Arunachal Pradesh 1.

District- West Kameng (Bomdila)

Major observations of Regional Evaluation Team, Kolkata on the Evaluation work carried out in West Kameng (Bomdila) district of Arunachal Pradesh in March, 2012. I. Details of the visited Institutions:
District visited West Kameng (Bomdila) DH/CHC and PHCs visited District Hospital: Bomdila CHCs: Rupa & Dirang PHC: Sinchung SCs visited Wanghoo, Jameri, Salary & Jerigaon

II. Major Observations:

1. Health Human Resources: a. At the district headquarter and visited facilities, no one was aware about the sanctioned strength of human resources in the district and the visited facilities. b. However as observed from the in position staff reported by the district office, there was a single Specialist (O & G), working as Superintendent at District Hospital Bomdila; Further, 32 MOs, 15 GNMs, 26 ANMs, 14 MPWs (M), 2 each of MPS (M & F), 3 Lab Technicians and 21 Pharmacists were also working in the district. c. During visit to the centres, acute shortage of manpower in the key posts i.e. Specialist, Medical Officer, Supervisor (M & F), Lab Technician, Pharmacist and MPW (M) etc. was observed. In District Hospital Bomdila, 1 Specialist, 9 MOs, 5 GNMs, 4 ANMs and 2 MPS (F); in CHC Rupa, 3 MOs, 5 ANMs, 1 MPW (M) and 1 Pharmacist and in CHC Dirang, 1 MO, 3 GNMs, 9 ANMs, 1 Lab Technician and 1 Pharmacist were working. d. 1 MO, 2 ANMs and 1 MPW (M) were in position at PHC Sinchung. e. 4 MOs, 4 Staff Nurse/ GNM, 2 Additional ANM and 8 Lab Technician were also appointed on contractual basis under NRHM in the district. 2. Functioning of Rogi Kalyan Samiti: It was observed that Rogi Kalyan Samiti has been constituted and registered but regular meetings of Rogi Kalyan Samiti were not being conducted at the visited facilities.

3. Functioning of ASHA and Village Health Sanitation & Nutrition Committee (VHSNC): a. District has fulfilled its target by selecting 215 ASHAs for its 215 villages in the district. b. It was reported that all selected ASHAs have been trained up to 6 modules and also provided with drug kits. c. 215 VHSNCs were reportedly functioning in the district. These committees were having ASHA as a member. d. VHSNC Untied funds to the tune of Rs. 16, 35,700 including opening balance of Rs. 25,700 was available in 2010-11 and utilized fully during the year. Further, the district had spent an amount of Rs. 7, 30,000 against the VHSNC allotted funds of Rs. 19, 80,000 during the year 2011-12. 4. Services of Janani Suraksha Yojana (JSY): a. As per details received, as many as 431 JSY beneficiaries in the year 2010-11 and 390 JSY beneficiaries in the year 2011-12 (up to February, 2012) were paid with cash incentive under the scheme.
b. The budget provision & expenditure in the district and at the visited DH/ CHCs / PHC under JSY as reported is given below: (Amt in Rs) Sr.No. For the year 2010-11 District CHC CHC PHC Office Rupa Dirang Sinchung Total fund available 8,52,900 1,45,500 86,100 88,800 Total expenditure under JSY 5,60,000 1,03,400 74,400 83,400 Balance amount 2,92,900 42,100 11,700 5,400 For the year 2011-12 Total fund available 5,90,000 1,17,100 81,700 80,400 Total expenditure under JSY 4,03,600 1,17,100 62,400 48,700 Balance amount 1,86,400 Nil 19,300 31,700 Particulars

1 2 3 1 2 3

The details were not made available at DH, Bomdila. However, it was reported that Rs. 5,00,000 provided as corpus fund to this hospital were utilized to meet the expenditure under JSSK.

c. During visit to DH and CHCs, the Incharge of these Institutions informed that they did not receive any guidelines for disbursing cash incentive to the JSY eligible mothers from their higher authorities. d. The team contacted and interviewed 30 JSY mothers in the district and observed that 29 JSY beneficiaries were provided with cash incentives and 22 mothers had been accompanied by ASHAs for institutional delivery. Post Natal visit was almost absent. e. JSY registers were maintained at CHC Dirang and PHC Sinchung, while it was not maintained properly at District Hospital Bomdila and CHC Rupa. 5. Untied Funds: a. Details of Untied Fund provided to the district for strengthening the services at different facilities and utilization of funds are given below:
(Amount in Rs.) Sr.No. 1 2 3 4 5 Particulars CHC level 2010-11 Opening balance 2,419 Fund received 1,50,000 Total available fund 1,52,419 Expenditure 1,51,612 incurred Balance 807 2011-12 807 2,00,000 2,00,808 1,13,858 87,949 PHC level 2010-11 1,25,700 1,00,000 2,25,700 1,86,630 39,070 2011-12 39,070 50,000 89,070 50,000 39,070 HSC level 2010-11 Nil 2,00,000 2,00,000 2,00,000 Nil 2011-12 Nil 2,40,000 2,40,000 70,000 1,70,000

b. Untied Funds released and expenditure incurred in the visited CHCs and PHC in the year 2010-11 and 2011-12 are as follow: (Amt in Rs.) Name of Institutions Opening Released Total Expenditure Balance Balance available fund incurred CHC 2010-11 919 50,000 50,919 50,900 19 Rupa* 2011-12 19 50,000 50,019 49,958 61 CHC 2010-11 Nil 50,000 50,000 50,000 Nil Dirang 2011-12 Nil 50,000 50,000 50,000 Nil PHC 2010-11 212 25,000 25,212 Nil 25,212 Sinchung** 2011-12 25,212 25,000 50,212 Nil 50,212

* The untied funds for the year 2010-11 and 2011-12 were utilized by CHC Rupa for purchase of medicines only. ** Untied Fund provided to PHC Sinchung for the year 2010-11 was released to the PHC in the month of March, 2011. Similarly, fund for the year 2011-12 was

released to this PHC in the month of September, 2011. The total fund for both years was lying unutilized at the PHC. c. Untied Funds were provided to the visited Sub Centres for 2010-11 and 2011-12 in March, 2011 and in March, 2012 respectively. 6. 24 hours Delivery Care Services: a. District Hospital Bomdila and CHCs at Rupa & Dirang were providing 24x7 hours delivery care services in the district. PHC visited at Sinchung was identified for providing 24x7 hours delivery care service institution but there was no indoor facility to take care of Post Natal mothers and new born baby. Neo-natal stabilization Unit and Blood storage facility was not available at all the visited facilities in the district. b. Single Medical Officer was posted at CHC Dirang and also at PHC Sinchung for providing 24x7 hours delivery care services. c. The following table shows availability of staff and performance during 2010-11, 2011-12 in the visited CHCs and PHC under 24x7 hours delivery care services:Name of the visited CHCs and PHC Total number of deliveries conducted under 24x7 services 53 63 102 120 62 42 Number of Doctors posted 3 3 1 1 1 1 Number of ANMs/ Staff posted

CHC Rupa CHC Dirang PHC Sinchung

2010-11 2011-12 2010-11 2011-12 2010-11 2011-12

5 5 11 11 2 2

d. DH, Bomdila is a big Institution and there are good facilities for 24x7 hours

delivery care services. In the visited CHCs and PHC, actual figure of night hour deliveries was not made available. 7. Physical infrastructure: (i) Health Sub Centres: a. The team visited Sub centres at Wanghoo, Jameri, Salary & Jerigaon for assessment of sub centre facility. In the visited Sub Centres, maintenance of building was not up to the mark. Labour room was not available there. b. Maclntsh sheet, Ambu bag/suction, Nischay pregnancy test kit, Delivery kit, Sanitary Napkins, Vitamin- A solution, DDKs, Oral Pills, CuT, EC Pills,

Chloroquine, Oxytocin tablets, Kits- A & B and Gentamycine injection were not available at all the visited centres. c. Examination table, Delivery table, Steam sterilizer and Condoms were not available at Sub Centres Jameri, Salary & Jerigaon.
d. RDT kit, Heamoglobinometer and Co-trimoxazole tablets were not available at Sub centres Wanghoo, Jameri and Jerigaon. e. No supply of ORS packets and IFA tablets at Sub Centres Wanghoo and Jerigaon was observed

(ii) BPHCs: a. Auto clave, Microscope & Labour room table was not available and Operation Theater with OT table was not functional in PHC Sinchung. b. AYUSH Medical Officer was not posted and residential accommodation for Medical Officers was not available in the PHC. (iii) DH/CHCs: a. Team visited District Hospital Bomdila, CHCs at Rupa & Dirang and found that maintenance of the hospital building was not up to the mark. Jeep, Blood storage unit, surgical equipments and Anesthesia equipment were not available there. Ambulance was not provided at District Hospital Bomdila. b. X-ray facility was not setup due to want of Technicians and Auto clave was not provided at CHC Rupa. c. Residential quarter for MOs & Para medical staff was not available at DH Bomdila and residential quarter for Para medical staff was found inadequate in CHCs Rupa and Dirang. 8. Opinion and awareness of the Community on the Health Services: Services of PHC:
To assess the opinion on the services provided in PHC Sinchung, 11 different community members i.e. pregnant women, recently delivered women, mothers upto two year old child, AWW, ASHA and also Villagers were interviewed. It was observed that community was generally satisfied with the services. However, proper attention to register the AN mothers within the 16 weeks of pregnancy, awareness about danger sign in pregnancy, sick new born care, breast feeding practices and also uses of contraceptive methods need to be increased. Community was having poor knowledge about HIV/STD/AIDS.

Community members were dissatisfied due to irregular visit by the MO to the remote villages.

9. Sample Verification of F.W. acceptors: a. The team selected a total of 70 F.W. acceptors and out of that 66 (94.3%) could be contacted for sample verification in the district. The contacted acceptors informed that they did not receive any follow up service after having accepted the services. b. During sample check, discrepant entries in age of spouse in 41 (62%) cases, total number of children in 6 (9%) cases, number of male child in 11 (17%) cases and in age of youngest child in 43 (65%) cases were found in the records. c. 44 beneficiaries of BCG/ DPT/ Polio, Measles and Vitamin- A were selected and were contacted. All contacted beneficiaries confirmed receiving the doses. Follow up service was provided to all contacted beneficiaries. 10. Reconciliation of the reporting performance under Sterilization: CuT, Oral Pills and Nirodh figures reported by DH Bomdila, CHC at Rupa and PHC at Sinchung for the year 2010-11 and 2011-12 (up to February, 2012) did not tally with the figures shown in the report of district office for these Centres. CuT reported cases were also found varying with the figures recorded in the service registers maintained at the reporting centres in DH/CHC & PHC. The details are given below:
Name of the Centres During the year 2010-11 Oral Pills cycle reported By the Centres As per By District By the service register office Centres 213 205 381 419 30 30 315 87 24 26 157 153 During the year 2011-12 (up to February, 2012) 208 210 279 336 27 27 146 232 13 19 81 124

CuT reported

By District office DH Bomdila 195 CHC Rupa 25 PHC Sinchung 25 DH Bomdila CHC Rupa PHC Sinchung 177 18 16

Condoms pieces reported By District By the office Centres 915 945 1359 76 2288 2186 2270 589 1229 2600 64 1833

11. Registers, records and reports maintained at the visited centres: a. Eligible Couple register which is one of the most important records for FW services was not maintained at the visited facilities.

b. Consolidated CuT service registers were maintained without all relevant details in the centres visited. c. Oral Pills, Nirodh users and Stock registers were not maintained properly at visited facilities. d. Post Natal Care register was not found to be maintained in visited centres of CHC Rupa and PHC Sinchung. 12. IT Infrastructure: Computers were found available at District and CHC level. Internet connectivity was found available at district level only. MCH tracking was not implemented in the district upto the visiting month. 13. Other observations: a. It was observed that monitoring and regular supervision at periphery level was not effective. Medical Officers and MPS (M & F) should conduct field work for supportive supervision in respective field area. b. IEC activity in the district was not visible; the team did not find any wall painting/ hoarding/ banners and posters at the periphery centres and district level. c. It is difficult to provide regular 3 Ante Natal checks up (2 doses of TT and 100 IFA tablets) to all pregnant mothers in the area of 80% or more Sub Centres in the district as no ANM/ Addl. ANM was posted in such Sub Centres. d. Immunization was done once in a month under outreach programme through EPI team consisting of ANM and Health Assistant (M) etc in rural area of the district. Most of the time outreach programme was not organized on regular basis due to non allocation/ lack of fund. For example, immunization work was not performed in rural areas under outreach since October, 2011 at the visited facilities, due to scarcity of fund under the scheme.

2. District: Tawang Major observations of Regional Evaluation Team, Kolkata on the Evaluation work carried out in Tawang district of Arunachal Pradesh in March, 2012. I. Details of the visited Institutions:
District visited Tawang DH/CHC and PHCs visited District Hospital: Tawang CHC: Jang PHCs: Khou & Kitpi SCs visited Lemberdung

II. Major Observations:

1. Health Human Resources: a. Sanctioned strength of the staff for the entire district was not available at district office as well as in the visited Centres. b. As observed from the status of in position provided by the district office, there was only one Specialist (O & G), working as Superintendent at District Hospital Tawang. Further, 15 MOs, 5 GNMs, 10 ANMs, 8 MPS (M), 5 MPS (F) and 4 Pharmacists were also working in the whole district. c. During visit to the centres, acute shortage of manpower in the key posts i.e. Specialist, Medical Officer, Supervisor (M & F), Lab Technician, Pharmacist and MPW (M) etc. was observed. In District Hospital Tawang, 1 Specialist, 8 MOs, 3 GNMs, 9 ANMs, 3 MPS (F), 1 Lab Technician and 2 Pharmacists; in CHC Jang, 3 MOs, 1 GNM and 1 Pharmacist; in PHC Lhou, 1 MO, 1 GNM, 2 ANMs, 1 MPW (M) and 1 Pharmacist and in PHC, Kitpi only 2 ANMs and 1 MPW (M) were working. d. 3 MOs, 5 Staff Nurse/ GNM, 4 Additional ANM and 4 Lab Technicians were also appointed on contractual basis under NRHM in the district. 2. Functioning of Rogi Kalyan Samiti: It was observed that Rogi Kalyan Samiti has been constituted and registered at all visited facilities. Regular meetings of Rogi Kalyan Samiti were not being conducted at visited facilities. 3. Functioning of ASHA and Village Health Sanitation & Nutrition Committee (VHSNC): a. District has selected 189 ASHAs for its 189 villages in the district.

b. It was reported that 179 ASHAs have been trained in all modules and all ASHAs were having drug kits. c. 189 VHSNCs were constituted in the district and all were having ASHA as a member. d. VHSNC Untied fund to the tune of Rs. 14,00,000 including opening balance of Rs. 11,10,000 were available and out of that, an amount of Rs. 9,28,521 was utilized in the year 2010-11 and the district spent an amount of Rs. 10,70,000 against the VHSNC funds of Rs. 22,72,469 during the year 2011-12. 4. 24 hours delivery care services: a. District Hospital Tawang, CHCs at Jang & Lumla were providing 24x7 hours delivery care services with inadequate facilities in the district. b. Blood storage facility was not available at all the visited institutions. c. The following table shows the performance and staff position in the visited 24x7 centres:
Name of Institutions Total number of deliveries conducted under 24x7 services DH 2010-11 190 Tawang 2011-12 240 CHC 2010-11 22 Jang 2011-12 16 Actual number of deliveries conducted in night hours 78 107 9 6 Number of Doctors/ specialist posted 9 9 1 1 Number of ANMs/ Staff Nurses posted 16 16 3 3

5. Untied Funds: a. Details of Untied Fund provided to the district for strengthening the services at different facilities and utilization of funds are given below: (Amt in Rs.) Sr.No. Particulars 1 2 3 4 5 CHC/FRU level PHC level 2010-11 2011-12 2010-11 Opening balance Nil 25,000 Nil Fund received 25,000 50,000 50,000 Total available fund 25,000 75,000 50,000 Expenditure incurred Nil 75,000 50,000 Balance 25,000 Nil Nil 2011-12 Nil 1,25,000 1,25,000 Nil 1,25,000 HSC level 2010-11 62,753 1,20,000 1,82,753 1,72,753 10,000 2011-12 10,000 80,000 90,000 80,000 10,000

b. Untied Fund released and expenditure incurred in the visited PHCs/CHC in 2010-11 and 2011-12 is as follow: (Amt in Rs) Name of Institutions CHC 2010-11 Opening Release Total Expenditure Balance Balance d available fund incurred Nil 25,000 25,000 Nil 25,000

Jang PHC Lhou PHC Kitpi

2011-12 2010-11 2011-12 2010-11 2011-12

25,000 Nil Nil Nil Nil

50,000 Nil 25,000 Nil 25,000

75,000 Nil 25,000 Nil 25,000

75,000 Nil 24,203 Nil 24,900

Nil Nil 797 Nil 100

c. It was observed that CHC untied fund for the year 2010-11 and 2011-12 was utilized by CHC Jang for purchase of medicine only. 6. Services of Janani Suraksha Yojana (JSY): a. As per details received, as many as 287 JSY beneficiaries in the year 2010-11 and 146 JSY beneficiaries in current year (up to February, 2012) have been paid with cash incentive under the scheme.
b. The budget provision and expenditure in the district and at the visited DH/ CHC as reported is given below: (Amt in Rs) Sr. No. Particulars For the year 2010-11 District DH Tawang CHC Jang office NA 80,000 NA NA 49,674 14,400 NA 30,326 NA 287 39 22 287 39 22 For the year 2011-12 2,47,000 1,36,326 NA 1,18,200 72,300 11,700 1,78,000 64,026 NA 146 87 15 146 87 15

1 2 3 4 5 1 2 3 4 5

Total fund available Total expenditure under JSY Balance amount Total no. of JSY beneficiaries No. of JSY mothers paid incentive Total fund available Total expenditure under JSY Balance amount Total no. of JSY beneficiaries No. of JSY mothers paid incentive

NA- Statement of fund received was not made available to the team. c. During visit to DH and CHCs, the In charge of these Institutions informed that they did not receive any guidelines for disbursing cash incentive to the JSY eligible mothers from their higher authorities. d. 17 JSY beneficiaries were interviewed in the district for on the field verification and it was observed that they had received JSY money. ASHA was accompanying with mothers for institutional delivery. But Post Natal visit was almost absent in the visited centres.

e. JSY beneficiaries register was found maintained at District Hospital, Tawang while it was not found maintained at CHC Jang. 7. Physical infrastructure (HSC/BPHC/CHC) (i) Health Sub Centres: a. The team visited Sub centre at Lemberdung and found that Benches for clients, Cupboard for drugs, Ambu bag/suction, Steam sterilizer, Nischay pregnancy test kit, RDT kit, Heamoglobinometer, Slide for blood test, CuT, Chloroquine, Oxytocin tablets and Gentamycine injection etc were not available in the Centre. b. Skilled Birth Attendance and IMNCI training was not given to the Auxiliary Nurse Midwives there. (ii) PHC: a. The visited PHCs at Lhou and Kitpi were upgraded to PHC from Sub Centre one year back. Still both PHCs were functioning in the old Sub Centre building with inadequate space and facilities. b. Jeep/ Ambulance, Auto clave, Steam sterilizer, Microscope, Lab Technician, Oxygen cylinder, Minor Surgical equipments, Labour room, Labour room table, Resuscitation equipment and functional Operation Theater with OT table were not available in both visited PHCs. c. Residential quarter for MOs was not available in both the visited PHCs. (iii) CHC: The team visited CHC at Jang and found that Jeep/vehicle, X-ray facility, Blood storage unit, surgical equipments, Anesthesia equipments and functional Operation Theater with OT table were not available. Specialist not posted and short supply of drug was also observed there. 8. Opinion of the Community on the Health Services: (I). Services of ANM: a. 20 mothers having child up to one year old were interviewed in the area of SC Lemberdung for assessing their opinion and knowledge about the services provided by the concerned ANM and found that mothers were mostly satisfied with the work of ANMs in the areas of centres visited. b. However, mothers were mostly unaware about danger signs of ARI and usage of ORS.
(II). Services of PHC:

a. To assess the opinion on the services provided in PHCs Lhou and Kitpi, 22 different community members i.e. pregnant women, recently delivered women, mothers upto two year old child, AWW, ASHA and Villagers were contacted. It was observed that community was generally satisfied with the services. However, awareness about referral transport, danger signs during ANC and sick new born babies and also about HIV/STD/AIDS was poor. b. Community members were dissatisfied with the irregular visit by MOs to the remote villages. 9. Sample Verification of F.W. acceptors: a. The team selected a total of 40 F.W. acceptors and out of that 34 (85%) could be contacted for sample verification in the district. 20 (58.8%) contacted acceptors informed that they did not receive any follow up service after having accepted the services. b. During sample check, discrepant entries in age of spouse in 29 (85%) acceptors, total number of children in 3 (9%) cases, male child in 3 (9%) cases and in age of youngest child in 34 (100%) cases were found in the records. c. 49 beneficiaries of BCG/ DPT/ Polio, Measles and Vitamin- A were selected and were contacted. All contacted beneficiaries confirmed receiving the doses. Follow up by health staff was found cent percent among the contacted beneficiaries. 10. Reconciliation of the reporting performance under Sterilization: CuT, Oral Pills and Nirodh figures reported by DH Tawang, CHC at Jang and PHC at Lhou for the year 2010-11 and 2011-12 (up to February, 2012) did not match with the figures showed in the report of district office for these Centres. CuT reported cases were also found varying with the recorded figures in the service registers maintained at the reporting centres in DH/CHC & PHC. The details are given below:

Name of the Centres

DH Tawang CHC Jang

During the year 2010-11 CuT Oral Pills in cycle Condoms in pieces By District By Centres Verified By District By By District By office office Centres office Centres 94 111 150 365 426 393 755 8 24 24 136 NA 84 NA

PHC Lhou DH Tawang CHC Jang PHC Lhou

1 95 12 -

2 2 98 143 230 During the year 2011-12 (up to February, 2012) 84 68 243 273 503 11 11 109 NA 94 90 98 195

235 297 NA 290

NA- Performance report not made available to the team.

11. Registers, records and reports maintained at the visited centres: a. Eligible Couple register which is one of the most important records for FW service was found maintained and updated at visited institution except District Hospital Tawang. b. Consolidated CuT service registers were maintained without relevant details at District Hospital Tawang and CHC Jang, and the register was not provided to the team at PHC Lhou. c. Oral Pills, Nirodh users registers were maintained without all relevant details at District Hospital Tawang and CHC Jang, and the same register was not found to maintain properly in the areas of PHCs Lhou and Kitpi. Stock registers were also not maintained properly by these centres. d. Post Natal Care register was not found to be maintained in all the visited centres. 12. IT Infrastructure: Computers were found available at District and CHC level. Internet connectivity was found available at district level only. MCH tracking was not implemented in the district upto the visiting month. 13. Miscellaneous observation and suggestions: a. Routine immunization was provided at District Hospital, CHC and PHC level only. b. IEC activity i.e. wall painting/ hoarding/ banners and posters was good in the periphery and as well as at district level. c. In the Sub Centre areas, immunization programme was done once in a month under outreach programme through EPI team consisting of ANM, Health Assistant (M) with vaccine carrier.