large and growing number of external donors providing support to state and

district to support the health system - SIHFW provides training support; quality monitoring and follow up is a challenge - CARE in Begusarai works closely with the district administration- focus seems to

be on service delivery, community mobilizational and demand creation

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11. Procurement System Present system of procurement of drugs

Bihar State Health Society has been declared as the “State Purchase Organisation” for the purchase of drugs, surgical items, instruments and other supplies. It floats open tender for National Competitive Bidding and follows fair and transparent procurement process for conclusion of Rate Contract of drugs. The rates are finalised by the Purchase Advisory Committee and also approved by the Governing Body of the State Health Society. Rate Contracts including names of drugs as well as companies name is sent to the Districts and Medical College Hospitals, who in turn place orders with the approved rate contracted agencies. The rate contracted companies are required to have their depots at State Headquarter level. Labour room equipment, dental chair and neo-natal equipment procurement is under process in all the districts. Govt. of Bihar has drawn up Essential Drug List (EDL) consisting of 33 drugs for OPD and 112 drugs for IPD from the level of addl. PHC upto the District hospital level. Similarly, for medical college hospital, 65 drugs for OPD and 120 drugs for IPD have been notified. This EDL has been rationalised and is available on the website of Bihar State Health Society. Further, all the health facilities are required to maintain a check-list of the same for public viewing. In course of visit to various health facilities, it was noticed that free distribution of medicines in OPD/IPD is being done at all the Sub-Centres, PHCs, District Hospitals and Medical Colleges. Civil Surgeons have been delegated financial powers to incur expenditure upto Rupees One lakh in each case for procurement of drugs etc. Medical Officer in charge of the block PHC can procure drugs medicines etc. up to Rs.15,000/-. During the inspection of health facilities in Begusarai District, it was observed that on an average 51 types of drugs were available for free distribution to the beneficiaries undergoing OPD/IPD. In Begusarai District, negligible warehousing facilities were noticed from block level to district hospital level while Kishanganj was reported to possess adequate warehousing facilities. It was fairly conceded by ED, SHS during the de-briefing session that Supply Chain Management is not in place.

II. Setting up of Central Drug Procurement Agency on lines of TNMSC Model

It was gathered from the State level briefing that the Govt. of Bihar is committed to

provide timely and effective healthcare services to the people of Bihar. This is necessary as the majority of poor people of Bihar usually depend on Public/Government healthcare delivery systems to address their preventive and curative health needs. Optimal availability of good quality drugs procured at competitive prices, quality provision of health related services and proper construction and maintenance of health facilities are of paramount importance for better healthcare delivery. In such a scenario, the financing and supply of drugs, medical equipments, services etc. for Govt. health services has emerged as one of the key concerns for Govt. of Bihar. The per capita expenditure on drugs in Bihar is Rs.7/- as compared to Rs. 29/- in Tamil Nadu.

To meet the above mentioned objectives in a professional manner, the Govt. of Bihar has

set up the Bihar Medical Services and Infrastructure Corporation (BMSIC) under the aegis of the Department of Health & Family Welfare (DoHFW). BMSIC is incorporated as a non-profit

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organization under the Companies Act 1956 and is responsible for procurement of quality drugs, equipments, consumables, services and civil construction for the DoHFW.

The overall objectives of the Corporation are to:

(i) Procure and ensure provision of quality drugs, equipments, services and works in right quantities in a timely manner at the most optimal rates

(ii) Ensure provision of value for money services in a transparent and equitable manner to the people of Bihar.

(iii)Improve the performance of the Healthcare system through systematic improvements in the quality, effectiveness and coverage of health service to proper infrastructure.

The BMSIC is expected to be fully operational 1st April, 2012 and in its first phase will

undertake procurement activities. Civil construction work will be initiated later. III. Establishment of Procurement Cell and Data Entry in ProMIS

Centralised Procurement Cell has been established in all 38 Districts of the States. However, ProMIS data entry is not being done either at the State level or at the district level warehouses. Several rounds of training have been conducted in Bihar for various level of personnel but the data entry is not being done. It was informed by the Principal Secretary(Health) during de-briefing session that they have approached DFID for getting the ProMIS Software customised to cater to the data entry requirements of Central Supplies as well as the State Procurement. Further DFID has asked M/s Broadline Consulting Services, Chennai to do the necessary modification to the ProMIS software. After the customisation is completed, data entry will be taken up.

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12. Effective use of Information Technology

The name based tracking system has been initiated and several instructions are issued for this programme. The total entry from the state is approx ………( ), The Kishanganj team observed a mismatch between prescribed format for MCTC and MCH registers available with ANM . The MCH registers are not completed, and the physical verification of the data is not being done although at the PHC level data entry operators had a good understanding of MCTS format. The District wise and PHC wise MCTS status is as below.

Health

Block

Health

Facility

Total

Mothers

Registered

Mothers

with Self

Phone No.

Mothers

With

Address

Mothers

with

ANM

Name

Mothers with

ASHA Name

Kishanganj 7,721 2 7,015 4,522 4,227

Bahadurganj 963 1 963 903 903 Dighalbank 1,520 0 1,517 7 5 Kishanganj 1,532 0 1,236 1,158 1,158 Kochandhamin 283 0 283 233 0 Pothia 886 0 867 860 860 Terhagachh 276 1 276 229 224 Thakurganj 2,261 0 1,873 1,132 1,077 Health

Block

Health

Facility

Total

Mothers

Registere

d

Mothers with

Self Phone

No.

Mothers

With

Address

Mothers

with

ANM

Name

Mothers with

ASHA Name

Begusarai 26,955 973 26,866 7,278 5,785

Bachhwara 1,334 0 1,334 1,051 621 Bakhri 616 8 616 298 298 Balia 188 0 182 52 45 Barauni 262 0 256 51 49 Begusarai 1,442 11 1,442 590 207 Bhagwanpur 2,610 301 2,610 274 160 Birpur 1,904 8 1,904 325 325 Cheria Bariarpur 2,502 0 2,497 18 18 Chhorahi 1,337 0 1,330 290 195 Dandari 1,921 1 1,921 56 51 Garhpura 2,764 5 2,764 424 424 Khudabandpur 374 1 374 89 89 Mansurchak 2,787 0 2,787 2,655 2,651 Matihani 1,144 1 1,143 445 399 Naokothi 942 1 942 60 41 Sahebpur Kamal 866 0 808 26 3 Shamho Akha Kurha 1,395 0 1,395 334 0 Teghra 2,567 636 2,561 240 209

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In Bahadur gunj PHC, Kishanganj district, the system of feedback through MCTS has not been started, However all PHCs are organizing meeting of the ANMs every Tuesday, with Block health managers reviewing the data for completeness and timeliness (Bahadurganj PHC,District- Kishanganj ) State, district and PHC level MCTC data is being reviewed by the respective officers. At this stage only two parameters entered in the software, completeness of data and the number of mothers are being reviewed at the State Level. The state has hired around 50 resource people for validation of data at HSC level. They are also expected to train ANM and data entry operator on accurate reporting and entry of MCTS data. The State has developed a new MCH register for data entry which is customized to the needs of the MCTS. The MCTS is also being reviewed in the monthly meeting of Civil Surgeons at the state level, to ensure pace of data entry and validation of data. The State has appointed nodal officer at all the level to track development of MCTS.

HMIS(Health Management information System)

Over the years, the State Health Society has taken necessary initiatives in enabling the requisite infrastructure for implementing effective HMIS in the state. To reduce the problems with data quality and their timely collection and utilization the state health society with the support of NHSRC, UNFPA and IIHMR has initiated the up gradation of the skills of health staff at various levels to ensure the quality of data recording, analysis, report generation and use of data for decision making. The State health society has made significant progress in terms of development of training modules and materials in collaboration with the State Health Society Bihar and NHSRC and has trained functionaries (mainly ANMs and LHVs) on various aspects related to Health Management Information System (HMIS). In this process SHSB formed State Resource Pool for training in HMIS. After training of the grassroots health functionaries a significant change has been observed at the Block and HSC level but there is still room for improvement of HMIS for data validation.

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Observations During field visit:-

- At the State level SHSB using HMIS data for district level review. - SHSB issued a guideline for HMIS that reflects proactive role on system straining

approach as “HMIS will be only one data source for any valid information .” - Infrastructure and internet connectivity available in all block PHCs and DH - The emoluments of the data entry operator at the PHC level are inclusive of purchase and

maintenance of the computer and other hardware. Thus the total income is only about Rs. 4300 per month, which is de-motivating.

- The quality of maintaining MCH registers in the district varies in the district. In some areas it is incomplete because the data gathered during actual service delivery, most often the VHND is not transferred to the main register. The focus is on the due list which is used for payment. Immunization data from the block

- In Bahadurganj PHC, HMIS data is being reviewed in the Tuesday meetings - ANM‟s understanding of the various indicators is good and they all are referring training

module for any doubt regarding definition of data element. - Little feedback and analysis from the district to block MOIC and also to the ANM - Data not being used as a planning tool in the DHS review meeting - MCTS is operational in all blocks; but beyond data entry very little action is being taken. - Data from programmes such as immunization, (and even polio into immunization) IDSP,

Finance are not being integrated into the HMIS. 13. Financial Management

There is 100% Usage of customized version of Tally ERP-9 software upto District, PHC and Block level. All 533 PHCs/Blocks under 38 Districts duly covered under Tally ERP-9. Smooth Electronic transfer of funds upto PHC level, which saves a lot of time. SOE's are upto date till 31st October, 2011. All JSY Records and Photographs of beneficiaries maintained properly. Cash Book, Stock Register, Cheque issuing Register, Cheque Book, receiving Register and

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Advance Register are maintained upto date and properly. Internal Auditors team constituted comprising 4 officials.

In Begusarai district, Ledger is not maintained w.e.f. 15th May, 2009 in respect of the PHC, Bakhri w.e.f. 01.05.2010 in respect of PHC, Teghra and w.e.f. 30.04.2008 in r/o PHC, Ballia UC's haven‟t been submitted since 2009-10 in respect of Village ealth and Sanitation Committees (VHSC), due to conflict between PRI'S member (Mukhiya) and ANM due to which the Untied Fund of Rs.10,000/- p.a hardly gets utilised. No quotations invited for Kent R.O. for Rs. 16,500/- installed at PHC, Bakhri. JSY Beneficiary list not displayed and their contact number are not also available at any PHC. RKS meetings are not held in a timely fashion. Bank Reconciliation Statement (BRS) is not upto date since April, 2011 at Referal Hospital, Manjhaul, PHC Nawkothi and PHC Bakhri.

Only 8 districts out of 38 have uploaded the financial monitoring report on the HMIS Portal. As per report Internet is quite slow due to which uploading at NRHM WEB Portal becomes time consuming. Concurrent Audit has not improved the internal control system as Bank accounts are not being reconciled on regular basis. The intervening period for Reconciliation varies from 3 months to 8 months. Further there is no periodic reconciliation of advances and age-wise analysis of advances.

Financial Leadership is in place now .All key posts viz. Director (Finance & Accounts), SFM, SAM at State level are in position. State has improved system of trouble shooting of problems faced in implementation of Tally with Tally Solutions Pvt Limited. State should adopt Kitty or Flexi pool method instead of issuing activity-wise sanctions which is the main reason for delayed release of funds to the districts. Adequate documentation has been made regarding ASHA & JSY by the State and no backlog of payments was seen. Adequate funds availability for JSY was seen.

Financial Management Checklist

All key posts viz. Director (Finance& Accounts), SFM, SAM at State level are in position. All key posts of District Accounts Manager (DAM) are filled up.

Funds transfer from State to Districts and from Districts to PHC is done through electronic channels (RTGS) which gets transferred on the same day. From PHC and Sub Centers funds are transferred through cheques which take about 15 – 20 days time in clearing.

Customized Version of Tally ERP-9 (Gold) in all the 38 districts & Tally ERP-9 (Silver) in all 496 Primary Health Centers are in full usage (Tally generated FMR is being received on E-mail from DHSs). As and when troubles arise, these have been effectively shooted by the representative of Tally Solutions Pvt. Ltd. during tally implementation. All DAMs have been

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trained in Tally and the response of TSPL has been good in solving the problems. The funds released have been utilized for the approved activities as per the SPIP.

To ensure timeliness and effectiveness system of Concurrent Audit is in usage at state as well as at district levels. Concurrent Auditors at HQ as well as at district levels are working to improve the internal control system. Summary of Concurrent Audit Report is being submitted to HQ on Quarterly basis. Prompt action is taken by issuing instruction to the concerned DHS in case of mild nature deficiencies, and by sending Internal Audit Team in the case of serious irregularities. State needs to improve the system of monitoring the concurrent audit in districts and timely submission of action taken reports by districts and ensure early submission of executive summary report to the Ministry.

The state has issued detailed guidelines on delegation of financial and administrative powers based on GOI guidelines to all districts on 15-12-2009 which are being followed at district and state level.

RPMU has already been authorized to conduct training to improve capacity building on regular basis of all the DAM and Block Accountants. Tally Training has already been conducted twice upto PHC level as regards Accounts training all the RPMU's have already been instructed for orientation of the Accounts personnel, funds have been provided for 2011-12 besides funds being allocated for exposure visit of finance personnel is in process.

Only 8 districts out of 38 have uploaded the financial monitoring report on the HMIS Portal. State is required to arrange HMIS training for DAMs and initiate steps to monitor progress in this activity.

There is inordinate delay in submission of SOE from Sub centre and VHSC to PHC which results in higher unadjusted advance reporting and low funds utilization. No funds have been released to VHSCs during current year. The main reason for delay in funds release to VHSCs is non-submission of utilization Certificates since 2009. State needs to issue instructions to districts for quick settlement of outstanding advances to VHSCs before release of funds.

The financial integration of NDCPs with state health Societies has been achieved and a single statutory auditor is being appointed by the State to carry out statutory audit of State Health Society and NDCPs and a consolidated FMR is sent covering expenditure details of all NDCPs.

To bring out the uniformity in the Books of Accounts, Model Accounting Handbooks (Software) has already been made available to districts with the instruction to make available to all the PHC's. Printing of Hard Copy of Model Accounting Handbooks is in process and will be made available by the end of December 2011. Model Accounting Handbooks published by the Ministry have been circulated upto district level but not available at sub-district levels. State should distribute Accounting Handbooks translated into vernacular language to Sub-district accounting staff for easy understanding and frequent usage.

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State has issued detailed guidelines for procurement of drugs and consumables which is in line with State Govt. procurement policy. Procurement is mostly centralized at state level. Rate Contracts are finalized at the levels of state programme officers by inviting tenders for purchases. State needs to examine possibility of adopting procurement software ProMis developed by GOI. Generally, no instances of mis-procurement were noticed in the State.

No concrete written answer was given by the State for pending Utilization certificates of Rs 189 crores from 2005-06 till 2010-11, but efforts have already been made to settle the pending advances.

Funds Tracking' under the head- Untied Funds and Annual Maintenance, is being done through FMR. Releases under these heads are not treated as expenditures. Sufficient funds have been released to the State for 2011-12 as per SPIP of the state and funds utilization is being monitored. Funds are released on the receipt of reported expenditure of 80% within 48 hours. In special circumstances, funds are released as per need of the districts. Funds are not utilized more than the approved budget of DHS.

The utilization of funds is increasing which is evident from the table below:-

FY GoI Approved

Envelope

Expenditure

(In Crores)

Expenditure as % of

Approved Budget

2006-07 346.94 92.14 27

2007-08 797.01 237.79 30

2008-09 766.69 339.75 44

2009-10 1097.30 580.66 53

2010-11 1273.88 878.69 69

Funds under RKS have already been released and utilization of funds is satisfactory. Rogi Kalyan Samiti is being monitored through Internal Auditor at the time of Audit. The state is contributing its share. Infrastructure activities are carried out from State contribution. Statutory obligation is strictly followed up to PHC level reg. TDS. The Statutory Audit for 2010-11 has now been concluded and on the basis of the same, the unspent balance under IAG & RCH-I is being worked out and all efforts is being made to settle the unspent balance. No expenditure has been incurred from Interest earned on NRHM funds. No Diversion of Funds is allowed.

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14. Decentralized Local Health Action

DHAP and BHAP prepared and are available. In Kishanganj, the District Health Plan exists, and has a well laid out vision and actions for the next year (i.e. 10-11). However the district has not been able to implement the plan in spirit and substance. Part of the issue is that:

- Lack of funding to certain budget heads like infrastructure (the plan asks for Rs. … and actually received Rs. ).

- Lack of human resources (see earlier section) - Limited understanding of guidelines and procedures among managerial and medical staff

leading to delays in expenditures despite availability of funding. - Guidance and support from the state needs substantial strengthening - Long delays in the supplies of drugs and equipment from agencies – there are stock outs

Joint accounts for SC untied funds and VHSNC in place at Panchayat level. SC untied funds utilised for stationery, storage, health camps etc VHSNC funds utilised for installation of hand pump, cleaning of drains in few locations etc. However in most places, funds have not been utilized. RKS funds for 2011-12 transferred but not utilised due to lack of clarity of guidelines Level of satisfaction about the services at health facilities among community has increased as a result of NRHM. NRHM has recently been included into the District Vigilance and Monitoring Committee, and in Kishanganj, one meeting was held where the CS participated. Minutes not yet issued by the DM‟s office VHSNC are not yet functional- accounts have been opened in the previous PRI regime, but since the recent elections, the recently elected representatives are still to be made bank signatories. Awareness of the VHSCN was low among the ASHA or community members. The state has identified a nodal agency (the population Foundation for India) for community monitoring in eight sates. Neither Begusarai nor Kishanganj are part of the eight. Kishanganj is not part of the state‟s SHG intervention. It is likely to be covered next year under the Jeevika scheme. In Kishanganj, the RKS has been set up at all levels, meetings take place, and members have been drawn from PRI, NGOs, beneficiaries. At least one third of the representatives are women. There is an increasing confidence in making expenditures although more systematic planning and comprehensive understanding of possible investments of RKS funds. The fund inflow is from blood banks, OPD registration, ambulance. Most expenditure is on repair and maintenance, have appointed a plumber and electrician for services to the DH. Audits of RKS are not taking place at any level. RKS at APHC have been formed, and accounts have been opened, but members need orientation.

55

15. AYUSH

The state has 1385 AYUSH practitioners co-located with allopathic doctors in health centers, with 1135 being supported through state funding. About 297 health facilites at the APHC level are managed by AYUSH. AYUSH doctors have been trained in IMNCI, immunization and oriented to NRHM. The AYUSH practitioners are using Allopathic drugs in some instances, because of non availability of AYUSH drugs although the state has recently put in place a contract to HLL Life care to provide AYUSH drugs in the facilities. 399 Facilities have been provided with AYSH drugs. 80% of AYUSH positions filled at APHC . In Begusarai, Ayurvedic and Homeopathic drugs were available. 16. Overall Outcomes: During the Mission period, the state has made significant progress across all areas which is highly visible. This is commendable given the baseline, the short time span, the context and the formidable constraints. The increasing functionality of the facilities, recruitment of staff, enabling systems for procurement and managing supply chains to ensue drugs and equipment, the establishment of the HMIS, and the overall strengthening of management structures have resulted in positive outcomes discussed in various sections of the report. Of the sixteen terms of reference reviewed in the CRM, there is forward movement on practically every area. The challenge ahead is to increase pace and quality which need substantial acceleration in almost every area. Part of the pace and quality issues are related to the management competencies and governance. These need special attention. Bihar now attracts substantial donor assistance in the health sector from UNFPA, DFID, the Gates foundation, the Packard Foundation, resulting in an unprecedented influx of several national and international NGOs including technical assistance agencies. The state will need to find intelligent ways of managing this influx to its advantage and ensure that all this funding and support results in supporting the public health system, or improved community processes and enables equitable scaling up of health services.

56

3. The progress of implementation of the PIP for FY 2011-12 in the State National Rural Health Mission offers unprecedented opportunity to improve the health of the people of Bihar. The capacity to manage the programme in the state has significantly strengthened. There is a significant increase in outpatients an d institutional deliveries. The availability of human resources has increased substantially at different level of health institutions. Several PPP interventions have been implemented to increase the reach out to the people. By and large the improved infrastructure, strengthened facilities and people‟s confidence in public health facilities has been improved considerably . Brief information on pr ogress of activities is as follows:

Activity wise Progress of NRHM

Sl.

No

Activity Status

1 24x7 PHCs Out of 1863 only 480 PHCs are functioning on 24x7 basis.

2 Functioning as FRUs 30 DH, 19 SDH and 6 CHC are working as FRUs.

3 ASHAs Selected

79952 ASHAs selected, 69402 have been trained upto 1st Module, and 52859 trained upto 4th Module. No ASHA is trained in 6th and 7th Module.

4 ANMs at SCs Out of 9696 SCs, 6903 are functional with 2nd

ANMs.

5 Contractual appointments

1743 Doctors, 414 Paramedics, 381 Specialists, 1384 AYUSH Doctors, 1498 Staff Nurses and 7422 ANMs are positioned under NRHM

6 Rogi Kalyan Samiti 2014 facilities (37 DH, 70 CHCs, 44 Other than CHCs & 533 PHCs and 1330 other than SC) have been registered with RKS.

7

Village Health Sanitation & Nutrition Committees (VHSNCs)

Out of 45098 villages, 7978 villages constituted VHSCs.

Institutional Framework of NRHM:

57

The institutional set up is comparatively slow and need to be improved. State and District Health Mission meetings are not held on a regular basis. At Panchayat level 7978 VHSCs have been formed however functioning at juvenile stage, need to take it on priority basis. Rogi Kalyan Samitis are operational at 37 DH, 44 SDH, 70 Referral Hospitals & 533 PHCs. All 38 districts have started developing their own DHAP.

Infrastructure Improvements:

Out of 534 PHCs, 480 are functional as 24 x 7, however due to shortage of staff nurses only 281 PHCs are strengthened with 3 Staff Nurses. 70 CHCs, 46 SDHs and 36 DHs are functioning on 24X7 basis. A total of 149 health facilities including DH, SDH and CHCs are operational as FRUs. Each district have functional Mobile Medical Unit (MMU), a total of 48 MMUs including 10 for Mahadalit Tola are functional in the state.

Human Resources: A total of 80967 ASHAs have been selected against the target of 87135, out of which 69402 ASHAs have been trained up to Module 1 and 52859 have been trained up to Module II, III & IV. 3640 Sub Cnters out of 9696 are functional with 2nd ANM. As far as Manpower augmentation is concerned 1632 MBBS Doctors, 1305 AYUSH Doctors, 1476 Staff Nurse and 7521 ANMs have been appointed under NRHM on contractual basis.

Services: Institutional deliveries in the State have improved from the total no. of institutional delivery has increased from 2.37 lakhs in the year 2005 -06 to 13.83 in 2010-11 , while the total n o. of deliveries from till June 2011 is 2.58 lakhs . Number of JSY beneficiaries in the state increased sharply from 0.90 lakh in 06-07 to 13.83 in 10 -11. The total no. of Family Planning operations has increased from 118678 in 2005-06 to 510830 in 2010-11, and from Apr. to June. 2011 a total of 29321 operations have been done. Contraceptive use has increased from 23 .1 percent (NFHS -I 1992-93) to 28.4 percent (DLHS-III -2007-08). During the year 2010-11, 500463 female and 10367 male sterilization has been reported.

Physical Progress of Institutional Deliveries and the JSY Scheme

Year No. of Institutional

Deliveries (In Lakhs)

No. of beneficiaries of

JSY (In Lakhs)

2005-06 2.37 0.00

2006-07 1.24 0.09

2007-08 8.38 8.38

58

2008-09 11.47 11.47

2009-10 12.46 12.46

2010-11 13.83 13.83

2011-12 2.58 1.84

Immunization and Family Planning Services

Services

06-07

07-08

08-09

09-10

10-11

11-12

Male Sterilisation 428 400 1537 6539 10367 1011

Female sterilisation 161943 300918 325185 398202 500463 28310

Full immunization (In thousands)

1237 1567 1274 1226 534

Reproductive and Child Health Programme (RCH)

a) Immunization Coverage

(Figure in percentage)

NFHS-

2

NFHS-

3 Coverage Evaluation Survey

Year

1998-

99

2005-

06 2005 2006 2009

Fully Immunized 11.6 32.8 19.0 37.7 49.0

BCG 36.0 64.7 52.8 75.2 82.3

OPV 3 42.2 82.4 27.1 47.6 61.6

DPT 3 24.9 46.1 36.5 49.0 59.3

Measles 16.2 40.4 28.4 46.0 58.2

b) Information on selected MCH indicators

Indicators DLHS -2 (2002-04) DLHS-3 (2007-08)

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Child feeding practices (%)

Children under 3 years breastfed within one hour of birth

5.7 16.2

Children age 0-5 months exclusively breastfed

NA 38.4

Children age 6-35 months exclusively breastfed for at least 6 months

6.0 11.8

Children age 6-9 months receiving solid/semi-solid food and breast milk

NA 61.3

Awareness about Diarrhoea and ARI

Women aware about danger signs of ARI (%)

79.3 80.4

Treatment of childhood diseases

Children with diarrhoea in the last 2 weeks who received ORS (%)

13.4 22.0

Children with diarrhoea in the last 2 weeks who were given treatment (%)

84.6 73.7

Children with acute respiratory infection of fever in last 2 weeks who were given advise or treatment (%)

81.3 73.4

Funds Released for total NRHM (In Crores)

Year Allocation Release Expenditure#

2005-06

382.89 255.51 186.69

2006-07

556.65 361.89 235.64

2007-08

590.66 350.24 423.25

2008-09

777.70 821.18 783.19

60

2009-10

860.29 649.71 826.20*

2010-11

977.40 1035.18 1434.84*

2011-12

1122.10 280.66 97.64*

Total 5267.68 3754.37 3987.45 *Allocation and Release figures are excluding kind grants.* *Expenditure figures for 2009-10, 2010-11 and 2011-12 are Provisional. # Expenditure is more than Release due to previous unspent balances and includes state share.

General Overview: Increased utilization of services such as - outpatients, in patients, institutional

delivery at CHCs and district hospitals Diagnostic services have been outsourced for maximum coverage. Improved supply of drugs, establishing generic medical stores at B lock PHC s. Increased human resources in SC s, PHC s, DHs; innovative HR policy , additional

ANM at SC. Nutrition rehabilitation programme and Muskan ek Abhiyan (immunization programme ) Rogi Kalyan Samitis are formed and are functional. First phase of community monitoring has been successfully implemented. Lack of nurses and mid wives hampers quality of care. MAMTA programme for women volunteers in hospitals is an innovation to meet

the nursing shortages in hospitals. There is significant increase in number of JSY beneficiaries and performance of

institutional deliveries has been improved In the Place of School Health Programme a new programme Nayee Pidhee Swasthya

Guarantee Karyakram has been launched to do screening of all children between 0-6 years, Children of schools run by government between 6-14 years, Adolescent girls between 14-18 years and at the same time to provide health cards to them.

IEC/BCC activity is deprived in the state

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4. RECOMMENDATIONS:

Infrastructure

- Pending finalization of the infrastructure corporation, the state should release funds to the district to rapidly expand infrastructure

- Districts should prioritize renovation/construction of facilities that have land for residential accommodationCorrect mis-match between land availability and resource allocation

- Promote the use of common property for building health facilities - Create systems for timely handing over of completed facilities and near complete needs

to be synchronized, through the intervention of divisional commissioner/other mechanisms

- Given the high IMR, construction and operationalisation of SNCUs across the state is required on priority

- Improved amenities for ASHA in facilities

Human Resources for Health

• Consider monetary and non monetary incentives for postings in difficult areas • Enforce the policy of additional points for post graduate studies, for those who serve in

difficult areas • Need for active recruitment of trained cadres such as ANMTC from local schools • Rationalizing work load- Lab. Tech, BHE • Expand the base of training organizations by involving Medical Colleges, NGOs etc • Set up skill labs in DH and BPHCs • Create a team of mobile trainers for on site supervision and mentoring Promotion of

skilled and better performing staff • Use of innovative pedagogical methods – that are able to more rapidly scale up training,

such as interactive AV • Intra-block transfers for contractual staff (after a set period of time) as an incentive • Find ways to retain managerial as well clinical cadres • Team based performance incentives • Performance incentives linked to workload • Timeliness in payment of salaries to be ensured • Consider the use of external HR agencies to facilities and fast track recruitment • Building a culture of supportive supervision, appreciative enquiry and team building

across the state Service Quality/RCH services

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• Strengthen lab and diagnostics services – regulation and monitoring of agencies of out sourcing work

• Non outsourced activities, ensure reagent supply and quality • Training orientation of LTs and clarity and justified work distribution • Drug inventory management needs to b ensured • Service guarantee and citizens charter needs to be displayed across all facilities • Grievance redressal cells need to be operationalised and active • Improve monitoring of services by contractual agencies that provide ancillary functions-

more active engagement of RKS • PPIUCD and interval IUCD needs to be strengthened • Support to ensure that protocols are followed. • Semi – auto analyser to be installed in all DH and block PHCs. • Pending the operationalization of the BMSC, consider establishing systems for drug

inventory at district and block • Ensure service guarantees and citizens charters in all facilities, and grievance redressal • Ensure bio-medical waste management in all facilities. • Establish and strengthen QA committees at the state and districts • Prioritize areas with high proportion of home deliveries to promote safe deliveries –

through demand generation and increasing access • Identify and strengthen delivery points across the districts • Attention to micro-birth planning at community level • Immediate implementation of JSSK to reduce out of pocket expenses • Institutionalize tools and processes to improve quality (e.g., partograph) • Demand generation and service provision for FP specially in outreach – more

involvement ASHAs, better training of ANMs, ensuring services through effective outreach

Maternal Health and JSY

• JSY payment should be linked to 48 hour stay • Lab diagnosis X-ray and USG at DH and SDH/ FRU level • JSSK to be implemented on priority to ensure service guarantee namely free delivery,

diet, drugs, diagnostics, blood and transport and drop back for mother and child upto 30 days

• SNCU to be established and operaionalised in all districts on priority • Better training for Mamtas to ensure quality postpartum and newborn care

Outreach Services

• Expand VHND services to encompass broader MCH services beyond RI • Ensure systems for complete reach of all mothers and children by identification of left-

out and drop-outs

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• Reduce burden of work for ANMs- can be done by strengthening ASHA and skilling her to provide community level care.

ASHA Programme

• Expand the capacity of the ASHA resource center • Fill in vacancies in district and block community mobilizer positions • Finalize recruitments of 21st ASHA as a facilitator • Incentive payments to ASHAs who are now covered under newly designated urban area

needs to be revisited as per JSY guidelines for urban ASHAs • Expedite ASHA training and provide communication kit to enable ASHAs for

counselling mother and family member • Ensure replenishment of supplies to ASHA drug kit at monthly ASHA diwas • Improve processes for mentoring ASHAs including monthly ASHA Diwas

Intersectoral action and convergence

• Differential programme planning based on local context and conditions • Leverage SHGs, CBOs for social mobilization and demand creation including for TSC • Reach out to religious leaders, community influencers • Minimize duplication of due list preparation by AWWs and ASHA and redirect the time

for home visits • Strengthen NRCs and don‟t impose limits • Convergence with TSC • VHSNC to be activated for action on social determinants, through involvement of PRI,

ASHA, AWW and community level organizations • Greater engagement with civil society organizations • Ensure attention to behavior change around high impact feeding interventions (breast

feeding and complementary feeding) Gender Issues and PC/PNDT

• Gender disaggregated data needs to be collected and used for planning and program management

• Expand access to safe abortion – MVA training and supply of kits • Rapid scale up adolescent programmes • Truly empower the ANM and ASHA- public face of programme • Train ANM and other service providers in RTI/STIPC-PNDT needs to be implemented • MTP services need to be made available at all levels. Yukti yojna is a good scheme and

needs to be implemented • NSV needs special attention for awareness generation in order to address TFR

Decentralised Local Action

- Strengthen capacity at district and levels below for using district and block level plans as a tool to guide program implementation

- Orient and train all RKS members in their roles and responsibilities

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- Improve coordination between health and civil administration dept to ensure timely RKS meetings and functionality

- Ensure regular audits of RKS accounts Programme Management

• Review of the different models of support in districts and disseminate effective strategies and replicable practices

• Use the opportunity of the management review to strengthen the relationship with Directorate

• Nodal officers for districts need training and orientation on support to district management,

• Joint team training of state and district officers in planning and implementation • Improve working conditions for DPMU staff through increased allocation of resources Financial Management

The concurrent audit system needs to made more effective by enhanced monitoring of the audit process so as to ensure timely completion of concurrent audit of all districts and action taken on the observations of concurrent audit

There is need to strengthen internal control at all accounting centres particularly at Districts, PHC and Sub-centres.

State to start training and implementation of HMIS System VHSCs and ANMs need orientation in proper utilization of untied funds and

Annual Maintenance Grants All districts and State to carry out age-wise analysis of Advances and submit it

along with monthly FMR Monthly review meetings of DPM, DAMs to be held regularly to monitor growth

in funds utilization and reasons to be identified for ensuring optimum utilization State to issue revised guidelines for funds utilization by RKS and in the light of

instruction issued by Ministry in Dec. 2010 and Model Accounting Handbook issued in April 2011

The reply to the audit paras in the statutory audit report and management letter to be submitted to FMG at the earliest

Procurement • Train data entry operators for ProMIS • Operationalize use of ProMIS in districts • Expand and improve management of storage facilities for drugs

NDCP

Micro planning for NVBDCP should be done and implemented. Orientation of Health functionaries on Malaria management. The lab confirmation should be completed and treatment should be start within 24

hours of contact. All LTs should be trained in malaria microscopy and rationalisation of work of

LTs is needed.

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National Drug policy on Malaria, 2010 should be displayed at Drs duty room or at the t/t sites.

Drugs as per NDP 2010 should be available in the all facility. Vector Control Plan should be available at earliest, implemented and incorporated

in DHAP/ PIP. Reporting formats should be available and NAMMIS must be implemented and

linked with HMIS. Incentives to the ASHAs should be given as per norms

Annexure 1: Team Composition

Name Designation Address

Mr. Deep Shekhar Director, Procurement; Ministry of

Health and Family Welfare

Nirman Bhavan, New Delhi

Dr. B. K Tiwari Advisor Nutrition, Ministry of Health

and Family Welfare

Nirman Bhavan, New Delhi

Dr. P. C Bhatnagar Programme Director, Voluntary Health

Association of India

B- Qutub Institutional Area; Tara

Crescent, Qutab Institutional Area,

Delhi 110016

Dr. Rajani Ved Advisor, Community Processes; National

Health Systems Resource Center

NIHFW Campus, 5, Baba Gangnath

Marg; Munirka New Delhi, 110067

Dr. S I Amir Senior Regional Advisor; Regional

Office For Health & Family Welfare,

(Bihar & Jharkhand), Govt. of India

5th Floor, Indira Bhawan, R.C. Singh

Path, Patna - 800 001

Mr. Billy Stewart Senior Advisor, Department for

International Development

B-28 Tara Crescent, Qutab

Institutional Area, Delhi 110016

Dr. Sher Singh

Kashyotiya

Assistant Director (Public Health);

National Vector Borne Disease Control

Programme

Directorate General of Health Services;

22, Sham Nath Marg, Delhi-110054

Ms. Usha Kiran Bill & Melinda Gates Foundation 3rd

floor, Capital Court Building,

Munirka, New Delhi, 110067

Ms. Medha Gandhi Consultant, ARSH; Ministry of Health

and Family Welfare,

Nirman Bhawan, MoHFW

Dr. Sarita Sinha Consultant NRHM, Planning & Policy;

Ministry of Health and Family Welfare,

526-C, Nirman Bhawan, New Delhi

Mr. Ravi Sawlani Consultant Finance; Ministry of Health

and Family Welfare,

510-D, Nirman Bhawan, New Delhi

Mr. Ajit Singh State Facilitator; National Health

Systems Resource Center

Mr Sunil Babu Bill & Melinda Gates Foundation 3rd

floor, Capital Court Building,

66

Munirka, New Delhi, 110067

67

Annexure 2: List of facilities visited by the team and persons met

5th Common Review Mission 8th November to 15th November 2011

Name of State Bihar Names of Districts visited

S.No Name District HQ Name of DM Name of CMO

1 Begusarai Begusarai Mr. Jitendra Srivastava

Dr. Sone Lal Akela

2 Kishanganj Kishanganj

Mr. Sandeep Pudulakutty

Dr. Inderdev Ranjan

Health Facilities visited

S. No Name Address / Location

Level (SC / PHC /

CHC/other)

Name of the Person in Charge

I Begusarai

21. Sadar Hospital

Begusarai District Hospital

Dr. Sone Lal Akela

22. PHC Bakhari

Bakhari PHC

23. Mohanpur HSC

Mohanpur SC

24. Anganwadi

Centre Chanhakat Mohanpur

AWC

25. PHC Naokothi

Naokothi PHC

26. HSC Maheshwara

Maheshwara SC

27. RH

Manjhaul Manjhaul RH

28. APHC Banwaripur

Banwaripur APHC

29. HSC Chandrapur

Chandrapur SC

30. HSC Atarwa

Atrwa SC

31. APHC Sokhra

Sokhra APHC

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32. HSC Baramuri

Baramuri SC

33. PHC Teghra Teghra PHC

34. HSC

Kasavarain Kasavarain SC

35. APHC Simaria

Simaria APHC

36. PHC Barauni

Barauni PHC

37. APHC

Phulwaris Phulwaria APHC

38. SDH Balia Balia SDH

39. HSC

Barbighi Barbighi SC

40. HSC Bagatpur

Bagatpur HSC

2 Kishanganj 1 DH Kishanganj DH

2 HSC Maheshbathna HSC (Delivery

point)

3 AWC Maheshbathna Anganwadi

Center Ashiana Begum (AWW)

4 PHC Terhagachh Block PHC 5 HSC Gamarhia Sub Center 6 HSC Jhala Sub Center Ruby Kumari (ANM)

7 AWC Jhala Anganwadi

Center Kumari (AWW)

8 Village visit Gamarhia Anganwadi

Center Sarita Kumari

9 PHC Pothia Block PHC 10 HSC Chhatargachh HSC 11 HSC Mirzapur Sub Center

12 AWC Bada Paka

Mana Anganwadi

Center Rita Devi (AWW)

14 PHC Bahadurganj Block PHC

15 HSC Mahadev

Dighi Sub Center

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16 AWC Khajurwadi Anganwadi

Center

17 HSC Bargarhiya Sub Center

AWC Bargarhiya Anganwadi

Center Puja Kumari (AWW)

18 M.G.

Medical College

Kishanganj Private Medical College

19 ANMTC Kishanganj ANM Training

School

20 Surya Clinic Kishnaganj Private clinic –for FP/MTP;

Janani