3 rd Common Review Mission Orissa (04 th – 10 th November 2009)

1. 3rd Common Review MissionOrissa(04th – 10th November 2009) New Delhi 22nd December 2009

2. Districts visited Balasore – A coastal district Kandhamal – A tribal, left wing extremist affected difficult district

3. The Teams

4. Facilities/Areas Visited

5. Major Health Issues Nutrition : Nutritional Status of Population in General Maternal nutrition Child Nutrition Burden of Disease : Malaria, Anaemia dispersed geographical distribution of high tribal population, lowest population per village, growing presence of LWEs in 3.5 blocks, ethnic fault lines

6. GAON KALYAN SAMITI (VHSC) • GKS & RKS mobilization good; most newly constituted • GKS-RKS interested, Focus on spending Rs.10,000 • higher utilization and increasing absorption of untied fund • Meet irregularly; dialogue on health issues yet to begin • PRI involvement perfunctory

7. ASHA - a vibrant group of activists • ASHAs take lead in mobilizing, contributing to increase in Inst. Deliveries, Full ANCs and in full Immunization • ASHA diwas on 10th of every month ensures that ASHAs receive their payments and problems addressed • “ASHA Gruha” – Help Desk cum Rest House • Bicycles, sarees, umbrellas to ASHA for identity • Interest, motivation, accountability.

8. MATERNAL HEALTH • increase in Inst. Deliveries, Full ANCs and in full Immunization • Prompt payment to JSY beneficiaries; pre-signed cheques • 24 hours minimum inpatient stay, post-delivery.

9. Infrastructure: • Mixed-some good, others dilapidated buildings • Exteriors often newly painted, with poor condition of floor • Many facilities are deficient in Power backup, Running water supply, Staff accommodation • Labour Rooms are constructed, often not connected to the main building • Difficulty of access during rains and at night

10. Human Resources • Dedicated Programme Management Support Teams at State and at district levels, under the able leadership. • On line Test for PMSU personnel is in place, needs to be utilized firmly. • Scarcity of manpower – doctors, nurses and allied health professionals–e.g.One GNM manning 24*7 PHC is frequent • Vacancies • increasing caseload • inequitable manpower distribution • inadequate equipment provision • Situation is especially poor for Nurses & MPWs (Male) • e.g. Huge vacancy in Staff Nurse and Additional ANM position (47 in SN and 25 in Additional ANM) in Kandhamal

11. Human Resources • Pre – service Training Capacity Nurses: • ANM Training Centres buildings need strengthening • Class rooms / accommodation are poorly lit with poor amenities • Other training facilities: • NGO sector (4) – good quality • private sector (many) - often with minimum/inadequate facilities

12. Human Resources • Capacity Building of medico & paramedics • Good to see multi-skilling of doctors is working • ANMs generally well trained in SBA, immunization & registers keeping, but poor in maintenance and in use of MCH cards • Lab Techs are knowledgeable, but taking short cuts eg slides being examined at CHC Khajuria were checked and found to be incorrect • Some physicians not very clear about management of undernourished children • Some senior physicians have their own perception on management of malaria cases and that in pregnant women.

13. Human Resources • Recruitment and cadre management: • Almost all Senior Functionaries in the District are holding officiating charge • Note: State has established a Human Resources Unit and cadre structure for doctors, and is doing one for nurses • LHVs and ANMs were not getting their salaries for months though these are reimbursed by GOI.

14. Human Resources • Staffing Model: • Strengthening of PHC New with trained AYUSH doctors, Staff Nurses, Pharmacist • Multi-skilling of staff • PHC (N) functional only with Nurses (to be explored) • MBBS and specialist doctors to staff Block-level CHC as pool, with full complement • Well-equipped SDH and District Hospital (DHH as a training cum teaching centre)

15. Professional development (Doctors) • Doctors with specialist qualifications are working where facilities do not support their specialisations Recommendations (learning and skill development): • DHH as teaching institutions: training facilities, diagnostic & clinical upgradation • Monthly teaching rounds by faculty from medical college • Increase specialised facilities (part-time) to patients at all levels especially DHH • Specialist facilities can be used by all with that specialisation • eg visiting anaesthetist monthly from med coll/pvt sector, elective surgeries referred from all facilities in district, to be operated by the referring specialist

16. Case load IN Public System • Increased utilization of Health facilities at all levels • Full ANC coverage (08–09) 10% increase against 06–07 • Institutional deliveries registers 14% increase. • Increase in FRU coverage area - 66% increase in caesarian sections. • Referrals through the Janani express Note: • Live Birth unrealistically low in 2007 – 08 • Decrease in ANC registrations by 7% in 2008 – 09 from 2006 – 07)

17. Preparedness of Facilities for Patient Care Services • Signage, patients charter, drugs position displayed in all facilities • Inpatient facilities in 24*7 PHCs & in FRUs. No arrangement seen for diet facilities for inpatients • ICTCs operational in DH and CHCs • Some facilities overcrowded - need to increase beds eg G.K. Bhatt Area Hospital Balasore • Drug norms to be reviewed: patients still required to buy from outside, and drug list from 2000 • Routine laboratory services need strengthening at each level • All DHH should have semi-automatic analysers

18. ? Quality of services provided • cleanliness of toilets and common areas mixed; some maintained in-house, others outsourced • Waste segregation and disposal still poor in some facilities • Privacy of services for labour room good but not for outdoor patients (screens) • Gloves not seen for outdoor services • No mosquito nets seen used in any wards – public health facilities not giving nets to patients

19. affairs of health haVEbecome visible to the community

20. difficult areas & vulnerable social groups • Excellent GIS mapping- better targeting • All facilities & villages to be classified in terms of location (accessibility) and vulnerabilities • differential planning needed- adequate resource flows & locally tailored strategies • Project Arogya is in the right direction • Primitive Tribal Groups (PTG)- focus on • Food security • Understanding customs & traditions • ASHAs and Anganwadi workers from their communities • Linking of TBAs with ANMs • Village-based Feeding centres

21. Principal Morbidity in the community is Malaria • PHC Belghar –50% of 154 • CHC Khejuripara –52% of 500 • CHC Gumagarh: 2000 blood slides for malaria in Oct 2009 alone • Children: Major morbidity is Malaria fever, sometimes children suffer from it every month

22. To check malaria • Assured and publicised Artesunate availability • Artesunate combination is often not prescribed because its availability at the pharmacy is not known by the doctor • Recommendations: • Active fever survey • RDK-testing (if available) mandatory before treatment • Training for Increased accuracy of malaria microscopy • Widespread conventional bed nets (treated) till LLIN supply for all is adequate • IRS spray should be proactively supervised to ensure quality • Expert survey to identify the vectors and their bionomics • Gambusia (now in demonstration hatcheries) to be proactively reared in community in all the waterbodies, large and small, ponds and puddle

23. Immunization • State and District figures show improving figures • Survey of village Bulughar in Belghar area of Tumuribandha block • 2 child between 1 and 2 year of age were incompletely immunized • 2 child less than a year were also incompletely immunized • In some villages, immunisation cards not available with families

24. G Udaigiri CHC: of 307 childbirths; 33% weighed <2500 G • Gumagarh CHC: of 40 childbirths, 32% weighed < 2500 G • Village in Ganjuguda SC: 2003-2008 shows that maternal weight tended to remain same; but birth weight of baby gained a bit over the years Low Birth Weight a problem

25. VH&N days • VHN Days are being held, not yet gelled into a system to make it a gala day • AWWs and ASHAs are also involved actively

26. Nutrition Nutritional support system is widespread Anganwadi nutritional supplementation regularly prepared; referral of downward movements in nutrition Pushtikar Divas: Provides separate track for Gr 3 and 4 Malnourished children with money for nutrition and treatment: may also need indoor care with double food ration for acutely ill and grossly malnourished Widespread Gr 1 and Gr 2 malnutrition; tend to remain status quo Irregular attendance by children of other villages and when mothers have other commitments eg NREGS.

27. Nutrition NEEDS: High protein nutrition supplement - locally available materials, prepared by women’s groups, tailored for each area/ cultural group (esp in the case of PTGs) local food basket reengineering for more nutritious diet Stronger prioritisation especially expectant mothers having anaemia or IUGR area/ cultural group (esp PTGs) Movement up the nutrition scale to be incorporated at angawadi and supervisory levels as a desirable outcome, individual tracking & family assessment for difficult cases. Monitoring focus on how many have moved up/ down/ static (results and not just inputs) Malaria and malnutrition to be tackled in tandem on a war footing with full community mobilization and commitment and multi-sectoral coordination

28. Decision support system needs improvement • No feedback mechanism for huge data generated, leading to sub-optimal. Understanding/ use of HMIS • Data entry: CHC Gumagarh examined 2000 blood slides in October 2009; but HMIS report by MO i/c reported 5 cases of Malaria • None of the ANMs examined were conversant/comfortable with the HMIS format that they are using currently. • Disease surveillance data reported in the IDSP system is not tallying to records at any level –CHC, PHC (N) or SC • Very limited supervision & monitoring was observed. CHC Khajuria P form is signed by pharmacist and not by MO i/c • Neither NRHM unit, nor IDSP unit analyze the data they forward to the State • The districts do not generate any Early Warning Signal

29. RNTCP and NBCP RNTCP has prominent presence in the district. Programme monitoring is poor. At G Udaigiri CHC the graphs for samples collected and positive were displayed for October 2009 without calculating the data for the month Blindness Control programme: Annual Cataract surgical rate (CSR) of 2,775 is much below the desired CSR of 6,000 for the state (NBCP and Vision2020 figures) Desired CSR to be used for target setting, with active participation of NGO sector

30. LEPROSY Control Programme Leprosy Data - Kandhamal ISSUE: Rising incidence and disability detection NEEDS: A screening survey to accurately establish incidence and strategise further

31. The dilemma of systems vs. speed: Building capacities • Need for evidence based planning • Differential planning for under-served areas • Dist Health Action Plan needed, and not a budget line. • Planning capacities need to be augmented - what is known needs to be written. Programmatic focus to synergise with systems focus: RCH, Malaria , TB, Leprosy as verticalities • Need for strengthening existing supervision mechanism in addition to creating newer ones: ICDS supervisor more inclined to monitor report generation on LBW then actual analysis and feedback to AWW • Need for greater dialogue with panchayats - as there are many young and enthusiastic members

32. Focus on consolidation before expansion • Staggered expansion in infrastructure • Health human resource expansion to be need based. Career path to be well defined • While developing the health infrastructure, to also fill critical human resource gaps esp. in Nursing, anesthetists, lab technicians • New initiatives to be evaluated and assimilated into the system for sustainability • ASHA and GKS efforts to have strong mentoring support outside the government

33. Thank You Sri P. K. Hota, Dr. Ashoke Roy, Mr. Billy Stewart, Dr. Vijay Aruldas, Ms. Archana Varma, Dr. Shah Hussain

34. Some Trends – Orissa