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UTTARAKHAND
STATE REPORT
Uttarakhand
1
Uttarakhand
Index
S. No. Content Page No.
1 Summary of approvals 2 – 5
2 Demographic Profile 6 – 7
3 Progress of NRHM 8 – 12
4 Reproductive & Child Health 13 – 16
5 Immunization 17 – 17
6 Revised National Tuberculosis Control Programme (RNTCP) 18 – 20
7 National Vector Borne Disease Control Programme (NVBDCP) 21 – 21
8 National Leprosy Eradication Programme (NLEP) 22 – 22
9 Integrated Disease Surveillance Project (IDSP) 23 – 24
10 National Programme for Control of Blindness (NPCB) 25 – 25
11 National Iodine Deficiency Disorder Control Programme (NIDDCP) 26 – 26
12 RoP approval under Mission Flexible Pool 27 - 30
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UTTARAKHAND
Summary of approvals
Financial Management under NRHM (Rs. in crore)
Years Allocation Release Expenditure % Release
against Allocation
% Expenditure against Release
2005-06 51.86 56.66 23.53 109.25 41.53 2006-07 71.89 50.67 23.87 70.48 47.11 2007-08 84.44 162.14 139.29 192.02 85.91 2008-09 92.37 107.89 129.56 116.80 120.10 2009-10 96.91 0.00
Total 397.47 377.35 316.25 94.94 83.81
S. No. Timeline Activities Achievement %
1 ASHA Selection 9923 157 Training 9923
2 VHSC 0 0 3 24X7 PHCs 67 29 4 Mobile Medical Unit 13 100 5 Rogi Kalyan Samiti 91 29
Budget Allocations (2005-09) ( Amount in Crores) Uttarakhand
Allocation Releases Expenditure RCH Flexipool
2005-06 14.10 7.46 3.98 2006-07 17.68 12.91 6.52 2007-08 14.35 12.97 16.57 2008-09 21.83 25.71 39.47 2009-10 25.77
Total (A) 93.73 59.05 66.54 NRHM Flexipool
2005-06 No separate allocation 17.54 0.33
2006-07 14.97 15.92 1.44 2007-08 26.17 34.09 13.59 2008-09 19.02 22.07 32.79 2009-10 22.74
Total (A) 82.90 89.62 48.15 National Disease Control Programme
2005-06 9.06 5.26 4.88 2006-07 7.48 5.03 5.60 2007-08 8.79 4.53 4.64 2008-09 8.54 4.68 1.90 2009-10 6.94 0.00 0.00
Total (A) 40.81 19.50 17.02 Grand Total (A + B + C) ������ ������ ������
Uttarakhand
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Record of Proceedings (2005-2009) for Mission Flexible Pool
Approval for Infrastructure (Rs. in Crore)
S. No Health Facilities 2005-06 2006-07 2007-08 2008-09 2009-10
1 Sub C 1.52 10.36 3.00 0.00
2 PHC 1.05 0.00 0.00
3 CHC 10.40 0.00 2.00 2.60
4 DH 0.00 0.80 0.00
5 Equipment 0.00 0.00 0.10
6 Transport 0.00 16.95
7 Others 7.12 11.09 11.20 0.00
Total 11.92 7.12 22.50 17.00 19.65
Approval for Human Resources(Rs. in Crore) S. No Personnel 2005-06 2006-07 2007-08 2008-09 2009-10
1 Doctors 0.00 0.00 3.02
2 Specialists 0.00 0.00 0.00
3 Staff Nurses 0.00 0.00 2.16
4 ANM 0.00 1.80 2.40
5 Others 0.30 0.17 2.57
Total 0.00 0.00 0.30 1.97 10.16
Approval for other activities (2005-2009) in Rs. Lakh
S.No Initiative 2005-06 2006-07 2007-08 2008-09 2009-10
Remarks Released Approved Approved Approved Approved
ASHAs
1 ASHA 633.77 985 985
2 Selection & Training of ASHA 257 500
3 ASHA Kit 12 TOTAL 269 500 633.77 985 985 Untied Funds, Annual Maintainence Grants and RKS fundsrelated matters 4 Rogi Kalyan Samiti 91
5 Rogi Kalyan Samiti- DH
95 80 90
6 Rogi Kalyan Samiti- SDH
12 12 18
7 Rogi Kalyan Samiti- CHC
49 51 55
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8 Rogi Kalyan Samiti-PHC/APHC
240
9 Untied Fund for CHC
24.5 26 27.5
10 Untied Fund for PHC 56.25 58 57.25 60
11 Untied Fund for SC 152 2.4 176.5 176.5
12 Untied Fund for VHSC 20
65.6 702.7 959.9
13 Untied fund for ANMTCs 3 6
14
Annual Maintenance Grant - CHC 40 52 55
15
Annual Maintenance Grant -PHC 112.5 88.5 89.5 89.5
16
Annual Maintenance Grant- SC 6.6 100 110
TOTAL 152 304.25 417.1 1349.95 1887.4 Infrastructure related matters
17 Ambulances/Referral/Operational Cost 1000 1335
18 MMU 508.3 1036 360 TOTAL 508.3 1036.00 1000.00 1695.00
Status of Infrastructure 2005-2010
As per RHS 2008 New Construction Upgradation / Renovation Number of Sub Centre 1765 0 2814 Number of PHC 239 0 535 Number of CHC 55 0 182 Number of DH 18
As per State Data Sheet, NRHM
0 18
Status of NRHM as on 15.05.2009
1 ASHA Selection 9923 Training 9923
2 VHSC 0
3 Joint A/C 1634
4 24X7 Facility 121
Uttarakhand
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5 FRU 72
6 Contractual Manpower
Doctors & Specialist 0
AYUSH Doctors 1
Staff Nurse 101 Paramedics 0
ANM 57 7 JSY Beneficiaries (in Lakhs) 1.48
National Disease Control Programme NLEP
Although state has reached elimination of the disease, still large number of new cases are being detected every year indicating active transmission in the community. An in-depth situational analysis with steps to complete treatment etc be started.
IDSP
It is a Phase I state. The recruitment of key human resources needs to be fast tracked .The data reporting should start from all the districts.
NBCP Reporting of utilisation of GoI grants need to be accelerated. Cataract performance and IOL implantation percentage needs to be improved.
NVBDCP
Fill up the human resources (Male MPW, Lab Tech, Malaria Technical Supervisors) gaps. RNTCP
There is downward trend in the performance of the State and Overall performance is not good. Vacant posts of key personnel need to be filled on priority.
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Demographic, Socio-economic and Health profile
HEALTH INDICATORS OF UTTARAKHAND The Total Fertility Rate of the State is NA. The Infant Mortality Rate is 48 and Maternal Mortality Ratio is 440 (SRS 2004 - 06) which are higher than the National average. The Sex Ratio in the State is 962 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows: Table I: Demographic, Socio-economic and Health profile of Uttarakhand State as compared to India figures S. No. Item Uttarakhand India
1 Total population (Census 2001) (in million) 8.5 1028.61 2 Decadal Growth (Census 2001) (%) NA 21.54 3 Crude Birth Rate (SRS 2007) 20.4 23.1 4 Crude Death Rate (SRS 2007) 6.8 7.4 5 Total Fertility Rate (SRS 2007) NA 2.7 6 Infant Mortality Rate (SRS 2007) 48 55 7 Maternal Mortality Ratio (SRS 2004 - 2006) 440 254 8 Sex Ratio (Census 2001) 962 933 9 Population below Poverty line (%) - 26.10 10 Schedule Caste population (in million) 1.52 166.64 11 Schedule Tribe population (in million) 0.26 84.33 12 Female Literacy Rate (Census 2001) (%) 59.6 53.7
Table II: Health Infrastructure of Uttarakhand Particulars Required In position Shortfall Sub-centre 1294 1765 - Primary Health Centre 214 239 - Community Health Centre 53 55 - Multipurpose worker (Female)/ANM at Sub Centres & PHCs
2004 1903 101
Health Worker (Male) MPW(M) at Sub Centres
1765 616 1149
Health Assistant (Female)/LHV at PHCs 239 340 - Health Assistant (Male) at PHCs 239 417 - Doctor at PHCs 239 866 - Obstetricians & Gynaecologists at CHCs 55 30 25 Physicians at CHCs 55 4 51 Paediatricians at CHCs 55 18 37 Total specialists at CHCs 220 67 153 Radiographers 55 30 25 Pharmacist 294 294 0 Laboratory Technicians 294 132 162 Nurse/Midwife 624 292 332 (Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI)
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The other Health Institution in the State are detailed as under:
Health Institution Number Medical College 3 District Hospitals 18 Referral Hospitals City Family Welfare Centre Rural Dispensaries Ayurvedic Hospitals 7 Ayurvedic Dispensaries 467 Unani Hospitals 2 Unani Dispensaries 3 Homeopathic Hospitals 1 Homeopathic Dispensary 60
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Note on Progress of NRHM in Uttarakhand (June 2009)
Uttarakhand is a newly formed state, carved out of the former Uttar Pradesh in the year 2000. NRHM has transformed public health service delivery in the State. The decentralization, responsiveness to local needs, paradigm shift in health system management and availability of untied funds has improved the facilities and their credibility among members of the public. The state has achieved success in improving service delivery at the grass root level. The ASHA programme has broadly led to an increased demand for institutional medical services and there is a remarkable shift from domiciliary to institutional delivery. The State is determined to implement NRHM in full swing. Brief information on progress vis-a-vi issues have been highlighted which are as follows: Institutional Framework of NRHM
Meeting of State & District Health Mission has been held regularly. Meeting of State Health Mission held 5 times and of District Health Mission held 70 times. Merger of societies is completed in 13 districts. VHSCs constituted and 1634 Joint Accounts are operational at SC level. Rogi Kalyan Samities are operational at 18 DH, & 55 CHCs. 13 districts have started developing their own IDHAP. Infrastructure Improvements
In total 48 PHC have been strengthened with three Staff Nurses each for 24x7 work. 36 CHC are functioning on 24X7 basis & facility survey completed in 26 below block level facilities. 18 SDH, 36 CHC including others below district level and 18 District Hospitals are functioning as FRUs. 13 districts have functional Mobile Medical Unit (MMU) Human Resources
A total of 9923 ASHAs have been selected & 9923 are trained upto 4th Module. 8055 ASHAs have been provided with drug kits. Overall 1604 Sub-centres are functional with an ANM and 57 SCs are strengthened with 2nd ANM. One Contractual AYUSH Doctors has been appointed. Contractual appointments of 101 Staff Nurse and 57 ANMs have been done under NRHM and need to strengthen the positioning of Specialists, MBBS Doctors and paramedics. Services Institutional deliveries improved from 0.36 lakhs (06-07) to 0.60 lakhs (07-08). 0.74 lakhs Institutional deliveries have been reported in the state during the year 2008-09. JSY beneficiaries increased from 0.21 lakhs (06-07) to 0.59 lakhs (07-08). The numbers of JSY beneficiaries were 0.66 lakh during the year 08-09. Female sterilizations have increased from 0.27 (06-07) to 0.27 lakh (07-08) and male sterlisation has increased from 1417 (06-07) to 1112 (07-08). During the year 2008-09, 33772 female & 3092 male sterilization have been reported so far. 4 districts are implementing IMNCI & 42 people have been trained so far. 79627 VHND were held since the launch of NRHM.
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General
Overall improvement in health system since NRHM Achievements made:-
• There is an increase in JSY beneficiaries and institutional deliveries. • The cases of male & female sterilisations have been improved comparatively. • Development partnerships outside the state for training the manpower. • Untied Funds, Annual Maintenance Grants, Rogi Kalyan Samitis (RKS) funds being utilized. • The State made DHAPs for 13 districts and later formulated the State plan. • In difficult areas, health services are being provided under PPP. • MMUs are functional in the districts. • VHSC constituted and have operational joint accounts.
Areas for Further Improvement
• Service utilization is very low. • Shortage of Medical Officers and paramedics needs due attention. • Need to strengthen and upgrade the health facilities of FRUs and 24 X 7 health facilities. • Capacity Building and orientation of VHSC and PRI members is required to facilitate the
planning and community processes. • TOR of SHRC has to be clearly spelt out to identify the areas of expertise required.
Infrastructure
• The State should consider variation for the infrastructure well suited for hilly terrains. • The State has undertaken a substantial situational analysis to identify the gaps in terms of
infrastructure, manpower and training and then attempted context-specific planning. Human Resources
• To address the HR gap, the state is trying various options like graded payments, walk-in interviews, advertisement in national dailies, incentives to students, etc.
• The SPMU and DPMU need to be trained properly to be familiar with technical aspects. • Continuing medical and nursing education should be considered by the State for medical
officers and nurses. • Efforts have been are made for filling the crucial HR gaps in terms of incentives and hard area
allowances to all categories of staff.
Service Delivery
• Service utilization is very low for different aspects of health care. There are significant differences between the urban and rural areas. This could also be attributable to the difficult terrain, especially in the middle and upper hills, and problems of mobility faced by the service providers.
• For hard to reach areas, BPL mothers should have provision of stay with at least one family member to increase the institutional deliveries
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An Analysis of Financial Monitoring Report for the year 2008-09
(A) RCH Flexible Pool:-
Component-wise expenditure & utilisation under RCH against approved PIP for the year 2008-09
Rs. in Lakhs
Activites SPIP Expenditure % Utilisation against PIP
Maternal Health 1716.03 1413.41 82.37 Child Health 127.96 95.61 74.72 Family Planning Services 557.46 458.36 82.22 Adolescent Reproductive and Sexual Health/ ARSH 25.20 0.00
0.00
Urban RCH 123.66 2.05 1.66 Innovations/PPP/ NGO 18.10 5.61 30.99 Infrastructure & Human Resources 54.13 124.99 230.91 Institutional Strengthening 68.20 72.23 105.91 Training 413.71 274.58 66.37 BCC / IEC 189.37 171.94 90.80 Procurement 16.75 1218.09 7272.18 Programme Management 127.00 110.00 86.61 Total 3437.57 3946.87 114.82
Based on table given on previous page and record available in FMG, observations are as under:- General Observations:
1. Significantly 114.82% amount (Rs.39.47 Crores) against the PIP approved (Rs.34.38 Crores)
has been utilized by your State under RCH-II whereas the National level expenditure against the PIPs approved is 71%.
2. 170% increase has been noticed in expenditure as compared to the last year performance. 3. Since the start of the programme more than 100% amount (Rs.64.55 Crores) has been spent
by the state against the releases (Rs.59.05Crores) made during the year 2005-06 to 2008-09. 4. More than 80% expenditure under MH, Family Planning, BCC/IEC and Programme
Management is also appreciable
Areas of Concern: 1. Compensation of Family Planning services to Male or Female is not clearly mentioned in the
FMR. 2. Formulas of sub-heads total does not appear in the FMR format. 3. Bifurcation between Institutional deliveries & Home deliveries has not been specified in the
FMR. 4. Expenditure under Urban RCH is just 1.66% of approved PIP. 5. Huge expenditure is booked under the head “Others”. No detail is provided by the State. 6. No expenditure has been booked under ARSH against the approved PIP of Rs.25.20 Lakhs.
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7. There is high expenditure reported under the head “Procurement” as state PIP is just 0.17 crores while expenditure is Rs. 12.18 crores which is 7272% of approved PIP;
8. Expenditures under the head “Infrastructure & Human Resources” and “Institutional Strengthening” is 230% of approved PIP which needs proper attention.
9. State is advised to use new format of FMR which can be download from the website www.mohfw.nic.in under the link “Financial Management Group”.
(B) Mission Flexible Pool:-
Componet-wise expenditure under NRHM against approved PIP Rs. In Lakhs
Activites SPIP Expenditure %Utilisation against PIP
ASHA 985.00 417.87 42.42 Untied Funds 962.45 266.54 27.69 Hospital Strengthening 343.00 388.62 113.30 Annual Maintenance Grants 241.50 237.02 98.14 New Constructions/ Renovation and Setting up 300.00 0.00 0.00 Corpus Grants to HMS/RKS 0.00 52.78 N.A. Mainstreaming of Ayush 7.50 177.99 2373.20 IEC-BCC NRHM 0.00 23.54 N.A. Mobile Medical Units 0.00 199.10 N.A. Referral Transport 1000.00 1000.00 100.00 Additional Contractual Staff (Selection, Training, Remuneration) 180.00 90.30 50.17
PPP/ NGOs 50.00 0.00 N.A.
Training 17.40 258.76 1487.13
Regional drugs warehouses 120.00 0.00 0.00 New Initiatives/ Strategic Interventions (As per State health policy) 0.00 27.44 N.A.
Research, Studies, Analysis 0.00 3.00 N.A. State level health resources center(SHSRC) 20.00 8.47 42.35 Support Services 8.40 0.00 0.00 NRHM Management Costs/ Contingencies 145.34 127.76 87.90 Total 4380.59 3279.19 74.86
Based on table above and record available in FMG, observations are as under:- General Observations:
1. During the year 2008-09, Rs. 43.81 Crores were approved by the NPCC and releases were Rs.
22.07 Crores, State has utilised Rs.32.80 Crores i.e. 75% of approved PIP, while the national average of expenditure against PIP is 68.14%.
2. As compared to last F.Y. 2007-08, 130% increases have been noticed in expenditure during 2008-09.
3. Since the start of the programme Rs. 89.62 Crores were released to the state, the utilization is only Rs.48.81 Crores (54%) and Rs.40.81 Crores (46%) remains unutilized.
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Areas of Concern:
1. There is high expenditure reported under the head “Mainstreaming of Ayush” as state PIP is just Rs. 7.50 Lakh while expenditure is Rs. 177.99 Lakhs which is 2373 % of approved PIP, reason for such huge difference is required to be looked into and explained
2. Expenditure under the Training is also 1487 % of the approved PIP, which may please be examined.
3. Why there are no expenditure incurred on activities New Constructionn Renovation, Support Services, PPP/NGO and Drugs Ware House for which there was approved budget.
4. Expenditure reported under “ASHA” and “Untied Funds” is less than 50% and needs to be improved.
5. Expenditure under the heads “Corpus grant to HMS/RKS”, Mobile Medical Units & IEC/BCC is either Rs. NIL or less than 2% of the total expenditure while in the state PIP, no funds were asked & approved.
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BRIEFING NOTE ON RCH II: UTTARAKHAND
A. Background/ current status
1. RCH II Goals Uttarakhand’s (including UP) MMR at 440 (SRS 04-06) has improved from 517 in SRS 01-03, but still way above the national average of 254. The IMR (SRS 2007) at 48 has increased from 41 in SRS 2003; however it’s lower than the national average of 55. TFR has remained static at 2.6 between NFHS-2 (1998-99) and NFH-3 (2005-06) and is higher than the target of 2.1 for the year 2012 (refer Annex 1). 2. RCH II Outcomes Uttarakhand’s progress during the four year period between DLHS 2 (2002-04) to DLHS 3 (2007-08) is encouraging (refer Annex 1):
• Mothers having full ANCs increased from 8% to 15.6%. • Institutional deliveries marginally increased from 24% to 30%. • Full immunisation in children 12-23 months increased from 44.5% to 62.9%. • Children with diarrhoea receiving ORS has increased from 21.6% to 44%. • Unmet need for family planning has reduced from 26.9% to 20.8%, while use of modern
contraceptives has increased from 44% to 57.7%.
3. Expenditure Audited expenditure has increased from Rs. 3.98 crores in 05-06 to Rs. 6.52 crores in 06-07 and Rs. 14.58 crores in 07-08; reported expenditure in 08-09 is Rs. 39.47 crores i.e. 115% of allocation (Rs. 34.37 crores). JSY accounted for 32% of the reported expenditure in 08-09. B. Key achievements 1. Maternal Health, including JSY
• Number of JSY beneficiaries in the state increased from 0.01 lakh in 05-06 to 0.24 lakh in 06-07 and 0.70 lakh in 07-08. A total of 0.66 lakh beneficiaries have reportedly availed of the services in 08-09. State has accredited 7 private institutions under the scheme.
• 72 FRUs (against a target of 10) and 67 24-hour PHCs (against a target of 120) have been operationalised in the state.
• Further state has trained 42 doctors in life saving anaesthesia skills (LSAS). • Training on Life Saving Anaesthesia Skills (LSAS): 1 medical college has been identified, 2
master trainers and 14 MBBS doctors have been trained in LSAS against a target of 10. • Tertiary centre is being established at the identified medical college in the state for
comprehensive Emergency Obstetric Care (EmOC) training. • Skilled Birth Attendant training (SBA): 3 districts have been identified, 14 district level
master trainers and 184 SNs/ ANMs have been trained as SBA, against a target of 360. • Jacha Bacha Swasth Divas: A camp approach; fixed day visit for providing ANC and child
health services in all villages located in a sub centre area on a rotational basis. • Voucher scheme for institutional deliveries (Hardwar): Use of vouchers for demand side
financing where RCH services for BPL women & children are provided through private practitioners.
• State has developed minimum performance level, facility/ personnel wise, for conducting institutional delivery and an incentive package would be given to facilities/ personnel performing above that level.
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• Linkages of 108 referral transport services for each delivery through ASHA: the expected date of delivery (EDD) list of all antenatal cases (block wise) is being provided to 108 services monthly.
• Nearly 80,000 VHNDs have been organised in the state so far. 2. Child Health
• IMNCI implementation is underway in 4 districts, with 42 personnel trained. • Infant Mortality Death Audit: At the community level, grassroots workers, such as CARE
change agents, AWWs, other community volunteers, school teachers, and opinion leaders, help identify cases of infant and maternal deaths during the last three years and advise on actions to follow up the audit.
3. Other initiatives
• State Govt. has enhanced the salaries of contractual doctors and paramedics to encourage them to provide services in difficult areas.
• Differential salary packages for specialist and GDMOs working at upper Himalaya, middle Himalaya and lower Himalaya region.
C. Key issues 1. Maternal Health, including JSY
• A large number of FRUs do not provide the stipulated range of services due to lack of access to blood storage facilities and lack of specialist staff. In a recent review, the state has acknowledged that the non-availability of lab technicians is a key bottleneck in setting up blood storage units at FRUs.
• EmOC training is yet to be initiated in the state. • Progress in SBA training is slow; only 46 staff nurses and 138 ANMs/LHVs have been
trained so far, against a target of 360 by the year 2010. • Only about 50% of the planned VHNDs (43430 out of 85357) were organised in 2008-09.
Microplans for VHNDs need to be made and monitoring of service utilisation needs to be ensured.
2. Child Health
• Increasing trend in IMR is a concern. State needs to investigate the reasons and take urgent steps for improvement. − Facility based new born care has not been adequately addressed. − With the high levels of home deliveries in the state (70%, DLHS-3), the large cadre of
ASHAs can be trained to provide essential newborn care; and post natal visits should be ensured and monitored.
• Pace of IMNCI training is very slow, with only 42 persons trained so far. Further, not much headway has been made for other child health training in the state.
• Strategies for children who are mildly underweight (grade I and II) as well sustenance of children who are appropriately weight for age to be maintained, has not been addressed appropriately in the State Programme Implementation Plan (PIP) for the year 2009-10.
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ANNEX 1 A. Progress on Key Indicators
1. RCH II Goals
INDICATOR UTTARAKHAND INDIA Trend (year & source) Current status RCH II/ NRHM
(2012) goal Maternal Mortality Rate (MMR)
517 (SRS 01-03)
440 (SRS 04-06)
254 (SRS 04-06) <100
Infant Mortality Rate (IMR) 41 (SRS 2003) 48 (SRS 2007) 55 (SRS 2007) <30 Total Fertility Rate (TFR) 2.6 (NFHS-2,
1998-99) 2.6 (NFHS-3,
2005-06) 2.7 (SRS 2007) 2.1
2. RCH II Outcomes
S. No. RCH OUTCOME INDICATOR
UTTARAKHAND INDIA* DLHS–2 (2002–04)
DLHS–3 (2007–08)
DLHS–2 (2002–04)
DLHS–3 (2007–08)
1. Mothers who received 3 or more antenatal care checkups (%) 21.2 33.8 50.4 51.0
2. Mothers who had full antenatal check-up (%) 8.0 15.6 16.5 19.1 3. Institutional deliveries (%) 24.0 30.0 40.9 47.0
4. Children 12-23 months age fully immunised (%) 44.5 62.9 45.9 54.1
5. Children age 6-35 months exclusively breastfed for at least 6 months (%) 61.3 37.1 22.7 24.9
6. Children with diarrhoea in the last 2 weeks who received ORS (%) 21.6 44.0 30.3 33.7
7. Use of any modern contraceptive method (%) 44.0 57.7 45.2 47.3
8. Total unmet need for family planning - both spacing methods and terminal methods (%) 26.9 20.8 21.4 21.5
* - Provisional results for DLHS-3 B. Trends in Financial Expenditure
(Rs. crores) FY 2005-06 FY 2006-07 FY 2007-08 FY 2008-09 Release 7.46 12.91 12.96 25.71 Audited Expenditure 3.98 6.52 14.58 39.47* * - Audited expenditure for 2008-09 is not yet available; reported expenditure is provided. - Allocation for 2008-09: Rs. 34.37 crores.
C. Progress on Key Strategies
1. Demand side interventions
S. No.
Indicators
Achievement (no. of beneficiaries) 2005–06 2006–07 2007–08 2008–09
1. Janani Suraksha Yojana 1,360 23,873 69,679 66,202 1. Total Sterilisation 34,980 32,767 34,799 na 2. IUD Insertions 1,30,447 1,40,899 1,40,932 na
(Source: M&E Division reports, and JSY reports from the states)
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2. Technical interventions
S. No.
Indicators
Achievement upto March 2009 Number %
1. No. of First Referral Units (FRUs) operationalised 72 720 (against the target of 10 FRUs)
2. No. of PHCs operationalised to provide 24-hour services 67 55.8 (against the target of 120 PHCs)
3. No. of private institutions accredited under JSY 7 NA 4. No. of districts implementing Integrated Management of
Neonatal & Childhood Illness (IMNCI) 4 30.7 (out of 13 districts)
5. No. of people trained in IMNCI 42 NA 6. No. of Village Health & Nutrition Days (VHNDs) held 79,627 NA
(Source: NRHM MIS report, April 2009)
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Immunization
Uttarakhand
Evaluated Immunization Coverage
Survey Indicator
NFHS 1 (1992-93)
NFHS 2 (1998-99)
NFHS 3 (2005-06)
CES (2005)
CES (2006)
DLHS 2 (2002-04)
DLHS3 (2007-08)
FI NA 40.9 60.0 61.1 72.2 44.5 59.8 BCG NA 76.8 83.5 80.6 90.2 73.0 88.7 Measles NA 56.0 71.6 72.0 78.6 54.6 82.7 DPT3 NA 56.1 67.1 69.7 77.5 56.1 68.3
Progress
� As per the evaluated survey the full immunization is 59.8 % in 2007-08 (DLHS 3). There has
been a good improvement in Measles coverage from 54.6% in DLHS 2 to 82.7% in DLHS-3.
� The State has made good progress in training of Health workers at 94.9% (2646/2789).
� The district level AEFI committees have been constituted in all the districts.
Issues
� The State continues to have high dropout from BCG to DPT 3 at 23% which is critical for
further improvement in full immunization coverage.
� In the year 2008 no case of AEFI reported though the immunization rates are increasing. The
State needs to strengthen AEFI reporting further to improve reporting of AEFI cases.
� The vacant positions at District and PHCs need to be filled which is critical for improving the
service delivery in the State.
� The tracking of beneficiaries need to be strengthened through counterfoils and beneficiary lists by
the ANM/ASHA/AWW.
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Brief on National TB Control Programme in Uttarakhand 1. Infrastructure Total Population - 96 lakh No. of Districts - 13 No. of Tuberculosis Units (TUs) - 30 No. of Designated Microscopy Centres (DMCs) - 140 2. Status of Implementation
• The whole of the state is covered under RNTCP with the assistance of GFATM.
3. State level Performance (Based on quarterly reports for 1st quarter 2009)
• There is downward trend in the performance of the State and Overall performance
is not good. • Referral of TB suspects is good. 170 TB suspects/lakh pop in 1st quarter 09 examined but
overall total case detection rate of 132/lakh and new smear positive case detection rate of 49/lakh (52%) are both very low.
• Also, the sputum conversion rate of 88% and cure rate of 83% are low in NSP patients. Cure rate of 62% in retreatment sputum positive patients is very low due to very high default rate of 20%.
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4-03
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1-04
Qtr
2-04
Qtr
3-04
Qtr
4-04
Qtr
1-05
Qtr
2-05
Qtr
3-05
Qtr
4-05
Qtr
1-06
Qtr
2-06
Qtr
3-06
Qtr
4-06
Qtr
1-07
Qtr
2-07
Qtr
3-07
Qtr
4-07
Qtr
1-08
Qtr
2-08
Qtr
3-08
Qtr
4-08
Qtr
1-09
Annualised New S+ve CDR Success rate
•Population projected from 2001 census
•Estimated no. of NSP cases - 95/100,000 population per year (based on recent ARTI report)
Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, Uttarakhand,2000-2009*
Uttarakhand
19
4. District wise performance (Based on quarterly reports 1st quarter 2009) • Less than 120 TB suspects/lakh pop examined in 3 districts (Chamoli, Pithoragarh and
Tehrigarwal) which is very low. • TCD rate of less than 128/lakh (50%) is very low in 5 districts. Similarly NSP case
detection rate of less than 50% is very low in 6 districts (Bageshwar, Champawat, Garwal, Hardwar, Pithoragarh and Tehrigarwal).
• Sputum conversion rate and cure rate in NSP patients are also very low in 3 districts
Districts
TB Suspects examined/
lakh population
Annualised total case detection rate (against >185/lakh)
Annualised new sputum positive case detection rate (against
>67/lakh)
Sputum conversion rate
new cases (against >90.0%)
Cure rate (new cases)
(against 85.0%)
Almora 191 117 51 53% 97% 90%
Bageshwar 133 100 41 43% 96% 84%
Chamoli 112 133 55 58% 90% 86%
Champawat 143 89 33 35% 84% 88%
Dehradun 237 174 55 58% 85% 79% Garhwal 159 126 47 49% 83% 70%
Hardwar 143 88 39 41% 88% 81%
Nainital 206 196 63 66% 87% 66%
Pithoragarh 113 91 43 45% 90% 88%
Rudraprayag 175 164 54 57% 90% 82%
Tehri Garhwal 109 114 39 41% 80% 81%
Udhamsingh Nagar 177 140 58 61% 92% 84%
Uttarkashi 192 151 49 52% 94% 84%
Overall 170 132 49 52% 88% 80% 5. Funds status as on 31st March 2009 (Rs. in lakh)
C/F Release Expenditure Balance 41.37 206.00 223.31 24.06
6. Drugs Drugs have been provided as per the projected requirement. 7. Issues:
• Human Resource
o STO is having additional charge of NRHM and STDC Director and not able to give adequate attention to visit districts.
o Posts of 5 MO-TCs, 1 STS and 23 LTs in DMCs are vacant. Vacant posts of these key personnel need to be filled on priority.
Uttarakhand
20
• Supervision and Monitoring
o Supervisory visits not happening as per guidelines. Advance tour programme and tour report not being submitted by DTOs to STO.
o Quarterly review meetings not happening regularly. o Internal evaluation not done this year as yet.
• Drug Store – Transportation of drugs from State and from districts to TUs is not as per
guidelines. • Performance
o Overall performance of the State is not good and shows a downward trend. All important performance indicators are low.
o Overall referral of TB suspects is satisfactory but TCD rate of 132/lakh is very low. Similarly NSPCD rate of 49/lakh (52%) is also low and in 6 districts (Begeswar, Champawat, Garwal, Hardwar, Pithoragarh and Tehri garwal) NSPCD rate is very low.
o Overall cure rate of 80% in NSP patients is low and cure rate in 3 districts (Dehradun, Garhwal and Nainital) is very lo (<80%). The main reason for low cure rate is high default rate.
o Cure rate in retreatment sputum positive patients is as low as 62% due to very high default rate of 20%. The State need to strengthen default retrieval mechanism.
• Recording and Reporting – EPI Centre windows version is not being utilized at the
State and 8 district level. • TB-HIV Collaboration – TB-HIV collaboration is sub-optimal. Cross referral is very
limited from both sides. • Intermediate Reference Laboratory (IRL)
o Installation of walk in incubator and Cold Room pending. o There is shortage of manpower – Lab Technicians and Lab Attendants.
• PPM – Limited involvement of Private Medical Practitioners, NGO and Medical
Colleges. Strong will power of the State to involve these sectors is lacking.
Uttarakhand
21
Fact Sheet on NVBDCP- Uttarakhand
Background Information The State has 13 districts with a population of 8.5 lakh. There are 49 CHCs, 232 PHCs and 1525 Sub-centres. There are 1785 Multipurpose Workers (Female)/ANM, 656 Health Worker (Male), 159 Health Assistants (Female)/LHV, 417 Health Assistant (Male) and 32 Laboratory Technician.The State has 16826 Villages. In addition, the state has 1489 Fever Treatment Depots (FTDs) and115 Malaria Clinics. Malaria
Epidemiological Situation
Year Total slide examined
Total Malaria cases
Total Pf cases Deaths
2006 288297 1108 6 0 2007 230677 953 2 0 2008 226903 1059 47 0
2009(upto, Mar.) 34729 58 1 0 Japanese Encephalitis: In the year 2006, 2007 and 2009 no case has been reported. Only 12 cases were reported during 2008.
Dengue/DHF: In the year 2007, no dengue case has been reported. In 2008 only 20 cases were reported. During the year 2009 till 27th May no dengue case has been reported.
Kala-azar: Only 2 cases and no death were reported in the year 2007. In 2008 and 2009, no case has been reported.
Chikungunya is not reported from the state.
Central assistance
(Rs. In lakhs) Year Allocation Release/Expenditure
Cash Kind Total Cash Kind Total 2004-05 0.00 48.20 48.20 0.00 31.06 31.06 2005-06 0.00 53.01 53.01 32.87 33.95 66.82 2006-07 21.02 31.99 53.01 0.00 29.12 29.12 2007-08 181.00 29.59 210.59 3.51 43.75 47.26 2008-09 5.00 52.47 57.47 0* 40.93 40.93 2009-10(B.E.) 25.40 31.68 57.08
* State was having unspent balance of Rs.24.58 lakh on 1.04.08, hence no release was made during 2008-09.
Uttarakhand
22
STATUS OF NATIONAL LEPROSY ERADICATION PROGRAMME IN UTTARAKHAND
• Epidemiological scenario- The state has achieved the goal of elimination of leprosy (i.e. prevalence rate of less than 1 case /10000 population). There were 436 leprosy cases on record as on March 2009.
• New case detection and treatment completion-
During 2008-09, a total of 667 new leprosy cases were detected as compared to 763 new cases detected during the corresponding period of previous year. Out of 767 cases discharged during the year, 630 cases (82%) were released as cured after completing treatment.
• During 2008-09, NLEP action plan amounting to Rs.70.90 lakh has been approved for the
State. Issues -
1. The state is reporting low level of fund utilization. During last 3 years no release was done to the state due to large unspent balance available from previous year. During 2008-09, the state action plan was approved for Rs.68.10 lakhs, however the State could utilize only Rs. 38.00 lakhs.
2. New leprosy cases are being detected in the state every year which suggest active transmission of the disease in the community. The state is advised to carry out indepth situational analysis in districts/blocks reporting large number of new cases and take suitable actions like –
(i) Ensuring completion of treatment in each of the new cases detected. (ii) Enhance awareness of the community to improve self reporting of suspected
cases to health facility and (iii) Carrying out family contact survey against all multibacillary and child cases.
3. There are about 16 leprosy colonies in the state. The state should ensure provision of proper
health care facilities like ulcer care, provision of supportive drugs and dressing materials to the persons affected with leprosy residing in these colonies.
Uttarakhand
23
State - Uttarakhand Integrated Disease Surveillance Project (IDSP) –Fact sheet as on 17 June 2009
Integrated Disease Surveillance Project (IDSP) was launched by Hon’ble Union Minister of Health & Family Welfare in November 2004. It is a decentralized; State based Surveillance Program in the country. It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. Uttarakhand is a Phase – I state under IDSP and has been inducted in the program during 2004-05. Dr HS Negi has been designated as the State Surveillance Officer. The component wise action points are as under:
1. Manpower: • Contractural supporting staff at State Surveillance Unit and District Surveillance Units has
been appointed in 13 districts. • 6 Epidemiologists and State Entomologist joined in the State under IDSP 2. Information Technology & EDUSAT: • SIT Equipments installed at State Headquarter and 10 Distict Surveillance Units. • Data Centre equipments delivered in all districts and installed. 3. Laboratory Strengthening
• Two priority district laboratories are identified for strengthening under IDSP. • Two priority district laboratories are identified for strengthening under IDSP, at Pauri and
Almora . Funds for Buying Lab. Equipments for these two labs has been released to the state and procurement is under process.
4. Data Reporting: • Data reporting on S, P, L forms and for outbreaks is undergoing from all districts in
Uttarakhand and have to be initiated from all districts by using IDSP portal (www.idsp.nic.in) which is one stop portal & has data entry, data analysis and resource sections.
5. Training: Persons trained under IDSP are as below
RRT member 61 Medical officer 319 Pharmacist 692 Lab technician 83 Health Worker 2948
FETP training for District Surveillance Officers is completed in the state 6. Finance:
Year Release Expenditure 2003-04 0.34 lakhs 2004-05 99.71 lakhs 0.23 2005-06 50.0 lakhs 58.14
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2006-07 129.33 lakhs 111.94 2007-08 25.0 lakhs 54.14 2008-09 0.0 lakhs 47.93 Total 304.38 lakhs 272.38 lakhs
Balance: 32.00 lakhs A total of 27 disease outbreak were reported in 2008. Outbreaks were of ADD, Measles, Food poisoning and Chicken pox Disease outbreaks reported in 2009
Disease No. of Outbreak
Acute Diarrhoeal Disease
1
Food poisoning
2
Measles
2
Chickenpox
3
Acute Respiratory Illness
1
Total
9
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NATIONAL PROGRAMME FOR CONTROL OF BLINDNESS STATUS NOTE ON UTTARANCHAL
Magnitude: Prevalence of blindness: 2003-04 0.56%
Estimated blind persons: 0.47 lakhs Infrastructure developed RIO 1(under consideration) Upgraded Medical Colleges - Nil Upgraded District Hospitals - 13 Mobile Eye Care Units - 10 District Blindness Control Societies - 13 Upgraded PHC’s - Nil Eye Banks - 1 Cataract Performance
School Eye Screening
YEAR TEACHER TRAINED IN SCREENING FOR REFRACTIVE ERRORS
SCHOOL GOING CHILDREN SCREENED
DETECTED WITH REFRACTIVE ERRORS
PROVIDED FREE
GLASSES
2007-08 4730 187283 8227 1415 2008-09 5908 146011 6852 1009
GIA released to Distt. Blindness Control Societies/State Blindness Control Society
(Rs in lakhs) Issues
• UCs for GIA released to State Blindness Control Society are not being received timely. • SOE for Cash Grant are also not being received timely. • Performance of School Eye Screening Programme needs to be improved.
YEAR TARGET ACHIEVEMENT
2007-2008 50000 55282 2008-2009 50000 48165
YEAR RELEASED EXPENDITURE BALANCE 2007-2008 81.20 39.20 42.00 2008-2009 200.65 181.03 19.62
Uttarakhand
26
NIDDCP
Approval issued for the year 2009-10
(In Lakhs)
Activity proposed Amount proposed Amount Approved
Amount (kind
component) over and
above PIP
Remarks
Establishment of IDD Control Cell
There is no proposal for fund under NIDDCP in the PIP
6.00 The State may carry out activities as per the fund allocation GOI.
Establishment of IDD Monitoring Lab
3.50
Health Education and Publicity
6.00
IDD surveys 2.50
Total 18.00
Uttarakhand
27
Mapping of Record of Proceedings of the NPCC of NRHM for 2005-06 to 2009-10
This has been prepared to indicate allocations to the State in the previous years for different activities as per the State Programme Implementation Plan. The mapping charts the NRHM Mission Flexipool approvals contained in the RoP in following broad thematic chapters.
1. ASHA (including selection, training, drug kits, mentoring, specific performance incentives and anything else associated with ASHA)
2. Infrastructure related matters (including construction, strengthening, renovation, new construction etc), equipments, transport (ambulances, EMRI, associated expenses) and others)
3. Human Resource related matters (including HR salary, contractual payments, incentives, etc)
4. Programme Management related matters (including PMUs, SHS/DHS, SHSRC, IDHAP, M&E, Mobility support to SHS etc)
5. Untied funds, AMG & RKS related mattes 6. Training & Capacity Building related matters (including trainings, workshops, training
institutions including their upgradation or new construction, courses, etc) 7. Innovations (including Procurement of medicines, School Health, Health Mela,
Insurance, Accreditations, Monthly VHND etc)
NATIONAL RURAL HEALTH MISSION Uttarakhand
Total MFP Approvals 4576.47 4380.59 5766.64 RoP Approvals for Various Years in Rs. Lakh
S.No Initiative 2005-06 2006-07 2007-08 2008-09 2009-10 Remarks Released Approved Approved Approved Approved
ASHAs 1 ASHA 985 985
2 Selection & Training of ASHA 257 500
3 ASHA Kit 12 TOTAL 269 500 0 985 985 Infrastructure related matters 4 Infrastructure
5 Construction of labour Rooms in PHCs 105.00
6 Renovation of existing SC 400.00
7 Construction of Sub-Centre as per IPHS 636 300
8 District Hospitals 80.00
9 Upgradation of CHCs to IPHS 104 200 260
10 Establishment of Call Centres 31.98
11 Rent of PHC 33.00
Uttarakhand
28
12 Ware House on rent 7.80 13 Ware houses 120.00
14 Ambulances/Referral/Operational Cost 1000 1335
15 MMU 508.3 1036 360
16
Walk in Incubator and Cold Room for TB culture lab
10
17
Establishment of Communication Channels
59.10
TOTAL 104 508.3 2308.88 1700.00 1965.00 Human Resources related matters
18 Hospital Managers
3.6
19 Microbiologist - IDSP 2.4
20 Salary of Contractual ANM 180 240
21 Salary of ANMTC Tutor 30 14.4 22 Refrigerator mechanics 8.64
23 Continuing Medical & Nursing Education
69.5
TOTAL 0 30 196.8 321.74 Programme Management related matters
24 State Health Resource Centre 20 33.78
25 Allowance for ANMs 11.88
26 Recharging of Mobile Phones to ANMs 44.54
27
Block PMU (Salary, Mobility and Contingency)
100.8
241.92
TOTAL 0 11.88 165.34 275.7 Untied Funds, Annual Maintainence Grants and RKS fundsrelated matters
28 Rogi Kalyan Samiti 91 29 Rogi Kalyan Samiti- DH 95 80 90
30 Rogi Kalyan Samiti- SDH 12 12
18
31 Rogi Kalyan Samiti- CHC 49 51
55
32 Rogi Kalyan Samiti-PHC/APHC
240
33 Untied Fund for CHC 24.5 26 27.5 34 Untied Fund for PHC 56.25 58 57.25 60 35 Untied Fund for SC 152 2.4 176.5 176.5 36 Untied Fund for VHSC 20 65.6 702.7 959.9
37 Untied fund for ANMTCs 3 6
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29
38 Annual Maintenance Grant - CHC 40 52 55
39 Annual Maintenance Grant -PHC 112.5 88.5 89.5 89.5
40 Annual Maintenance Grant- SC 6.6 100 110
TOTAL 152 304.25 417.1 1349.95 1887.4 Training & Capacity Building related matters
41
Modular training of AYUSH Medical Officers
7.5 1.8
42
Two ANMTCs (additional) under PPP mode
50
60
43
Construction/Renovation/Establishment of ANMTC
204 279 111
44 Renovation of GNMTC, Nainital 132
45
Construction and Establishment of SIHFW at Haldwani
75
TOTAL 204 411 57.5 247.8
Innovations related matters 46 Health Melas 40 47 Transit Home Scheme 122.40
48
Innovation/PPP/NGO: Mobile Van in Tehri & Chamoli
40
49 Procurement of IUD kits 3.75 50 Procurement of NSV kits 4 51 Procurement of Dai Kits 6
52
Laptop- 2, Desktop -4 and Data Cards and Online UPS(for hmis)
5
53 Computerisation & E-health 50.00
54 HMIS server and misc. 15
55 Integration of AYUSH at PHC & CHC 541.44
56
Research & Analysis 50.00
57 Self Care Kit-NLEP 6 58 Study- Medical Manual 3
Uttarakhand
30
59
IEC – (Short Film - Hiring camera, Editing, graphics & music, Miscell.)
1.53
60 State Cell for NPPCD. 5.72
61 Drug supply for CHC/FRU
213 76.01 44.59
62 PHC Kits 142.11 63 SC Kits (Kit A & Kit B) 168.5 64 ASHA Kits 278.57 TOTAL 213 116.01 1397.61 6 84
