I. INTRODUCTION Objectives of the study

Current Status of Service Delivery in the Health and Family Welfare Sector in Kerala

I. INTRODUCTION

Kerala State in India is often quoted as a model for the developing world because of its high achievements in the field of health and family welfare with low cost (1,2). This has been achieved with a low state domestic product of US $ 275 (3) per capita per person per year in Kerala against a national average of US $ 350 and the US $ 23090 for the developed countries (2). Further Kerala ranks highest among the Indian states in Human Development Index with a value of 63.8 followed by Punjab with a value of 53.7 (4). However, studies in Kerala have shown that the utilization of primary health centres and sub-centres in the state have been lower than expected levels (5, 6, 7). There was a gradual shift in utilization of certain type of health services from primary health centres over time. This was probably due to the increase in literacy levels and expectation of high quality care. For example, institutional delivery was moving to major government hospitals like women and children hospitals, district hospitals and medical college hospitals in the government sector and major hospitals in private sector. Majority of pregnant women were consulting obstetricians and gynaecologist compared to MBBS doctors leave alone the female health workers. Fall in fertility rate might have also played a role in this. Each couple has only one or two children and they would like to get the best quality care for antenatal, natal and postnatal services. Although the state has been spending a substantial proportion of its budget to health only around a third of the population is covered by the public sector. In his study Ajay Mahal (8) pointed out that the financial benefit from outpatient services and primary health care are generally less unequally distributed than the benefits from hospital services; but the majority of government health service expenditures goes to hospitals. Due to a reduction in the public health sector allocation the quality of care in the government services was gradually coming down and there was a shift from government to private sector for antenatal and natal services (9). Globalization has been reported to adversely affect the Kerala model of health that was developed on equity and justice over a period of time (10). No state wide study of utilization of health services was conducted recently in Kerala. In order to understand the current status of service delivery under the health and family welfare sector with particular reference to the reproductive and child health (RCH) services in Kerala we conducted a study in five selected districts of Kerala.

Objectives of the study The major objective of this study was to find out the current status of service delivery in the health and family welfare sector with particular emphasis on RCH and to come out with suggestions to redesign the service delivery system. 1


II. SURVEY DESIGN AND METHODOLOGY In order to collect information from the clients and health care providers we decided to use both qualitative and quantitative methods of data collection. We used a multistage sampling process to select the households for data collection Districts Two districts each from erstwhile Malabar region of the state namely Malappuram and Kannur (north of Ernakulam district) and two from the erstwhile Travancore Region namely Ernakulam and Alappuzha were selected for the study. Kollam District was also included in the study since this was taken up by the state to implement the project supported by the sector investment programme of the European Commission Technical Advisory Group (ECTA). Institutions From each of the selected district we selected two community development blocks randomly. One First Referral unit (FRU), one Community Health Centre (CHC) nearest to the selected block, two block Primary Health Centres (PHC), two mini primary health centres under the selected block PHC, and 7 sub centres each under each of the block PHC were selected for the institutional survey. Thus it was decided to collect information from 14 sub centres, 4 mini primary health centres, 2 block PHCs, 1 CHC and 1 FRU from each selected district. The institutional survey collected information on the facilities available at each of the selected institution, which was obtained both by interviewing the personnel at the institution using a structured interview schedule and by personal interview undertaken by one of the investigators of the team and from the records kept in the institution. A total of 103 institutions were covered in the survey.

Household survey Rural area From each of the selected sub-centres, one-day block each (the households under the sub centres are divided into 20 day blocks for field work by the staff of the sub centre) was randomly selected for household survey. All the households in the selected day block (approximately 50 households in each day block) were surveyed using a pre-tested structured questionnaire. The total number of households in each district was expected to be around 700 in the rural area making a total of 3500 households in the five selected districts. Urban area In the urban area one ward of a Municipality or a Corporation was selected randomly and a cluster of 300 households were selected from that ward. In districts with more than one municipality one municipality was selected randomly. Thus we decided to cover a total of 1000 households in 2

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MAP 1. MAP OF KERALA SHOWING THE SELECTED STUDY DISTRICTS

3


each of the selected district (700 in rural area and 300 in urban area). This proportion of households was based on the rural urban population distribution in the state as per the 1991 census. Total sample size for the state was 5000 households. Population in each of the selected district ranged from 2.11 million in Alappuzha to 3.63 in Malappuram district. For each district there were 2 field investigators for data collection. They were trained at the Achutha Menon Centre for Health Science Studies (AMCHSS) of the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram. Household interview schedule The schedule for the household survey was discussed and finalized in two workshops organized in Thiruvananthapuram. In addition to the faculty of AMCHSS senior medical officers from directorate of health services, public health nurses from district medical office Thiruvananthapuram, and faculty members of the regional health and family welfare training centre Thiruvananthapuram also participated in the workshops. A separate instruction manual was printed and circulated to all field investigators to ensure uniformity in data collection. Household information included age, sex, number of individuals, occupation, monthly household income, and awareness and utilization of sub centres, primary health centres, community health centres, and first level referral units. Households were grouped into 3 based on monthly percapita income viz low < _ 250, middle 251-675, and high more than 675. The kind of health services that the household was receiving from each level of organization and the quality of each service was also assessed using a three-point scale. There were questions to collect information on family planning services, adolescent health services, and other services. Information on antenatal care including frequency of check ups, Tetanus Toxoid (TT) immunization, iron and folic acid supplementation, source of care (private or public) etc was collected. All mothers in the selected day blocks who delivered within a period of two years preceding the date of survey were included in the survey. Information on delivery care included place of delivery, who attended the delivery and complications during delivery. In the postnatal period information on birth weight of the baby (the youngest baby if there were more than one baby) breast feeding, family planning and their preference for a female health provider to conduct delivery was collected. Information on immunization coverage was collected from mothers of children between 12 to 23 months of age only. This age group was fixed for comparison of our survey results with previous surveys and considering the timings of each immunization in the national immunization schedule. If a child follows the national immunization schedule, by the end of one year each child could receive 3 doses of DPT vaccine, 3 doses of Polio vaccine, one dose of BCG vaccine and one dose of Measles vaccine. Availability of an immunization card at the time of interview, vaccination date and source of vaccine was also collected with regard to all vaccines in the immunization schedule. 4


In addition information on MMR (Mumps, Measles, Rubella) and Hepatitis B vaccine, vitamin A first dose was also collected. Form for institutional survey Through this schedule we collected information on the facilities of individual institutions. The services provided through each institution, number of beneficiaries in the last one-month, availability of drugs and other facilities were also assessed using this schedule. Access to the institution, water supply, electricity, and safety of the building was also collected through the schedule (See Annexure). Focus group discussions In addition to household surveys we conducted 8 focus group discussions; four in the northern district of Kannur and four in the southern district of Kollam. FGDs were conducted separately for junior public health nurses, junior health inspectors and selected women in the age group of 15 to 50 years from the community. Some of the important information, which the schedule could not capture, could be obtained through these focus group discussions. Particularly the ‘why’ part of many questions could be collected through FGDs. Personal Interviews We also met various state level, district level, and block level health officials and conducted personal interviews regarding the health care services in the health and family welfare sector. The questions were mostly on problems faced by the officials in the health service delivery and their suggestion to improve the quality of services. Data collection The household data collection was conducted during the months of June to September 2001 by the trained field investigators. Most of the institutional data was collected by one of the authors (RP) and the rest by trained medical officers. Focus group discussions and personal interviews were conducted by one of the authors (KRT) during the same time period. Data cleaning, Data entry and analysis One of the investigators visited various districts for supervising the data collection. During the visits he used to collect back the completed schedules from the field investigators. Other data sheets were sent by courier to the AMCHSS office at the end of one month. As soon as the data sheets arrived they were manually checked by the data entry operator in the AMCHSS office and the data sheets were arranged district wise. After the manual checking all data were entered in computer using excel programme. Data analysis was done using SPSS software.

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III HOUSEHOLD SURVEY RESULTS Study Sample Characteristics Out of 5000 households surveyed 23 Schedules were discarded (0.4%) due to incomplete information and 4977 schedules were used for analysis (Table 1). Out of this 4977 households, 69.9 per cent was from rural and 30.1 per cent from urban areas Table 1. Number of households surveyed in the five selected districts Households District

Rural

Urban

Total

Kollam

717

299

1016

Alappuzha

690

301

991

Ernakulam

715

300

1015

Malappuram

668

299

967

Kannur

689

299

988

3479

1498

4977

Total

Antenatal Care Ante natal care (ANC) refers to the health needs of women during the time of pregnancy. Several studies have shown that ANC attendance has a strong influence on the health and reproductive behavior of mothers and the survival condition of children (11). The main objective of antenatal care is to ensure that the women maintain good health throughout their pregnancy and deliver a safe and healthy live child. To achieve these objectives the pregnant mothers should be seen by a health provider early in pregnancy and in the absence of complications, at specified periods throughout her pregnancy and delivery (12) Obstetricians recommend antenatal care visits to be made on the monthly basis up to 28 th week, fortnightly up to 36th week and weekly until 40th week. The reproductive and child health programme recommends that as a part of antenatal care, women receive two doses of tetanus toxoid vaccine, adequate amounts of iron and folic acid tablets or syrup to prevent and treat anaemia, and at least three antenatal check-ups that include blood pressure checks and other procedures to detect pregnancy complications (13, 14). According to NFHS-2 only 65 per cent of pregnant rural women in India received ante natal check-ups. Our results show that 94 per cent of pregnant women received ante natal check-ups. Compared to NFHS -2 data of 99% antenatal checkups in Kerala, our result is slightly lower. In 6

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some of the districts of Bihar, Rajasthan, Uttar Pradesh and Madhya Pradesh full antenatal care was given to only less than five per cent of pregnant women during the period 1995-99. The lowest proportion of full antenatal care in Kerala was reported to be 68% in that report (15). 7.6%

92.4%

received at least 3 ante natal ckeck ups

Others

Fig 1 Percentage of pregnant women who received at least 3 ante-natal check ups

The average number of antenatal visits in the sample was over 8. This is close to the figure reported in NFHS 1 and 2. For a developing economy like Kerala do we need these many antenatal check-ups? Can we afford these many? This is the average number of antenatal visits followed in the developed countries. One recent study has shown that there is not much difference in the outcome of mortality and morbidity for the mother and baby when the number of visits was only four (16). Therefore the ideal number of antenatal check ups for a pregnant woman has to be revised. In our study there was no significant difference in the average number of antenatal visits between rural and urban areas. This high figure represents several unnecessary visits to a single medical problem and the society’s over dependence on health facilities during pregnancy. In India 44 % of mothers received at least three ante-natal check-ups (17). In the present study 92.4 per cent of mothers received at least 3 antenatal check-ups. In terms of district-wise analysis, Ernakulam and Alappuzha had the maximum visits and Kannur had the minimum number of visits. Immunization of children and pregnant women is considered to be one of the most cost-effective public health interventions. The success of the RCH Programme is also dependent on the logistics and access developed under the immunization programme. Tetanus Toxoid Vaccination An important component of ANC is to ensure that pregnant women and children are adequately protected against tetanus. The National Immunization Schedule suggests that a pregnant woman should receive two doses of tetanus toxoid vaccine. Table 2 below shows the distribution of mothers by the tetanus toxoid vaccination status in the five districts in Kerala. For births in the two years proceeding the survey 93.3 per centage of mothers received two tetanus toxoid injections during pregnancy, and 3.7 per cent received one 7


injection only. Coverage of tetanus toxoid has been high in Kerala in previous studies also. The objective of this vaccination in pregnant women is to prevent tetanus infection in the mother as well as to prevent neonatal tetanus in the newborn baby. Kerala has reported no neonatal tetanus in the last three years and is in the elimination stage. High coverage of this vaccine and nearly hundred per cent institutional deliveries could be major reasons for the elimination of neonatal tetanus in the state. Surprisingly in Ernakulam district, one of the most advanced districts in Kerala both socially Table 2. Percentage of mothers received TT injection and average number of antenatal check ups District

TT injection received

Average no. of

First dose

Second dose

ante-natal check ups

Kollam

100

98.9

8

Alappuzha

100

99

10

Ernakulam

89.3

76

10

Malappuram

94.4

90.3

7

Kannur

99.4

97.4

7

Urban

97.8

94.5

8

Rural

96.8

89.5

8

97

93.3

8

Kerala

and economically, the TT coverage was found to be less than other districts, while the district is reported to have the maximum number of antenatal visits in the state. Antenatal visits are generally done by medical doctors in the state. NFHS 1 reported that most of these visits were to doctors. Only a small fraction of the visits were to health workers. This adds to the cost of health care in the state and for the individuals and households. Quality of antenatal visits is questionable since some of the outcomes of pregnancy and delivery are not commensurate with the number of antenatal visits. For example the proportion of low birth weight babies is still above 10 and the state has not achieved the target of LBW proportion set by the National Health Policy of 1983 at less than 10 even after the year 2000. The focus group discussion supported many findings of our study from the households. They reported that the antenatal visits are regular and as per the instructions of the doctors. This could be the reason for a high number of antenatal visits in the state. People select doctors according to their fame in the society. This was irrespective of whether the doctor works in the private sector or in the government sector. If the doctor was in the government sector they went to their private consultation. The number of antenatal visits was determined by doctors and not by the pregnant women. The doctor would be very unhappy if the visits are not regular. Therefore the women stick to the actual number of visits suggested by the doctor, which is around 10. For each visit the 8


average expenditure would be around Rs. 200 including the cost of medicines and the consultation fees to the doctor. Since the average number of children per couple in Kerala was less than 2, each pregnancy was considered precious. This was another reason for regular antenatal visits. The use of technology like ultrasound scanning was also increasing recently (18). All the groups of male health workers, female health workers and community members were not aware of any sex selective abortion practices. We collected information on the source of TT injection to all the mothers. The result indicates that more than half of them approached private health institutions. And among the government health institutions PHCs, Sub centres and district hospitals play a major role. The role of district hospital is mainly seen in Kollam district, since it is the main mother-care centre in the district. Iron and Folic acid supplementation and consumption Despite the fact that most of the anaemia seen in pregnancy is largely preventable and easily treatable if detected in time, anaemia still continues to be a common cause of maternal mortality and morbidity in India. Distribution of IFA tablets from 4th month onwards will help in preventing anaemia. Ensuring that pregnant woman receives the 100 IFA tablets that are distributed free by the Government of India will help in reducing the incidence. In addition to these IFA tablets the practice of employing iron utensils for cooking and not discarding the water in which rice or vegetables have been cooked also ensure that iron and nutrients are not lost. This entails no extra expenditure and attempt can be made to ensure its adoption. By advocating the use of locally available foods that are rich in iron, nutrients and proteins can help in reducing the prevalence of nutritional anaemia (19). This is relevant in a low income State like Kerala.

Table 3. Source of Iron and folic acid tablets (%) Source

Kollam

Alappuzha

Ernakulam

Malap- Kannur puram

Rural

Urban Kerala

Medical college

0

5.8

0

0.8

0

1.7

0

1.3

District Hospital Taluk Hospital FRU CHC BPHC PHC Sub centre Private Hospital Govt. Hospital

2.2 0 6.7 0 0 17.8 12.2 54.4 6.7

3.9 5.8 0 0 1.0 10.7 22.3 50.5 0

1.4 2.8 0 1.4 0 1.4 20.7 66.7 5.6

10.7 0 0 0 4.1 1.7 19.8 47.9 0.8

10.6 12.1 0 10.6 0.7 13.5 7.1 44.0 1.4

5.2 2.2 1.5 3.7 0.5 11.8 19.5 47.8 2.2

11.6 13.2 0.8 0.8 4.1 0.8 3.3 62.0 3.3

6.6 4.7 1.3 3.0 1.3 9.3 15.7 51.0 2.5

100.0

100.0

100.0

100.0

100.0

100.0

100.0

100.0

Total

9


Even though there is provision for free supplementation of IFA tablets in the government sector, more than half of the mothers depended on private sources particularly in the southern districts and in urban area. Even in the rural area half of mothers depended on private sector. This is probably linked to the antenatal visits to specialists who are mostly available in the private sector in the state. The second main source of IFA was the subcentres for the state as a whole (15.7%). In the rural area 19.5% received IFA from subcentres where as the corresponding figure for urban areas was 3.3 per cent. This low figure in urban areas is expected because there are no subcentres in urban areas in Kerala. Urban mothers depended more on private sources than the rural mothers. The spatial difference on the source of IFA tablets is clear from the above table. Urban people depended mainly on the District hospitals, Taluk hospitals, Private sources and Government hospitals than the rural users for obtaining the IFA tablets. Ernakulam district showed the highest dependence of private hospitals for IFA tablets and Kannur and Malappuram showed a comparatively lower proportion. In spite of having a high consumption of iron and folic acid tablets there has been high prevalence of anemia among pregnant women in Kerala. Studies in different parts of India have estimated that the proportion low birth weight ( 675

A lot of information could be collected through the FGDs on delivery practices. Most women prefer the doctor who checks up her during the antenatal visits to conduct the delivery also. Since more hospital beds are available in private hospitals they go to the private doctors/hospital for antenatal visits also. However there are some women who go to antenatal visits to the government sector and for delivery to the private sector. This is mainly due to lack of cleanliness, rude behavior of staff in labor room, and lack of facilities in the government hospital for delivery. They will have to purchase many items from outside and bribe the staff in the labour room. In one of the groups it 13


was reported that the labour room staff asked to bring coffee for all the staff in a Pepsi bottle. She reported that even if they asked to bring coffee in a bucket they would have brought because her daughter was in labour room with labour pains. In exact words of the woman who reported this “Makal prasavavamuriyil kidakkumbol pepsi bottle alla buckettil kappi vangan paranjaalum vangendi varum”. Regarding the increased proportion of cesarean section the group felt that cesarean is safe and there is no labour pain for the mother. Most often the decisions are made by the doctor to go for a cesarean. The choice for the mother in this is limited. All the groups agreed that the cost of cesarean section delivery will be higher than that of normal delivery. However if there was a need of cesarean delivery they would not have any other choice. A few women also reported that cesarean has become so casual and even for getting good ‘birth star’ for the baby some women would go for cesarean delivery. High rate of cesarean section delivery was reported from the state in earlier studies also (24, 25, 26, 27). The fees for cesarean delivery depended on the hospital. They said there was no standard rate for either normal delivery or cesarean section. The doctor of the hospital management in the case of private hospital decided this. In a government hospital the amount of expenses would be certainly high for a cesarean section compared to normal delivery. The average cost of cesarean section delivery in the state was around Rs 3800 (6). This is not very high as one would expect. However the total unnecessary expenditure for cesarean section delivery is enormous. However neither the doctors nor the community felt that the cesarean rates were high. From the personal discussions with obstetricians and primary health centre doctors they did not believe that mortality and morbidity due to cesarean section are higher compared to normal delivery. They were not aware of the literature on this issue that mortality and morbidity are higher in cesarean deliveries compared to normal vaginal deliveries. Assistance during delivery Table 6 provide the information on assistance during delivery in the selected districts under consideration. If more than one attended the delivery the most qualified is reported. Ninety four

Table 6. Percentage of women by the assistance during delivery Assistance during delivery Gynaecologistmale Gynaecologistfemale MBBS-male MBBS-female Others-male Others-female Total 14

Kollam

Alappuzha

Ernakulam

Malap- Kannur puram

Rural

(N=79)

(N=101)

(N=74)

(N=142) (N=151) (N=419)

Urban Kerala (N=128) (N=547)

7.6

8.9

6.8

2.8

7.9

6.9

5.5

6.6

92.4

89.1

93.2

80.3

82.1

85.2

88.3

85.9

0 0 0 0 100

0 0 0 2 100

0 0 0 0 100

2.1 1.4 0 13.4 100

1.3 3.3 0 6.6 100

1 1.2 0 6.2 100

0.8 1.6 0 3.9 100

0.9 1.3 0 5.7 100

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per cent of all births were attended by doctors. About 93% of deliveries were attended by obstetricians and gynaecologist and female obstetricians and gynaecologist attended 86% of the deliveries in this study. There is less rural-urban difference in assistance during delivery. The proportion of deliveries attended by other females was comparatively higher in rural areas of Malappuram and Kannur district. In Malappuram district where home delivery was reported, 13.4% of deliveries were attended by other females. In Kollam and Ernakulam District all deliveries were assisted by Gynaecologist mostly women Gyanecologists. Female doctors were preferred by 98 per cent of the respondents for conducting delivery.

Birth weight Information collected through the mother coverage form also included birth weight of babies. Low birth Weight was defined as less than 2500 grams at delivery, which is the internationally accepted criterion for LBW. The babies weighing less than 2000 grams at the time of birth were classified as very low birth weight (VLBW) babies. Only a small (1 %) per cent of babies in our sample was born with a very low birth weight. 1%

12%

87%

Very low birth weight Normal birth weight

Low birth weight

Fig. 3 Distribution of Low birth weight Low birth weight proportion in our sample was 13.3. It was higher in the rural area (14.4%) compared to the urban area (9.6%). Government of India set certain targets in the health sector to be achieved by the year 2000. The state of Kerala achieved most of these targets viz. infant mortality rate of less than 60, life expectancy of 64 years for males and females, crude birth rate of 21 for 1000 population etc. For low birth weight the target was set at less than 10% by the year 2000. Most studies on low birth weight in Kerala (17, 18, 28) reported that proportion of low birth weight in Kerala is over 10%. Our figure of 13.3% is lower than the figure reported in NFHS 2. In Urban Kerala the rate has come down to less than 10%. There is a lot of variation in LBW proportions ranging from as low as 6.4% in Kannur to as high as 26.7 % in Ernakulam, while Ernakulam had the maximum number of antenatal visits and Kannur had the minimum number of antenatal visits. Due to low sample size, district wise estimates of LBW has limitations, we may not be able to infer much from this. Proportion of LBW babies was higher in lower income groups compared to middle and high income groups. This was reported by earlier studies also in Kerala (18). 15


The low birth weight proportion seems to be decreasing over the years. In the NFHS 1 the low birth weight proportion in Kerala was 18% and it came down in the NFHS 2 to 15% and now in our study it came down to 13%. Similarly the Infant Mortality Rate of the State has also been coming down in the state for the last many years finally reaching at 10 for the state as a whole in the year 2003 (29).

Postnatal Care The health of a mother and her new born child depends not only on the health care she receives during her pregnancy and delivery, but also on the care she and the infant receive during the first few weeks after delivery. Postpartum check-ups within two months after delivery are particularly important for births that take place in non-institutional settings. Recognizing the importance of postpartum check-ups, the Reproductive and Child Health Programme recommends three postpartum visits (14). Since postnatal care service is an essential component of RCH programme we collected information on the problems during postnatal period and the treatment that the mother received for it. We also collected the source of treatment for the problems and JPHN’s visit during the postnatal period. Only a very low per centage of our mothers experienced some problem during the post-natal period probably due to the high proportion of institutional deliveries. Most of them who reported complications sought treatment from Government health institutions. In our sample 63 per cent of our mothers were visited by JPHN during post natal period and the average number of visits was 3.

Child Immunisation The Universal Immunization Programme (UIP) was introduced in 1985-86 with the following objectives: to cover at least 85 per cent of all infants against the six vaccine-preventable diseases by 1990 and to achieve self-sufficiency in vaccine production and the manufacture of cold chain equipment (30). This scheme was introduced in every district of the country. In our study immunization coverage was collected through a schedule addressed to mothers of children of 1 to 2 years. In the survey mothers were asked whether they had an immunization card for the present child under consideration. If the card was available, the interviewers copied the information on child vaccination against each disease. If the vaccination card was not available, mother’s report was accepted and information was recorded based on that. The information was collected on the date and dose of immunization as well as the source of immunization. Immunization cards were shown for 81.4 per cent of children in urban area and 84.2 per cent in rural area.

DPT Three doses of DPT and three doses of polio are to be given to children before the age of one year. Both are administered simultaneously to children and hence generally, the per centages of 16


children having 3 doses of DPT and three doses of polio would be almost the same. But in certain situations when the child is ill or when vaccine is not available the per centages will be different. Here the information on the three doses of DPT and polio were available. DPT3 coverage in the state was 86.5 per cent. This was slightly higher than the target of 85 per cent. There was clear spatial difference in DPT3 coverage in the state with urban area having better coverage. Among the five districts Ernakulam showed 100 per cent coverage of DPT3 and Malappuram (only 47.6%) showed the lowest per centage. The rural area in Malappuram showed 47.4 per centage and urban area 50.0 per centage of coverage of DPT3. The low per centage of the state average may be due to the comparatively low coverage in Malappuram district. Malappuram district is continuing to be lagging behind other districts in immunization coverage. Polio Per centage of children who received polio3 in Kerala was 85.7 per cent. The district-wise analysis showed that Kollam and Ernakulam districts had 100 per centage of polio3 vaccination and Malappuram showed a far low per centage of 47.6. Malappuram did not improve the vaccination coverage from the year 1993 when the polio 3 and DPT 3 coverage was around 45% (21). This district reported a case of acute poliomyelitis in the year 2000 (31). Efforts on Polio eradication from the state will not be successful unless routine immunization programme in backward districts and backward areas of forward districts are given special attention. There may be isolated pockets in many other districts in the state. Identification of low coverage areas and action plan to improve coverage in those areas would be the key in achieving polio eradication and control of other vaccine preventable diseases in the state. The zero dose of polio vaccine is recommended in all institutional deliveries. However there was a mismatch between the proportion of institutional delivery and the proportion of children received zero dose of polio vaccine. This could be due to lack of awareness regarding the need for this polio dose or lack of availability of polio vaccine in all hospitals where deliveries are taking place in Kerala. Another reason for this low coverage could be the higher proportion of institutional deliveries in the private sector where polio vaccine may not be available. Usually vaccines for the private sector are also provided by the government and if the coordination between public sector and private sectors is not good vaccine may not be available in the private sector. In Malappuram district zero dose polio vaccine was given to 73% while first dose was given to only 60.3%. This shows that for institutional delivery the zero dose polio was given to the babies in the hospital itself. For the first dose of polio babies will have to be taken to a health facility. In Malappuram it is possible that some mothers were not convinced about the importance of vaccination or due to cultural reasons mothers may not be allowed to go out during this time. Measles According to the national immunization schedule, all primary vaccinations, including measles, should be completed before the age of one year. Measles vaccination is expected to be given as soon as the child completed 9 months. In our sample 81.6 % of children were given measles. This proportion ranges from 97.3 per cent in Ernakulam district to 44.4 per cent in Malappuram district. 17


The rural-urban difference showed that the coverage of measles vaccination was higher in urban (85.7%) area than in rural area (80.6%)

BCG BCG vaccination is an injection in the left shoulder that most often leaves a scar. This can be given at birth or at six weeks. In our sample 92.9% of children had received BCG vaccination. The three districts Kollam, Alappuzha and Ernakulam showed 100 per cent BCG coverage while Malappuram showed only 74.6%. The coverage in Kannur district was 95.4%. Table 7. Percentage of children (12-23 months) received vaccines and other services Kollam

Alappuzha

Ernakulam

Malap- Kannur puram

(n=49)

(n=52)

(n =37)

(n=63)

DPT 1 100.0 DPT 2 100.0 DPT 3 98.0 Polio ‘0’ dose 83.7 Polio 1 dose 100.0 Polio 2 dose 100.0 Polio 3 dose 100.0 Measles 95.9 BCG 100.0 MMR 22.4 Hepatitis B-1 34.7 Hepatitis B-2 32.7 Hepatitis B-3 14.3 Vitamin- A 1 dose 91.8

98.1 98.1 98.1 100.0 98.1 98.1 98.1 92.3 100.0 3.8 17.3 15.4 15.4 94.2

100.0 100.0 100.0 81.1 100.0 100.0 100.0 97.3 100.0 16.2 45.9 45.9 37.8 64.9

57.1 50.8 47.6 73.0 60.3 50.8 47.6 44.4 74.6 0 6.3 3.2 3.2 41.3

Vaccines

Rural

Urban Kerala

(n =65)

(n=217)

(n=49) (n=266)

100.0 98.5 98.4 36.9 96.9 95.4 93.8 89.2 95.4 6.2 4.6 0 0 89.2

88.0 85.7 85.3 73.3 88.0 84.8 83.9 80.6 86.2 9.2 14.3 12.0 9.2 76.0

95.9 95.9 91.8 69.4 95.9 95.9 93.9 85.7 95.9 6.1 38.8 34.7 22.4 75.5

89.5 87.6 86.5 72.6 89.5 86.8 85.7 81.6 92.9 8.6 18.8 16.2 11.7 75.9

Hepatitis B Hepatitis B vaccine is not included in the immunization schedule. This is usually given at request, mostly from private institutions. Hepatitis B coverage in the state was only 11.7 per cent; 22.4% in urban areas and 9.2% in rural areas. The district-wise analysis showed that Ernakulam district had the highest coverage of 37.8% and Kannur District had zero per cent coverage.

MMR MMR is also not included in the national immunization schedule but has been recommended by the Indian Academy of Paediatrics and several other organizations. Therefore this vaccine is given to those children at request and mostly through private institutions. MMR coverage of 8.6% is less than that of Hepatitis B. Malappuram district did not report any MMR vaccination. 18

State/District DPT3

19

Kerala (n=230) Kollam (n=48) Alappuzha (n=51) Ernakulam (n=37) Malappuram(n=30) Kannur (n=64) Polio 3 Kerala (n=228) Kollam (n=49) Alappuzha (n=51) Ernakulam (n=37) Malappuram (n=30) Kannur (n=61) Measles Kerala (n=217) Kollam (n=47) Alappuzha (n=48) Ernakulam (n=36) Malappuram (n=28) Kannur (n=58) BCG Kerala (n=247) Kollam (n=49) Alappuzha (n=52) Ernakulam (n=37) Malappuram (n=47) Kannur (n=62) Hep - B3 Kerala (n=31) Kollam (n=7) Alappuzha (n=8) Ernakulam (n=14) Malappuram (n=2) Kannur (n=0)

Medical Dist. College Hospital THQ 0 0 0 0 0 0 .4 0 0 2.7 0 0 0 0 0 0 0 0 1.2 0 0 0 4.3 1.6 0 0 0 0 0 0

15.7 12.5 43.1 2.7 6.7 7.9 16.2 12.2 45.1 0 6.7 9.8 17.1 17.0 43.8 0 3.6 12.1 13.4 10.2 5.8 18.9 12.8 19.4 0 0 0 0 0 0

3.5 0 0 0 0 12.7 3.9 0 0 0 0 14.8 5.1 0 0 0 0 19.0 4.0 0 0 0 0 16.1 0 0 0 0 0 0

FRU 3.9 2.1 13.7 0 0 1.6 3.5 2.0 11.8 0 0 1.6 3.7 0 12.5 0 0 3.4 8.1 4.1 32.7 0 0 1.6 0 0 0 0 0 0

CHC

BPHC

PHC

SC

7.0 0 0 0 0 25.4 6.1 0 0 0 0 23.0 7.4 0 0 0 0 27.6 4.5 0 0 0 0 17.7 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 .4 0 0 0 2.1 0 0 0 0 0 0 0

17.0 31.3 0 10.8 10.0 27.0 16.7 28.6 0 8.1 10.0 29.5 16.1 31.9 2.1 8.3 10.7 22.4 5.3 6.1 0 0 2.1 14.5 3.2 14.3 0 0 0 0

26.6 20.8 19.6 35.1 76.7 7.9 27.2 24.5 19.6 35.1 76.7 6.6 28.6 25.5 22.9 38.9 78.6 5.2 12.1 4.1 0 32.4 31.9 1.6 3.2 14.3 0 0 0 0

Private

Govt. Hosp.

22.3 25.0 21.6 40.5 6.7 17.5 21.5 24.5 21.6 40.5 6.7 14.8 18.0 23.4 14.6 38.9 7.1 8.6 36.4 49.0 30.8 40.5 44.7 22.6 90.3 71.4 100.0 92.9 100.0 0

3.9 8.3 2.0 10.8 0 0 4.4 8.2 2.0 13.5 0 0 4.1 2.1 4.2 13.9 0 1.7 14.6 26.5 30.8 8.1 2.1 4.8 3.2 0 0 7.1 0 0


Table 8. Source of immunization in the selected districts (%)


Source of Immunization The main source of immuniation for DPT, polio and measles coverage was sub centres. And the highest per centage approached private health institutions for BCG, Hepatitis-B and MMR. The other main sources for the immunization were the district hospitals and PHCs. Source of various vaccines is given in table 8. Except in Ernakulam district where around 40% of vaccines were taken from the private sector in all the other districts only around 20% vaccines were taken from the private sector. This has been shown in many previous studies also. Whether the comparatively low proportion of TT coverage in Ernakulam district has something to do with this increasing trend of privatization of immunization services needs to be examined. The high proportion of immunization from public sector is probably due to the better quality of immunization services provided in the public sector particularly after the Universal Immunization programme that was started in the year 1985. This again shows that people would certainly use the government services if good quality services were provided. Sub centres provide immunization services to around a quarter of the children. This proportion has to be increased substantially. For immunization there is no need to go to a primary health centre except when the PHC is nearer than a sub centre. The FGDs on immunization coverage revealed the following. Most groups said that immunization coverage was very good. Since we did not conduct any FGD in Malappuram district where the immunization coverage was the lowest we could not get information from this district regarding why the immunization coverage was low there. Most FGD groups suggested that hepatitis B should be included in the national immunization schedule as there is a lot of demand from people and the incidence of hepatitis is going up in the community. Similarly they suggested inclusion of MMR vaccine in the schedule. They also reported that some of the doctors were against the pulse polio immunization and this affected campaign for even routine immunizations.

Vitamin A first dose Vitamin-A deficiency is recognized as one of the most important micronutrient deficiencies of public health significance, leading to irreversible blindness in young children. Its supplementation prevents nutritional blindness (19). The National Programme on Prevention and control of blindness targets children of under - 5 years and oral doses of Vitamin A are administered to children every six months. The first dose of vitamin A which is given usually along with the Measles vaccine was also captured in our survey along with immunization coverage. Alappuzha district had the highest coverage of 94.2% while Malappuram had only 41.3% coverage. For the state as a whole nearly 25% of children were not given even the first dose of Vitamin A. Vitamin A coverage was unexpectedly low in Ernakulam district. The low coverage of Vitamin A in Ernakulam district could be due to nonavailability of Vitamin A in private sector. Nearly 40% of Measles vaccine in this district was taken from private sector. However in spite of availability (90%) the coverage was low in Malappuram district. Since Vitamin A first dose is given along with measles vaccine both per centages are likely to be similar. In Malappuram Measles coverage was also low (44.4%). 20

cmyk


85.7

76.9

89.2

81.5

72

Ke ra la

Ka nn ur

al ap pu ra m M

Er na ku la m

ap pu z

ha

36.5

Al

Ko lla m

100 90 80 70 60 50 40 30 20 10 0

Fig. 4. District wise per cent of children who were fully vaccinated Children who received BCG, measles, and 3 doses each of DTP and polio (excluding polio 0) are considered as fully vaccinated. In Kerala about 72 per cent of children were fully vaccinated. The district-wise coverage is given in figure 4. Fully Vaccinated children in Kerala were reported to be 84% by NFHS -2. Our figure was lower than this because of the low figure of Malappuram. If Malappuram district is excluded from the sample the fully immunized children in Kerala would be 83 per cent. Tamil Nadu state had already taken over Kerala in the proportion of fully immunized children. In Tamil Nadu the proportion of fully immunized children was 92% (NFHS-2) which topped the state averages for India. The lowest proportions of fully immunized children were reported from Bihar (22%), Rajasthan (37%), Uttar Pradesh (44%) and Madhya Pradesh (48%). Utilization of health facilities House visits by the health workers were reported to be higher than the previous figures reported in many studies. About 39 per centage of the households reported that some one from the health centre visited their household in the last one month. This was higher compared to 17 per cent in 1987 and 25 percentage in 1996 (6). Although there was a slight increase in the house visits from 1987 to 1996 the increase from 25% to 36% in 2001 is substantial. Kannur district that reported a house visit of 64% is the major reason for this increase in the state. In all districts there was some improvement. One reason could be the effect of decentralization that started in the year 1996. The male health workers visit was reported to be very low. Female workers conducted the majority of house visits. Only in Kannur district both male and female workers visited in about 42 per cent of households. Utilization of sub centres was found to be better in the northern districts of Malappuram and Kannur. Here the utilization was defined as using any service from the above institution within one month preceding the survey. Since we do not have a standard to compare the utilization of these institutions we would not be able to say whether this rate of utilization was more or less than expected levels. However we could see the difference in the rate of utilization between the districts. 21

cmyk


Sub centres in Kerala follow the national pattern. Usually it covers 5000 population in plain areas and 3000 population in hilly and tribal areas. Mini Primary Health Centres cover a population of 30000 in plain areas and 20000 in hilly and difficult to reach areas. Block Primary Health Centres are similar to that of a mini primary health centre in terms of population coverage. However the number of doctors in a Block PHC will be more than one whereas in most mini PHCs there is only one doctor. There are exceptions to this general rule. Information was also collected on the kind of health services and quality of each service that the households received from Sub-centres, PHCs, CHCs and FRUs. Sub-centre (SC) The proportion of persons reported to have the knowledge of a sub-centre in their locality was 68.9. During the last one month preceding the survey, about 11 per cent of the households availed the service from the sub centre. Out of those who utilized the services of sub centres most of them (29%) utilized the facilities for immunization and 13% for health education. Those who utilized the service from the SC in the last month preceding the survey were asked about the quality of services. Most of them reported that the service was good (82.7%) and 4.5 per cent reported that the quality was poor. 4.5%

12.7%

82.7%

Poor

Good

Excellent

Fig: 5 Level of satisfaction of the services from Sub Centres The survey also collected information from the respondents regarding the suggestion to improve the service delivery in sub centre. Twenty two per cent of the respondents gave some suggestions and among them the highest per centage reported the need for service of a doctor at least once in a week in Sub centres Primary Health Centre (PHC) About 72 per cent of the households knew the PHCs in their locality. Out of them 15.6 per centage utilized the service during the last one month preceding the survey. As in the case of SC, 22

cmyk


a high proportion of them utilized PHC for immunization (23.6%) and 11.8 per cent for STI/RTI services . The district-wise analysis showed that Kannur and Alapuzha districts reported the highest per centage of users of PHCs. The level of satisfaction of PHC is given in the following pie diagram . 3.2%

11.1%

85.7%

Poor

Good

Excellent

Fig: 6 Level of satisfaction of the services from PHCs Even though 72 per cent of respondents were aware of the PHCs in their locality, only 30 persons (0.6%) had knowledge on any facility in the PHC to refer pregnant women having complications of emergency nature. Twenty six per cent of the respondents gave some suggestion to improve the service delivery in PHCs. Half of the respondents among them stressed the need for round the clock services of doctors and more facilities and 30 per cent expressed the need for in-patient service. These suggestions provide some of the reasons for the low utilization of primary health centres.

Community Health Centre (CHC) In our study group about 25 per cent of respondents knew about CHCs. Out of the total sample only 4.3 per cent availed the service from their CHC in the last one-month preceding the survey. The highest proportion of them used the facility for temporary contraception like insertion of Copper T. Other utilization of CHC was for permanent sterilization like laproscopy, temporary contraception like condom, natal care, MTP/abortion and adolescent health care. About the level of satisfaction of the service availed from CHCs, most of them (96.5%) reported the service as ‘good’. ‘ Out of those who knew about CHCs, 11.5 per centages of them gave suggestions to improve the service delivery in CHCs. The main suggestions were to improve the facilities like equipment in the CHC, transportation for referral, and full time availability of doctors, supply of medicine from the hospital itself and better behavior of the staff in CHCs. 23

cmyk


0.5%

3%

96.5%

Poor

Good

Excellent

Fig: 7 Level of satisfaction of the services from CHCs

First Referral Units (FRU) Most of our respondents knew about the first referral centre (hospital) in their area (95 per centage). Among them about 9 per centage availed some service from FRU in the last one month preceding the survey. Most of them approached the FRU for antenatal, natal, temporary contraception and detection of CA cervix. The level of satisfaction of FRU is given in the following figure. 5%

15%

80%

Poor

Good

Excellent

Fig: 8 Level of satisfaction of the services from FRUs From the information gathered during the survey, the main suggestions to improve the service delivery in FRU were to provide adequate medicines and adequate manpower. Another suggestion was to stop bribery and corruption in the hospitals. 24


Awareness and practice of specific health services Family Planning Services The respondents were asked whether anyone in their family used any contraceptive method. Ninety two per cent of the respondents knew which method of family planning was used by the members of the family. Vast majority of the respondents reported that female sterilization as the most common family planning method. NFHS 2 reported a proportion of 86% female sterilization among any modern method of contraception in Kerala.

MTP Services More than half of our respondents were aware of MTP/Abortion services available in the Government sector. However lack of cleanliness, non-availability of drugs, female doctors, rude behavior of staff were reported to be restricting factors for seeking abortion services from the public sector Private hospitals were doing more of first trimester abortions and second trimester and complicated abortions were usually referred to public sector (32).

RTI/STI Services Among the members of the respondent’s family only 2.5 per centages attended some sessions regarding adolescent health care during the last one year preceding the survey. About 92 per cent of our respondents had knowledge on RTI and STIs and out of them 36.8 per cent were aware of RTI/STI service provisions in the public health system. There is a need to create more awareness on RTI and STI service facilities in the public health system. The main source of information about RTI /STI was print media. The role played by radio and television was also high. Only 6.7 per cent of them got the information from health workers. Half of our respondents reported that the participation of male members is important for the successful implementation of RCH programmes.

Health Education Sessions Around 16 per cent of our respondents attended health education sessions in the last 3 months preceding the survey. Due to the high literacy levels in the state and availability of newspapers and magazines people have access to health information provided through the print media. In addition television and radio have very high reach in Kerala, which also provide health information. Therefore there is a need to provide tailor made health education programs to the public in Kerala. Some of the recent studies reported that the cost of health has been increasing in the state and quality and quantity of health care provided through the public sector were decreasing. In the present survey we collected information on the preference of government and private institutions 25


for health services. Among those who had responded 53.3 per cent preferred private institutions and 43.3 per centage preferred government institutions. The remaining 2.3 per centage preferred both, by giving equal importance to government and private institutions. This comparatively high proportion of the preference for private health institution is the reflection of people’s difficulties in availing government health facilities. There are so many indirect factors which push people to approach private institutions. In their study on health seeking behavior of women and cost incurred in India, Bhatia and Cleland (33) pointed out that in theory, government health institutions are supposed to provide free services, but in practice the patients have to give bribes, buy medicines from the market and incur expenditure on travel, etc. Also government and private practice may not be easily distinguished, since many government doctors do private practice outside working hours and encourage patients to visit them at home or in their private clinics. This results only a narrow gap between the cost involved in private and government practice so that the patients would obviously like to patronize private practitioners.

26


IV INSTITUTIONAL SURVEY RESULTS For institutional survey our objective was to survey 70 sub centres 20 Mini PHCs, 10 block PHCs, 5 CHCs and 5 FRUs making a total of 110 institutions. We could survey 65 sub centres, 19 mini PHCs, 10 block PHCs, 4 CHCs and 5 FRUs. As a whole we covered 103 institutions. In the following sections we provide the institutional survey results for each type of institutions. Table 9. Number of institutions surveyed in the five selected districts SC

MPHC

Institutions BPHC

Kollam

14

4

Alappuzha

14

Ernakulam

Districts

CHC

FRU

2

1

1

4

2

1

1

10

3

2

1

1

Malappuram

13

4

2

0

1

Kannur Total

14 65

4 19

2 10

1 4

1 5

Sub Centres Infrastructure and equipment The facilities that we found in the sub centres are given in Table 10. The JPHNs are expected to stay in the sub centres. If electricity, water supply and toilet facilities are not available it would be extremely difficult for the JPHNs to stay there. A third of the sub centres did not have these facilities. Nearly 35 per cent of the sub centres were unsafe according to assessment of the investigators and report of the JPHN. In Kannur district eighty six per cent of the sub centres were unsafe, while in Malappuram it was only 14%. This low proportion of unsafe sub centres in Malappuram could be due to the impact of IPP- 3 when infrastructure facilities were provided under this project. Malappuram, Palakkad, Wayanad and Idukki districts were selected for the IPP 3 project. Clinic facilities were there in the entire sub centres in Malappuram. This could be the reason for the highest coverage of immunization services from sub centres in Malappuram, although the overall immunization coverage was lowest in this district. Availability of equipment was not uniform in the five districts (Table 11). Some of the very useful ones like the Hemoglobinometer were available only in a third of the sub centres. The sub centres’ current function needs to be augmented by providing all the necessary equipment and supplies like reagents for urine sugar and albumin examinations. The facilities in the subcentres will need to be re-looked at with the background of services provided through the sub centres in Kerala. This is particularly important in the light of the findings that no deliveries are taking place in subcentres in Kerala and antenatal check-ups are done mostly by obstetricians and gynecologists. 27


Table 10. Infrastructure facilities of sub centres (%)

Kollam (n=14)

Alappu- Ernakuzha lam (n=14) (n=10)

Malappuram (n=14)

Kannur

Kerala

(n=13)

(n=65)

Electricity

71.4

71.4

60.0

78.6

75.0

66.1

Water supply

57.1

71.4

40.0

92.9

87.5

64.6

Toilet

57.1

71.4

60.0

100.0

100.0

70.8

Government building

57.1

50.0

60.0

100.0

61.5

66.2

Rental

35.8

50.0

30.0

0

0

23.1

0

0

10.0

0

0

1.5

7.1

0

0

0

38.5

9.2

Safe

78.6

57.1

60.0

92.3

12.5

64.4

Unsafe

21.4

42.9

40.0

7.7

87.5

35.6

New

28.6

7.1

11.1

7.1

12.5

13.6

Old

71.4

92.9

88.9

92.9

87.5

86.4

Requires repair

42.9

42.9

20.0

85.7

50.0

50.8

Space for clinic

71.4

64.3

70.0

100.0

35.7

69.2

Space for Residence

57.1

50.0

60.0

100.0

35.7

61.5

Free No building

Manpower Each sub centre is expected to have a female multipurpose health worker known as Junior Public Health Nurse (JPHN) in Kerala. In all the 65 subcentres surveyed there was a JPHN available during the time of survey. Out of the 65 JPHNs 24 (37%) were staying in the subcentres. Only 65% of the subcentres were found to be safe for the JPHN to stay. In addition to safety problems there could be many other reasons for the JPHNs not to stay in the subcentres. Positions of male multipurpose health workers known as Junior Health Inspectors (JHI) in Kerala are not sanctioned in sufficient numbers. Therefore in many subcentres JHIs would not be available. One JHI will be responsible for more than one sub centre. This is mainly because the salary of the JPHN comes from the family welfare programme which is a 100% centrally sponsored programme and the salary of the JHI comes from the state health budget. 28


Table 11. Equipment and accessories at the Sub Centres (%)

Kollam (n=14)

Alappu- Ernakuzha lam (n=14) (n=10)

Malappuram (n=13)

Kannur

Kerala

(n=14)

(n=65)

Spirit lamp

35.7

50

70.0

50.0

100.0

53.8

BP apparatus

64.3

85.7

50.0

71.4

91.7

73.8

Vaginal Speculum

28.6

71.4

70.0

50.0

100.0

61.5

Fetoscope

92.9

92.9

60.0

85.7

100.0

86.2

Bench

50.0

42.9

90.0

57.1

92.9

66.2

Examination table

50.0

50.0

70.0

42.9

100.0

61.5

50

85.7

70.0

50.0

100.0

69.2

Thermometer

92.9

78.6

60.0

85.7

100.0

83.1

Stove

42.9

64.3

70.0

28.6

92.3

58.4

Electrical Sterilizer

28.6

0

0

0

0

6.2

Immunization cards

50

85.7

100.0

14.3

92.9

67.7

14.3

21.4

20.0

14.3

92.9

36.9

0

7.1

10.0

7.1

7.1

6.1

50.0

14.3

60.0

28.6

100.0

49.2

Haemoglobinometer

7.1

57.1

40.0

28.6

15.4

27.7

Weighing Machine

78.6

21.4

60.0

57.1

100.0

61.5

Growth charts

64.3

23.1

70.0

7.7

71.4

44.1

Measuring Tape

Vaccine carriers/ day carriers Reagents for urine Albumin/sugar Test tube

Service provision from subcentres Antihelminthic and IEC materials were available only in less than 25% of sub centres. On an average 108 antenatal cases were registered. Considering a crude birth rate of 17 per 1000 population the total number of anticipated births in 65 subcentres was estimated to be 5500. In one sub centre area there will be around 85 births. If we add 10% for pregnancy wastage there would be around 90-95 antenatal cases. Therefore the average number of antenatal registration is likely to be an 29


over report. This kind of over reporting of services has been reported previously also from the state (7).

Table 12. Availability of drugs and supplies in Sub Centres (%) Kollam Iron and folic acid

Alappu- Ernakuzha lam

Malappuram

Kannur

Kerala

92.9

78.6

100.0

100.0

92.9

92.3

0

7.1

0.0

28.5

100.0

23.1

Paracetamol

57.1

14.3

20.0

71.4

78.6

49.2

Co-trimoxazole

57.1

78.6

10.0

85.7

78.6

69.2

Vitamin A

85.7

85.7

90.0

92.8

100.0

89.1

Syringes & Needles*

7.17

78.6

70.0

50.0

92.9

50.8

ORS

92.9

100.0

100.0

92.8

42.9

93.8

Bleaching Powder

85.7

78.6

90.0

42.8

100.0

75.4

Cu T

0

7.1

40.0

92.8

78.6

29.2

Condom

0

64.3

90.0

85.7

14.3

56.9

85.7

85.7

100.0

92.8

50.0

90.8

0

0

10.0

50.0

92.9

21.5

50.0

78.6

90.0

78.6

35.7

64.6

Anti-helminthic

Oral pills IEC Material Immunization cards

* In some districts syringes and needles are brought to the sub centre from the PHC Other services reported from the sub centre included child immunization, mothers meetings, health education classes, and house visits. The mean number of households visited by the JPHN in the last one month was reported to be 247. In each sub centre area there would be approximately 5000 population. Based on an average family size of 5 there will be 1000 households in one sub centre area. The JPHN is expected to cover all the households in a month along with JHI. As per the reports of JPHN they have covered only 247 households. This comes to around 25% of the households in a sub centre area. It may not be possible to cover all the 1000 households in a sub centre area by the JPHN particularly when the JHI is not available in many places. In such circumstances she could get the help of ICDS workers to update the information at least on infant mortality and maternal mortality. Out of the 65 sub centres that we studied a total of 3 maternal deaths were reported (Table 13). This is likely to be an underestimate since they reported to have visited only 25% of the expected households in the area. Although this sample may not be enough to estimate the maternal mortality 30


ratio based on the reported figure of 3 maternal deaths from 65 sub centres the estimated figure comes to 54 per 100000 live births. Since the health workers covered only 25% of population the total maternal mortality is likely to be four times higher than this which is 12 maternal deaths or 216 per 100000 live births. This is close the MMR of 198 per 100000 live births reported by the SRS in the year 2000. Only 16 sub centres reported infant deaths in the last one-year and the number of infant deaths reported by these 16 subcentres was 20. Considering the average birth rate (17/1000) of the state the total expected live births in the area of 65 sub centres (65* 5000 = 325000 population) would be around 5500. Table 13. Services provided from sub centres (N = 65) Variables

No of sub Mean number* centres reported

Antenatal services Antenatal cases registered in the area during last one year High risk cases among them Antenatal clinics conducted in the centre for the last 1 month New cases attended for the last one month Old cases attended for the last one month Pregnant women with anemia detected for the last 1 month Immunization services Children brought for immunization in the last 4 sessions at the sub centre Children brought for immunization for the last 4 sessions who couldn’t be given the appropriate vaccine Outreach sessions conducted for immunization in the area for the last 1 month Children brought for immunization for all the outreach session for the last one month Other services Mothers meeting conducted in the area for the last 3 month Health education sessions conducted during the last 1 month Households visited by JPHN in the last 1 month Maternal death in the area for the last year Infant death in the area for the last year

63

108

60 59 32 57 31

11 4 6 16 5

53

78

0

0

13

1

11

32

60 61 62 3

8 4 247 1

16

1

* Mean numbers rounded off 31


The estimated infant Mortality rate from this reported figure would be around 20/5500 or 3.6 per 1000 live births. The lowest infant mortality rate or 4/1000 live births was reported from Japan (23). It is unlikely from the area under the 65 sub centres to have achieved that level of infant mortality. From an estimated 5500 live births in the area of these 65 sub centres we should be able to get a reasonable estimate of the infant mortality rate. If we assume that only 25% of the Infant deaths were captured, the total infant deaths would have been (20 x 4) 80. This comes to an IMR of 14.5 per 1000 live births, which is very close to the figure of 14 reported by SRS in that year. Both the reported MMR and IMR are likely to be a gross underestimate of the actual situation. There could be many reasons for this under reporting. Since the health workers are expected to provide a detailed report in case of a maternal death or an infant death they might not be reporting some of the deaths. Since they visited only 25% of the households they might not be aware of the deaths that might have happened in the unvisited houses. With regards to the antenatal registration the reported figure of 108 per sub centre is little more than our estimate of 6600 antenatal cases in the area of 65 subcentres. Immunization and antenatal check ups were reported to be higher than the proportion of coverage that we obtained from the household surveys. This finding is similar to what was reported earlier (31).

Mini PHCs Infrastructure and equipment Infrastructure facilities were reported to be fairly adequate in the 19 Mini Primary health centres surveyed (Table 14). Accessibility was reported to be not adequate in three of the mini primary health centres. This was due to the location of the primary health centre that required more than half hour walking. Non-availability of water throughout the year was reported in 2 mini primary health centres. These are absolutely essential facilities without which it would be extremely difficult to run a primary health centre. About half of the mini PHCs required repair and one mini PHC did not have power supply. Out of the 19 MPHCs 7 had inpatient facilities. One MPHC had 40 beds and another 28. One of the problems of this kind of bed sanctioning is that there would not be commensurate sanction of manpower. Then this would become an idle capacity. Such idle capacity has been reported in the Kerala public health system recently (34). Table 14. Infrastructure, equipment and service facilities at Mini PHC (n=19) Infra structure Buildings (Government) Buildings constructed within 5 years Building requires repair Supply of electricity Water supply available throughout the year (all from wells) Inpatient beds available Mean number of beds (n =7) 32

17 3 10 18 17 7 20

Current Status of Service Delivery in the Health and Family Welfare Sector in Kerala (Table No. 14 contd...)

Equipment Examination Table Blood Pressure apparatus Ice lined Refrigerators Deep freezer Vaccine Carriers Day Carriers Weighing Machines Separate Table for IUD insertion Vaginal Speculum

18 13 17 18 18 16 18 13 18 Man power

Medical Officer in position No Medical Officers in position Medical Officers trained Staff nurse available for OP service

17 2 4 10 Services No Delivery services in the PHC for the last one year 1 Any program/ session failed to be conducted due to non-availability of vehicles 1 Any immunization session cancelled during the last 1 month 2 Institution get adequate help from the local body 18 Conducting medical audit for maternal death 2 Mean No Days the MO could be present in the PHC during the last one month 20 Days the vehicle of the block PHC/others was available to the PHC during the last month 5 Antenatal cases attended in the PHC in the last one month 23 Antenatal cases referred by JPHN to the PHC from the field 15 IUD inserted in the PHC during the last one month 7 RTI/STI cases reported to the PHC for the last 1 month (male ) 4 RTI/STI cases reported to the PHC for the last 1 month (female ) 12 Children attended in the immunization clinic for the last 4 weeks 141 Abortions reported during the last one month 2 Cases of acute respiratory infection reported during the last one month 225 Diarrhoea cases among under 5 year reported to the PHC during the last one month 26 ORS depot functioning under the PHC 29 Maternal death occurred in the area during the last 1 year 3 Infant death occurred in the area during the last year 3 Deaths of the children between 1-5 years in the area during the last one year 1 33


Overall equipment availability seemed to be satisfactory. However, some of the equipments like BP apparatus were not available in 6 mini primary health centres out of 19 (Table 14). Kerala state was reported to have a high prevalence of hypertensive patients in many studies. (35, 36, 37). If there is no provision of checking blood pressure even at the level of a primary health centre where medical officers are available it would be difficult to monitor blood pressure of patients reporting to PHCs. Six of the mini PHCs did not have table for IUD insertion. Cold chain equipments like ILR and deep freezers were available in vast majority of mini PHCs.

Man power In 17 (85%) mini PHCs at least one medical officer was available for duty. Out of this 17, 13 had one medical officer and 4 had two medical officers each. The two mini PHCs with 40 beds and 28 beds respectively had 2 medical officers. Out of the total number 21 medical officers 4 had already undergone RCH training programme. In addition to the medical officers, in 10 mini PHCs staff nurses were available for outpatient services. The entire mini PHCs had supporting staff like pharmacists and attendants.

Services Provided Most of the Mini PHCs provided services for Acute Respiratory Infections, immunization, antenatal chek-ups, treatment of diarrhea and other outpatient services. Some of the centres provided RTI/STI services for male and female. On an average 12 women and 4 men utilized these services from the min PHCs in the preceding one month of the survey. Only one mini PHC reported that they conducted delivery in the last one year. The role of mini primary health centre has gradually evolved into an outpatient only facility in Kerala. A few beds that were allotted for the mini PHCs were mainly for conducting delivery. Since vast majority (92.5%) of deliveries in our study was conducted by obstetricians and in major hospitals there was only very limited role for mini PHC to conduct delivery. Therefore we need to redefine the services to be provided from a mini PHC. The mean number of days the medical officer was present in the mini PHC was 20. For the remaining days in the month there was no alternative arrangement to have the services of a doctor. This introduces some irregularity even in the outpatient care. Patients would not know whether the doctor will be available in the PHC. Mean number of antenatal cases in a month was reported to be 23. This was almost same as that reported from a sub centre. Reason for this low utilization needs to be studied. It could be due to the inclination of pregnant women in Kerala to consult an obstetrician during the antenatal period so that the same person will conduct the delivery also. Although deliveries were not taking place in min PHCs 7 centres provided MTP services in the preceding one month of the survey. The average number of abortions was 2 per centre. 34


Block PHCs Infrastructure Out of the 10 block PHCs studied, 4 Block PHCs (BPHC) reported that all the buildings were fit for use (Table 15). Three PHCs did not have electricity. A functioning labour room was available in 5. Since deliveries were taking place in higher-level hospitals the use of labor room even in BPHC was low. All the BPHC had a vehicle and it was in working condition. All the 10 PHCs had regular water supply from wells. Out of the 10 block PHCs studied all of them had inpatient facilities. The bed strength varied from 6 to 42 and the occupancy on the day of visit ranged from 0 to 32. One PHC had 18 inpatients while the sanctioned strength was only 12. Four PHCs did not have any occupancy. Most other PHCs were under utilized. Out of the total bed strength of 202 for all the 10 PHCs only 87 beds were occupied. Thus the occupancy rate was 43%.

Man power A total of 34 sanctioned posts of doctors were there in the 10 Block PHCs studied. Out of these 31 doctors (91%) were in position during the time of survey. Among the doctors two third were specialist, while the rest were generalists (MBBS). Vacancies of staff nurse, pharmacists, lab technicians and other supportive staff were comparatively less. One of the major differences between the mini primary health centre and the block primary health centre was that there was more than one medical officer in most of the block primary health centres and most of them were specialists. This was another problem restricting the activities at the PHC. Specialists are interested in the area of their specialization. For example an orthopedic surgeon would not be interested in taking delivery. Most PHCs were working similar to that of a mini PHC because they did not have additional facilities to take care of inpatients. Unless there are a minimum number of doctors posted to a centre they will not be able to provide services throughout the day and night.

Service delivery Only two PHCs had adequate staff to conduct delivery during night. This could be one of the reasons for the low utilization of BPHC for delivery. Only three PHCs reported delivery in the last one month. One PHC in Malappuram district reported the maximum number of delivery (91) in the preceding month of the survey. The other two PHCs were in Kannur district where 8 and 9 deliveries were reported. Labour pain can start any time and it is an emergency service. If there is no staff to provide service day and night people will be reluctant to go to the PHC for delivery. This was the major reason expressed by the participants of the FGDs in Kollam and Kannur. This is probably the most important reason why the deliveries are taking place in major government hospitals where 24 hours services are provided. However it was reported in the focus group discussions that in the private sector deliveries were taking place even in smaller hospitals. This was because the doctor would be available day and night. Even if there was only one doctor that doctor will be available all the time. In case of emergency they would be willing to transport the 35


patient to a higher centre. These services were not available in the public sector. One of the problems in providing 24 hour service in block primary health centres is the lack of sufficient number of doctors. Once these block PHCs are also converted to community health centres with at least 7 doctors in position 24 hour service could be provided. Table 15. Infrastructure and service delivery in Block PHC (N=10) Infra structure All the buildings fit for use Supply of Electricity Water Supply available throughout the year (All from well) A functioning labour room is available Vehicle in running condition Services Earmarked Functioning maternity Ward Adequate staff for 24-hr delivery services Number reported to conduct medical audit of maternal deaths Recognized for MTP Medical Officer in position Adequate privacy for examining STI/RTI cases Any immunization session cancelled during the last 1 month Getting help from local bodies Male participation ensured in health education sessions No. of days in which OP services was not available during the last one month Antenatal cases reported to PHC during the last one month Deliveries conducted in last one month Antenatal cases referred to higher centres Maternal deaths in the area during the last 1 year Antenatal cases reported to have anemia MTP done during the last 1 month IUD inserted during the last month No. of STI/RTI cases reported to the centre during the last 1 month Miscarriages reported during the last month Children immunized during the last one month Cases of ARI cases reported during the last 1 month Manpower Mean no. of specialists Mean no. of generalists 36

No. of BPHCs 4 7 10 5 10 3 2 9 4 4 7 1 8 9 3 50 11 5 2 16 1 12 38 2 342 114 2 1


Other services provided through the mini PHCs were being given by block PHCs also. In addition continuing medical education programme was provided in 9 out of the 10 block PHCs in the last one month.

Community Health Centre Infrastructure Even at the community health centres level only one out of 4 CHCs had adequate labor room facility (Table 16). Most facilities were lacking in community health centres. The focus group discussions revealed that most of these community health centres were block primary health centres and they changed the name without adding any facilities. Community health centres are expected to function as referral centres. They should have facilities for specialty care including obstetrician, pediatrician, physician, surgeon and anesthesiologist. There should be facilities to undertake surgery at any time of the day with provision for blood transfusion. Without these facilities changing the name of a block primary health centres into a community health centre will not provide any additional services. Blood transfusion facility or X-ray facility was not available in any one of them. Community health centres were found to be the least functioning institution in the government health sector according to many people in the focus groups. Sanctioned bed strength for the four CHCs ranged from 18 to 30. This is also similar to the block PHCs. In the four CHCs there were a total of 100 beds and the occupancy was 48. This is slightly more than the occupancy rate in the block PHCs. However in two CHCs there was no occupancy at all. A lot of restructuring of the CHCs and PHCs are required if these centres are to function properly. Table 16. Infrastructure facilities and services provided at CHC (n=4) Infra structure Adequate space for service modalities Water supply Power supply Adequate labour room facility Adequate newborn resuscitation facilities Functioning X-ray unit Any vehicle attached to the CHC 24hr Ambulance Services 24hr functioning lab 24 hr functioning operation theatre Resuscitation Corner Nebulization Corner Functioning Diarrhea Treatment Unit Incinerator

No. of BPHCs 2 3 4 1 0 0 3 0 1 1 0 3 1 0 37


Infra structure 24hr delivery services Regularly recording the statistical events Any one from the DMO visit CHC In the last 1 month Separate clinic for STI/RTI functioning’ Adolescent Clinic functioning Infertility clinic being conducted Services Gynecologist available continuously during the last 3 months Pediatrician available continuously during the last 3 months 24 hr service of anesthesiologist Services Antenatal cases registered by JPHN during last 1 month Antenatal cases attended in the clinic during the last 1 month Anemic pregnant women detected in the last 1 month Low Birth weight babies (2.5kg) born during the last 1 month IUD insertions during the last 1 month IUD insertions during the last 1 year MTPs performed in the last 1 month MTPs performed in the last 1 year Laproscopic sterilization in the last one month Laproscopic sterilization in the last 1 year Mini-lap in the last one month Mini- lap in the one year Vasectomy in the last one month Vasectomy in the last 1 year PPS in the last one month PPS in the last 1 year Permanent sterilization failure reported for the last 1 year Contraceptive failure during the last 1 month Maternal emergencies reported during the last 1 month Pediatric emergencies reported in the last one month Maternal deaths reported in the last one year Infant deaths reported in the last one year Child deaths reported in the last 1 year Blood transfusions during the last 1 yr from this CHC Children with ARI attended during the last one month

38

No. of BPHCs 2 3 3 1 0 0 0 1 0 Average no.of cases 56 33 2 1 12 101 7 99 3 28 4 20 0 3 15 78 0 0 1 0 0 0 0 0 719


Man power There were 18 post of doctors sanctioned in the 4 CHCs studied. Sixteen doctors were in position. Among the 16 doctors the following specialists were there; one obstetrician and gynaecologist, two general physician (Internal Medicine) and three pediatricians. There was no surgeon or anesthesiologist in any of the CHCs. Out of the 16 doctors 8 were specialists (50%). In all the CHCs there were 4 doctors each. CHCs are expected to be referral centres and if there are only 4-5 doctors it would be difficult to provide 24 hour service in that centre. As we have seen above in some of the block PHCs there were more than 4 doctors and two third of doctors in block PHCs were specialists. When CHCs are expected to function as referral centres it is important to make sure that more specialists are posted in the CHCs. Therefore there is an urgent need to implement specialty cadre in the health services so that specialists could be posted to those centres where they are required the most.

Service delivery In one of the CHCs there were 10 deliveries in the preceding one month and they reported only 24 deliveries in the last one year. In the second CHC there were 39 deliveries in the last one month and 213 deliveries in the last one year. In the other two CHCs there were no deliveries. As we noted in the focus group discussions delivery depends on the doctor in the CHC. When the doctor is good there will be more patients. Other services were similar to that of a PHC. No. CHC functioned as a referral centre.

First Referral Units Infrastructure Even in the FRU adequate facility in labor room was available only in 2 out of 5 that we studied (Table 17). Blood bank was available only in 1, and lab facility was not available in any one of them. Nebulization corner and 24-hour ambulance service were available in all the 5 FRUs Water and power supply was available in all the FRUs studied. Operation theatre was functional in 4 FRUs Table 17. Infrastructure facilities and services provided at First Referral Unit (n=5) Infrastructure Adequate space for service modalities Water supply Supply of electricity Adequacy of labor room facility Adequacy for newborn resuscitation Functioning X-ray unit 24hr. functioning blood bank

2 5 5 2 2 4 1 39


Infrastructure Any vehicle attached to the FRU 24hr ambulances services 24 hr functioning lab 24 hr functioning operation theatre Resuscitation corner Nebulization corner Functioning DTU Corner Incinerator Post Partum Unit Services 24 hr delivery services All FRU kits available Average number of family welfare clinics in the last 1 month Regularly recording the statistical events Anyone from the DMO visit FRU in the last 1 month Knowledge of FRU News Bulletin Separate clinic for STI/RTI functioning Adolescent clinic functioning Infertility clinic being conducted Gynaecologist available continuously during the last 3 months Pediatrician available continuously during the last 3 months 24hr. service of anesthetist available in the last 3 months Antenatal cases registered by the JPHN during the last 1 month Antenatal cases attended in the clinic during the last 1 month Anemic pregnant women detected in the last 1month Number of deliveries in the last one month Average number of low birth weight babies in last 1 month Number of IUD insertions during the last 1 month Number of IUD insertions during the last 1 year Number of MTP’s performed in the last 1 month Number of MTP’s performed in the last 1year Laparoscopic sterilization in the last one month Laparoscopic sterilization in the last one year Vasectomy in the last one month Vasectomy in the last one year PPS in the last one month 40

5 5 0 4 3 5 3 1 5 5 4 13 5 3 4 4 1 3 5 5 3 Mean 43 416 30 341 30 11 196 47 465 20 197 1 14 146


PPS in the last one year Permanent sterilization failure reported for the last 1 year Average number of contraceptive failure during the last 1 month Number of maternal emergencies reported in the last one month Number of pediatric emergencies reported in the last one month Average number of maternal deaths occurred in the last one year Average number of infant deaths occurred in the last one year Average number of child deaths in the last one year Number of blood transfusions during the last 1 yr from this FRU Number of children with ARI attended during the last 1 month

878 3 1 6 9 1 8 0 292 115

The bed strength ranged from 105 to 781. One of the FRUs selected was a district level hospital which had the maximum bed capacity. In the five FRUs studied there was a total of 1510 beds and 1207 beds were occupied at the time of survey. One of the FRUs had more than 100% occupancy rate. The average occupancy rate was 80%

Man power A total of 88 doctors were sanctioned in the five FRUs studied. Out of them 86 (98%) were in position during the time of survey. In all the FRUs studied at least one Obstetrician and gynecologist and pediatrician was available. In one FRU which was a district level women and children hospital there were 11 obstetrician and gynecologist. Anesthesiologists and general physicians were available in three out of the five FRUs. Surgeons were available in two of the FRUs. The manpower situation in the FRUs was much better than the CHCs. In addition other facilities were also much better. Therefore the occupancy rate in these institutions was much better compared to other type of institutions studied. Table 18. Number, type and proportion of cesarean section deliveries in the five FRUs District/FRU

Total # Delivery # of Normal in one month delivery

# of Cesarean Section

Proportion of Cesarean %

Kollam

906

443

463

51

Alappuzha

171

130

41

24

Ernakulam

231

110

121

52

Malappuram

319

271

48

15*

74

74

00

00*

1704

1028

673

39

Kannur Total

*Regular anaesthesiologist was not available. 41


Cesarean section in urban areas was reported to be 38% by NFHS 2 in Kerala. Our figure from the FRUs is slightly more than that of the NFHS. This could be due to the presence of two district level hospitals where more complicated cases are seen and the possibility of cesarean section would also be high. However the proportion of cesarean section in two of these FRUs is extremely high. Post partum sterilization was conducted in all the FRUs and laparoscopic sterilization was conducted only in three of the FRUs.

42


V CONCLUSIONS The present study tried to understand the health seeking behavior of people especially mothers with particular emphasis on reproductive and child health services in Kerala. With this main objective we collected data from five selected districts of Kerala. For the present survey we used an interview schedule for households and another one for the selected institutions. In our household survey of nearly 5000 households from five selected districts of Kerala we collected information on antenatal care, delivery practices, postnatal care, immunization services and utilization of health services. Overall 39% of the households reported that someone from the health centre visited their households in the last one month. The proportion of households visited in 1987 was 17% and 25% in 1996. The increase in house visits in our study was mainly contributed by Kannur district that reported 64% house visits. In other districts also there was increase in house visits but the maximum was reported in Kannur. The decentralization process in Kerala started in 1996 could be one of the reasons for this increase in house visit. Other studies have also reported the positive impact of decentralization on the performance of primary health centres (38). Continuation of the decentralization in health care is likely to enhance the performance of primary health care system in the State. Medical termination of pregnancy was reported to be available in both government and private sector hospitals. However this procedure was reported to be very expensive both in government and private hospitals. Female health workers in the FGD reported that expenses for MTP were directly proportional to the duration of pregnancy. Awareness regarding STI and HIV was good among the respondents. This was reflected in the large number of STI/RTI cases reported in first referral units. Antenatal care was provided mostly by the specialists and an average of 8 visits was made to the doctor by a pregnant woman. Considering the increasing cost of such visits and in the light of new research findings that more than 4-5 antenatal visits are generally not necessary organizations like the FOGSI (Federation of Obstetric and Gynaecological Societies of India) may take up this issue and come out with new guidelines. Immunization coverage was generally high in four of the five districts. However in Malappuram district it was low. Efforts need to be concentrated in such districts and back ward areas of other districts to improve the routine immunization. Proportion of fully vaccinated children in the state was not the highest in the country, as expected. Tamil Nadu has taken over Kerala in this as per the NFHS. This could be due to the poor performance of districts like Malappuram and certain other backward areas of the state. Demand for Hepatitis-B vaccine and MMR in the immunization schedule also may be considered by the government. 43


Institutional delivery was found to be the norm. Only in Malappuram district there was home delivery. In this district also the proportion of home delivery is coming down. Proportion of cesarean section deliveries in our sample of FRUs was 39% which is very high. In two of the FRUs the CS proportion was more than 50%. This is unacceptably high. Most of the doctors, health staff and people in Kerala reported that cesarean section is a safe procedure. This is not true according to scientific information. WHO has suggested that the maximum proportion of CS should be limited to 15% due to high morbidity and mortality associated with cesarean section deliveries compared to normal deliveries. Low birth weight babies’ proportion was found to be 13.3. Although this figure was much better than that reported previously, there is a need to reduce this proportion to less than 10%. Most studies reported that low socioeconomic status is the principal determinant of low birth weight in Kerala. Provision for nutritional supplementation to poor women and improving the quality of antenatal care would be required to further reduce the LBW proportion in the state. There is no reliable data on maternal mortality rate in the State. The SRS report of maternal mortality for the state was 195 in the year 1999 and 198 in the year 2000. Other reports like those estimated from NFHS 2 was also high, 262/100000 (39). Therefore there is need to generate a reliable estimate of MMR for the state. All these figures are unacceptably high for a state like Kerala where the IMR is as low as 10. Increased proportion of cesarean section is likely to be associated with the high MMR in the state. This needs to be studied further. Infrastructure facilities in most of the institutions were reported to be inadequate. Many sub centres did not have minimum facilities for the female health workers to stay there. Sub centres in Malappuram district were better thanks to the India Population Project that constructed many primary health care institutions in that district. Infrastructure facilities of the subcentres in the state need improvement. A good proportion of immunization and antenatal check-ups are done at the sub centre level. This could be increased substantially if the facilities in those institutions are improved along with supervision and monitoring of those institutions. In the focus group discussions that we had with health workers it was reported that the skills of those workers are grossly under utilized. Sub centres could also function as screening centres for chronic diseases like hypertension, diabetes and cancer. Since there are no deliveries taking place in sub centres those equipments and supplies for taking delivery need to be re-distributed to higher centres that require those supplies. The mini primary health centres are currently working as outpatient clinics only. Those beds allocated to maternity care are not utilized. There are two options here. Since there is only one primary health centre in a Panchayat they need to provide inpatient care. In order to provide inpatient care one doctor is not enough. Therefore the first option is to provide more doctors in the mini primary health centres so that inpatient services can be provided from these mini PHCs, the cost of this additional input needs to be worked out. If this is not feasible all the block level primary health centres should be upgraded to functioning community health centres with 44


obstetricians, paediatricians, surgeon, physician, and anesthesiologists and a total of at least 7 doctors. Blood banking or transfusion facilities should be available with 24-hour emergency care. The mini primary health centres could then work with only one medical officer. All those requiring inpatient services could be referred to the community health centre. Alternatively there can be a system where the doctors working in the private sector in the Panchayat could be utilized for providing primary health care. This has to be worked out carefully so that it would be beneficial to the society. Most of our respondents’ preference for private health institutions was due to hidden cost of care in public institutions, staff behaviour and access issues. Even though in theory government health institutions are supposed to provide free service, some indirect cost like the ‘out-of pocket expenditure’ may push people to private institutions. The accessibility is another major problem in government health institutions. In case of the modern life style diseases, which are increasing in our society, cost of treatment is a main problem since the treatment lasts for a long period of time. According to the results of a study by Bhatia and Cleland the expenses incurred on visiting government and private practitioners were more or less the same. The patients would obviously like to patronize private practitioners where perceived quality of care is higher and doctor-patient rapport and interactions are presumably better. Inspite of all limitations of the health sector a substantial proportion of RCH Services were provided through the public health sector institutions of Kerala.

45


VI RECOMMENDATIONS

Frequency of antenatal visits could be reduced from the current average of 8 visits to 4 or 5 in the state without any adverse effects on the mother or baby. This will reduce the overcrowding of maternity homes and reduce the cost of pregnancy and delivery in the state. This issue needs to be discussed with the obstetricians and general practitioners in the state. Increasing proportion of cesarean section deliveries in the state needs to be controlled. There is a need to find out the actual maternal mortality in the state because all the reported rate of MMR are from indirect estimates. Since more than 98% of deliveries are institutional, this should not be a problem. Delivery kits and other supplies for conducting delivery need not be supplied to sub centres since vast majority of sub centres are not conducting deliveries. Those supplies could be redistributed to centres where deliveries are taking place. There is an urgent need to find out the reasons for the low coverage of immunization in certain districts like Malappuram and to take appropriate measures to improve coverage there. MMR and hepatitis-B vaccine needs to be included in the immunization schedule of the state. Infrastructure facilities of sub centres need to be improved so that the female health workers could stay there. Sub centres’ functions should be re-designed to provide screening of hypertension, diabetes and certain cancers and health education activities related to noncommunicable diseases. The entire block Primary health centres need to be upgraded as community health centres to function as a rural referral centres. Speciality cader, which can address this issues, needs to be implemented as early as possible.

46


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Krishnan, TN. Health Statistics in Kerala State, India. In Good Health at Low Cost, edited by S.B. Halstead et al., Rockefeller Foundation, and New York, 1985.

2

Thankappan KR, Valiathan MS. Health at Low Cost - The Kerala Model: Lancet, 1998, 351:1274-1275.

3

Kumar BG. Low mortality and high morbidity in Kerala reconsidered, Population and Development Review, 1993; 19(1).

4

National Human Development Report, Planning Commission, Government of India, March 2002.

5

Kannan KP, Thankappan KR, Raman Kutty V, Aravindan KP (Eds.), Health & Development in rural Kerala, KSSP Thiruvananthapuram 1991

6

Aravindan KP, Kunhikannan TP. Health Transition in Rural Kerala 1987-1996, KSSP, Kozhikode, 2000.

7

Nair VM, Thankappan K R, Sarma P S and Vasan R S. Changing roles of grass root level workers in primary health care: an inter-district primary health centre based study from Kerala, India. Health Policy and Planning 2001; 16 (2): 171-179.

8

Ajay Mahal. Do the poor or the rich benefit more from government health services? The case of India, National Council of Applied Economic Research, New Delhi, 2000.

9

Kutty V R. Historical development of health care in Kerala. Health Policy and Planning 2000; 15 (1): 103-109.

10 Thankappan K R. Some health implications of globalization in Kerala, India. Bulletin of the World Health Organization 2001; 79 (9) 892-893. 11 Obermeyer C M, Potter J E. Maternal health care utilization in Jordan:a study pattern and determinants, Studies in Family Planning, 1991;22(3):117-187. 12 Mudaliar A, M.K.K.Menon. Clinical Obstetrics, Edited by M.K.K.Menon and Palaniappan, Orient Longman Limited, 1998 13 Ministry of Health and Family Welfare (MOHFW), Reproductive and child Health Programme:Schemes for Implementation, New Delhi:Department of Family Welfare, MOHFW, 1997. 14 Ministry of Health and Family Welfare (MOHFW), Family Welfare Programme in India, Year Book, 1996-1997, New Delhi: Department of Family Welfare, MOHFW, 1998b. 47


15 Peters D, Abdo S, Yazbeck, Rashmi R Sharma, GNV Ramana, Lannt H, Pritchett, Adam Wagstaff. Human development network, Health, Nutrition and Population series, Better Health system for India’s Poor. Finding, analysis and options. Page 88 Table.4.2, World Bank DC 2002. 16 Carroli G, Villar J, Piaggio G, Khan – Neelofur D, Gulmezoglu M, Mugford M, Lumbiganon P, Farnot U, Bersgio P. WHO Antenatal Care Trial Research Group. WHO systematic review of randomized controlled trials of routine ante-natal care Lancet 2001; 357: 1565-1570 17 International Institute for Population Sciences (IIPS) and ORC Macro, National Family Health Survey (NFHS-II), 1998-99, India, Mumbai: 2001. 18 Radhakrishnan T, Thankappan K R, Vasan R S, Sarma P S. Socioeconomic and Demographic factors associated with birth weight: results of a community based study in Kerala. Indian Pediatrics 2000; 37: 871-75. 19 National Institute of Health and Family Welfare, Reproductive and Child Health Module for Medical Officers (Primary Health Centre), Integrated Skill Development Training, New Delhi, 2000. 20 Nutrition Foundation of India, NFI bulletin 14(4), 1993 21 Government of Kerala, State Plan of Action for the Child in Kerala, chapter one: Child Health. Government of Kerala 1995:6-24. 22 Srinivasan K. et al. India: Towards Population and Development Goals, United Nations Population Fund, Oxford University Press, 1997. 23 UNICEF. The state of the world’s children. UNICEF house, 3 UN Plaza, New York, NY 10017, USA, 2000. 24 Hemachandran K. Burden cause and cost of Cesarean sections Working Paper Series No. 2, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology Thiruvananthapuram, May 2003. 25 Thankappan K R. Cesarean Section deliveries on the rise in Kerala. The National Medical Journal of India 1999; 12 (6): 297. 26 Padmadas S S, Kumar S S, Nair S B, Anitha K R. Caesarean section delivery in Kerala:Evidences from a National Family Health Survey, Social science and Medicine, 51(4):513-521. 27 Mishra US, Ramanathan M. Delivery-related complications and determinants of cesarean section rates in India. Health Policy and Planning, 2002; 17: 90-98. 48


28 Population Research Centre, Thiruvananthapuram (University of Kerala) and International Institute for Population Sciences (IIPS). National Family Health Survey (MCH and Family Planning) Kerala 1992-93, Bombay:PRC, Thiruvnanthapuram, 1995. 29 Registrar General of India, Sample Registration System Bulletin, Office of the Registrar General, New Delhi: 2003; 33(1) 30 Ministry of Health and Family Welfare (MOHFW), Family Welfare Programme in India:Year Book, 1989-90, New Delhi: Department of Family Welfare, MOHFW,1991. 31 Nair VM. Polio eradication-global initiative, Strategy challenged in Kerala, India. Journal of Public Health Medicine, 2002; 24(3):207-210 32 Ramanathan M, Sarma P S, Krishnankumar K. Situational Analysis of MTP Services in Kerala: Community perspective, Published report of Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 2004 33 Bhatia, J.C, Cleland J. Health seeking behaviour of women and costs incurred:an analysis of prospective data, In S Pachauri and S.Subramanian (Eds.) Implementing a reproductive health agenda in India: the beginning, The Population Council, New Delhi, 1999. 34 Varatharajan D, Rajeev Sadanandan, Thankappan K R, Mohanan Nair V. Idle Capacity in resource strapped Governement hospitals in Kerala: size, distribution and determining factors, Published report of Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 2001. 35 Manu G Zachariah, Thankappan K R, Shiney C Alex, Sarma P S, Vasan R S. Prevalence, correlates, awareness, treatment and control of hypertension in middle-aged urban population in Kerala, Indian Heart Journal, 2003;55:245-251. 36 Kutty V R, Soman C R, Joseph A, Pisharody R, Vijayakumar K. Type 2 diabetes in southern Kerala:variation in prevalence among geographic division within a region, National Medical Journal of India, 2000;13(6):284-286. 37 Thankappan K R, Mini G K. Prevalence of Non-communicable Diseases (NCDs) risk factors in Kerala, India, Programme and Abstract Hand Book, 36th APACPH Conference, Australia, 2004:49-50. 38 Varatharajan D, Thankappan K R, Jayapalan Sabeena. Performance of Primary health centres under decentralized Government in Kerala, India. Health Policy and Planning 2004; 19(1):41-51. 39 Mavalankar D, State of maternal health, Chapter 2, State of India’s newborn report, Edited by Dadhich J P and Paul Vinod, National Neonatology form and saving new born lives-Save the children, New Delhi.2004.

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HOUSEHOLD SURVEY FORM Date of survey: 1. District Code:

Corporation/Municipality code

2. (a) Block Primary Health Centre Code

(b) Mini PHC Code:

3. House No. and Address :

4. Household details : No.*

Name

Age

Relation with head of the Sex Household

Marital Status

Age at marriage

EducatiOccup- Monthly onal ation Income Status

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

*Informant’s details should be entered first. Marital Status. 1. Currently married 2. Never Married 3. Divorced. 4 Seperated. 5 Widow. 6 Widower. 50


If there is a child below 1 year use the mother coverage form only. If there is a child between 1 year and two year old use both mother coverage form and child coverage form which are provided seperately. 5.

Do you have a sub centre in your locality? (1. Yes 2. No 3. Don’t know)

6.

Do you know where it is located? (Answer has to be confirmed with correct location) (1. Yes 2. No)

7.

Did any Health worker from the Subcentre visit your house during the last one month? (1. Yes 2. No 3. Don’t know)

8.

If the answer is ‘Yes”, who was it? (1. Male worker 2. Female Worker 3. Both of them)

9.

If the answer is No, when was the last visit? How many months back? (Write actual month of visit) If the exact month is not known enter code 99 (don’t know)

10. Have you or your family availed any services from the subcentre during the last 1 month (1. Yes 2. No) 11. If yes, what were they? Response

Antenatal Service

Postnatal Service

Immunization

Contraception

Health Education

Other (Specify)

Yes No *Level of Satisfaction (* 1. Poor 2.Good 3. Excellent) All the services denote services provided at the subcentre

12 Do you have any suggestions to improve the service delivery in subcentre? (1.Yes 2. No) 13. If yes, what are the suggestions? 14. Do you know the primary health centre in your area? (1. Yes 2. No) 15. Have you or your family availed any services from the PHC during the last one month (1. Yes 2. No) 51


16. If yes, what were they? Response

Antenatal Natal

Post Immuniz- Contrace- Adolescent STI/RTI natal ation ption Health Services Care

Detection Others of (Specify) C CA A Cer Br vix ea st

Yes No *Level of Satisfaction (*1. Poor 2. Good 3. Excellent)

17. Are you aware of any facility in your Primary Health Centre to refer pregnant women having complications of emergency nature? (1.Yes 2. No) 18. If Yes, What is the facility? 19. Do you have any suggestions to improve service delivery in PHC? (1.Yes 2. No) 20. If Yes, What are the suggestions? 21. Do you know about Community Health Centre? (1. Yes 2. No) 22. If Yes, Did you avail any services from the CHC in the last one-month? (1. Yes 2. No) 23. If Yes, What were they? Response Yes No

Services Antenatal Natal Postnatal Permanent Sterilization (a) (b) (c) (d) Temporary Contraception (a) Copper T (b) Oral Pills

(c) Condoms 52

Vasectomy Mini Lap Lapro Others

*Level of Satisfaction


MTP/ Abortion RTI/STI Care Adolescent Health Care Infertility care Detection of CA Cervix Detection of CA Breast Other services (Please specify) * 1. Poor 2. Good 3. Excellent 24. Do you have any suggestions to improve service delivery in CHC? (1.Yes 2. No) 25. If Yes, What are the suggestions? 26. Do you know the referral centre (hospital in your area) ? (1. Yes 2. No) 27. If Yes, Did you or your family avail any service from the FRU in the last one month? (1. Yes 2. No) 28. If Yes, What were they? Response Yes No

Services

*Level of Satisfaction

Antenatal Natal Post Natal Permanent Sterilization (e) (f) (g) (h)

Vasectomy Mini Lap Lapro Others

Temporary Contraception d) Copper T e) Oral Pills f) Condoms MTP/Abortion RTI/STI Care Adolescent Health Care Infertility care Detection of CA Cervix Detection of CA Breast Other services (Please specify) * 1. Poor 2. Good 3. Excellent

53


29. Do you have any suggestions to improve service delivery in FRU? (1.Yes 2. No) 30. If Yes, What are the suggestions? 31. Are you using any contraceptive methods? (1. Yes 2. No) 32. If yes, mention the contraceptive method used 33. Is anyone else in your family use contraceptive methods? 1. yes 2. No 3. Don’t know 34. If Yes, Do you know what method he/she is using? 1. yes 2. No 3. Don’t know 35. If yes, mention the method 36. Have you ever used condoms? (1. Yes 2. No) 37. If yes, from where did you get them? 1. SC. 2 PHC 3 CHC 4 FRU 5 THQ 6 Dist Hospital 7 MCH 8 Private 38. Reasons for selecting Govt./Private? 39. Did you have any problems using condoms? (1.Yes 2. No) 40. If yes, can you mention the problems? 41. Have you ever used Oral Pills? (1. Yes 2. No) 42. If Yes, for what? (1. Contraceptive 2. Others specify) 43. Did anyone in your family attend any sessions regarding adolescent health care during the last 1 year? (1. Yes 2. No) 44. If Yes, number & place of sessions? 45. Do you know from where MTP/Abortion services can be availed in the Govt. Sector? (1. Yes 2. No) 46. If Yes, Where? 47. Do you know what are Reproductive Tract Infections and Sexually Transmitted Infections? (1.Yes 2. No)

54


48. If your answer is “yes”, from where did you get the information? (1.From print media 2. from Radio 3. From Television 4. From friends 5. From relatives 6. From health workers 7. From Primary Health Centre 8. Any other) 49. Are you aware of any centre where RTI/STI services are provided? (1.Yes 2. No) 50. If Yes, Where? 51. Do you think that participation of male members is important for the successful implementation of RCH programmes? (1. Yes 2. No) 52. If Yes, Why? 53. How many health education sessions did you attend since last 3 months? 54. Do you prefer to go to Govt or private institutions for health services? 1. Govt. 2. Private 55. If Govt, Why? (Multiple answers possible)

56. If Private, Why? (Multiple answers possible)

Name of the Investigator:

Signature

55


MOTHER COVERAGE FORM District

:

Range of dates of birth : 1/6/1999 to 1/6/2001

PHC

:

Sub Centre

Mother number

1

Age at first pregnancy Date of Previous Delivery Date of Birth of the Child Immunization Card

Yes Other record

TTI

Date Source

TT2/Booster

Date Source

IFA Tablets

Given (Nos) Consumed Y/N Source

No. of Antenatal Check-ups Place of delivery *Birth Wt. of the youngest Child Gynaecologist Atte nd ed by

M F

MBBS

M F

Others

M F

Sex preference for doctors (M/F)? Any problem during antenatal period? If yes what?

56

: 2

3

Total


Did you seek health care? If yes from where? Any problem during delivery? If yes, what?

Any problem during postnatal period? If yes, what? Did you seek health care? If Yes, from where? Did JPHN visit during postnatal period? If yes, how many times? *If no records available underline, 1 Medical college, 2 Dist. Hosp, 3 THQ, 4 FRU, 5 CHC, 6 BPHC, 7 MPHC, 8 SC.

57


CHILD COVERAGE FORM District : Range of dates of birth: 1/6/1999 to 1/6/2000 PHC : Subcentre: Child No 1 2 3 Name (As given in the household) Sex: M/F Shortest Sibling Interval (months) Date of Birth Immunization Card Yes No DPT 1 Date Source DPT 2 Date Source DPT 3 Date Source Polio 0 Date Source Polio 1 Date Source Polio 2 Date Source Polio 3 Date Source Measles Date Source BCG Date Scar + / 0 Source Hepatitis-B 1 Date Source Hepatitis-B 2 Date Source Hepatitis -B 3 Date Source MMR Date Source Vit A Dose 1 Date Source Source: Govt. Hospital, PHC, SC, CHC, FRU OUT-Out Reach, PRIV-Private Name of the investigator 58

Total

Signature


INSTITUTIONAL SURVEY FORM FOR SUB CENTRES 1.

District Code

:

2.

Block PHC Code

:

3.

Mini PHC Code

:

4.

Name of the Sub Centre with Code

:

5.

Panchayat

:

6.

Ward

:

7.

Name of the JPHN

:

8.

Contact Telephone

:

9.

Total Population of the area

:

Male

Female

Below 1 year Below 5 year

A) Infrastructure Facilities: Site Accessible*

Electricity Not Accessible

Available

Not Available

Water supply Available

Not Available

Toilet Available

Not Available

*Subjective Assessment by the Investigator. (Use Tick Marks) Buildings Govt. Rental Free Others (specify) Safe Unsafe *New Old Requires repair **Space adequate Clinic Residence Mode of paying rent

Regular

Irregular

Pending for how long

*Up to 5 years after completion of construction ** (Use tick marks) 59


10. Equipments & Accessories: Equipments

Available

Did you use if for the last month

Not Available

Telephone Pressure Cooker Spirit Lamp BP Apparatus

Equipments

Available Did you use Not it for the Available last month

Stove Electrical Sterilizer Immunization Cards Vaccine Carriers Day Carriers Reagents for Urine Albumin/Sugar Test Tube Haemoglobinometer Weighing Machine

Vaginal Speculum Foetoscope Bench Examination Table MeasuringTape Thermometer

Growth Charts

11. Availability of Currently using Registers Name of the Currently using Register

Available

Not Available

12. Idling Equipments Idling Equipments

60

Idling for how long (in months & Years)

Action taken


13. Drugs & Supplies Medicines & Accessory

Available throughout the year & on the day of survey

Occasionally available

Not available on the day of survey

1FA/L 1FA/S T. Antihelmenthic Paracetamol Co-trimoxazole Others Vit. A Syringes & Needles ORS Bleaching Powder Cu T Condom OP IEC Material Immunization Cards Others 14. No. of Maternal Deaths in the area for the last 1 year 15. No. of Infant Deaths in the area for the last 1 Year 16. No. of antenatal Cases registered in the area for the last 1-year No of high-risk cases among them 17. No. of Antenatal Clinics conducted in the centre for the last 1 month. 18. No. of beneficiaries attended in the weekly clinic (Antenatal) for the last one month New Old Total 19. No. of anaemic pregnant women detected in the area for the last 1 month 20. No. of children brought for immunization in the last 4 sessions at the sub centre. 21. No. of outreach sessions conducted for immunization in the area for the last 1 month. 22. No. of children brought for immunization for all the outreach session for the last 1 month. 61


23. No. of children brought for immunization for the last 4 sessions who couldn’t be given the appropriate vaccine 24. If so, Why appropriate vaccine couldn’t be given? 25. Was the JHI was available in the last immunization session. 26. No. of mothers meeting conducted in the area for the last 3 months 27. Did you attend the last months ICDS sector meeting 1. Yes

2. No

28. Does the JHI help you in the RCH Programme 1.Yes

2. No

29. Did you cancel any immunization session in the last 3 months 1. Yes

2. No

If yes Reasons

30. Supply of vaccines 1. Regularly

2. Irregularly

31. Do you find out any STI/ RTI cases during the last 3 months 1. Yes

2. No

If Yes, number and type

32. How many Health Education sessions conducted during the last 1 month 33. No. of Houses visited by JPHN during the last 1 month 34. How many priority houses did JPHN visit in the last 1 month (3 top priorities) (1) (2) (3) 35. Are you currently staying in the sub centre? 1. Yes

2. No

36. If No, Give reasons. Name of the Investigator 62

Signature


INSTITUTIONAL SURVEY FORM FOR MINI PHC 1.

Name & Address of the Mini PHC with code & Tel. No.

2.

Name of the Concerned Block PHC with Code :

3.

Name of the nearest FRU:

4.

Total Population Covered:

5.

No. of Panchayaths covered:

6.

Total No. of Wards

7.

Infrastructural Facilities

8.

Location of the PHC(Name of locality:

9.

Panchayat

10. Ward

11. *Accessible to the public 1. Yes 2. No *(Assessment by the Investigator) 12. If Not Accessible, details? Buildings: 13. Whether 1.Govt. 2.Rental 3. Free 14. Whether 1.**New 2.Old (**Up to 5 years of completion is regarded as New) 15. Whether it 1. Require repair 2.Not 16. Safety of the Building: 1.Safe 2.Unsafe 17. Date of handing over the building to the department 18. No. of buildings fit for the occupation 63


19. Supply of electricity 1. Yes 2. No 20. Whether pure water supply 1. Available throughout the year 2. Occasionally 3. rarely 4. Not at all 21. Source of Water Supply: 1. Pipe 2. Well

3. Others

22. No. of beds sanctioned if any 23. If Yes, whether the wards are 1. adequately equipped

2. not

24. If not, Give details

Manpower Infrastructure: 25. Staff position & vacancies including period of vacancies in each category. Staff

64

Sanctioned

In position

Vacancy

Period of Vacancy


Staff

Sanctioned

In position

Vacancy

Period of Vacancy

Man power Distribution in the Field:26. No. of S/C s: 27. Whether there is any staff nurse for the OPD of the PHC 1. Yes 2. No 28. If No, Whether the JPHN is posted for the purpose 1. Yes 2. No 29. Injection in the OPD is being given by the 1. Staff Nurse 2. JPHN. 30. No. of days the MO could be present in the PHC during the last 1 month 31. Training Status of the MO in RCH: 1.Trained 2. Untrained

Vehicles 32. No of days the vehicle of the block PHC/others was available to the PHC during the last 1 month 33. Any programme /session failed to be conducted due to non-availability of vehicles. 1. Yes 2. No 34. If Yes, Specify

65


35. Equipments: Name of Equipment

Working condition

Available but not working

Not available

Examination Table BP Apparatus ILR Deep Freezer Vaccine Carriers Day Carriers Weighing Machines Table for IUD insertion Vaginal Speculum Torch Light Foetoscope Autoclave Electric Sterilizer Others Service Facilities: 36. No. of antenatal cases attended in the PHC in the last 1 month. 37. Out of the above, how many cases were referred by JPHN to the PHC from the Field 38. No. of IUD (Cu T) inserted in the PHC during the last 1 month 39. Who are the persons trained in IUD insertion. Category

66

Number


40. No. of STI/RTI cases (both male & female separately) reported to the PHC for the last 1 month Male

Female

41. Is there any private institution in the area where STI /RTI cases are being attended 1. Yes 2. No 42. If yes, give the Name & Address of the Institution 43. Which is the nearest STD clinic available in the District where you can refer (Govt. and private) Govt.

Private

44. Whether any delivery cases conducted in the PHC for the last 1 year. 1. Yes 2. No 45. If Yes, give Numbers. 46. Is there any Private Institution in the PHC area offering maternity services? 1. Yes 2. No 47. If Yes, Name & address of the of each institution 48. No. of children attended in the immunization clinic for the last 4 Wednesdays. 49. Was any immunization session cancelled during the last 1 month? 1. Yes 2. No 50. If Yes, Reasons? 51. No. of Abortions reported during the last 1 month 52. Whether the Institution get adequate help from the local Body. 1. Yes 2. No 67


53. If Not, what are the difficulties. 54. How many cases of ARI reported during the last 1 month? 55. Out of the above how many ARI cases were referred from the field by the JPHN. 56. How many cases of Diarrhoea were reported to the PHC among under 5 years during the last 1 month? 57. No. of ORS depot functioning under the PHC area 58. No. of Maternal Death occurred in the area during the last 1 yr if any, give the cause of the death Number of MD

Cause of the Death

59. For the maternal death if any, Whether Medical Audit was conducted for the Maternal Health 1. Yes 2. No 60. No. of Infant Death occurred if any in the area during the last 1 year. 61.If so, the cause of the death. 62. No. of deaths of the children below 5 years in the area during the last 1 year. If so, Cause of the death Number

Cause of the Death

63. Suggestions of MO in charge to improve the services in Mini PHC.

Name of the Investigator 68

Signature


INSTITUTIONAL SURVEY FORM FOR THE BLOCK PHC 1.

Name & address of the Block PHC with code & Tel. No.

2. 3.

Location of the PHC with population covered Panchayat: Ward:

4.

Accessibility of the centre to the Public: 1. Accessible 2. Not Accessible

5.

If not, Why? No. of Buildings available :

6. 7.

Which is the nearest CHC? Which is the nearest FRU?

8.

Name of the Mini PHC’s under this Block? (1) (2) (3) (4) (5) (6)

9.

Whether all the buildings are fit for use? 1. Yes 2. No

If not, specify. 10. No. of M/O available with specialties: 11. No. of M/O available without specialties: 12. Whether all the buildings are electrified or not. 1. Yes 2. No If not, give details. 13. Source of Water Supply 1. Pipe 2. Well

3. Others

14. Water Supply (1) Available throughout the year (2) Not available at all (3) Occasionally available 15. Number of days OPD was cancelled in the last one month Reasons if any 69


16. No. of antenatal cases reported to the centre during the last month 17. Out of the above how many cases were referred from the field by JPHN. 18. Is a labour room functioning ? 1. Yes 2. No 19. Details of Vehicle: (Use tick marks) Available On road

If Off road, how long

Not Available

Off road

20) Is there any functioning maternity ward being earmarked 1. Yes 2. No 21) Give the Staff Details: Staff

Sanctioned

In Position

Vacancy

Period of Vacancy

22. Details of ward and Bed Strength: Paediatric

Medical M F

Surgical M F

Maternity

General M F

Others M F

Number of Wards Number of beds sanctioned Number of beds occupied

23. Do you have adequate staff for conducting delivery regularly throughout day & night? 1. Yes 2. No If not, the reasons.

24. Number of deliveries conducted in the last 1 month?

25. How many antenatal cases were referred to higher centres? If so, specify with details (last 1 month) 70


26. No. of maternal deaths in the area during the last 1year?

If so, the details 27. Whether the Medical audit was conducted for the maternal deaths?

1. Yes

2. No

28. How many antenatal cases reported who had anaemia? 29. Is this centre recognized for MTP?

1.Yes

2.

No

30. How many MTP’s done during the last month? 31. How many IUD’s were inserted during the last month? 32. How many STD/RTI cases were reported to the centre during the last month? 33. Do you have adequate privacy for examining the STD/RTI cases ?

34. Which is the nearest referral centre for STD/RTI cases? 35. How many abortion cases were reported during the last month? 36. Are you aware of any private institution dealing STD/RTI cases in the area?

1. Yes If so, give details

2. No

37. No. of Children attended for immunization in the centre during the last 4 Wednesdays.

38. Whether any immunization session was cancelled during the last 1 month? 1.Yes 2. No If Yes reasons 39. How many cases of ARI reported during the last 1 month in the meeting? 40. Any CME programmes conducted in the last conference:

1. Yes

2. No

41. Are the whole area of the PHC being divided between the M/O for supervision

1. Yes

2. No

42. Do you get help from the local bodies?

1. Yes 2. No If No, give details. 43. Is male participation ensured in health education sessions? 1. Yes 2. No If No, Why? 71


44. Field Visits of the staff during the last 1 month? Category

No. of field visits

45. Whether all the field staff is maintaining Tour Diary?

1. Yes 2. No If No, give reason? 46. Details of Staff quarters. No. of Quarters

Category of Staff allotted

Category of Staying

47. If none of the doctors staying in quarters where do they stay? (Place & Distance from PHC) No. of Doctors not staying in the quarters

Place of Staying

Distance from PHC

48. Suggestions to improve the Services of the Block PHC ?

Name of the Investigator 72

Signature


INSTITUTIONAL SURVEY FORM FOR CHC (a) Name & address of the CHC with Tel No : (Block Letters)

(b) Location: Panchayat/Block/ Municipality : (c) Accessibility to the public : 1.Excellent 2. Good 3.Poor (d) Whether the post of Chief Medical officer in position? 1. Yes 2. No If no, since when? Infrastructural Facilities 1. Whether adequate space to house all the service modalities: 1. Yes 2. No If no, give details 2. Water supply 1. Regular 2. Irregular 3. Supply of electricity: 1. Yes 2. No 4. Whether generator available? 1. Yes 2. No 5. Details of ward and bed Strength Paediatric

Medical M F

Surgical M F

Maternity

General M F

Others M F

Number of wards Number of beds sanctioned Number of beds occupied 6.

Adequacy of labour room facility 1. Adequate 2. Not Adequate If Not Adequate, what are the inadequacies?

7.

Adequacy for newborn resuscitation 1. Adequate 2 Not Adequate If Not Adequate, What are the inadequacies? 73


8.

Whether there is a functioning X-ray Unit? 1. Yes 2. No If No, give details.

9.

Whether there is a 24 hr functioning blood bank 1. Yes 2. No If No, Give details

10. Whether there is any vehicle attached to the CHC? 1. Yes 2. No If Yes, 1. On Road 2. Off road If Off road, how long? 11. Whether there are any 24hr Ambulance services 1. Available 2. Not Available If Not available, give reasons. 12. Is there any 24 hr Functioning Lab? 1.Yes. 2. No If No, give reasons? 13. Is there a functioning operation theatre round the clock? 1. Yes 2. No If No, Why? 14. Resuscitation corner 1. Adequate 2. Inadequate If Inadequate, why? 15. Is there any Nebulization corner? 1. Adequate 2. Inadequate If Inadequate, why? 16. Is there a functioning DTU? 1. Yes 2. No 17. How do you dispose waste? 18. Is there an incinerator? 1. Yes 2. No 19. Is there any PP Unit? 1. Yes 2. No If Yes, 1. Functioning 2. Not Functioning 74


Man Power Infrastructure

Others

Paediatrician

Anaesthetist

Surgeon

Physician

Specialities O&G

Perid of Vacancy

Vacancy

In Position

Sanctioned

Category of staff

20. Staff Position

MO

21. No. of doctors staying in Hospital quarters 22. Accommodation facility for other staff (Details) 23. Has the service of the gynaecologist been available continuously during the months? 1. Yes 2. No If No Why ?

last 3

24. Has the service of the paediatrician been available continuously during the last 3 months? 1. Yes 2. No If No Why 25. Is the service of anaesthetist available round the clock? 1. Yes 2. No If Yes, 1.Regular Posting, 2. On Call 3. Contract If No, Why? 26. Population covered by the PP Unit area 27. How many antenatal cases were registered by the JPHN during the last 1 month during the field visit? 75


28. How many antenatal cases attended in the clinic during the last 1 month? 29. How many anaemic pregnant women detected in the last 1 month? 30. How many beneficiaries received IFA, TT immunization during the last 1 month (Use the Table) Polio

No. of doses

Measles

DPT

TT to Pregnant Women

MMR

0 1 2 3 Booster Booster No. of doses

Vit. A

31. How many days the JPHN visited her area during the last 1 month? 32. Deliveries conducted during the last 1 month?

Type of delivery

Total number of deliveries during the last 1 month

1 Year

No. of elective CS during the last 1 month

1 Year

LSCS Assisted Normal

33. No. of babies born with birth wt. below 2.5 kg during the last 1 month? 34. How many IUD insertions made during the last 1 month? 76


35. How many IUD insertions made during the last 1 year? 36. No. of MTP’s performed in the last 1 month 37. No. of MTP’s performed in the last 1 year 38. No. of Sterilization performed during the last 1 month. Number During last During last 1 month 1 year

Type of Sterilization

Laproscopic Sterilization Minilap Sterilization Vasectomy Others (PPS) 39. No. of Permanent sterilization failure reported if any for the last 1 year. 40. No. of contraceptive failure during the last 1 month 41. No. of emergencies reported during the last 1month? Maternal

Paediatric

42. No. of cases referred to the higher centre during the last 1 month Maternal Paediatric Referred In Referred Out Referred In Referred Out

43. No. of maternal death /infant death/child death (under five) occurred during the last 1 year. MD

ID

CD

44. How many blood transfusions during the last 1 year from this CHC? 45. No. of ARI in children attended during the last 1 month 46. No. of cases referred OUT in the above cases 47. Do you provide 24 hr delivery services? 1.Yes. 2. No 77


48. How many times fumigation of the operation Theatre was done during the last 3 months? 49. The relationship with the local body 1. Excellent 2. Good 3. Poor 50. How many days the family welfare clinics were working for the last 1-month? 51. Are the statistical events being regularly recorded? 1. Yes 2. No 52. Is a classroom available? 1. Yes 2. No 53. Did anyone from the DMO or above visit your CHC in the last 1 month 1.Yes 2. No If Yes, What instructions were given? 54. Did you or anybody else examine for breast cancer for the last 3 months? 1. Yes

2. No

If No, Why? 55. Did you or anybody else examine for cervical cancer for the last 3 months? 1. Yes

2. No

If No, Why? 56. Is there a separate clinic for STI/RTI functioning? 1. Yes . 2. No If Yes, how frequently? If No, why? 57. STI/RTI clinic was being conducted by 1.Gynaecologist

2. Skin & VD Specialists

58. Is there a adolescent clinic functioning? 1. Yes 2. No If Yes, how frequent? If No, why? 59. Is there any infertility Clinic being conducted? 1. Yes 2. No If Yes, how frequently? If No, why? 78

3. General Duty Doctor


60. Details of Staff quarters Category of the staff allotted quarters

*Whether the allottee is staying in the quarters

*If No, Who is staying

* 1, Yes 2. No

61. If the MO’s do not stay in quarters where do they stay? Category

Place of Stay

Distance from the Institution

Gynaecologist Paediatrician Anaesthetist Surgeon Physician 62. Suggestions of the MO in Charge to improve the Service delivery of the CHC, if any?

Name of the Investigator

Signature

79


INSTITUTIONAL SURVEY FORM FOR FRU (a) Name & address of the CHC with Tel. No. (Block Letters)

(b) Location: Panchayat/Block/ Municipality : (c) Accessibility to the public : 1.Excellent 2. Good 3.Poor (d) Whether the post of FRU Coordinator/Supt./M.O in charge is in position ? 1. Yes 2. No If no, since when? Infrastructural Facilities: 1. Whether adequate space to house all the service modalities: 1. Yes 2. No If no, give details 2. Water supply 1. Regular 2. Irregular 3. Supply of electricity: 1. Yes 2. No 4. Whether generator available? 1. Yes 2. No 5. Details of ward and bed Strength Paediatric

Medical M F

Surgical M F

Number of wards Number of beds sanctioned Number of beds occupied 6.

Adequacy of labour room facility 1. Adequate 2. Not Adequate If Not Adequate, what are the inadequacies?

7.

Adequacy for newborn resuscitation 1. Adequate 2. Not Adequate If Not Adequate, What are the inadequacies?

80

Maternity

General M F

Others M F


8.

Whether there is a functioning X-ray Unit? 1. Yes 2. No If No, give details.

9.

Whether there is a 24 hr functioning blood bank 1. Yes 2. No If No, Give details

10. Whether there is any vehicle attached to the FRU? 1. Yes 2. No If Yes, 1. On Road 2. Off road If Off road, how long? 11. Whether there are any 24hr Ambulance services 1. Available 2. Not Available If Not available, give reasons. 12. Is there any 24 hr Functioning Lab? 1.Yes. 2. No If No, give reasons? 13. Is there a functioning operation theatre round the clock? 1. Yes 2. No If No, Why? 14. Resuscitation corner 1. Adequate 2. Inadequate If Inadequate, why? 15. Is there any Nebulization corner? 1. Adequate 2. Inadequate If Inadequate, why? 16. Is there a functioning DTU? 1. Yes 2. No 17. How do you dispose waste? 18. Is there an incinerator? 1. Yes 2. No 19. Is there any PP Unit? 1. Yes 2. No If Yes, 1. Functioning 2. Not Functioning 81


Man Power Infrastructure

MO

21. No. of doctors staying in Hospital quarters 22. Accommodation facility for other staff (Details)

23. Has the service of the gynaecologist been available continuously during the months? 1. Yes 2. No If No Why ?

last 3

24. Has the service of the paediatrician been available continuously during the last 3 months? 1. Yes 2. No If No Why 25. Is the service of anaesthetist available round the clock? 1.Yes 2. No If Yes, 1.Regular Posting, 2. On Call 3, Contract If No, Why? 26. Population covered by the PP Unit area 27. How many antenatal cases were registered by the JPHN during the last 1 month during the field visit? 82

Others

Paediatrician

Anaesthetist

Surgeon

Physician

Specialities O&G

Perid of Vacancy

Vacancy

In Position

Sanctioned

Category of staff

20) Staff Position: -


28. How many antenatal cases attended in the clinic during the last 1 month? 29. How many anaemic pregnant women detected in the last 1 month? 30. How many beneficiaries received IFA, TT immunization during the last 1 month (Use the Table) Polio

No. of doses

Measles

DPT

TT to Pregnant Women

MMR

0 1 2 3 Booster Booster No. of doses

Vit. A

31. How many days the JPHN visited her area during the last 1 month? 32. Deliveries conducted during the last 1 month?

Type of delivery

Total number of deliveries during the last 1 month

1 Year

No. of elective CS during the last 1 month

1 Year

LSCS Assisted Normal

33. No. of babies born with birth wt. below 2.5 kg during the last 1 month? 34. How many IUD insertions made during the last 1 month? 83


35. How many IUD insertions made during the last 1 year? 36. No. of MTP’s performed in the last 1 month 37. No. of MTP’s performed in the last 1 year 38. No. of Sterilization performed during the last 1 month. Number During last During last 1 month 1 year

Type of Sterilization

Laproscopic Sterilization Minilap Sterilization Vasectomy Others (PPS) 39. No. of Permanent sterilization failure reported if any for the last 1 year. 40. No. of contraceptive failure during the last 1 month 41. No. of emergencies reported during the last 1month? Maternal

Paediatric

42. No. of cases referred to the higher centre during the last 1 month Maternal Paediatric Referred In Referred Out Referred In Referred Out

43. No. of maternal death /infant death/child death (under five) occurred during the last 1 year. MD

ID

CD

44. How many blood transfusions during the last 1 year from this FRU? 45. No. of ARI in children attended during the last 1 month 46. No. of cases referred OUT in the above cases 47. Do you provide 24 hr delivery services? 1.Yes. 2. No 84


48. How many times fumigation of the operation theatre was done during the last 3 months? 49. The relationship with the local body 1. Excellent 2. Good 3. Poor 50. Whether the following staffs are FRU trained (a) Paediatrician

: 1. Yes

2. No

(b) Obstetrician

: 1. Yes

2. No

(c) Nurses

: 1. Yes

2. No

(d) Anaesthetist

: 1. Yes

2. No

(e) Blook Bank Technician : 1. Yes

2. No

51. Whether FRU Kits E to P are in use 1. Yes 2. No If No, Why ? 52. Has any FRU trained staff transferred out within 5 years after receiving the training? 1. Yes 2. No If Yes, specify ? 53. How many days the family welfare clinics were working for the last 1 months 54. Are the statistical events being regularly recorded ? 1.Yes 2. No 55. Is a classroom available ? 1.Yes 2. No 56. Wheather any in-house FRU Training during the last 3 month? 1.Yes 2. No 57. Did anyone from the DMO or above visit your FRU in the last 1 month 1.Yes 2. No If Yes, What instructions were given ? 58. Do you know about the FRU News Bulletin ? 1.Yes 2. No If Yes, did you provide any news from your FRU in the last 3 months? 1.Yes 2. No 59. Did you or anybody else examine for breast cancer for the last 3 months ? 1.Yes 2. No If No, Why ? 85


60. Did you or anybody else examine for cervical cancer for the last 3 months ? 1.Yes 2. No If No, Why ? 61. Is there a separate clinic for STI/RTI functioning ? 1.Yes 2. No If Yes, how frequently ? If No, Why ? 62. STI/RTI clinic was being conducted by 1. Gynaecologist 2. Skin & VD Specialists 3. General Duty Doctor 63. Is there a adolescent clinic functioning ? 1.Yes 2. No If Yes, how frequent ? If No, Why ? 64. Is there an infertility clinic being conducted ? 1.Yes 2. No If Yes, how frequently ? If No. Why? 65. Details of Staff quarters Category of the staff allotted quarters

* 1, Yes 2. No

86

*Whether the allottee is staying in the quarters

*If No, Who is staying


66. If the MO’s do not stay in quarters where do they stay? Category

Place of Stay

Distance from the Institution

Gynaecologist Paediatrician Anaesthetist Surgeon Physician 66. Suggestions of the FRU co-ordinator/Supt./MO in Charge to improve the Service delivery of the FRU, if any?

Name of the Investigator

Signature

87