Infrastructure Assessment Study in IPD Districts in MP India

Introduction
Department of Public Health and Family Welfare, Govt. of M.P. is implementing Integrated Population and Development (IPD) Project sponsored by UNFPA in five districts of M.P. These districts are Chhatarpur, Panna, Satna, Rewa, and Sidhi. They were selected based on the criteria on Crude Birth Rate, Female literacy, hospital based deliveries, antenatal registration and deliveries by untrained hands.
The objectives of IPD project are:
¨ To enable individuals and couples to achieve their personal reproductive intentions and to ensure the survival and development of their infants and children’s.
¨ To eliminate discrimination against girls and to improve their health, nutrition and educational status.
¨ To achieve gender equity and equality between men and women and to enable women to achieve their full potential.
IPD Project is headed by Director, Public Health and Family Welfare. In state IPD has one State Project Officer and at each district it has one District Project Officer.

Research methodology and sampling criteria:
The study focused on Sub Health Centers, sector PHCs & CHCs. It has been limited to the equipments & infrastructure required for NSV, Laproscopy, RTI, STI & conducting delivery. It studied the issues whether the equipments & infrastructure were in working conditions or were requiring repair & maintenance. It also obtained data on caseload & placement of adequately trained manpower for the job.
This study aimed at:
§ Assess the community need for health interventions. (limited to IPD project goals)
§ Assess the status of health infrastructure & health facilities at health institutions in the project districts at Sub Heath Center. Sector Primary Health Center, Community Health Center / Block Primary Health Center level.

The designed instruments had been sent to all project districts and were distributed to all CHC/BPHC, sector PHC and SHC. The filled instrument would constitute as secondary data. Institute's research team collected the primary data at the sampled institutions.
In each IPD districts 2 CHC/BPHC were selected randomly. In each selected CHC/BPHC 3 sector PHCs were selected. In each selected sector PHC 3 SHCs were selected on random basis. In PHC's having only three or less than three SHCs, all were covered.
Focus group discussions (FGD) were organized in all selected Sub Health Center villages by research team. These focus group discussions were focussed on community need regarding reproductive health and to get the opinion from the community in the village about the functioning of ANM and SHC.

Salient features:
The primary data were collected from 9 CHC/ BPHC, 24 sector PHCs and 80 SHCs. The details regarding need of repair and renovation were collected from 23 SHCs, 8 PHCs and 9 CHCs/ BPHCs as these data were collected from only those institutions which have Govt. owned buildings.

A. Infrastructure available to health centers:

1. Multipurpose worker male and female each must be posted in a SHC but only SHCs of Chhatarpur dist. has all post of multipurpose worker females and Rewa has all post of multipurpose worker males occupied.
2. In Satna district 100 percent SHCs were situated within village locality where as 50 percent of SHCs buildings were outside the village locality in Chhatarpur. 100 percent PHC buildings in Satna and Sidhi district were located at centre of the village. In total 25.00 percent PHCs were located at one end of village and 25.0 percent were located out of the village. Only one of the sampled CHC building in Sidhi district was located at one end of the locality whereas in rest of all CHC buildings were located at centre of the village.
3. Distance of ILR from SHC plays an important role in maintenance of cold chain for effective immunisation. For 17.4 percent SHCs the ILRs were situated more than 50 Km away. and also for 17.4 percent SHCs the ILRs were situated within 5 Km. Whereas for 26.1 percent cases the ILRs were situated between 30 – 50 Km. away from SHCs villages.
4. Although 5 PHCs and 6 CHCs have operation theatre but none of them were performing caesarian deliveries. Only in Sidhi district the sampled CHCs did not have operation theatre.
5. 47.8 percent SHCs had separate labour room but in Satna no SHC had separate labour room. 4 PHCs also had separate labour rooms, but in Sidhi district no PHC had separate labour room. At 4 CHCs separate labour rooms were found available.
6. 41.7 percent PHCs had no facility for admitting patients. Whereas 45.8 percent PHCs had six to ten bed facility, 25.0 percent PHCs at Rewa district had bed capacity more than 15 beds. 6 CHCs had bed capacity less than 30 whereas 3 CHCs had bed capacity between thirty to fifty beds.
7. 91.3 percent SHCs had pucca building, 33.3 percent SHC in Panna and 20.0 percent SHCs in Rewa had katchcha buildings. None of the PHCs had katchcha building. Only one PHC in Rewa district had semi pucca building. In all 7 PHCs had pucca building whereas all sampled CHCs had pucca buildings.
8. 34.8 percent SHCs building had no cracks. 39.1 percent buildings had cracks in inside walls. Only SHCs at Chhatarpur district did not have any cracks in their walls. 5 sampled PHCs buildings had cracks in walls. Sampled CHC buildings at Chhatarpur, Panna and Rewa district had cracks in the walls, but in Satna and Sidhi district only one CHC building in each districts have cracks.
9. Floor of all SHCs building in Panna, Rewa and Satna district were broken and having pits whereas in total 52.1 percent SHC building floors were properly tiled or plastered suitably. Three PHC building floors were found broken whereas in 6 PHC buildings floors were found plastered suitably. At all sampled CHCs at Chhatarpur, Panna and Satna districts and one at Rewa district the floor was found either properly tiled or plastered suitably.
10. 91.3 percent SHC had no proper wastewater disposal facility whereas only half of the sampled PHC in Sidhi district had open pit. One CHC each at Panna and Sidhi district had open pit available for waste disposal, rest of them had no facility for safe disposal of hospital waste.
11. In 56.5 percent SHCs building inside walls and door & windows were found properly painted/ white washed. Outside walls of 60.9 percent SHC buildings were found properly whitewashed whereas only 40 percent of the existing boundary walls were found properly painted / whitewashed. In 5 PHC buildings inside walls were found properly / white washed. In 4 PHC buildings outside walls, doors and windows found properly painted/ white washed. Four CHC buildings were found properly painted / white washed.
12. 69.5 percent of SHCs were using hand pump water as a main drinking water source. In PHCs also the major source of drinking water was hand pump only (5 PHCs). In CHCs as well the major source of drinking water was hand pump. 5 CHCs were using hand pump water, 3 CHCs were using tap water and 1 CHC was using tube well water as drinking water.
13. 65.2 percent SHCs had flush laterines, 13.0 percent had pit laterines where as 21.8 percent SHCs did not have any type of toilet. 5 PHCs had toilet either type flush or pit. All sampled CHCs at Chhatarpur, Rewa, Panna and Satna and one CHC at Sidhi districts had toilet facility.
14. Only 30.4 percent SHC have electric connection but 47.8 percent SHC have proper electric wiring done. Only 4 PHCs have electric connection whereas all sampled CHCs had electric connection but in 3 CHCs proper electric wiring was not done.
15. For ANC check-ups 65.2 percent SHCs were assuring privacy, 30.4 percent SHCs were assuring privacy for RTI / STD diagnosis, 47.8 percent SHCs were ensuring at the time of delivery and 60.9 percent SHCs were ensuring privacy to female patients for IUD services.
16. All sampled PHC did not have any type of vehicle whereas 8 sampled CHCs had Jeeps out of which 7 were in working order, one CHC at Rewa district and both sampled CHCs at Satna district had ambulance facility available in working order.
17. 91.3 percent SHCs needed finance for repair / renovation. 2 PHCs needed financial assistance of less than Rs. 5,000/-, 3 PHCs needed assistance of Rs. 50,000/- to Rs. 1,00,000/- and 2 PHCs needed more than Rs. 1,00,000/-. 4 sampled CHCs needed financial assistance of Rs. 50,000/- to 1,00,000/-, 2 CHCs needed amount more than Rs. 2,00,000/- in same number CHCs needed amount less than Rs. 50,000/-. Whereas one CHC needed amount between Rs. 1,00,000/- to Rs. 2,00,000/-.

B. Workload, stock position and training status:

1. 67 MPW (F) were trained in conducting deliveries and 65 in IUD insertion. 38 MPW (F) were also trained in child survival and safe motherhood. But only 54 MPW (F) were using the skills in conducting deliveries and 51 in IUD insertion at SHCs. At PHCs 10 M.Os were trained in conducting delivery cases while only 5 were found using the skill. In 9 CHCs sampled only 5 M.O.s were found trained in conducting deliveries and all of them were applying these skills also.
2. Availability of trained dai’s in sub health center areas were less than 5 in 46.2 percent of the SHCs, whereas more than 10 trained dai’s were found in only 7.5 percent of SHCs. Availability of 25-50 trained dai’s in the PHCs were in 45.8 percent whereas 4.2 percent PHCs had trained dais in between 50-75 persons. 16.7 percent PHCs had more than 75 trained dais. In CHC areas less than 100 trained dai’s were found in 2 CHCs whereas 4 CHCs had trained dais in between 100-200 and 3 CHCs had more than 200 trained dais.
3. 30 percent SHCs had less than 5 AWCs, whereas 68.8 percent SHCs had 5-10 AWCs and 1.2 percent SHCs did not have AWC in their field. 61.2 percent SHCs had less than 5 Jan Swasthya Rakshaks in the area and 8.8 SHCs had more than 20 JSRs in area.
4. In 15.0 percent SHCs oral pills were not distributed during October 2002. Whereas 100 packets of pills were distributed in 65.0 percent SHCs. In 7.5 percent SHCs distribution of oral pills were made to more than one thousand eligible women. 45.8 percent PHCs did not distribute oral pills, whereas at 20.8 percent PHCs the distribution made was between 1-250, in 16.7 percent PHCs distribution of oral pills was made between 250-500 and in 4.2 percent PHCs distribution made was more than 1,000. Less than 500 oral pills were distributed in 2 CHC/BPHCs area. Between 500-1,000 pills were distributed in 4 CHCs and more than 1,000 pills were distributed by 3 CHCs.
5. 17.5 percent SHCs did not distribute condoms during the month of October 2002. 38.8 percent of SHCs distributed condoms in between one hundred to five hundred and 5.0 percent SHCs distributed more than one thousand condoms. In 45.8 percent PHCs condoms were not distributed during the month of October 2002 whereas above one thousand condoms distribution were made by 20.8 percent PHCs. 5 CHCs distributed condoms less than 5,000 during the month of October 2002. One CHC each at Rewa and Satna districts were distributed more than 10,000 condoms.
6. 46.3 percent SHCs distributed IFA tablets to one to twenty five pregnant women, 5.6 percent SHCs at Chhatarpur and 6.7 percent SHCs at Sidhi district did not distribute IFA tablets to any pregnant women. 20.0 percent SHCs distributed more than hundred tablets also to pregnant women. In 50.0 percent PHCs no distribution of IFA tablets was made, where as 8.3 percent PHCs distributed IFA tablets to 250-500 pregnant women. 5 CHCs distributed IFA tablets to less than one thousand pregnant women, whereas 1 CHC distributed IFA tablets more than 5,000 pregnant women. 3 CHCs distributed IFA tablets to one thousand to five thousand pregnant women.
7. Total deliveries conducted in all the SHC areas were 1694 and 4 cases were referred to PHC/ CHC. Total deliveries conducted in the PHC areas were 1759 out of which 28 were admitted and 19 were referred to BPHC/ CHC. No. of institutional deliveries were 194 out of which only 2 deliveries were conducted in Satna district. 2 caesarian deliveries were also conducted at Sidhi district. Total deliveries conducted in the area were 6023 out of them 1981 were home deliveries that were attended by ANMs. 635 home deliveries were attended by untrained dais also. Number of institutional deliveries were 227. Highest number of institutional deliveries were 98 conducted at CHCs of Satna district whereas lowest number of Institutional deliveries were 12 which were conducted at Sidhi district. No caesarian delivery was conducted at any CHC/ BPHC.
8. 61.3 percent SHCs had adequate stock of IFA tablets. Disposable delivery kits were found adequate in 61.5 percent SHCs at Panna district. Medicines for RTI/ STD were found adequate in only 23.1 percent SHCs at Panna district. At Satna district PHCs did not have adequate stock of all the essential medicines, vaccines, contraceptives etc. In all districts medicines for RTI/ STD were not available in adequate quantity. The stock of T.T. doses were not kept at PHCs because of unavailability of deep freezer/ ILR. The vaccines were taken from CHC/ BPHC on daily requirement basis. Out of 9 sampled CHC/ BPHCs 7 had adequate stock of disposable delivery kits. Only 2 CHCs had adequate stock of copper T, disposable needles, reusable needles and medicines for RTI/ STD. One sampled CHC at Chhatarpur district did not have adequate quantity of reuasble syringes, needles and medicines for RTI/ STD.

C. Equipment status in health institutions:

a. At SHC:
Only 27 haemoglobinometer were found available at 26 SHCs. Out of them 16 were found in working condition. Only 49 infant weighing scales were found available in 34 SHCs. Out of them only 25 were reported in working condition. 83 adult weighing scales were found available at 54 SHCs. 68 were in working conditions, 5 needed repairing. At 20 SHCs adult weighing scales were needed. Only 8 examination tables and footsteps were found in 7 and 4 SHCs respectively. 1 of them was unserviceable. 26 SHCs had reported about inadequacy of examination tables whereas 21 reported inadequacy for footsteps. 85 vaccine carriers were found in stock at 66 SHCs. Out of them 78 were in working condition. 25 SHCs had reported about the inadequacy of vaccine carriers. 37 steam sterilisers were found available at 34 SHCs. Out of them 6 were unserviceable and 2 needed repair. Cheatle forceps were found available only in 44 SHCs (1 each). Out of them 4 were unserviceable. 18 knife handles were found in working condition. Only 2 SHCs reported about adequacy of knife handles, 86 artery clamps were available at 33 sHCs and only one was unserviceable. 14 SHCs had reported their inadequacy.

b. At PHC:
Only 11 infant weighing scales were found available. Out of them 9 were in working condition. Demand was made for 23 infant weighing scales. 22 adult weighing scales were available. Out of them only 12 were in working condition and 6 needed repairing. 6 weighing scales were needed in various PHCs. Only 4 uterine sound were available in working condition and 8 PHCs needed 12 uterine sound. 3 vulsellum forceps at 2 PHCs, 11 Sim's vaginal double ended speculum at 6 PHCs, 6 Sim's vaginal depresser/ retractor at 3 PHCs, 4 Cusco's bivalve vaginal speculum at 2 PHCs and 10 IUD removal forceps at 7 PHCs were found available. Only 5 ILR at 5 PHCs and 7 deep freezers at 6 PHCs were found available, 2 deep freezers needed repairing.

c. At CHC:
20 ILR were found available at 6 CHCs. Out of them only 6 were in working condition and 3 needed repairing, whereas 12 deep freezers were found in stock at 3 CHCs. Out of them 9 were in working condition and 3 needed repairing. Not a single CHC had catheter either nasal or endotracheal. But required quantities were expressed by 3 CHCs for 102 and 81 respectively. Catheter suction rubber type was found in 5 number at 1 CHC but all were unserviceable. 21 catheters were found in further demand by 2 CHCs. Only 6 complete tubectomy kit were found available in 2 CHCs and all of them were in working condition. One CHC expressed the need for one complete tubectomy kit.

D. COMMUNITY NEEDS ASSESSMENT:

For assessing the need of community regarding reproductive health FGDs were conducted at each sampled SHC village. The persons involved in the discussions were mainly among the following:
§ Local people of the same and adjoining villages.
§ Teachers posted and residing in the village.
§ Elected representatives of PRI, Member of Parliament, Member of Legislative Assembly or local leader.
§ Anganwadi worker of the village.
§ Traditional birth attendant.
§ Members of self help groups and mahila mandals.
§ Shopkeepers.
§ Govt. employee posted or residing in the village.
§ Influential persons of the village.
The major needs of the community are listed below:
1. Health needs before marriage/ Adolescents:

They did not know the reason behind fixing of minimum age at marriage so they marry their children at early age. At some places of Chhatarpur and Panna districts female group members suggested that proper awareness generation programmes should be organized for creating awareness about causes of maternal mortality.

2. Health needs after marriage:

Most of the people did not know the importance of small family and also the measures to be taken in this direction. The reasons for low CPR were told as:
1. Place for getting contraceptives was not known.
2. Contraceptives were not made available at health centers at times.
3. Unaware regarding importance of use of contraceptives.
4. The incentive money was not distributed regularly and money should also be given to motivators.
5. Females did not like taste of oral pills.
6. Oral pills can cause ill effects on their health.
7. At some places in Panna and Chhatarpur district women complained that a few MPW (M) and ANMs asks for fee for LTT operations.

3. Antenatal care need:

Community did not prefer ANC check-ups because ANMs perform these check-ups in the presence of other patients also. A mobile health care unit providing privacy for such check-ups will increase ANC registration. At some places in case of any complication ANMs did not intimate family members regarding steps to be taken at that stage. Because of unawareness of complication family members did not make any arrangements to take pregnant women to higher health institutions and at the last moment due to lack of time and lack of transport facility maternal mortality takes place. Community members were well aware about the advantages of immunization during pregnancy.

4. Need during delivery (Natal care):

A few of them talked of disposable delivery kit but very less in numbers. The VHC should be trained for ensuring cleanliness during home delivery in the village.

At Jawa PHC community wanted training of dais should be done. In case of emergency women feel insecured with untrained dais. In Panna and Chhatarpur districts many villages were inaccessable. People of that region told that in some of the delivery cases they had taken pregnant women to the hospitals on cot. In one of the case women died on the way to the hospital.

5. Need after delivery (Post natal care):

At some places community had misconception regarding side effects of immunisation, i.e., fever etc. They also think that no one can prevent their children from God’s curse. There is a need for proper campaigning of importance of immunisation at such places.

6. Child care:

Almost all the places few women were not aware about the importance of weighing children after birth. Women were also not aware regarding early initiation of breast-feeding in the areas of Chhatrpur, Panna and Sidhi. At all the districts men as well as women were found unaware regarding importance of oral rehydration solution. Community members were also not well aware about early diagnosis of morbidity.

7. Other needs:

Due to lack of medical stores and poverty medicines written by health institutions could not be bought by community. There is a need to increase number of Jan Swasthya Rakshak. Even at few places they suggested the JSR should be a women equipped with more knowledge in ANC and PNC. The TBAs may also be encouraged for JSRs course. At some time in case of emergency health centers were found closed because of lack of staff.
All the villagers of Tingudi PHC expressed about the need of lady doctor at sector PHC. Due to lack of staff 5 mothers and 6 children died there.
At a PHC group members reported that the doctors were posted but attend duty only once a month. At Sinhawal BPHC all the three sampled PHCs doctors were posted but due to not having residential accommodation doctors were not residing in the PHC village. At the places where ANMs were locally posted, due to Parda Pratha and social customs they fail to visit the field and their husbands carry out routine work on their behalf. In Sinhawal block at few places ANM and MPW (M) were carry out private practices and they charge fee for their routine works.

8. Observation by research team of IIDM:

At one place at Panna district research team saw early marriage where bride as well as bridegroom both were of below 10 years. One place in Sinhawal block husband of ANM was conducting immunisation of children. At some places where ANM or MPW (M) were of upper caste they hesitated to check-up lower caste patients and vice versa. Many posts of ANM and MPW (M) were found vacant at the time of data collection which affected proper implementation of health services. There is a need to construct SHC buildings with ANM residence having all basic amenities like toilet facility and electric connection.
At Raipur PHC in Teonthar block community informed that doctors did not want to reside at PHC level and the health services suffered. Wine shop and restaurants were located nearby Chandrapur SHC at Teonthar block. So women were hesitating to come to SHC.
Garhi SHC at Jawa PHC is located other side of river and did not have bridge over river. Area was “Daquiat” affected also, so doctor and other servants did not want to posted there even patients were also not want to go for treatment at this PHC.