5TH COMMON REVIEW MISSION

Gujarat- 8th-15th November 2011

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Common Review Mission

8th- 15th November 2011

GUJARAT

Dahod Team Rajkot Team

Dr.Manisha Malhotra, AC-MH, MoHFW

Mrs.Anuradha Vemuri, Director, MoHFW

Dr.Prabha Arora, JD, NVBDCP

Dr.Vikaram Rajan Senior Health Expert, World bank

Dr.Parminder Gautam Senior Consultant, NHSRC

Vd. .Smita Bajpai Coordinator,RRC-CHETNA

Dr.Arpana Kullu Consultant- NRHM, MoHFW

Mr.K.Kaushal FMG, MoHFW

Dr.Mahaveer Golecha PHFI

Regional Office

Dr.Jai Karan Regional Director, Ahemdabad

State Officials

State Officials

Dr.Prakash Waghela Assistant Director, Family Welfare

Dr.N.B.Dholakia Deputy Director, Family Welfare

Ms.Shika Bansal, Programme Officer-Planning

Dr.Kiran Narkhede Programme Officer-Planning

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LIST OF ABBREVIATIONS

AFHS : Adolescent Friendly Health Services

ANC : Ante Natal Care

ANM : Auxiliary Nurse Midwife

ASHA : Accredited Social Health Activist

AWC : AnganwadiCentre

AWW : Anganwadi Worker

BCC : Behaviour Change Communication

BPL : Below Poverty Line

CDHO : Chief District Health Officer

CDMO : Chief District Medical Officer

CDNC : Child Development and Nutrition Centre

CHC : Community Health Centre

CEmOC : Comprehensive Emergency Obstetric Care

DH : District Hospital

DLHS : District Level Household Survey

ECP : Emergency Contraceptive Pill

EmOC : Emergency Obstetric Care

FGD : Focus Group Discussion

FP : Family Planning

FRU : First Referral Unit

HB NC : Home based New born Care

GoI : Government of India

IEC : Information, Education and Communication

IMNCI : Integrated Management of Neonatal and Childhood Illnesses

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IMR : Infant Mortality Rate

IPC : Interpersonal Communication

IPHS : Indian Public Health Standards

IUD : Intra Uterine Device

JSY : Janani Suraksha Yojana

LSAS : Life Saving Anaesthesia Skills

MH : Maternal Health

MMR : Maternal Mortality Ratio

MoHFW : Ministry of Health and Family Welfare

MOs : Medical Officers

MPW : Multipurpose Worker

MVA : Manual Vaccum Aspiration

NRCs : Nutritional Rehabilitation Centres

NRHM : National Rural Health Mission

NSSK : Navjat Shishu Suraksha Karyakram

NSV : Non Scalpel Vasectomy

PHC : Primary Health Centre

PIP : Programme Implementation Plan

PNC : Post Natal Care

PRI : Panchayati Raj Institutions

RCH II : Reproductive and Child Health, Phase II

RKS : Rogi Kalyan Samiti

ROP : Record of Proceedings

RTI : Reproductive Tract Infection

SBA : Skilled Birth Attendant

SC /ST : Schedule Castes and Scheduled Tribes

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SN : Staff Nurse

TFR : Total Fertility Rate

VHND : Village Health and Nutrition Day

VHSNC : Village Health Sanitation and Nutrition Committee

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INTRODUCTION

Demography

Gujarat is characterized by sea-coastal, tribal, desert and geographically hostile terrain having sparse and scattered population at the periphery. Administratively, the state has been divided into 26 districts, sub-divided into 172 blocks, having 20,738 villages and 242 towns. The population of the state is 6,03,83,628. There are 6 high focus districts in the state.

Population 6,03,83,628

Population between 0-6 years 74,94,176 (12.41%)

Percentage Decadal Growth Rate 19.17%

Percentage of Urban Population 42.58%

Population Density 308

Literacy Rate 91.83%

Sex ratio 918

Child Sex Ratio 886

Source: Census 2011

Status of Key Health Indicators

Sl. No Indicators Gujarat India

1 Infant Mortality Rate (SRS* 2009) 48 50

2 Maternal Mortality Rate (SRS 2007-09) 148 212

3 Total Fertility Rate (SRS 2009) 2.5 2.6

4 At least 1 ANC (CES** 2009 ) 94.8% 89.6%

5 Full ANC (CES 2009) 45.75% 26.5%

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6 Institutional Deliveries (CES 2009) 78.1% 72.9%

7 NLEP Prevalence Rate/10,000 0.79 0.71

New case Detection during 2011-12 1846 33207

8 NPCB No. of Cataract Surgeries (in lakhs) 2011-12 1.70 7.96

9 RNTCP

Annualized new smear Positive cases detection Rate 79% 70%

Success rate of new smear positive patients 88% 87%

*SRS – Sample Registration Survey **CES – Coverage Evaluation Survey 2

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5th Common Review Mission - 8th - 15th November, 2011

Complete list of facilities visited by the Teams 5th Common Review Mission

Name of the State- Gujarat

S.No. Districts Visited Names of the CDHO

1. Rajkot Dr.Sanghvi

2. Dahod Dr.Dhanlaxmi B. Rathore

Health facilities Visited

S.No. Facility Location Level Person Incharge 1. District Hospital,

Padamkunvarba Hospital

Rajkot District hospital

Dr. Rupali Mehta, CMHO, Civil Surgeon

2. District Hospital Dahod Dr.Patel-CMHO, Civil Surgeon

3. Morbi Sub District Hospital Rajkot Sub district Hospital

Dr. Dudreja (MS) 4. Sub District Hospital,

Jetpur Dr. Sukhanand

5. State Hospital, Devgarh Baria

Dahod Dr.V.K.Jain,

Superintendent

6. Raj Shobag Satsang Mandal,Saila CHC,Surendranagar PPP Model

Rajkot CHC Dr. Maytra, MO

7. CHC Jhalod (designated FRU)

Dahod Dr.I.N.Singh- MO

8. CHC Limkheda Dr.Satish Azad, MO 9. PHC Rajpar Rajkot PHC Dr. Bavrana, MO 10. PHCKhankhrechi Dr. Bhaven Bhatti, MO 11. 24x7PHC Gomta Dr.C.K.Ram,MO 12. PHC, Khirsara NABH

Accredited Dr. Mahendra Rathod, MO

13. PHC Bordi Khurd, Dahod Dr.Hemant Vahoriya 14. PHC Panchvada Dr. Hiral Desai, MO 15. PHC Bandibar Dr. Vinod Goswami,

MO

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16. Thorala Sub Center Rajkot SHC

17. Makansar Sub Center Geetaben FHW

18. Ambardi SC Muktabehn, FHW

19. Vadmajari SC Gulabbehn, FHW

20. Sub Health Centre Dungarpur

Dahod Machari Ellis, FHW

21. Sub Health Centre Thanda Hansa Ben Parmar FHW

22. SHC Agara U.N.Baria, FHW

Chiranjeevi & Bal Sakha Facilities

S.No. Name of the Facility Location Person In Charge 1. Vatsalya Hospital Rajkot Dr. Padmabehn Kunpara

2. Shri Ram Hospital Trust Hospital Dr. Vikram

3. Goyal Hospital Dr. Hitesh Kalria

4. Santok Bai Maternity and Children Hospital Dahod

Dahod Dr. Sneha Mandowra

5. Neil Maternity Home, Limkheda Dr.Rohit Sanghani

S.No. Name of the Institutions Location Person In Charge

1. State Institute of Health & Family Welfare

Ahemdabad Dr.Gandhi

2. College of Nursing, Civil Hospital Ahemdabad

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Key Findings

I. Health Infrastructure

The health infrastructure available in the state and districts visited are given below-

Health Institutions Gujarat Dahod Rajkot

District Hospital 24 1 1

Sub District Hospital 26 1 5

Community Health Centre 318 11 15

Primary Health Centre 1152 65 46

Sub Health Centre 7274 332 330

Mobile Health Unit 88 1 1

Chiranjeevi Providers 646 17 32

Bal Sakha Providers 267 6 12

The state has established a PIU (project Implementation Unit) which is a nodal

agency for the infrastructure development in the State. This has helped in reducing

time in getting approvals and completion of projects as compared to when other

government agencies like PWD is involved.

Monitoring of the execution system for infrastructure development is done by the

Health Commissionerate in association with the state health ministry department who

overlook at the adequacy, time-schedules, effectiveness, and constraints issues

Currently, there are 60 SHCs, 4 PHCs and 4 CHCs are under renovations in the state.

Under Family Friendly Hospital Initiative (FFHI) many patient friendly initiatives

were taken i.e. stay and cook facilities for the patient relatives,

In the year 2010-11, total 31 Govt. Health Facilities (5 DH, 7 CHCs & 19 PHCs) got

FFHI accreditation.

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There are 163 designated FRUs in the state. However, all the designated FRUs are not

operational as per guidelines. 119 FRUs out of the total designated FRUs are fully

functional as per guidelines.

In Dahod, there are 4 designated FRUs in the district out of which only 2 (DH and

State Hospital, DevgarhBaria)are completely functional as per norms and the other 2

CHC Limkheda and CHC Jhalod are not conducting C-Sections. Whereas, in Rajkot,

Out of the 9 FRUs, only 4 are functional mainly due to shortage of specialists.

II. Human Resource

Current Status of Human Resource in the State

Sanctioned In Position

Gap Gap % Regular Contractual

Human Resource in DH/SDH

Specialist

Doctors 718 273 8 437 60.9

Nurses 1891 1391 - 500 26.44

Pharmacists 373 241 53 79 21.17

Lab technicians 136 65 69 2 -

X-Ray

technicians 78 38 5 35 44.8

Human Resource in CHC/PHC

Doctors

(Allopathic) 3208 2494 - 714 22.25

AYUSH Doctors 919 0 886 33 3.6

Human Resource in CHC

Lab Technician 388 207 47 134 34.5

Pharmacist 382 268 70 44 11.5

X Ray

Technician 330 168 0 162 49

Staff Nurse (CHC 2162 1475 65 622 28.9

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& other Centre)

Human Resource in PHC

MPHW (Male) 7203 4720 0 2483 34.47

ANM 6991 6045 415 531 7.59

Pharmacist 1149 675 420 54 4.69

Lab Technician 1149 725 278 146 12.7

Staff Nurse 715 (PIP

Sanctioned) 0 453 262 36.64

Shortage of human resource is one of the biggest challenges faced by the state,

particularly specialists, obstetricians & gynecologists, pediatricians and anaesthetists.

51% positions for medical officers and 69% positions for specialists in Dahod and

53% positions for medical officers and 63% positions for specialists in Rajkot are

lying vacant.

Retention of human resource especially specialists in the districts like Dahod is an

area of concern and has resulted in high attrition rate.

Low remunerations for both regular and contractual medical officers and specialists

offered by the public health system as compared to private were observed in both the

districts. And it has become demotivating for health providers to work in tribal

districts like Dahod. There are no additional allowances given to health providers for

working in these underserved areas.

Lack of career progression opportunities for MOs in order to retain them in the public

institutions.

There was lack of definite plan for rational deployment of skilled human resource in

the district to ensure services in the high case load facilities. Redeployment of staff is

done as per need involving part time services at facilities. HR capacity augmented

through PPP with private trusts Eg.lab technician and pharmacist. Pharmacist at SDH

Jetpur is on deputation from Red Cross Society.

Mainstreaming of AYUSH

There are currently 886 AYUSH doctors against 919 sanctioned positions in the state.

Due to shortage of MBBS doctors some PHCs are run managed by AYUSH doctors

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who are conducting normal deliveries even if not SBA trained. Eg PHC Panchwada

and Bandibar in Dahod and PHC Khirsara, Rajpar,Gomta in Rajkot.

AYUSH doctors are managing the National Health Programmes extremely well.

Knowledge of the programmes, surveillance activities, education/awareness provided

to the community is admirable and records wererecords were well maintained.

o AYUSH doctors were found to be managing PHCs independently; they are not co-

located with Allopathic doctors. They are utilized as substitutes for Allopathic doctors

rather than promoting AYUSH and providing people with alternative Indegenious

system of medicine.

The services delivered by AYUSH doctors includes OPD, conducting deliveries,

training of ASHAs, ANMs, FMPW, MPWs, outreach activities and management of

National Health Programmes.

They have received orientation training on National health programme during

recruitment and have not received any training on SBA and IMNCIAYUSH doctors

were found to be motivated and using their skill sets to the best of their ability. During

FGDs community rated the services delivered by AYUSH doctors to be highly

satisfactory.

Utilization of AYUSH systems-

o In Dahod, AYUSH doctors were found to be hardly practicing their own system of

medicines. Less than 2% of patients were availing the traditional system of medicines.

In the district. Although, being tribal local population have preferences for

Ayurvedica (herbal) medicines

o In Rajkot, Ayurved and homeopathy was also reported to have a sizeable demand.

The doctors reported excellent results in conditions such as arthritis, hyper acidity . It

was observed that these facilities are faced with a shortage of supplies from the state

level in the district inspite of demand for the same.

There was no evidence of any IEC for mainstreaming AYUSH, promotion and

education about AYUSH system was not displayed at any of the facilities visited.

.

ASHAs have not received any training on AYUSH. No AYUSH medicines are

provided in ASHA drug kit.

AYUSH doctors were concerned about their unpredictable future because of their

contractual status and low remunerations without any increments.

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Pre- Service Training Capacity

Medical Education

Current status of Medical College in the state is as below

Colleges No. of Institutes Number of seats

UG PG

Medical 16 2380 1383

Dental 12 1080 90

Physiotherapy 25 1305 77

Nursing 23 1210 75

Gujarat Medical education Research Society (GMERS) has been set up in September

2009 as a registered society under the Societies Registration Act, 1860

State Government has planned to establish seven New Medical Colleges as

Self-financing institutions under GMERS at Sola (Ahmedabad), Gotri(Vadodara),

Gandhinagar, Patan, Valsad, Vadnagar & Junagadh

Shortage of specialists in Rajkot district was observed inspite of having a Medical

College in the district.

ANM Training institution

Status of Training Institutions in the state are given below

Institution Number

Regional Public Health (Nurse) Training Institute 1

Female Health Supervisor Training Schools 2

Female Health Worker (FHW) Training Schools 26

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MPW Male Training Schools 5

College of Nursing, Civil Hospital, Ahmedabad was visited. It was located in the

premises of Civil Hospital, Ahemdabad. The college has 6 centres across the state ,

namely Ahemdabad, Baroda, Surat, Bhavnagar, Rajkot and Jamnagar.Total intake of

these 6 centres is 130. Except for the centre in Jamnagar which has an intake of 30 the

rest of the 5 centres has an annual intake of 20. The college runs several courses like

Public Health Nurse, Psychiatric Nursing and Post- Basic in Nurse Practitioner in

Midwifery.

The Post- Basic Course in Nurse Practitioner Midwifery is one of the recent initiatives

to train ANMs & GNMs in midwifery skills. Duration of the course is one year and

during the course the students undergo practical training under the supervision of

gynecologists. This course is mainly meant for enhancement of midwifery skills.

There is a provision of self financed admissions to this course also, 60% of the seats

are for ANM/GNMs serving in government institutions (DH/CHCs/PHCs). Currently

there are only 28 students enrolled and in the previous year only 14 were enrolled.

There seems to be a declining trend in the intake into these courses over the years.

Many candidates do not want to join this course as they do not have any additional

monetary incentives after the course. And in previous years after completion many

students have joined big hospitals instead of serving in rural areas. Further, one of the

nurses trained in the Post Basic course was posted in the District Hospital Dahod and

was found to possess good skills and knowledge..

State Institute of Health and Family Welfare-

• SIHFW, is located in Gandhinagar. SIHFW has been recognized as one of the Nodal

& Collaborating Training Institute (CTI) for planning & implementation of RCH-II

training Programmes. The institute provides an umbrella support to HFWTC-1,

Divisional Training Centers-4, District Training Teams-17, Regional Public Health

(Nurse) Training Institute-1, Female Health Supervisor Training Schools-2 and

Female Health Worker Training Schools-26. It also works as a link between NIHFW,

New Delhi and the State and in turn to HFWTC, DTCs DTTs, RPHTI, FHSTs &

FHWs School.

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Currently the institute is facing difficulties due to frequent shifting of premises

and poor infrastructure and there is no provision for accommodation for trainees. The

residential trainings are conducted in Infocity, Gandhinagar. The institute has 1

Director, 2 Associate Professor and 3 Medical Officers. The institute also has an

additional responsibility of screening and admission of candidates for pre-service

ANM & GNM schools which takes away 2-3 months of their time from their core

work of conducting trainings.

In Service Training

The status of training in the state is as given below-

TRAINING MO ANM Staff Nurse LHV

IUCD 796 6081 - -

NSSK 1132 3249 1392 314

SBA 2506

IMNCI 1728 5970 793 819

F-IMNCI 117 - 14 -

CeMOC 69 - - -

LSAS 96 - - -

MTP/MVA 1394 - - -

NSV 227 - - -

Minilap 284 - - -

CCSP - - - -

Laproscopy 916 - - -

AFHS 752 5507 - -

RTI/STI 541 4763 - -

INDUCTION

M.O

191 - - -

AYUSH 500 - - -

Hospital

Management

278 - - -

CCC/ CCC+* 447

Immunization 529 6574 40

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HBNC (TOT) 62 1 Batch all districts have completed HBNC

sammelan)

*In service training on computer application essential for the doctors in the state

NSSK and IMNCI training has been done in significant numbers across the state and

post training follow up for IMNCI is being conducted by SIHFW.

Training of doctors on LSAS and CEmOC is one of the areas where the state requires

improvement. In Dahod there was no LSAS doctor in the district and only one

CEmOC doctor was placed in the State Hospital Devgarh Baria who has not used his

skills after his training since last 3 years.

Steps taken to augment capacity of training institutions

• Four New FHW schools taken up by GOG through new item in the budget.

• One model ANM school at Sachin, Surat taken up by GOG through new item in

the budget.

• Special budget line for infrastructure strengthening and audio visual aids provided

in PIP of each year under NRHM to all the training institutes.

• Appointment of principals, warden, nursing tutors at these institutes taken up

through walk-in-interview.

• Teaching staff of these institutes of all cadres are regularly trained, oriented,

refreshed through various training & workshops.

• Training skill evaluation was done at SIHFW for majority of the faculties under

its training centers/ schools.

• Formative evaluation of training schools / institutes are done on regular basis in

review meetings.

• Monitoring visits done at training centre level and feedback from trainees

obtained to improvise the lacunae.

Plan for Augmentation of Health Human Resource

The State initiatives undertaken for bridging the gaps included the following –

Enhancement of retirement age to 65 for doctors, nurses and other categories.

Contractual appointment of specialists and Medical Officers.

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Appointment of staff nurses from other state institutions.

Walk in interview every Monday/Tuesday for MOs / Specialists.

Outsourcing of paramedical staff.

For Professional development staff is sent to various workshops all over country.

On The job training to doctors, nurses and paramedical staff.

HR capacity augmented through PPP with private trusts Eg.lab technician and

pharmacist. Pharmacist at SDH Jetpur is on deputation from Red Cross Society.

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

Case loads and Service Delivery

There has been a progressive increase in the OPD and IPD services in the mission

period. The data is given below-

Year

Total Annual

OPD in the

State (Medical

Service Data)

Percentage

increase of

OPD over

previous year

Total annual

In-Patient

admissions in

the State

Percentage

increase of

IPD over

previous

2005-06 8722040 0.56% 1527890 2.67%

2006-07 8848330 1.44% 1603445 4.94%

2007-08 9615925 8.67% 1637025 2.09%

2008-09 10216350 6.24% 1662210 1.53%

2009-10 10613105 3.88% 1664765 0.15%

2010-11 11602985 9.32% 1679730 0.89%

The Chiranjeevi Yojana (CY), is one of the PPP initiatives by the state government to

involve private providers in conducting deliveries as there is an acute shortage of

doctors in public health facilities. Currently there are 646 CY providers in the state.

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As per the data provided the state uptill now 612495 deliveries have been conducted

in the CY facilities across the state. 6.2% C-Sections have been conducted by them

and 4.9% complicated deliveries including ruptured uterus, eclampsia etc.

The public health facilities (PHCs/CHCs/SDHs) through endowed with infrastructure,

equipments and supplies were generally found to be underutilised. However

Makansar Subcenter in Rajkot District is an exception as 220 deliveries were

conducted in 2010-2011; More subcentres providing delivery services have been

reported by the health authorities during the visit.However, there was absence of a

clear cut strategy of strengthening of sub centres based on case load . CHC Jhalod in

Dahod also has a good case load of about 300 deliveries per month.

In Rajkot District Hospital,in the absence of ultrasound facilities and blood bank,tie-

up with private providers for the services have been undertaken.Similarly in Morbi

Sub District Hospital due to non-availability of pathologists,linkages with private

blood bank has been taken up.

However, CY facilities in the vicinity of the public health facilities are taking the bulk

of the case load. Eg. CHC Limkheda, Dahod has shown a declining trend of number

of deliveries from 2008-09 (10 del per month) when no CY facility was registered in

the area to less than 5 deliveries per month after registration of CY facility- 2 ½ years

back which conducts 470 deliveries per month.

In Dahod, from April to September 2011, 3936 deliveries were conducted at 13

Chiranjivi facilities against 789 at 67 Public institutions. At State Hospital Devgarh

Baria, one full time Gynecologist and one CEmOC trained medical officers are

available and only 2 LSCS are performed every month.

Chiranjeevi Yojana facilities were found to be overcrowded due to high case load and

the infrastructure being grossly inadequate, the patients were found sitting outside

wards.

Chiranjeevi Yojana and Bal Sakha doctors have forged partnerships in ownership of

the same premises. In one of the CY facilities visited, there were two separate

premises housing the Obstetrician-Gynaecologist and Pediatrician and delivered

beneficiaries were being shifted from one premise to the other after 12 hours.

Despite the good skill sets of some of the CY doctors it is not possible for them to

provide quality care given the constraints of infrastructure and support staff which

often consists of ‗Dais‘ and class 12 pass staff trained on the job.

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Ensuring 48 hr stay after delivery in CY facilities is a weak area due to space

constraints and unwillingness of the clients. Sometimes beneficiaries are also advised

discharge within 8-10 hrs by CY providers.

Services at the Health Institutions

Labour Room: Labour rooms were found fully equipped with functional new born

corner. State may relook into their policy of providing radiant warmer and paediatric

suction machine to Additional 24 x 7 PHCs, particularly those conducting deliveries

eg. PHC Panchwada. Relocating equipments from little utilized facilities like CHC

Limkheda (which had 3 radiant warmers) should be considered. No foot suction,

suction bulb, mouth suction was found at PHC Paanchwada. In Makhansar SC,Rajkot

there is a high case load of deliveries(approx..200 in 2010-11) ,a baby warmer would

be more safe compared to the naked bulb currently in use for the purpose. There

were no batteries in laryngoscope. Practice of using partographs to monitor the

progress of labour was not evident except in District Hospitals of Dahod and Rajkot.

Accident and Emergency: Shri J.S. Chauhan State General Hospital Dev Garh Baria

has a dedicated and 24x7 functional Emergency Department which is easily

accessible from the main entrance. It is fully equipped with life saving equipments

and drugs. At district Hospital Dahod there is no dedicated area to treat, observe and

stabilize patients coming for emergency treatment. Patients are registered in separate

building and then have to follow a Zig-zag path to reach main building housing indoor

facilities. Treatment could only be started once patient reaches the respective

ward/Mini ICU. At times, this undue delay in initiation of the treatment may be fatal.

Current area designated as Emergency does not have life saving equipments (Oxygen,

suction, Defibrillator, cardiac monitors, pulse oxymetere etc) and drugs.

Upkeep and Cleanliness: Sub centers and PHCs visited were found to be reasonably

clean. Cleanliness needs to be improved at District Hospital Dahod and State General

Hospital Devgarh Bari. Toilets in the wards were found clogged and dirty. Stray

animals (cows, dogs and goats) were found roaming inside the hospital premises.

Heaps of garbage with coconut shells, food leftovers, plastic cups were found

scattered throughout the premises.

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Biomedical Waste Management:

• The state has outsourced health care waste management to Govt treatment

facilities which will cover district hospitals, SDH and CHCs health centers in a

phase manner, though there was segregation of waste being observed in many

facilities, it was variable across. The lower level facilities and relatively newer

staff were not observing safe needle disposal practices. Use of deep burial pits

and sharp pits were observed. Use of safety clothing for health workers managing

the waste (storage and disposal) were not observed. Training and retraining of

staff in HWM practices needs to be done.

• Biomedical waste is not being handled as per Biomedical waste handling Act

1998. Mixing of waste and mismatching of Bins and liners was also observed at

all the facilities visited. 1% sodium hypochlorite solution is placed in liners at

State General Hospital Devgarh Baria Staff is not fully aware about biomedical

waste management. Facilities which are not provided with outsourced CTF

(Common Treatment facilities) have not deep burial pits. Placenta is either being

thrown in open spaces or put in shallow pits. Sharp pit and deep burial pit is

under construction at PHC Panchwada.

Availability of Drugs: Supply of Drugs and disposables were found to be adequate at

all the facilities visited. Essential Drug list was available. (but not displayed publicly

in the hospitals and health facilities at Rajkot Facilities were able to cope with the

minimal shortages whenever encountered with the help of RKS fund. Injection

Atropine with Expiry date of 06/2011 was found in the emergency tray of Labour

room of PHC Bordi Khurd. There was evidence of shortage of IFA tabs at one

facility.

Ancillary services:

• Two meals are provided to patients. Only Normal and liquid diet is provided. Diet

is not provided as per patients‘ requirements; e.g. diabetic diet, renal diet, high

protein diet, low salt diet etc. Diet is distributed in closed buckets without any hot

trolleys. At PHCs diet is provided with the help of self help groups.

• In Rajkot, Meals are being provided to patients in DH and SDH. Diet is

distributed in tiffin boxes supplied by the local MP at Morbi SDH .Charitable

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groups also provide food to the patients attendants, free of charge. In Gomta

PHC (24x7), the MO informed that tiffin services were available to patients on

payment basis

Laundry services: laundry services are in house. All the beds were found with clean

linen. Linen is changed daily or as and when required. 3 to 4 sets of linen were found.

Display of IEC and Signages- Citizen charter: with service guarantee was displayed in

Guajrati at all facilities visited.

IEC on JSSK was displayed at all facilities and some places excellent IEC on health

were displayed eg PHC Panchwada.

Quality cell

The state has instituted a quality assurance cell and has created district level quality

assurance cell, a probable first of its kind in the country. The quality cell is mandated

to improve quality of care in public sector facilities using tools such as accreditation.

15 facilities including 2 district hospitals, 5 blood bank, 2 labs, 6 PHCs and 1 F & D

lab have received accreditation so far. A total of 89 facilities of various types have

been identified for accreditation.

Status of Accredited Institutes in the state are given below-

Sr. No. Type of Accreditation (NABH /

NABL)

Total no.of

Accreditation

1 NABH Hospital 2

2 NABH Blood Bank 4

3 NABH CHCs and PHCs 6

4 NABL Hospital Laboratory 2

5 NABL Food & Drug Laboratory 1

Total 15

The State Quality Improvement Programme under which facilities are undertaken for

accreditation are as follows-

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Name of the

Facility

Total Facility

Under NABH

/NABL

Pre

Assessment

done

Facilities under

Process for NABH/

NABL

District Hospital 15 3 7

Medical college,

Blood bank 6 0 1

Medical college,

Laboratory 6 1 3

Mental Hospitals 2 0 0

Dental Hospitals 2 0 2

Paraplegia

Hospitals,

Ahemdabad

1 1 0

Primary Health

Centre 29 4 19

Community

Health Centre 26 0 26

NABL Food &

Drug Laboratory 2 1 0

The Rajkot team visited an NABH PHC that had been newly constructed. The

efficiency and quality of service delivery including the skills of staff in the various

sections of the PHCs, OPS, Pharmacies, lab etc. was evident. The patient satisfaction

observed was exceptionally high and overall facility cleanliness was impressive.

There was transparency of all facility related information as well as complain

handling system in place. The areas that can be further improved are clinical diagnosis

and rational use of drugs. The state can consider some form of capacity building and

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training in these areas. In terms of general RCH services the skill of the staff

including nurses and doctors was satisfactory, while SBA training has been provided

to CHC level and below. It would also be useful to train staff nurses in district and sub

district hospital as they have the highest load of public sector institutional deliveries.

Equipment‘s and drugs for these services were also found to be in place. In the Rajkot

district hospitals the team found the protocol to manage the complicated deliveries as

well as partograph to monitor labour. There was good knowledge among the staff

nurses on protocols related to service delivery, infection control and waste

management. The Obst. In-charge was mostly responsible for this and it would be

useful to identify such people in each district to work with the respective QA cell to

improve and standardized quality of OBST and Neonatal care.

It is heartening to learn that Gujrat has adopted the highest available standards i.e.

NABH and NABL for accreditation of Public health facilities and has maximum

number of NABH and NABL accredited Public Hospitals and Laboratories. There are

few concerns on this approach. First and foremost is facilities which are being taken

up for NABH accreditation are those which already have better infrastructure and are

functioning well. Remote and tribal areas like Dahod contributing decidedly for high

IMR and IMR are completely neglected. As a result good facilities are becoming

better and bad, worse. On one hand there are NABH accredited hospital with

excellent infrastructure, Policies, procedures, Practices and outcomes and on the other

hand place like DH Dahod are without functional Accident and Emergency

department, compromised level of cleanliness, Burn wards without isolation, and

Autoclaves with faulty gauges. Second issue is the cost involved for both

implementation and ssustenance is mammoth, which can not be afforded if all the

facilities are to be accredited. furthermore, for attaining accreditation even the core

services like Nursing, Doctors, specialists, biomedical engineers etc are out sourced.

This further raises question mark on sustenance of accreditation. Thirdly, core

activities of Public Health e.g. National Health Programmes, Community

participation, Preventive and Promotive aspects, Public Health Planning and

administration are not part of the standards adopted by the state. Considering all these

facts, state may like to adopt a more comprehensive approach for Quality Assurance

and improvement with focus on universal coverage. This can be done simultaneously

25

with the existing approach. Whilst some facilities are undergoing accreditation,

others could be prepared for the same. State may like to Grade all Public Health

facilities from Sub centre to Medical Colleges against State specific Standards. State

may develop their own standards incorporating-IPHS, lessons learned from NABH

(what works and what not) and National Health programmes. The grading will help

state in identifying HIGH Focus facilities where maximum interventions are required.

No accreditation or quality improvement process is undertaken at Dahod. At Dahod

District Quality Cell is represented by Block Health Officer (Dr. Pahadia). There were

no activities undertaken to measure, evaluate or improve quality of services. There

were no meetings held by the cell.

The existence of Grievance Redressal Cell was not very evident in the two districts

visited.

Utilization of Untied Grants and Annual Maintenance Grants- the Untied grants are

utilized for various activities at the facilities which include local purchase of drugs,

medicines and consumables, minor civil works etc.

Rogi Kalyan Samiti meetings are regularly held and funds to all Samitis are disbursed

from the state to below. Further the PHCs and SHCs receive funds from the District

Health Society whereas funds to the CHCs are through the Regional office in the

state.

IV. Outreach services

Sub Health Centre Functioning- There are 7274 Su Health Centres in the state out of

which 2062 are not functioning in government building without paying rent. In

Rajkot, Ambardi SC was operating from anganwadi centre as the SC building was not

built.

In Rajkot, an inventory of migratory labour population (Vadivistar) has been drawn

up with telephone numbers of the land owners. Outreach sessions require to be more

streamlined as the population have no records of immunisation services, BPL card etc.

MAMTA DIWAS (VHND)

They are being conducted very well every Wednesday, across the states. It provides

the full complement of ANC, Immunization, PNC and Growth monitoring etc. VHSC

funds are being utilized to provide requisites for Village Health and Nutrition Day.

26

Details of Mamta Diwas are given below-

Particulars Year 2010-11 Year 2011-12 (Apr.-Sept)

Mamta Divas Planned 394448 1,91,343

Mamta Divas sessions

held

384412 (97.5%) 1,86,151(97.3%)

No. of ANC registered 13,82,680 6,87,074

Particulars Year 2010-11

Year 2011-12

(April’11 to

Sept’11)

No of pregnant women with severe

anemia

47569 32065

No. of Antenatal women given IFA

tablet

1197648 (86.6%) 507045 (73.7%)

No. of PNC registered 11,95,845 568812

No. of Postnatal mothers given IFA

tablet

9,56,676 (80.0%) 3,86,223 (67.9%)

No. of Antenatal and Postnatal women

given iodised salt

7,73,558 (30.0%) 4,50,863 (35.9%)

There was an active involvement of all field functionaries, AWW, ASHA and FHW,

along with availability of weighing machine, electronic BP apparatus, nischay kit,

condoms, EC Pills, HIV testing kits, RDT kits for malaria etc.

Mobile Health Units (MMU)-

There are in total 88 MMUs in the state out of which 32 are for tribal areas in the

state. 86 MMus have GPS systems installed in them. The services provided by the

MMUs include, OPD services for minor ailments, immunization, IFA Tablet

27

distribution to mothers and children, ANC TT and referral to health facility for

treatment.

There has been a significant increase in the OPD cases-

Year OPD Cases Attended Percentage increase

2005-06 100122 -

2006-07 171445 71.24

2007-08 431067 151.43

2008-09 622499 44.41

2009-10 627106 0.74

2010-11 625992 -0.18

Referral Transport

EMRI 108 ambulances –

506 Service is currently available throughout Gujarat through the toll free number

108 is available in the entire state which includes both Basic and Advanced Life

Support Ambulances.

Response time in urban areas is between 7-14 minutes and rural areas between 30-45

minutes depending on remoteness

The pre hospitalization emergency care provided by 108 is free and the patient is

admitted to a hospital of his or her choice.

More than 400 hospitals in the state collaborating with EMRI to stabilize the patient

brought in, free of charge. Due to the good road infrastructure in the district extending

upto most of the villages the time taken from home to most facilities has been reduced

considerably.

28

In few areas where motorable roads are not available, Mamta Doli provides means of

transport to the pickup point for 108.

108 bring patients to public sector and CY facilities. However most of beneficiaries

accessing CY facilities arrange their own transport on which the cost incurred is

approximately Rs.300 one-way. JSY component of Rs.200 is paid to each CY

beneficiary. There is no separate arrangement for drop back home from CY facility.

Ambulances from the Red Cross and DH are utilized by CY doctors in case of

referrals.

There are 254 ambulances at CHCs available with the health facilities which are often

utilized for referral from one facility to another.

There are various NGO Grant-in-aid hospital ambulances also available in the state

for referral services in the state.

There are 24 ICU on wheels also available in the state.

V. ASHA Program

The ASHA Program has introduced a fleet of grass root level health volunteers across

the state, who have contributed immensely by improving access of healthcare delivery

system by the community.

There are 29055 ASHAs selected against a requirement of 33358. However concerns

were expressed regarding selection of ASHAs in Rajkot, as many were selected by the

health functionaries with little involvement of the community.

402 ASHAs have dropped out of the total selected. The main reasons for their

dropping out are; family problems, social problems, personal reasons and marriage.

All the selected ASHAs in the state are trained uptill 5th module and currently training

in 6th module is under process. In Dahod, module 6 training is ongoing in 2 blocks in

Dahod (218 ASHAs out of the 1494 in the district). In Rajkot out of the 1314 ASHAs

so far 1028 ASHAs have been trained in Module VI

ASHAs feel empowered and confident. They are well trained and aware of their roles

and responsibilities. They have good knowledge and skills to perform functions

efficiently.

Knowledge and skills of ASHAs were evident during the FGDs .There was a

significant level of trust amongst people and in case of information required about

health services they often approached them for advice.

29

Books were available with all the ASHAs in Gujarati which were easy to understand.

29055 ASHAs in the state have been given drug kits. During interaction drug kits

were available with ASHA‘s and they were aware of their use as well.(This was not

observed in Rajkot)

Incentives are being paid timely through A/C Payee cheques to ASHAs

Records were maintained meticulously by ASHAs which included ASHA Diary (day

to day work record), Malaria, family survey, attendance register, eligible couple

register.

Social marketing of contraceptives program has been launched in the district and

ASHAs have started distributing condoms in the community. However, the Re.1 is

only being taken by the ASHA only if the client volunteers.

One ASHA Ms. Praman Lila was found escorting a patient for general surgery to DH

Dahod, even though she will not get any incentive. This reflects their commitment

and concerns for community.

Janani Suraksha Yojana- The number of JSY beneficiaries‘ has been on the rise

since 2005-06. However, there has been a slight decrease from 356263 in 2009-10 to

353600 in 2010-11 (Source:HMIS). All beneficiaries are paid by bearers cheque.

Payments were being made after delivery however the state claimed that women were

being paid in the 7th month of their pregnancy. Encashment of cheque is yet another

concern as most of the families struggled to get the Rs.500, several months after the

baby was delivered.

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

Maternal Health-

As per the HMIS, in 2010-11 86.7% deliveries have been reported against the

expected number and approximately 14% were unreported. And 89.6%

institutional deliveries have been reported against the expected deliveries in the

state. The same was reflected in the districts visited.

There has been a progressive increase in the institutional deliveries over the

mission period in the state.

Given the high rates of institutional deliveries that take place in private sector and

the difficulty in getting specialist in the public sector. The Chiranjeevi and

Balsakha scheme enable beneficiaries to access MCH services. The increase in

30

institutional delivery is due to the accessing of services at the Chiranjeevi Yojana

facilities and motivation of women by ASHAs.

In spite of registration at the Mamta Diwas often beneficiaries access care late

during labour (at times in late 2nd stage). Many of the do not receive the full

complement of ANC care, as they belong to the ST population who migrate to

Surat and Rajkot and other districts during summer months and do not try to

access care during their stay in these districts.

CY are handling complicated cases including ruptured uterus, obstructed labor etc.

although C-Section rates are not high . C-section rate varied from 10-20% as one

of the hospital was also the referral centre for many other facilities.

JSSK- is advertised in all public sector facilities and all mandated services are

being provided including diet and Referral transport. However, Knowledge of the

entitlements under JSSK among potential beneficiaries requires more efforts to be

undertaken.

CY is a proxy for public sector, but there is no provision for drop back home to

the mother and newborn.

Trainings

In Dahod, There is only 1 CemOC trained doctor and no LSAS trained doctor in

the district. Out of 327 regular and 29 contractual ANMs only 23 are trained in

SBA. One nurse in the DH trained in Post Basic Diploma Course in Nurse

Practitioner in Midwifery. Only one SHC (SHC Thanda) is identified as a delivery

point but the ANM was not SBA trained.

Partograph was only evident at the DH, Dahod where the Nurse Practitioner in

Midwifery was posted. Partograph was being maintained in DH Rajkot.

In State Hospital Devgarh Baria, Dahod 1 CeMOC trained doctor has not utilized

his skills for C-Sections and conducts only normal deliveries, all the C-sections

are performed by the gynaecologist posted since last 6 months.

Even in the high case load facilities except for DH Dahod, PHC Bandibar and SDH,

Devgarh Baria, SBA trained health staff was not present. SBA trained nurses at

Devgarh Baria were not using partograph.

TBAs are no longer active in the community and are gradually fading out.

31

MVA syringes and Medical abortion drugs not available in most of the facilities

visited. Gynaecologist at SDH was not aware of latest Comprehensive abortion care

guidelines and was still using D& C as a method of Surgical Abortion.

Availability of Technical Guidelines to the doctors was found to be an issue in the

district.

Privacy of patients in the labour room of DH Hospital needs to addressed, given that

delivery case loads are high in the facility.

Maternal Death Audit

Although Gujarat has been doing verbal autopsy for some years the process of

MDR has not been institutionalized in Dahod as per GoI guidelines. The DH does

not have an Facility Based Maternal Death Review committee and is merely

reporting numbers to the district with no analysis.

The report of the causes of death shows that postpartum hemorrhage and sepsis

are the leading causes of death. One area of concern is the high percentage of the

deaths that are reported as “others”. Knowledge about causes of death in these

cases varied. The data from maternal and infant death reviews need to be related

to systemic causes of why the deaths take place. The state has identified severe

anemia as a significant cause of Maternal death besides PPH.

However, the orientation of field functionaries on MDR needs to be done and it is

evident that quality analysis and review of maternal deaths is yet to take off.

Copies of MDR guidelines and tools were provided to the CDMO of the DH and

the CDHO of the district. The BHO Dahod however was not aware and in

possession of the GoI guidelines.

Child Health and Immunization

As per HMIS 2010-11, 96% children were reported fully immunised against the

reported live birth in the two districts visited.

There are 31 SNCUs, 14 NBSUs and 296 NBCCs in the state. However, there was

no SNCU in the district Dahod. The DH, Dahod has an NBSU and only one 1

Paediatrician to manage the OP, IP, Labor Room and NBSU case load assisted by

one MO trained in 1 month capsule on new born care. Whereas DH, Rajkot has a

six bedded SNCU and 2 neonatal corners.

32

The sick new borns admitted in the NBSU in DH, Dahod were inhouse deliveries,

sick new borns referred from elsewhere or from the community were mostly

referred to Baroda Medical College hosp.

In the DH, Dahod and across facilities MOs trained in 1month or 4 months

capsule in newborn care (state initiative) and NSSK trained staff including

medical officers and ANMs were present.

Infant Death Audits- District Dahod has reported increase in infant deaths from

171 in 201-11 to 670 in 2011 upto October 2011 The process of infant death

review is not institutionalized yet (absence of GoI guidelines). Neonatal deaths are

being reported from CY facilities and community. Neonatal deaths in the

community are possibly due to early discharge from the CY facilities.

Equipments for ENBC were available in most of the facilities. Relocation of

equipment needs to be done from underutilized facilities. For eg.from CHC

Limkheda which had 3 radiant warmers, one can be relocated to Panchwada

(APHC).

Family Planning

The TFR of the state is high at 2.5. The average number of children in Dahod is 4-

6 in each family. Out of the choice of FP methods, 18% in Dahod and 15% in

Rajkot (all of them are female sterilization and no NSVs) were sterilizations; 32%

in Dahod & 42% in Rajkot , IUDs and to some extent OCs and condoms. Spacing

methods are better accepted by most of the communities (STs & OBCs) in

preference to sterilization.

Post partum sterilization is not accepted except by theVora community. There was

no evidence of Post Partum IUCD being used as a method in any facility.

Social Marketting Scheme has been launched in the district, supplies for condoms,

OCPs and ECPs have reached the district. Training/ Orientation about the

programme has been completed for the distt. & block health officials and ASHAs

as well.

ASHAs are accepting payments of Re.1 only if the client volunteers as they feel

that it affects their reputation adversely. Therefore, in reality contraceptives are

being distributed free.

33

Condom vending machines and availability of condoms at PHCs and SHCs have

not been withdrawn yet; the state has taken this decision to allow till the system of

distribution of condoms gets fully established.

Sterilizations are being done on Thursdays at the District Hospital. Lap Ligations

are performed by General Surgeon at SDH Devgarh baria on fixed days. The

gynecologists have not yet undergone the field component of the training.

VII. Preventive & Promotive health services including Nutrition and Inter-

Sectoral convergence

The state has an actively functioning State Nutrition Cell. The Nutrition Programs

ongoing in the state are as follows-

­ Child Development Nutrition Centre (CDNC) at CHCs and District

Hospitals.

­ Health & Nutrition Day (MAMTA Abhiyan)

­ Iodine Deficiency Disorder Control Program (IDDCP)

­ Vit. ―A‖ regular and Bi-annual Round

­ Adolescent Girls Anaemia Control Program (AGACP) & Mamta Taruni

­ Nutrition Counseling and Rehabilitation Centre (NCRC)

There are 60 CDNCs functional across the state. The activities undertaken at these

centres are as follows:-

­ Severely malnourished children admitted for 10 days

­ Examined by Medical Officer, CHC

­ Children are given nutrition rich food under guidance of nutritionist

­ Mothers counseled on various topics of Health & Nutrition

­ Children are given IFA syrup or tablets, De worming tablet, Multi

Vitamins tablets at CDNC.

­ Children are called at CDNC for follow up visits after 15th day, 30th day,

45th day and 60th day from discharge date.

In both the districts well equipped CDNCs were visited. Human resource at the

CDNCs- Nutrition supervisor, Nutrition assistant, cook cum helper and Ayah were all

in position particularly in Dahod.

34

In district Dahod, CDNC at CHC Jhalod had 10 beds with 9 beds occupied with

children. CDNC occupancy is good. Effective linkages have been established in the

district between the ICDS and Health care system. Eg. Follow up of CDNC treated

children by AWW and growth monitoring.

The linkages between the CDNC and the community are well developed and provided

by the AWW.

A Community Based Nutrition Support called as the Bal Gram Parivar Yojana is

planned to be undertaken in the state to address malnutrition.

­ The program will be owned, run and actively supported by the community

­ A community based approach based on the principle of Positive Deviance

and Demonstrative Feeding. ---The Positive Deviants are mothers of the

same village whose children are well nourished.

­ The mothers feed the malnourished children Three additional nutritious

meals per day for 1 month at the Anganwadi in addition to 2 home diets

and 2 diets available at the Anganwadi.

VIII. Gender issues & PCPNDT

The sex ratio in the state is 918 which is quite low as compared to the national

average of 940. However there has been a 3 point increase in child (0-6 years) sex

ratio from 883 to 886.

Monitoring and inspection of ultrasound Clinincs- At state level, the State Inspection

Monitoring Committee, at district level, District Appropriate Authority & CDHO and

at block by Block Appropriate Authority & BHO at the Sub-district level

In Rajkot, VatsalyaHospital(CY) was inspected for implementation of PC-PNDT. The

board and records as mandated under the act were found in order. The registration of

the clinic was due to expire in December 2011 and the owner informed that she was in

the process of completion of formalities. Most of the F forms revealed self referrals.

To promote gender equality- Dikari Yojana, BCC/IEC campaign named ―Beti

Wadhao‖ (‗wadhao‘ meaning welcome) and advocacy campaigns by involving MLA

and MPs has been carried out by the state.

IX. National Disease Control Programmes

35

RNTCP

The state data indicates that the incidence amongst the pediatric cases is rising;

this aspect needs to be investigated as it could be due to better awareness and

availability of services or due to some other epidemiological cause.

Second medical officer is not there in the DTC of district Dahod. One post of LT

is vacant Out of 38 DMCs, in addition these DMCs are performing additional

task of other programmes as well. The Lab consumables and water facility are

available at the DMCs visited. Laboratory Technicians at the DMCs are 37 in 38

and are doing other microscopy work also.

Gap in capacity building is mainly in the category of MPWs. (25% untrained)

The RNTCP is achieving its targets as per the programme, however new smear

case detection rate is 102% (more than 100 in 5/8 blocks) and total case detection

rate is 73%. the detection from OPD is < 70% (4/8 blocks) probably Indicating

the need of sensitization of MOs in subjecting chest in symptomatic to Sputum

examination).

Treatment success rate in New smear positive case is 90.5%, and in retreatment

cases is 76%.

Default rate in is less than 3%. (more than 6 in 2/8 blocks). default rate in

retreatment cases is 9.5%. The probable reasons of low performance in detection

and default is due to migrant population, and non compliance of the patients. In

addition the patients have to sustain themselves by moving for work related tasks

to other districts and upon interacton with one retreatment case it was found that

the patient dropped the treatment after feeling well and later started visiting the

religious places for getting well, and despite contact from the Programme he only

contacted after around 6 months for retreatment and is now committed to

treatment. There is need to consider providing some family support system for

sustenance so that the patient can take complete treatment.

Visit to Block Jhalod:

DMC was visited. The Quarter wise reports are being prepared and sent to the

DTO.

During2010 the cure rate was 90% and during 2011 in all the quarters it was

between 90 – 93%.

36

Detection rate and defaulter rate during the 1st quarter was 62% and 1%,and

during the second quarter were 86% and 7%.the high defaulter rate probably was

due to festival season. The treated cases could prove to be good DOTs providers

and for generating awareness among the positive cases for improving treatment

compliance and for reducing defaulter rates.

NVBDCP

At the state, district, block and facility level the number of malaria cases

including the number of PF cases are increasing. Some of the reasons mentioned

across were increases migratory population may be carrier of parasite as well as

are more vulnerable to vector borne disease. Secondly, the numbers of

multipurpose male health worker are 60-70% of the sanctioned posts. Third,

while the new malaria treatment policies are being observed in most places. This

is not adhered to in the private sector. Lastly vector control through treatment of

water bodies can be improved. While the identification of these vulnerable

population have been done very well. The strategy and resources for providing

various primary care services (RCH, Malaria, TB) needs to be planned and

implemented effectively. Long lasting insecticide bednets were available in

limited quantities at PHCs and were distributed to ANC mothers and endemic

areas at a priority. These were not being distributed to the migratory population,

as there was no policy to do so.

During 2010, Surveillance in the district is high due probably to two reasons, that

the ASHA incentive for slide examination is being paid in very transparent

manner and the fact that the contact surveey is being carried out for treatment and

follow up of cases. The contact survey data is being added towards ABER thus

increasing the ABER. Overall API is 7.3 and Slide positivity rate is 1.7 and SPR

is highest ie, 4.4 in Borwani ‗ During current year surviellance has further

increased and SPR has declined to 1.3 and in Borwani to 3.4.

Around 50% of the population comprising 3 81 villages is high risk and Synthetic

pyrethroid is recommended for spray. Spray operation was going on.

Drug policy of 2010 is being followed. Drugs are available. SP-ACT combipacks

are available.

37

100000 LLINs have been distributed in 86 high risk villages. LLIN were

distributed and a beneficiary was asked regarding its use. Bed net are being used

and the woman was informed for not washing the LLINs and she along with 2

kids was using the nets.

Block Jhalod: The SPR is increasing from 1.7 in 42nd week to 1.9 in 44 th week

of 2011. Even though Pf cases are on decline

PHC Bordi: line lsiting of malaris positive cases seen. Treatment compliance

forms are being maintained, however the defaulters in Pv are more and therefore

these ASHAs do not get paid for the treatment completion.

All the registers are well maintained.However display of the Malaria microscopy

posters is not there and old drug policy guidelines of treatment of cerebral

malaria is displayed.

PHC Panch wada. PHC is being manned by AYUSH doctor who has been

trained in Public Health Programme and is managing the programmee well. The

surviellance has increased by around 33% and cases of P f malaria have

increased by 50% as compared to previous year. Increase is practically seen in all

the villages of the PHC

Innovation: Jute balls called ―TADA‖ soaked in used Engine Oil are placed in

all pits. When pits are filled with water the oil from the jute balls made from

―Taad-Patti‖ disseminate in the pit and forms a thin layer on the top. When the pit

dries the same oil get absorbed in the jute ball.

NLEP

PR of Leprosy is more than 1 in 4/8 Blocks.

Leprosy Cell at District Headquarter is manned by the trained DLO and one

Medical Officer, one post of State Leprosy Supervisor, medical officer each and

23 posts of Leprosy assistant are vacant. No assistance is received from ILEP.

The district has achieved activities of around 25% against the action plan for the

year 2011-2012.. Action plan for year 2012-2013 has to be prepared yet. Case

detection activities have continued but the IEC activities have not been up to the

mark as funds were released during the month of August. 2011.

Annual New case detection rate has remained in the range of 40 – 34 per 100,000

population

38

Treatment completion rate in urban areas is 100% nad above 99% in MB and PB

cases.

Coordination with NRHM on release of funds, reports, meetings and for holding

the IEC and Health camps for detection of new cases is being done.

Out of 63, 48 MO PHCs are trained in Leprosy.

There is no orthopedic or skin specialist at the Distt HQ for specialized case for

the cases requiring referral. However skin specialist comes to the Hospital twice

a week.

SSG hospital Baroda is designated for tertiary care of the cases. 12 reconstructive

surgeries have been conducted during 2010 and 5 during 2011.

Total beneficiaries of Microcellular rubber footwear are 429, so far 650 have

been given and 128 is balance with the Programme, and procurement is under

process.

PHCs send the indent based on the requirement and District sends quarterly

indents for requirement.

ASHAs are being paid incentive upon diagnosis of a case of Leprosy but not upon

bringing suspected cases of leprosy to the PHC for examination. 43 ASHAs have

been paid incentive for detection of case, and 23 have been paid upon completion

of treatment (14 PB and 9 MB cases).

Bandibar and Limkheda PHCs were visited for the Programmatic activities. In

jhalod MB cases have increased and PB cases have decreased due to increas in

suspec cases being identified. The PR has marginally declined from 1.68 in 2010

to 1.65 in 2011-12.

Sub centre AGARA Case follow up action is being taken up. Records are with the

Leprosy Supervisor. MPW Mr. Christian Amit is new and is yet to be trained in

Leprosy

IDSP

IDSP unit is established at the District Headquarter.

In the district during the year 2010 3 out breaks were reported and got

investigated by the AIHPH Kolkata.

Data collection from the District hispital is not routinised activity, the Programme

officers have to personally collect the data from the hospital Pathologist/Lab.

39

The Laboratory surviellance needs to be improved by routinisng the activity

along with the details of the cases detedted so that appropriate follow up

measures could be taken up in timely and effective manner by the RRTs and the

Programme divisions.

There has been improvement in S form which is due to the lack of MPWs in the

Sub cnetres. The P and L forms are better reported. Report of IDSP Forms were

seen. Reports (L form) are being sent to the Distt Hq regularly, except when the

LT is absent.

Visit to SREE S J Chauhan Hospital Deogarh Baria in Baris Block It is mainly

inhabited by OBC population (77.7%) and mainly rural population (90%). There

are 86 villages, 9 PHCs and 2 CHCs under this Hospital. 22/23 posts of

MPW(M) are vacant. 152 ASHA are in place against the207 sanctioned posts, as

the existing ASHAs were upgraded to ASHA helpers. The replacement of the

ASHAs needs to be taken up on priority.

The Programme management was seen at the Hospital, Dr. Shinde, BMO is in

charge of the Programmes and is trained in various Programmes (except in

Mental Health), however all MOs are not trained in all the Programmes.

Laboratory is a DMC and running water facility is present. The waste disposal is

done in color coded dust bins. Laboratory records are maintained and quarterly

reports are being sent. Work load of Lab tests per LT is around 600 to 800 per

month.

Leprosy : HR constraints as one SLTS is in position against the sanctioned

strength of 2. Leprosy PR increased from 2.27 to 2.67 during the current year. 6

ulcer cases receive the necessary support. MCR for 111 beneficiaries has been

given once and to 58 twice, remaining cases are 106. Detection of MB (39

cases)is more than the PB(29) cases, indicating active transmission. No IEC

camps were held during the year.

RNTCP: Cure rate is > 90% I all the quarters.

NACO: met Mr. Amarish Amaliar. Positivity of HIV among ANC is 2/1007 and

in general population is 10/2247. Registers maintained.

Malaria RDT for malaria is not available, diagnosis is done by slide microscopy

(three LTs are present 1- Regular, 1- contractual under Red cross and 1 under

40

RNTCP all trained in disease control Programmes.) SP=ACT combipacks are

available for PF cases.a

PRACTICES: contact survey for the positive malaria cases is being done and the

data is being reflected under ABER, this gives a false impression of high feveer

rate , survey data is not to be merged with surveillance data.

VHSC funds were utilised for payment of wages to seasonal workers for Indoore

residual spray.

User charges were displayed in the Laboratory.

Incentives are paid to ASHA for slide examination as the RDT is not available,

and for treatment of cases. Proper tracking of the money and maintainence of

accounts is done.

Jhalod Block HIV testing for screening and counselling has improved during the

past few years and likely to improve during the current year also.

LABORATORY TECHNICIANS

Microscopy services are essential part of health delivery system. PHC level

microscopy services are important for all the Programmes namely, Malaria, TB,

Leprosy, HIV and for RCH for ANC examinations and for routine tests for

inpatients and outpatients. 1 LT is working for 8 PHCs.

Despite the recruitment of contractual LTs through Red cross, there is still a

situation where one LT is working for one CHC and looking after the work of 8

PHCs. Detailed discussions were held with 8 LTs at The Office of DMO Dahod.

The main reasons of their problems were that the additional work load is being

dealt with by part extra time that the LTs spend to overcome the shortage of LTs

and specially during the transmission season for which neither incentive is

permitted nor OT allowance is being calimed by them due to delays and non

payment. Compensation for extra Swork done during the transmission season

should be paid @ Rs.5/- per slide examined.

Discussions on improving the work load of LTs were held. LTs desired that the

salary of the contractual LTs that are recruited through Red Cross should be at par

with the regular LTs and an annual increment of 5% should also be paid to them.

Further there should be schemes for regularization of the contractual LTs.

41

Salary should be more for serving in interior areas due to the distances and cost of

travel to interior PHCs. Resident from the areas should be trained for the post of

LT after a bond of tenure of service.

Sickle-cell Anemia Control Program

Gujarat is the first state in the country to incorporate the Sickle-cell Anemia

Control Program- SAP in the existing health services of the state government,

which is based on public private partnership. The program targets 61.62 lakhs

tribal population with an expected 10 lakhs people with sickle trait and 1-lakh

sickle disease patients.

Strategies adopted in the program- In all the 12 districts screening of antenatal

mothers and their husbands who are positive will be taken up on priority. There

will be synergy with the RCH program so that screening of ante natal mothers

will be carried out on ―Mamata Diwas‖

If antenatal mother and her husband both found positive for Sickle gene she will

undergo prenatal diagnosis an expensive method of screening and if foetus will

found sickle cell disease mother can be offered legal MTP, if in first trimester.

The estimated expenditure for this activity is Rs. 20.00 lakhs per annum.

Every new borne in tribal population will be screened for sickle cell anaemia by

dried card method.

Screening of all adolescents will also be done for sickle cell anaemia and counsel

for their marriage to prevent birth of sickle cell disease child in future.

Now this year main approach is focuse on targeted age group so that aims and

objectives of this program can be achieved effectively in time period.

X. Program Management

Organizational Structure

State Level- The State Health Mission headed by the Chief Minister and the

Governing Body of State health Society is headed by Chief Secretary. The Executive

Committee of the SHS is headed by the Principal Secretary- Health.

The Executive Committee supervises the functioning of the Programme Committees ,

and The State Programme Management Unit & The State Health Mission.

42

The Mission Director is responsible for steering the course of the mission in the state

along with the support from the Executive and programme Committees.

The Programme Committees are lead by Additional Directors who provide technical

assistance to the program.

District level- The District Health Mission headed by the District Panchayat and the

Governing Body of District Health Society is headed by District Collector. The

Executive Committee of the DHS is headed by the District Development Officer.

The Executive Committee supervises the functioning of the District Programme

Committees , and The District Health Society and the District Management Unit.

PMU Structure and Capacity Building

Established Programme Management Unit structure at different level to support and

manage NRHM/RCH-II Programme at various level like

­ State Level –SPMU

­ Regional Level -RPMU

­ District Level –DPMU

­ Block Level – BPMU

The District Programme Management Unit (DPMU) is operational in all 26 districts,

and majority of positions at the DPMU are filled. Block Program Management Unit

(BPMUs) are also well institutionalised in the state. In Dahod, out of the 7 Block

Programme Management Units only one Block Finance position are filled. There are

65 positions of PHC Data Operator-cum-Accountant out of which only 4 are vacant.

Hence overall a good staff strength.

Managers functioning at various levels like Project Officers /RPC/ DPC/AHA are

qualified Health/Hospital Management Professionals to ensure their technical

capabilities and focus on the programme management

Orientation Training of the NRHM / RCH-II Programme has given to all Managers at

the time of recruitment and periodically whenever required.

Prepared Terms of Reference for every staff are in place which includes their

Qualifications Criteria and Job Responsibilities to ensure their technical capabilities

and performance.

Managerial Support- Program Officers are involved in preparation of DHAP /

RHAP / SHAP under NRHM, providing regular managerial support to various

programmes at different level for better implementation of NRHM /RCH-II

43

programme in the state and involvement in preparation of monthly progress report,

FMR Preparation and analysis of the indicator reports.

Monitoring and Supervisory structure at state, regional and district levels.

State Level Mission Director (NRHM) is the overall Supervisory Authority and

respective Additional Directors / Programme Officers are the Monitoring Authority

for the various staff functioning at SPMU under NRHM

Regional Level Regional Deputy Director is the overall supervisory and Monitoring

authority of the various staff function at RPMU/CHC under NRHM

District Level CDHO is the overall supervisory authority and different programme

officers are the Monitoring authority of the various staff functioning at DPMU/BPMU

under NRHM

However, there were concerns expressed by the PMU staff which were their low

remunerations and uncertain future leading to low motivation amongst them.

District and Block Health Action Plans are available and are reviewed by the District

Development Officer and The CDHO. And quarterly financial and physical progress

reports are prepared.

Regular meetings of the District Health Society were being held and minutes of

meeting and their agendas were also available at the DPMU.

XI. Procurement System

CMSO function as a Central Drug Procurement Agency at State level. Established in

1978 under the H.&F.W. Department of Government of Gujarat.

The CMSO is responsible for procurement of 90% of the drugs procured and supplied

to vary public sector facilities. The district store sends the indents for the requirement

of the district to the state through E-Procurement system.

Field visit indicated that drugs were available, in stock and patients were getting drugs

free of charge. While there were no observed stock out of vaccine, there were some

complain about shortage of OPV in Rajkot. The essential drug lists were not displayed

prominently in all facilities. Some equipment such as Oxygen concentrator were

supplied to facilities without any explicit need from facilities on the same.

44

XII. Effective Use of Information technology

The state has considerably invested in Information Technology system for at the

Medical college and District Hospital level, Public health information system, primary

health care and information system to monitor and deliver services at the grass root

level. The various aspects of these information systems are described briefly below:

Hospital Management Information System: This has been operationalized in 6

medical colleges and 24 district hospitals. The HMIS has several modules including

outpatients, inpatients, Pharmacies, Laboratories, Human Resource, non-clinical

services, equipment, billing etc. The District hospital, Rajkot has this system and was

being utilized by the hospital authorities for more effective management of the

hospital services. Data operators were used for data entry at different service location

at the hospital. An MIS Manager has been hired to manage the overall system

including problem with hardware and software. The team was informed that the

remuneration of the staff has recently been increased, which is the welcome step to

retain such skill within the sector. Primary Health MIS: Gujarat has developed a

Health MIS as well as well functioning IDSP system. Data reported through the

HIMS is timely and to a large extent accurate, incentives to improve reporting of vital

events through the civil registration system increase the accuracy of CRS data.

Program managers at the district, block and facility level are quite aware of this

system. Two areas where some improvement can take place are to triangulate data

with data generated from E-Mamta system as well as use of this data to improve

program performance

Training of Public sector staff: The state has initiated a basic computer course (CCC)

to be taken by all employees including the health department. The number of

employees covered by this course is 447. There is an advanced computer course

CCC+ for program managers. There could be some training emphasis on the analysis

of data and feedback to improve program performance.

E-Mamta: is a well established system in the state It is a system to track beneficiaries

(Mother and children) to ensure services are provided and reduce dropouts. All

facilities visited had an operational E-Mamta system for the primary health care level

and generated work plans for the ANM, FHW to perform their weekly duties. While

full coverage is not yet achieved. This is a significant step to track and provide MCH

45

services to beneficiaries. This model in various forms is being implemented by other

states as part of the maternal and child tracking system. This is the best practice for

other states to learn from. When the team made efforts to trace JSY beneficiaries, it

was not possible to link it with the e mamta data at PHC Gumta and PHC Khirsara.

Due to large scale migration in Dahod the tracking of all the pregnant women and

newborn is not possible.

HMIS- In Dahod, at PHC Paanchwada forms and formats of HMIS were traced to the

sub centre level. Form 6 submitted by all the 6 attached sub centers were found to be

complete in all respects. The figures were also verified by ASHAs. Form 7 submitted

by PHC was also complete. It was verified with the PHC records and Registers. Many

discrepancies were found in the data of District Dahod which is sent to state for

uploading on GOI website.

Entry against column 2.31 (b) under the heading ―Number of institutional deliveries

where JSY incentive paid to ASHAs‖ is 0 for months of June, July, August,

September and October 2011. On checking ASHAs‘ passbook and interviewing them

this was not found to be true.

Entry against column 5.3.1, 5.3.2, 5.3.3, 5.3.4 under the heading ―number of

complicated pregenancies treated with-IV antibiotics, IV antihypertensives, Mag.

Sulphate, IV oxytocin, and Blood transfusion is 0.

Column 12.9 ―number of children admitted with respiratory infections‖ shows—0

whereas in column 17.3.1 ―infant/child deaths up to 5 years by cause-Pnumonia‖

shows 37.

The problem was found to be in collation, and compilation of data at Block and

District Level. Data entry operators receive time to time different contrary instructions

from state causing confusion. Wherever they have any doubt, they put a 0.

Training on HMIS is required from state to sub centre level. The HMIS data should be

analyzed at all levels and should be used for planning and decision making. Root

cause analysis should be done for any deterioration in indicators and a time bound

Action Plan should be formulated to take timely action.

XIII. Decentralized Local Health Action

17433 Village Health Sanitation and Nutrition Committees have been formed in the

state and the joint accounts are in place for all VHSNCs.

46

The untied fund given to the VHSNCs is utilised to undertake various activities in the

village. The VHSNCs in Dahod have mainly used their fund for purchasing furniture,

durries,etc for their AWC, to take up cleanliness activities in their village etc.

Village health plans involving the VHSCs have not been made.

The process of making District health actions plans should reflect the needs of

individual facilities and the needs strengthening, although some inputs are being given

by the Block Health Office this is essential in order to prioritise allocation of

resources to selected facilities needs from the health facilities are also required to be

taken into account.

A suitable platform for all stakeholders to be actually involved in planning is not

present in the district and needs to be evolved.

Though need based district action plans are formulated, CDHOs are often faced with a

cut in their budget projection leading to gaps in infrastructure, equipment etc. as a

result extension of existing sub centre facilities often face a roadblock.

XIV. Financial Management

i. Humans Resource:

State level: The Programme Manager (Finance) in the rank of Deputy Director has been

positioned on deputation from the State Government. The State Finance Officer position is

vacant; two State Accounts Officers along with three Finance Assistants on Contract basis

and one Senior Assistant-FMG on deputation are positioned. Apart from this one

Administrative Officer-FMG along with one Office Superintendent-FMG are positioned on

deputation from the State Government.

Regional District Level: At Regional level all position of Regional Finance officer are filled

up but there are vacancies of 3 Regional Programme Co-ordinator out of 6 Regional

Programme Co-ordinator, while at district level there is one vacancy of District Finance

Officer, 4 vacancies of District Programme Co-ordinator out of 26 districts and 4 vacancies

of District Finance Assistant out of 52 sanctioned positions. Further at Block level there are

vacancies of 9 Block Finance Assistant out of 172 blocks, while at CHC level there are 26

47

vacancies out of 318 sanctioned positions and there are 75 vacancies out of 1147 at PHC

level. The process of appointment for vacant positions has been started.

ii. Books of Accounts:

Books of Accounts at state level are being maintained on Tally ERP 9.0. Books of Accounts

in the District of Rajkot are also maintained on Tally up to Block level while it is maintained

manually at PHC level.

iii. E-Banking: Funds from State to District and further to the block is being done

through e-transfer. From block to peripherals level funds is also being transfer electronically.

E- Transfer at from State to Regional/district level is done through ICICI Bank while from

District to Block and below funds is transfer through State Bank of India. Sanctioned letter

for release of funds emailed to the district. As expenditures are not being captured

electronically hence e-banking system is not being followed.

iv. Release of Funds: Funds from the State to district level is transferred pool wise not

activity-wise. District Health Action Plan is not being used for transfer of funds. In the

beginning of the year approved PIP is being sent to district. From the district to block level

funds is being transferred activity wise. However, from block to PHC level funds is also

transferred activity wise. Further at the time of release of funds unspent balance available at

the facilities are not taken into account up to third quarter it is factored only in last quarter.

v. Banking operation: At District level there is two bank account is maintained one in

ICICI Bank and another in State Bank of India.ICICI Bank is only use for receiving funds

from the State. While State Bank of India is used for further disbursement of funds to Block.

Funds received from State are transfer to SBI Account for further disbursement and other

expenditure:

Details of movement of funds from ICICI Bank to State Bank of India are as under:

Date of Fund Received from SHS in ICICI

Bank

Amount Received (in Rupees)

Date of Transfer to S.B.S

Amount Transferred (in Rupees)

01-04-2011 3333621.00 (Opening Balance)

19-04-2011

3333621.00

09-05-2011 5000000.00 17-05-2011 95863.00 20-05-2011 5090000.00 15-06-2011 10000000.00 16-06-2011 10000000.00

48

30-06-2011 2199351.00 18-07-2011 2200000.00 02-08-2011 10000000.00 02-08-2011 5000000.00 09-08-2011 137950.00 11-08-2011 15000000.00 01-09-2011 45304.00 16-09-2011 13000000.00 19-09-2011 13100000.00 07-10-2011 270000.00 14-10-2011 30000.00 18-10-2011 4824528.00 19-10-2011 10000000.00 19-10-2011 10000000.00 20-10-2011 5200000.00

20-10-2011 20000000.00

vi. Funds transferred from different level : It was observed that in the state funds is

being transferred to District Health Society ,Regional Deputy Director Office and Urban

Health Offices. From Regional level funds is transferred to CHC, Sub-District and District

Hospital. Further District Health Office also transferred funds to CHC and Sub district office

for Family Planning services. District Health Society also transferring funds to Urban Health

Society for Chiranjeevi Scheme and Bal Sakha Yojana. Further Urban Health Society is

received funds from State Health Society. In the State CHC and Sub District Hospital is

receiving funds from Regional Deputy Director office ‗s office for RKS ,Untied Funds and

AMG,while funds for Family Planning activities received from District Health Society. Due

to multiple source of funds and different level of reporting there is lack of proper monitoring

was found.

vii. Status of Pending Utilization Certificates:

The State had not furnished Utilization Certificates to the Government of India of Rs.

50.37 crore under Mission Flexi Pool and Rs. 5.23 crore under RCH as on 31.03.2011.

Programme 2010-11 (Rs. in Crore)

RCH-II Flexible Pool 50.37

Mission Flexible Pool 5.07

viii. Advances : State had Rs. 54.01 crore outstanding as advances under RCH Flexible Pool as on 31.03.2011 which increases to Rs.118.39crore as on 31.10.2011 and Rs.88.60 crore was outstanding as advances under the Mission Flexi pool as on 31.03.2011 which increases to 103.73 crore as on 31.10.2011.It is also observed that advance amounting to Rs. 1.07crore under RCH and amounting to Rs.17.40 crore

49

under NRHM is outstanding since April,2010.The State has not done Ageing analysis of Pending advance. Advance Percentage to the Unspent Balance for the State and as on 31.10.2011 are as under :

Rs.In lakhs

Activities Available Funds (Opening Balance

+Release)

Advances % of Advances against Unspent

Balance

RCH Flexible Pool

5128.24 5910.00 115%

NRHM Additional ties

9659.0 10373.73 107%

Immunisation 34.64 107.76 311%

State may take corrective actions to settle the pending advances in the subsequent quarters under RCH, Mission and Routine Immunization.

ix. State contribution: During the year 2010-11 the state contributed Rs. 56.89 crore as

state share. There was a shortfall of Rs.146.57 crore in the state share due for the

period from 2007-08 to 2011-12.The breakup of the outstanding state share is as

below:

Year Amount required to be credited on basis

of releases (Rs. in Crore)

Amount Credited in SHS Bank Account

(Rs. in Crore)

Shortfall/ (Excess) (Rs. In Crore)

2007-08 69.69 0 69.69 2008-09 60.50 60.93 (0.43) 2009-10 88.22 66.68 21.54 2010-11 98.26 91.85 6.41 2011-12 105.95 56.89 49.06 TOTAL 422.62 276.35

146.57

50

x. Funds of other activity mixed with RKS : In RAJKOT district funds not related

to NRHM (such as Govt. of Gujarat grant for RKS funds, NCD grants,ICTC grant) are also

credited in RKS bank account. Further at facility level funds related to RCH activities

(specialist Salary,FBNC,FFHI) is credited into RKS bank account.

xi. Urban Health Society: In the State Urban Health Society(for Municipal Corporation)

are getting funds from State Health Society for different RCH activities and also

getting funds from District Health Society for Chirnajeevi Yojana. But Urban Health

Society is not maintaining books of accounts as per NRHM guidelines, as their final

Accounts is not showing income recognition up to expenditure level and balance as

unspent balance under grant in aid. Every grant is routed through Advance accounts.

In the year 2010-11 the State Health Society disbursed funds Rs.20.06 crore and

unspent balance of previous year was Rs.7.83 crore and urban health Society has

incurred expenditure amounting to Rs.25.44 crore.In the year 2011-12 state has

disbursed funds amounting to Rs.12.82 crore till 31st October,2011 but till date no

expenditure is being reported by Urban Health Society. Urban Health Society Rajkot

has advance of Rs.130.06 lakhs as on 9th November,2011.There is no reconciliation

between State Health Society and Urban Health Society (Rajkot Municipal

Corporation).

xii. Financial Reports: PHCs are sending SOE to Blocks on monthly basis which

subsequently are send FMR to DHS every month in prescribed format which is

consolidated at district level. State compiles those SOEs and submits FMR to GOI on

Quarterly basis. While CHCs,District and Sub-district Hospitals are sending SOE to

Regional Programme Management unit for RKS related grant which compile those

SOE and sent it to State level. CHCs, District and Sub-district Hospital Send for

expenditure related to family Planning to District Health Society.

xiii. Concurrent Audit: Concurrent Auditor for the year 2011-12is appointed in all 26

districts and State Health Society in the month of September, 2011 after delay of six

months, further Concurrent Audit is yet to start in the district and State Health Society.

In the district Concurrent Audit of CHC, Sub-district and District hospital has not been

done. Further Concurrent Audit is not being done Urban Health Society also. Further

there is no mechanism for compliance of Concurrent Auditor‘s observation at District

level as no compliance report has been shown to the team.

51

xiv. Tally: Tally ERP 9.0 procured at State as well as district level. Accounts is being

maintained on Tally at state as well as district and block level but customized version

of Tally ERP 9.0 is not being used.

xv. Statutory Audit: In the State Statutory Audit for the year is completed for the year

2010-11.But Audit report for the district Rajkot was not available. Compliance of the

statutory audit for the year 2009-10 was not available with district. Further State has

not submitted Consolidated Audit for the year 2010-11. Further in the district different

auditor is appointed for CHCs and Sub & District Hospitals and Urban Health Society

which is against GoI guidelines.

xvi. Monitoring, Evaluation and Capacity Building: There is no financial monitoring

and evaluation done by the State level. There is no formal visit of State Finance &

Account s personnel to district and sub-district level. Bi- monthly meeting is being

organised at State level for Regional and District Finance personnel.

xvii. Utilization of funds: Utilization of funds is low in case of both RCH (27.40%) and

Mission Flexible Pool (34.92%) up to second quarter of the year 2011-12.The State

has reported less expenditure under the following activities which needs to be

clarified by the state

(Rs. in lakhs)

FMR Code Activity SPIP Utilisation

% Utilisation of SPIP

A.6 Tribal RCH 790.00 18.67 2.36%

B8 Panchayati Raj Initiative 75.00 4.29 5.73%

B22 Support Services 927.25 67.62 7.29%

The state has reported an expenditure of Rs. 326.50 lakhs under New Constructions/ Renovation and Setting up and Rs. 132.42 lakhs under Other Expenditures (Power Backup, Convergence etc), though there were no provision of budget under the activity. The state may please be clarified the reason for the same and source of diversion of fund

52

xviii. Integration of NDCPs: There is no integration of disease control programme with

DHS and SHS. : In the State all disease control programme are registered as separate

societies. There should be one integrated State Health Society for the entire Mission in

the State

xix. JSY Payment : Although the State has policy to pay Rs.500 to JSY beneficiaries in

the last trimester and balance Rs.200 for Rural and Rs. 100 for Urban beneficiaries

after deliveries for transportation expenses .It was observed that in PHC Rajpura and

PHC Khiresara that payment to JSY beneficiaries has been made much after delivery.

Further transportation expenses were not paid to beneficiaries in PHC Khiresara and

most of the case in deliveries under Municipal Corporation. There is no record

available in the PHC which can substantiate that beneficiaries had used Refferral

transport.

xx. Payment for Female Sterilization: It was observed that compensation for female

sterilisation has not paid from the facilities where it was perform. It was paid from the

facilities under which the particular beneficiaries reside. It is recommended that

payment should be made from the facilities where the activity actual perform.

xxi. ASHA Payment: It was observed that payment to ASHA through cheque in some case

bearer also on monthly basis. It is recommended that payment to ASHA should be

made through e-transfer instead of cheque.

xxii. Utilization of Untied funds. Utilization of untied funds and Annual Maintenance

Grants at CHC ,PHC and SHC level is given in the following table .Utilisation of

untied funds ,AMG and RKS has increased from 2009-10 onwards.

Utilisation of Untied Fund /Annual Maintenance Grant (for District Rajkot) (Rs. In Lakhs)

Levels 2007-08 2008-09 2009-10 2010-11 2011-12(up to

Oct'11) Release

Utilisation

Release

Utilisation

Release

Utilisation

Release

Utilisation

Release

Utilisation

Untied Funds

RKS

21.50

3.28 26.00 41.65 40.80 42.08 43.19 44.58 23.00 18.29

PHC

10.75

15.80 6.55 10.86 9.89 10.68 10.37 10.57 5.75 5.43

53

SC 1.19 7.86 33.65 31.68 31.10 31.06 31.11 30.33 8.25 5.66

VHSC

86.40

60.22 66.01 79.47 73.40 75.90 76.94 76.29 42.85 17.31

AMG PHC

21.54

34.72 13.68 21.62 22.50 20.38 20.35 21.46 11.50 10.27

SC

32.10

14.25 16.56 30.86 29.72 28.30 28.58 29.47 8.25 4.87

xxiii. High Unspent Balance of RKS Funds: It is observed that in Rajkot there is huge

unspent balance available at different RKS as detailed below -

a) District Hospital ,Rajkot - Rs. 46.23 lacs

xxiv. Mixing of Untied funds for VHSC with Sub centre: It was observed that Untied

Funds for VHSC and Sub centre was not separated till September ,2010 both has

single bank accounts in Sub centre Thorala.Both Accounts is operated by ANM

,ASHA was seems to be only signatory. Expenditure was also not bifurcated in Sub

centre Maknesar.

xxv. Negative Bank Balances: In the state it was observed that in the State there is

negative bank balance at state level and district level which reflects that there is

frequent diversion of funds from one pool to other which is not permissible as per

guidelines. Bank Balance as on at State and District level are as under

Rs.In Lakhs

State level as on 31.10.2011 District Rajkot level as on 31.03.2011

RCH 6830 NRHM 10663 60.97

Immunization 394.90 5.02

xxvi. Model Accounting Hand books for sub-district level: It is made available with

district and block but it is not adopted by PHC ,Sub centre and VHSC.

54

xxvii. Interest Earned: Interest earned not used by State, district and below level. It remains

unutilised at different level and use in case of shortage of funds. In the state there is

accumulated interest amounting to Rs.22.68 crore as on 31st March 2011.Interest

earned as on 31st March, 2011 is Rs.11.13 lakhs at district level. All interest is

remaining utilised at all level.

xxviii. Income tax return for the society was not filled by the state since beginning.

55

Recommendations

Quality of services in Chiranjeevi facililities with a focus on 48 hour stay to be ensured, for which orientation of CY providers needs to be taken up.

System to remove out of pocket expenditures incurred by CY and Bal Sakha beneficiaries to be worked out by the state, as the schemes are handling substantial number of cases

Maternal Death Review to be institutionalised as per the GoI Guidelines and penetration of guidelines and formats to be filled by the health providers to be ensured. CY Facilities ,particularly those identified as delivery points to be brought into the fold of MDR.

Post training follow up after skill based training of the trained staff, by a dedicated team at District level, to ensure the skills are being utilised to provide services, for which SIHFW can be actively involved.

Rational distribution of equipments to the facilities with adequate case load to be taken up.

The specialists and medical officers serving in difficult and tribal districts can be provided with difficult area incentives which can be linked to their performance.

The supply of AYUSH drugs to be available especially in places where the demand for them is prevalent.

Financial Management: Funds should be released to single entity Mixing of Non-NRHM funds should be avoided and all non NRHM funds

should keep in separate bank Accounts. State should implement e banking at the earliest State should appoint concurrent Audit on time for better internal check and

control Regular monitoring for funds released to Urban health Society is required State should utilise interest earned and recognised the same income State should start e-transfer for payment to ASHA State should start monitoring mechanism for regular payment of transport to

JSY beneficiaries State should implement payment for Sterilization from the facilities where

activities actually perform

56

ANNEXURES

57

Infrastructure Up gradation

A 1. Overview of Health Infrastructure and achievements in the Mission - High Focus Districts

Number of High Focus Districts in the State = 6

Health Facility

Required as per

population norms (census 2001)

Number of facilities functional in 2005 (i.e. at

the start of Mission)

Number of facilties functional as of 30th

September 2011

Number of new

facilities under

construction

Total no. of

facilities which will be

functional at the end of

the Mission period

31721595

Gov

t. bu

ildin

g

Ren

ted

build

ing

No.

func

tioni

ng in

oth

er

bldg

s with

out p

ayin

g re

nt*

Gov

t. bu

ildin

g

Ren

ted

build

ing

No.

func

tioni

ng in

oth

er

build

ngs w

ithou

t pay

ing

rent

*

1 2 3 4 1+2+3+4

District Hospitals (DH)

6 6 0 0 6 0 0 0 6

Sub-Divisional Hospitals and other hospitals

above CHC

5 4 0 0 5 0 0 0 5

CHCs

30 0 19 55 0 3 0 58

PHCs

139 0 92 220 0 35 0 255

Other Health facilities above SC but below

block level (may include APHC etc.)

0 0 0 0 0 0 0 0

Sub-Centres

987 0 531 1199 0 319 0 1518

* Facilities functional in other buildings like Panchayat buildings/ voluntary/ social organization, etc.

58

Name of the State/ UT: Gujarat

Infrastructure Upgradation

A 2. Overview of Health Infrastructure and achievements in the Mission - Non High Focus Districts

Number of Non High Focus Districts in the State = 20

Health Facility

Required as per

population norms (census 2001)

Number of facilities functional in 2005 (i.e. at the

start of Mission)

Number of facilties functional as of 30th September 2011

Number of new

facilities under

constru-ction

Total number

of facilities

which will be

functional at the end

of the Mission period

31721595

Gov

t. bu

ildin

g

Ren

ted

build

ing

No.

func

tioni

ng in

oth

er

build

ings

with

out p

ayin

g re

nt*

Gov

t. bu

ildin

g

Ren

ted

build

ing

No.

func

tioni

ng in

oth

er

build

ings

with

out p

ayin

g re

nt*

1 2 3 4 1+2+3+4

District Hospitals

(DH) 18 17 0 0 18 0 0 0 18

Sub-Divisional Hospitals and other hospitals

above CHC

21 17 0 0 21 0 0 0 21

CHCs

195 0 28 245 0 15 0 260

PHCs

582 0 259 800 0 97 0 897

59

Other Health facilities

above SC but below block level (may

include APHC etc.)

0 0 0 0 0 0 0 0

SubCenters

3875 0 1881 4013 0 1743 0 5756

* Facilities functional in other buildings like Panchayat buildings/ voluntary/ social organisation, etc.

Name of the State/ UT: Gujarat

A. 3 Status of Block-wise Availability of Health Facilities

(Information to be collected only at District Level)

Sr. No Name of District

Popu

latio

n

No.

of S

ubce

ntre

s

No. of Health

facilities above SC but below block level other than PHCs (may

include APHC etc.)

No.

of P

HC

s

No.

of C

HC

s

No. of Sub-

Divisional Hospitals and other hospitals

above CHC but

below District Level

No. of Distri

ct level

hospitals if any

1 Ahmedabad 1133814 279

44 12

2. Kheda 1617766 293

50 12

3 Ananad 1348901 298

45 11

4 Surendranagar 1112700 200

32 12

5 Gandhinagar 867195 174

25 8

6 Sabarkantha 1857402 413

68 20

7 Mahesana 1426175 245

52 16

8 Patan 944281 253

34 14

9 Banaskantha 2228743 422

80 20

60

10 Vadodara 1995580 465

80 17

11 Bharuch 1018096 157

38 7

12 Narmada 462298 157

23 4

13 Dahod 1480110 332

63 12

14 Panchmahal 1771915 400

67 14

15 Tapi 650119 226

30 5

16 Surat 1349238 375

51 14

17 Navsari 893110 281

39 11

18 Valsad 1029392 330

41 11

19 Dang 186729 47

9 1

20 Bhavnagar 1534592 359

48 17

21 Amreli 1080960 247 38 15

22 Junagadh 1736645 390 57 17

23 Rajkot 1544019 330 46 19

24 Porbandar 275460 85 10 4

25 Jamnagar 1068022 265 40 11

26 Bhuj 1108333 251 42 14

Total 3172159

5 7274 1152 318

Name of the State/ UT: Gujarat.

B. Information on Progress of New Constructions taken up under NRHM in the State

(cumulative till 30th September 2011)

Health Facility

New Construction

sanctioned under NRHM

so far

Progress of New Constructions

Remarks/ Shortcomi

ngs Completed Under

Construction Sanctioned but

Yet to start

61

High Focus Distric

ts

Non High Focus Distric

ts

High Focus Distric

ts

Non High Focus Distric

ts

High Focus Distric

ts

Non High Focus Distric

ts

High Focus Distric

ts

Non High Focus Distric

ts

District Hospitals (DH)

0 0 0 0 0 0 0 0

Sub-Division

al Hospitals and other

hospitals above CHC

0 0 0 0 0 0 0 0

CHCs 5 9 3 2 1 3 1 4 *Land Problem

PHCs 13 86 7 59 0 4 6 23 *Land Problem

Other Health facilities above SC but below block level (may

include APHC

etc.)

0 0 0 0 0 0 0 0 -

Sub-Centres

48 210 17 101 15 45 16 65 *Land Problem

62

Name of the State/ UT: Gujarat

C. Information on Progress of Upgradation of Health Facilities under NRHM in the State (cumulative till September 2011)

Health Facility

Upgradation sanctioned

under NRHM so far

Progress Remarks/

Shortcomings

Completed Under Construction

Sanctioned but Yet to start

High Focus

Non High Focus

High Focus

Non High Focus

High Focus

Non High Focus

High Focus

Non High Focus

District Hospitals

(DH) 6 17 4 5 2 7 0 5

Sub-Divisional Hospitals and other hospitals

above CHC

0 0 0 0 0 0

0

0

CHCs

52 230 36 77 3 18 0 0

*Land & Administrative

Problem

** 148 dropped out

PHCs 0 0 0 0 0 0 0 0 -

63

Other Health

facilities above SC but below

block level (may

include APHC etc.)

0 0 0 0 0 0 0 0 -

Sub-Centres

0 47 0 25 0 0 0 7 *15 dropped

out

Name of the State/ UT: Gujarat.

D. Status of Accommodation for Health Care Providers:

Facility Type Availability and Shortage of Staff Quarters at all faciltiies

Doctors/ Specialists Nurses and Paramedics Other staff

Required (Sept 2011)

Available (Sept 2011)

Added during

Mission period

Required (Sept 2011)

Available (Sept 2011)

Added during

Mission period

Required (Sept 2011)

Available (Sept 2011)

Added during

Mission period

District Hospitals

(DH) 427 140

Infrm. Not

Available

1191 406

Infrm. Not

Available

823 364

Infrm. Not

Available

Sub-Divisional Hospitals and other hospitals

above CHC

253 112

Infrm. Not

Available

660 276

Infrm. Not

Available

431 318

Infrm. Not

Available

64

CHCs NA NA NA NA NA NA NA NA NA

PHCs NA NA NA NA NA NA NA NA NA

Sub-Centres NA NA NA NA NA NA NA NA NA

65

Name of the State/ UT: Gujarat

E. Sources of Funds for Health Care Infrastructure:

2006-07 2007-08 2008-09 2009-10 2010-11 2011-12

NRHM - 23533.74 23797.29 33975.27 34925.12 10422.35

Other Central Ministry

Funds

Nil Nil 1920.06 1213.51 3431.43 4485.89

State Budget 103639.82 115686.79 134198.50 169210.66 252614.76 285232.65

Donor funds - - - - - -

Financial Commission

Grants - - - - - -

Other sources - - - - - -

Total 103639.82 139220.5

194928

204399.4

290971.3

300140.9

66

Name of the State/ UT: Gujarat

F. Human Resources augmentation under NRHM at all facilties

Category

Required as per IPHS (March 2005)

Required as per IPHS

(Sept 2011) Sanctioned

In Position

Regular

Contractual

NRHM Funds Other Sources

Mar 2005

Sept 2011

Mar 2005

Sept 2011

Doctors (Allopathic) - -

3208

2494 0 0

AYUSH doctors - - 0 919 NA NA 886 -

Specialists (DH/SDH) - - 347 718 245 273 8 -

Specialist (CHC) - - - 389 - 84 36 -

Paramedics - - - - - - - -

Staff Nurses - - - 4053 - 2866 608 190

( Out source under NABH)

MPW - - - 7203

4720

ANM - - - 6991 - 6045 415 -

PHN - - - 140 - 126 0 -

Lab Technician - - - 1673 - 997 394 -

Pharmacist - - - 1904 - 1184 543 -

AYUSH Paramedics - - - - - - - -

X-Ray Technician - - - 408

206 05 -

67

Ward Staff

2298

1043 0

Cleaning Staff

2298

1335 0

ASHA Facilitators

- - -

- - - -

ASHA Co-ordinators

- - -

- - - -

Name of the State/ UT: Gujarat.

G. Training requirement and training institutions in the State

Sr. no

Category

Annual training require-ement in March 2005

Annual Training require-ment in

Sept 2011

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

1 ANM Schools 480 1020 26 1020 14 540 12 360 29 1184

2 LHV Schools 80 80 02 80 - - - - - -

3 GNM Schools 682 2797 19 557 - 60 57 2240 50 2055

4 MPHW Schools

200 200 05 200 - - - - - -

5 Post Basic

B.Sc(Nursing)- College

NA 30 01 30 01 30 05 140 05 140

6 B.Sc.

(Nursing)- College

30 1080 07 350 06 320 16 730 16 730

7 M.Sc.

(Nursing)-College

NA NA 01 25 01 25 03 50 03 50

8 D.Pharm NA NA NA NA NA NA NA NA NA NA

9 B.Pharm NA NA NA NA NA NA NA NA NA NA

68

10 Lab.

Technician (DMLT)

NA NA NA NA NA NA NA NA NA NA

11 Lab.

Technician (Degree)

NA NA NA NA NA NA NA NA NA NA

12 Others

a Others (DNEA

& ECN) 15 15 01 15 - - - - - -

b

Post Basic Dip. in Nurse

Practice in midwifery

130 6 130 6 130

c Post Basic Dip.

in Mental Health

30 1 30 1 30

Name of the State/ UT: Gujarat

H. Achievements of training of Health Functionaries

Type of Training Cumulative number of functionaries trained

(2005 to September 2011)

MO Specialists ANM Staff Nurse LHV

IUCD 796 - 6081 - -

NSSK 1132 - 3249 1392 314

SBA

2506

IMNCI 1728 5970 793 819

69

F-IMNCI 117 - 14 -

BeMOC - - - - -

CeMOC 69 - - - -

LSAS 96 - - - -

MTP/MVA 1394 - - - -

NSV 227 - - - -

Minilap 284 - - - -

CCSP - - - - -

Laproscopy 916 - - - -

Communicable Diseases - - - - -

Others *

Training Technology 85

AFHS 752 - 5507 - -

RTI/STI 541 - 4763 - -

INDUCTION M.O 191 - - - -

ORIENTATION

AYUSH 500 -

-

- -

Hospital Management 278 -

- - -

CCC / CCC+ 447

Immunization 529 6574 40

HBNC (TOT) 62 (1 batch – all districts have completed HBNC sammelan)

70

Name of the State/ UT: Gujarat

I. Checklist for ASHA

Information on ASHA, September - 2011

Districts Number of ASHA required

Number of ASHA Selected

Number of

ASHAs dropped

out*

Number of

ASHAs in place

Number of ASHA trained up to

following Modules till date

Number of

ASHAs with

drug kits

5th 6th 7th

Ahmedabad 1360 1135 59 1135 1135 0 0 1135

Kheda 1718 1622 5 1622 1493 0 0 1622

Anand 1639 1418 0 1418 850 0 0 1418

Surendranagar 1244 1021 0 1021 931 0 0 1021

Gandhinagar 955 895 2 895 811 0 0 895

Sabarkantha 2109 2032 0 2032 1283 0 0 2032

Banaskantha 2645 2245 24 2245 2066 1240 474 2245

Mehsana 1158 972 15 972 743 0 0 972

Patan 1236 1041 0 1041 863 0 0 1041

Vadodara 2221 2064 0 2064 1478 0 0 2064

Dahod 1633 1494 92 1494 917 0 0 1494

Panchmahal 1007 968 0 968 887 784 430 968

Bharuch 1100 898 0 898 889 0 0 898

Narmada 590 490 23 490 387 222 222 490

Surat 1320 1042 0 1042 912 0 0 1042

Navsari 782 716 0 716 663 0 0 716

Valsad 1431 1134 0 1134 535 0 0 1134

Tapi 700 673 0 673 673 0 0 673

71

Dang 186 196 0 196 186 196 0 196

Bhavnagar 1563 1314 59 1314 1262 965 0 1314

Amreli 1081 865 0 865 811 185 0 865

Junagadh 1694 1494 9 1494 1012 910 0 1494

Rajkot 1442 1314 0 1314 1153 1267 0 1314

Jamnagar 1050 667 86 667 474 0 0 667

Kutchh 1188 1108 28 1108 835 0 0 1108

Porbandar 306 237 0 237 237 157 0 237

TOTAL 33358 29055 402

29055 23486 5926 1126 29055

* According to monthly status of District

Ii. Reasons for drop outs:-

1. Family Problems 2. Social Problems 3. Personal reasons 4. Marriages 5. Better job opportunities, Better Future opportunity 6. Some ASHA has Joined as Asst. FHW 7. Absorbed as helper ANM,

72

Name of the State/ UT: Gujarat

J. Mother and Child Tracking System

Sub-centres

Other Health

facilities above SC but below

block level

PHCs

Other than CHC at or

above block

level but below

District Level

CHCs

Area Hospitals / General Hospitals

(SDH)

DHs

No. of Data Entry Points

- - 1147 128

(PP Unit) 318 26 24

No. of facilities reporting on MCTS portal

7274 - 1147 128 318 26 24

No. of facilities where DEOs are deployed for data entry

- - 1147 128 318 26 24

No. of facilities where ANMs/ DEOs are trained for data capturing on MCTS formats and uploading on MCTS portal

Training of District/Block/PHC level staff is under process and facility based reporting will be started from 1st April 2012

No. of facilities where computers with internet connectivity available

- - 1147 128 318 26 24

73

No. of faciltiies using CSC (Common Service Centre) SWAN centes for data entry on MCTS portal

All health facilities (PHC and above) having internet connection provided by Health Department

No. of facilities generating and using work-plan of MCTS

Workplans are being generated by all health facilities through E-Mamta (Mother and Child Tracking Application)

No. of facilities doing verification of data to reduce errors and anomalies occurred at the time of data capturing and entry

- - 1147 128 318 26 24

74

Name of the State/ UT: Gujarat

K. Information on Programme Management Units

Level No. of

Regular Staff

No. of contractual Staff in important positions like

Programme managers and Consultants who have

been employed for their technical expertise

No. of contractual support staff such as programme assistants/ DEOs/ typists/ peons

Total Number of

Staff in SPMU

SPMU 8 27 107 142

RPMU 0 9 12 21

DPMU 0 47 73 120

BPMU 272 0 382 654

Total 272 83 574 937

75

L. Total functional delivery points in Public Health Facilities of the States/UT

State/UT- Gujarat Year: (2010-11)

S.No Indicator Number

1 Total No. of SCs 7274

a No. of SCs conducting >3 deliveries/month 70

2 Total No. of 24X7 PHCs 333

a No. of 24X7 PHCs conducting > 10 deliveries /month 79

3 Total No. of any other PHCs 819

a No. of any other PHCs conducting > 10 deliveries/ month 6

4 Total No. of CHCs ( Non- FRU) 222

a No. of CHCs ( Non- FRU) conducting > 10 deliveries /month 91

5 Total No. of CHCs ( FRU) 96

a No. of CHCs (FRU) conducting > 20 deliveries /month 73

b No. of CHCs (FRU) conducting C-sections 31

6 Total No. of any other FRUs (excluding CHC-FRUs) 43

a No. of any other FRUs (excluding CHC-FRUs) conducting > 20 deliveries /month

25

b No. of any other FRUs (excluding CHC-FRUs) conducting C-sections

20

7 Total No. of DH 24

a No. of DH conducting > 50 deliveries /month 17

b No. of DH conducting C-section 24

8 Total No. of District Women And Children hospital (if separate from DH)

0

a No. of District Women And Children hospital (if separate from DH) conducting > 50 deliveries /month

0

76

b No. of District Women And Children hospital (if separate from DH) conducting C-section

0

9 Total No. of Medical colleges 6

a No. of Medical colleges conducting > 50 deliveries per month 6

b No. of Medical colleges conducting C-section 6

10 Total No. of Accredited PHF (Chiranjivi Yojana Accredited Hospitals)

662

a No. of Accredited PHF conducting > 10 deliveries per month 662

b No. of Accredited PHF conducting C-sections 662

*Provide the status in a soft copy and upload it on the State/UT NRHM website. *Upload on State/UT NRHM website, the name wise list of the above facilities which are delivery points. * Send the name wise list of these delivery points, in soft copy. eg. Names of all sub-centres conducting >3 deliveries per month; names of all DH conducting > 50 deliveries per month; names of all DH conducting C sections, etc.

77

Name of the State: Gujarat

M. Information on Community Monitoring

1. State the Number and Names of the District in which community monitoring had been initiated: 26 ( All district of Gujarat)

2. Is the activity out sourced to NGOs: Yes (Capacity building of the VH&SCs only being out sourced).

3. If yes, kindly specify the names of the NGOs: list attached here with as annexure.

4. What is the number of villages covered under the imitative? 6390

5. Which are the activities that are monitored by the community a. The Village MAMTA Divas b. Water Supply c. Anagawadi d. Sanitation

6. Have citizen report cards or any other such instruments been provided? No.

7. Has any evaluation /impact assessment of the community monitoring initiative been under taken?

Yes (The impact of capacity building has been done) If yes what are the findings? The report is under preparation.

78

Name of the State / UT : Gujarat

N. Other Indicators

A INFRASTRUCTURE As on 01.04.2005 As on 31.03.2011

1 Blood Storage Units 0 40

2 Blood Banks 101 141

3 SNCUs 0 31

4 NBSU 0 148

5 NBCC

296

6 Total Number of Beds

CHC - 9920 PHC - 6894

SC - 0 DH - 4328

SDH - 2728

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

0.37 0.39

8 Number of facilities functioning as per IPHS As on 01.04.2005 As on 31.03.2011

Total No of

Facilities

Functioning as per IPHS

Total No of

Facilities

Functioning as per IPHS

DH 23 12 24 12

CHC 253 0 318 0

PHC 1044 0 1156 0

Sub Centre 7274 0 7274 0

B Utilization of United Grants No. of Facilities having more than 50 % utilization in 2010

-11

Total No. of Facilities receiving grants in 2010 -11

Utilization of RKS Grants 50 50

Utilization of United Funds Nil Nil

Utitilzation of Annual Maintainance Grants 50 50

Amount of funds spent on NGOs/ PPPs cumulative till Total Expenditure under NRHM

79

2010- 11 cumulative till 2010 -11

C PPP / NGOs *MNGO SNGO Scheme - 82309209

* MNGO - SNGO Scheme up to September 5428556

D Total Annual OPD (Medical Services) in the District / State

Percentage increase over previous year

2005 - 06 9337881

2006 - 07 8723182 -6.58

2007 - 08 7272607 -16.63

2008 - 09 6987966 -3.91

2009 - 10 7014119 0.37

2010 - 11 7324888 4.43

E Lab Services 01.04.20005 31.03.2011

No of patients tested for any ailment in labs at the PHCs

1930804

8716976

No of patients tested for any ailment in the labs at CHCs 14559308

% of 24 x 7 facilities where 24 x 7 lab services are available

Nil 331

CHECKLIST FOR REVIEW OF IMPLEMENTATION OF PC&PNDT ACT

A. State level

S.N Key points Yes No Remarks

1 A multi-member state level appropriate authority appointed

by notification in the official gazette Yes

G.R. No. GP-24-PNDT-102006-1190-GH, 7th May 2007 & 28 July 2008 & 16th August 2010.

2 A state supervisory board constituted Yes G.R. No. GP-25-PND-102003-GOI-31-B.1-, 8th August 2008.

2.1 If response to S.N. 2 is yes – How many meetings of state supervisory board have been organized during 2010-2011

(state board should have meeting once in four months) Two (26.6.09 & 1.4.10)

2.2. Availability of minutes of the meeting Yes

2.3 Availability of action taken reports on minutes of the Yes

80

meeting.

3 A state advisory committee constituted Yes Under Process

3.1

If response to S.N.3 is yes – How many meetings of state advisory committee have been organized during 2010-2011 (Rule 15) The intervening period between any two meetings of advisory committee constituted under sub section (5) of

section 17 shall not exceed sixty days)

Nil

3.2 Availability of minutes of the meeting No

3.3 Availability of action taken reports on minutes of the

meeting. No

4 A state level PC&PNDT cell constituted No Assi.Dir. - FW is Nodal Officer

for State PC & PNDT Cell

4.1 If response to S.N.4 is yes, who are the members of the state

PC&PNDT cell (verify from order/circular)

1

NA 2

3

4

4.2 Has the state constituted a state inspection and monitoring

committee Yes

G.R. No. FPW-PIU/102011/351/B.1, Dt. 5.8.11.

4.2.1 If response to 4.2. is yes – who are the members of state

inspection team

1 Chair Person & Commissioner of Health

2 Member & Under Secy. Dept. of H &

FW

3 Member & Prof. of Obg & Gyn., B.J.

M.C, Ahmedabad

4 Member & Prof. of Radiology, M.C.,

Vadodara,

5 Member Secy. & Assi. Dir. FW,

Gandhinagar.

4.2.2 How many independent inspections of USG clinics have been done by the state level inspection team during 2010-

Two

81

2011

4.2.3 Record of follow up actions available on important

observations of inspections of USG clinics Yes

Three USG Machine Sealed, at Surat.

5 Total number of cases in the state filed in the court during

2010-11 20

5.1 Total number of cases filed (cumulative) 105

5.2 Out of 5.1- total number of cases dismissed with key

reasons 26

5.3 Out of 5.1, total number of cases where charge sheets have

been framed

5.4 Out of 5.1, total number of convictions 4

5.5 Total number of registrations of doctors suspended by state medical council after framing charge sheets against them or

after convictions Nil

7 Total number of appeals received by state appropriate

authority during 2010-11 from the districts 7

7.1 On how many appeals, actions have been taken (verify from

records) 7

7.2 How many appeals received have been disposed of by state appropriate authority within 60 days of receipt of appeals?

7

8

As per Rule 16 (3) has the state appropriate authority published the list of registered genetic counseling centers, genetic laboratories, genetic clinics, ultrasound clinics and

imaging centers and findings from the reports and other information in their possession, for the information of the public and for use by the experts in the field (verify from

records)

Yes

9

As per Rule [3 A. (2), are the suppliers/providers of such machines/equipment to any person/body registered under

the Act are sending the state Appropriate Authority, once in three months, a list of those to whom the machine/equipment has been provided

Yes

9.1 If response to 9 is NO – What action/s have been taken by

state AA against the suppliers NA

10 Availability of annual state action plan for PC&PNDT

related activities Yes

82

10.1 Budget sanctioned for 2010-11 for implementation of

various activities exclusively from state level for implementation of the Act

A.

Budget sanctioned under RCH/NRHM PIP:

72,70,000

B. Funds sanctioned from state budget:

Nil

10.2 % utilization of budget sanctioned

A. 70.55%

B. Nil

11 Periodical reports from state PCPNDT cell to GOI submitted in time and copies of the report available

Yes

12 Suggestions from state level authorities for better addressing sex selection issues and concerns and

implementation of PCPNDT Act

1 On line Form-F Submission Should be

Implemented through out the Nation and to consider making it as a part of Rules.

2 Ambiguity about Trainning of medical

practitioners should be rectified

3 Sencitization of Judiciary at all level

4 On line web complaints portal should be

started

5 Capacity bulding of implimenting

officers

6 Sharing of best practices from States need to be sustained on a long term

basis

IMPLEMENTATION STATUS OF JANANI SHISHU SURAKSHA KARYAKARAM (JSSK): STATE LEVEL

83

State/ UT: .........Gujarat............No. of districts: ...26. No. of Blocks: …171…… Reporting Month/Year: …Sep/2011…

State Nodal Officer in place (Y/N): ……Y………. State Grievance Redressal Officer in place (Y/N): ………Y…

No. of District Nodal Officers in place: ….26…… No. of District Grievance Redressal Officers in place: ……26

A) ENTITLEMENTS: CASHLESS SERVICES & USER CHARGES Sno. Provision for Cashless deliveries for all pregnant women

and sick newborns at all public health facilities

Whether G.O. issued (Y/ N)

Month when started / proposed timeline

No. of districts implementing

1. Provision of Free Drugs/ Consumables Y* Jul 2011 26

2. Provision of Free Diagnostics Y* Jul 2011 26

3. Provision of Free Diet Y Jul 2010 & Aug 2011 26

4. Provision of Free Blood (inclusive of testing fee) Y* Jul 2011 26

5. Provision of Free treatment to Sick newborns up to 30 days Y* Jul 2011 26

6. Free Referral Transport for PW (to & fro, 2nd referral) Y Dec 2008 & Jul 2011 26

7. Free Referral Transport for Sick newborns (to & fro, 2nd referral)

Y* Jul 2011 26

8. Exemption from all user charges for all PW and sick newborns

Y Jul 2011 26

9. Empowerment of MO in-charge to make emergency purchases

Y Jul 2011 26

* JSSK is the new initiative so budgetary provisions related to JSSK are not incorporated in PIP 2011-12, to implement all components of JSSK extra budget allocation is needed.

NOTE: Pls. provide a copy of relevant Govt. Order(s)(provide one time, and when any updation/ revision is done)

B) ENTITLEMENTS: REFERRAL TRANSPORT (RT) Sno. Referral transport services State

owned EMRI/ EMTS

PPP Other

1. Total number of ambulances/ referral vehicles in the State/ UT

254 (In CHC)

506 - -

2. Whether vehicles fitted with GPS (specify no.) 0 0 0 0

3. Call centre(s) for the ambulance network: Districts (No.) - …………0………… State (Y/N): …Y……

4. Toll free number (provide number, if available): ………108…………………………..

C) IMPLEMENTATION: CASHLESS SERVICES Sno. Provision for Cashless deliveries for all pregnant women and sick newborns at all Govt.

health facilities Status

1. No. of districts where free entitlements are displayed at all health facilities Data collection under process

84

2. No. of districts where free diet is available to PW (at all facilities 24x7 PHC and above level) 26

3. No. of districts where lab is functional for basic tests for PW (at all facilities 24x7 PHC and

above level) 26

3a. No. of districts where any facility has stock outs of lab reagents / equipment not working Data collection under process

4. No. of districts where any facility has stock outs of essential drugs / supplies for PW and sick newborns

Data collection under process

5. No. of districts where any facility has user charges for PW / sick newborns for:

i. OPD 0

ii. Admission / delivery / C-section 0

iii. Lab tests / diagnostics 0

iv. Blood 0

6. Total no. of govt. medical colleges in the State 6

7. Total no. of govt. medical colleges not levying any type of user charges 6

D) SERVICE UTILISATION: REFERRAL TRANSPORT (RT) Sno. Referral transport services State vehicles EMRI/ EMTS PPP Other

1. No. of PW who used RT services for:

i. Home to health institution Data being collected

817786*

ii. Transfer to higher level facility for complications

Data being collected

iii. Drop back home Data being collected

2. No. of sick newborns who used RT services for:

i. Home to health institution Data being collected

13842*

ii. Transfer to higher level facility for complications

Data being collected

iii. Drop back home Data being collected

*Since launch of 108 EMRI services (2007) to till date.

85

E) GRIEVANCE REDRESSAL Sno. Grievance redressal Status detail

1. No. of complaints/ grievance cases related to free entitlements No case received

2. No. of cases addressed / no. of cases pending No case pending

IMPLEMENTATION STATUS OF JANANI SHISHU SURAKSHA KARYAKARAM (JSSK): DISTRICT LEVEL

District / State: DAHOD (GUJARAT) Total no. of blocks : 7 Reporting Month/ Year: Sept.-2011

District Nodal Officer in place (Y/N): Y District Grievance Redressal Officer in place (Y/N): Y

A) CASHLESS SERVICES

Sno

.

Provision for Cashless deliveries for all pregnant women and

sick newborns at all Govt. health facilities

Sub-

centre

PHC Block

PHC/

CHC

SDH DH

1. No. of govt. health facilities in the district 332 65 11 1 1

1a. No. of facilities where deliveries take place (“Delivery points”) 2 8 11 1 1

2. No. of facilities where free entitlements displayed 0 0 0 1 1

3. No. of facilities where free diet is available to PW 0 0 11 1 1

4. No. of facilities where lab is functional for basic tests for PW 1 0 8 11 1 1

4a. No. of facilities with stock outs of lab reagents / equipment not

working

0 0 0 0 0

5. No. of facilities with stock outs of essential drugs / supplies 0 0 0 0 0

6. No. of facilities with user charges for PW / sick newborns for: 0 0 0 0 0

i. OPD 0 0 0 0 0

ii. Admission / delivery / C-section 0 0 0 0 0

iii. Lab tests / diagnostics 0 0 0 0 0

iv. Blood 0 0 0 0 0

v.

B) REFERRAL TRANSPORT (RT)

1 Lab technician is in place and pregnancy test, Haemoglobin, urine routine for sugar and protein are available

86

Sno. Referral transport services State vehicles EMRI/ EMTS PPP Other

1. Total no. of ambulances/ referral vehicles in the

district 12 24 01 01

2. Whether fitted with GPS (specify no.) 0 0 0 0

3. No. of PW who used RT services for: - - - -

i. Home to health institution 0 1725 0 0

ii. Transfer to higher level facility for complications

8 0 3 4

iii. Drop back home 0 0 0 0

4. No. of sick newborns who used RT services for:

i. Home to health institution 0 13 0 0

ii. Transfer to higher level facility for complications

2 0 0 0

iii. Drop back home 0 0 0 0

5. No. of blocks where referral transport service is available: 03

6. Whether district level call centre in place (Y/N): NO

C) GRIEVANCE REDRESSAL

Sno. Grievance redressal Status detail

1. No. of complaints/ grievance cases related to free entitlements 0

2. No. of cases addressed / no. of cases pending 0

3. Average no. of days taken per case 0

IMPLEMENTATION STATUS OF JANANI SHISHU SURAKSHA KARYAKARAM (JSSK): DISTRICT LEVEL

District / State: Rajkot Total no. of blocks: 7 Reporting Month/ Year: Sept-Oct-2011

District Nodal Officer in place (Y/N): YES District Grievance Redressal Officer in place (Y/N):

YES…………………..

A) CASHLESS SERVICES

87

Sno. Provision for Cashless deliveries for all pregnant women and sick

newborns at all Govt. health facilities

Sub-

centre

PHC Block

PHC/

CHC

SDH DH

1 No. of govt. health facilities in the district 330 46 15 5 1

1a. No. of facilities where deliveries take place (“Delivery points”) 21 17 15 5 1

2 No. of facilities where free entitlements displayed 60 46 15 5 1

3 No. of facilities where free diet is available to PW 12 17 13 4 1

4 No. of facilities where lab is functional for basic tests for PW [1] 0 46 15 5 1

4a. No. of facilities with stock outs of lab reagents / equipment not working 0 0 0 0 0

5 No. of facilities with stock outs of essential drugs / supplies 0 0 0 0 0

6 No. of facilities with user charges for PW / sick newborns for: 0 0 0 0 0

i. OPD 0 0 0 0 0

ii. Admission / delivery / C-section 0 0 0 0 0

iii. Lab tests / diagnostics 0 0 0 0 0

iv. Blood 0 0 0 0 0

B) REFERRAL TRANSPORT (RT)

Sno. Referral transport services State

vehicles

EMRI/

EMTS

PPP Other

1 Total no. of ambulances/ referral vehicles in the district 34 25 0 27

2 Whether fitted with GPS (specify no.) 1 0 0 0

3 No. of PW who used RT services for: 0 0 0 0

i. Home to health institution 17 461 5 0

ii. Transfer to higher level facility for complications 54 32 5 0

iii. Drop back home 56 1 5 57

4 No. of sick newborns who used RT services for: 0 0 0 0

i. Home to health institution 6 29 5 0

ii. Transfer to higher level facility for complications 6 8 5 0

iii. Drop back home 6 0 5 0

88

5 No. of blocks where referral transport service is available 7

6 Whether district level call centre in place (Y/N): NO

C) GRIEVANCE REDRESSAL

Sno. Grievance redressal Status

detail

1 No. of complaints/ grievance cases related to free entitlements 0

2 No. of cases addressed / no. of cases pending 0

3 Average no. of days taken per case 0

[1] Lab technician is in place and pregnancy test, Haemoglobin, urine routine for sugar and protein are available