POPULATION RESEARCH CENTRE

KERALA
Sponsored by

Ministry of Health and Family Welfare

Government of India

Monitoring of NRHM PIP, Kerala 2013-14

Monthly Report
October 2013
ALAPPUZHA DISTRICT
Contributors
Dr. Shylaja.L
Rajesh J Nair

Kariavattom
Thiruvananthapuram
2013
Table of Contents

Page 1 of 20

Executive Summary...............................................................................................................4

Introduction............................................................................................................................5

State Profile and district profile............................................................................................5

Key health and service delivery indicators..........................................................................7

Health Infrastructure:............................................................................................................7

Human Resources...................................................................................................................8

Other health System inputs...................................................................................................9

Maternal health.....................................................................................................................11
8.1

ANC and PNC...........................................................................................................................11

8.2

Institutional deliveries................................................................................................................11

8.3

Maternal death Review..............................................................................................................13

8.4

JSSK..........................................................................................................................................13

8.5

JSY............................................................................................................................................13

Child health...........................................................................................................................14
9.1

SNCU........................................................................................................................................14

9.2

NRCs.........................................................................................................................................14

9.3

Immunization.............................................................................................................................14

9.4

RBSK.........................................................................................................................................15

10

Family planning................................................................................................................15

11

ARSH.................................................................................................................................16

12

Quality in health services.................................................................................................16

12.1

Infection Control........................................................................................................................16

12.2

Biomedical Waste Management.................................................................................................16

12.3

IEC.............................................................................................................................................16

13

Clinical Establishment Act...............................................................................................17

14

Referral transport and MMUs........................................................................................17

15

Community processes.......................................................................................................17

15.1

ASHA........................................................................................................................................18

15.2

Skill development......................................................................................................................18

15.3

Functionality of the ASHAs.......................................................................................................18

Y1 Executive Summary...............................................................................................................4
2

Introduction............................................................................................................................5

State Profile and district profile............................................................................................5

Key health and service delivery indicators..........................................................................6

Health Infrastructure:............................................................................................................6
Page 2 of 20

Human Resources...................................................................................................................8

Other health System inputs...................................................................................................9

Maternal health.....................................................................................................................11
8.1

ANC and PNC...........................................................................................................................11

8.2

Institutional deliveries................................................................................................................12

8.3

Maternal death Review..............................................................................................................12

8.4

JSSK..........................................................................................................................................12

8.5

JSY............................................................................................................................................13

Child health...........................................................................................................................14
9.1

SNCU........................................................................................................................................14

9.2

NRCs.........................................................................................................................................14

9.3

Immunization.............................................................................................................................14

9.4

RBSK.........................................................................................................................................15

10

Family planning................................................................................................................15

11

ARSH.................................................................................................................................15

12

Quality in health services.................................................................................................16

12.1

Infection Control........................................................................................................................16

12.2

Biomedical Waste Management.................................................................................................16

12.3

IEC.............................................................................................................................................17

13

Clinical Establishment Act...............................................................................................17

14

Referral transport and MMUs........................................................................................17

15

Community processes.......................................................................................................18

15.1

ASHA........................................................................................................................................18

15.2

Skill development......................................................................................................................18

15.3

Functionality of the ASHAs.......................................................................................................18

16

Disease control programmes............................................................................................18

16.1

Malaria.......................................................................................................................................18

16.2

TB..............................................................................................................................................19

16.3

Other Communicable Disease....................................................................................................19

17

Non Communicable Diseases...........................................................................................19

18

Good Practices and Innovations......................................................................................19

19

HMIS and MCTS..............................................................................................................20

20

Untied Fund and AMG. 21

21

Supervisory visits 21

Page 3 of 20

22

Household Visits.. 22

23

Key Conclusions and Recommendations........................................................................22

24

Annexure..24

Executive Summary

The implementation of Government sponsored programmes under NRHM has been providing good quality health
care to the people. After 5 years of implementation in the state, there has been tremendous progress in access to
services especially the rural masses. Evaluation and monitoring are integral components for the success of any
programme. The present report is one in this direction that provides inputs into service delivery aspects under
NRHM in the district of Alappuzha as part of the monthly monitoring of NRHM PIP in Keral initiated by Govt. of
India and carried out by the Population Research Centre, Kerala. The health facilities selected in Alappuzha district
are District Hospital Alappuzha, Kurathicad CHC, Chettikulangara PHC, and Nadakkavu SC. The field work was
done during the first week of October 2013.
The Taluk hospital, Mavelikara was upgraded to DH level in the recent past. With increasing demand from the
public for services that they expect from a DH, human resource and the infrastructure short comings pose to be a
challenge. All the sanctioned posts are suitable for a Taluk level hospital. No change in the staff pattern has been
made along with upgradation to DH. Service delivery at the Orthopedic, PP Unit, Paediatric wing and Gynaec wing
are mostly affected by lack of sufficient staff. The hospital is presently managing with RSBY support. Supply of

Page 4 of 20

drugs for smooth functioning of projects from the KMSCL is problematic. AYUSH services are not offered in any of
the selected facilities.
JSSK has been successfully implemented in the district. Yet IEC activities regarding JSSK entitlements have to be
improved at the community level as beneficiaries were found to be ignorant about most of the free entitlements.
Pregnant women are aware of the birth preparedness and JSY but not about JSSK. Only 30 percent of pregnant
women are aware about JSSK programme and most of them gathered sufficient information from the health facility.
Palliative care project is running successfully in the hospital. JSY payments are properly documented. CHC and
PHC are doing palliative care programme. Source reduction activities and NCD services are organized quite
satisfactorily. As Nadakkave SC functions in a rented building, utilization of the facility is less. Awareness on
breastfeeding initiation within an hour after birth is universal in the area of Nadakkavu sub centre. No separate
Nutrition Rehabilitation Centre is present in any of the facilities visited or any other facility selected. ARSH clinics
should be set up. In the CHC and PHC and the SC, the necessary registers like OPD, IPD, ANC, Indoor bed head
ticket, Family Planning, Immunization etc are available and correctly filled in the facility. The average OPD in
Chettikulangara PHC is almost double the numbers in Kurathicad CHC. The service load in terms of ANC,
immunization, FP services are much greater in the PHC. School health programmes are being organized regularly in
the CHC and PHC area. Biomedical waste management is not as per IMEP protocols in the PHC and SC. Infection
control measures in the PHC are has to be stepped up.

Introduction

The implementation of Government sponsored programmes under NRHM has been providing good quality health
care to the people. After 5 years of implementation in the state, there has been tremendous progress in access to
services especially the rural masses. Evaluation and monitoring are integral components for the success of any
programme. As part of the monitoring of NRHM activities in the state, Population Research Centres were made
nodal agencies in their respective states to review the activities under NRHM. The present report is based on
monthly monitoring activities initiated by Ministry of Health and Family Welfare, Government of India. Alappuzha
district forms the area of present study. The health facilities selected in Alappuzha district are District Hospital
Alappuzha, Kurathicad CHC, Chettikulangara PHC, and Nadakkavu SC. The field work was done during the first
week of October 2013. About 7 JSSK beneficiaries present at the time of visit were interviewed and for household
level interviews, 10 households each with pregnant women and 0-6 children were included in the interview from the
SC area.

State Profile and district profile

Kerala is divided in 14 districts. There are 152 blocks and 1018 villages in the state. The population of the state as
per Census of India 2011 is 33406061 out of which 16027412 are males and 17378649 are females. The sex ratio of
1084 females to 1000 males gives Kerala the distinction of having the only state with sex ratio favourable to females
in the country. Kerala is also the most literate state with 93.91 percent of its population literate. The density of
population is 860 persons per sq.km.
Kerala
No. Districts
No. of Blocks
No. of Villages

14
152
1018
Page 5 of 20

Alappuzha
District
12
91

Population (2011)
33406061
Literacy
93.91
Sex Ratio
1084
Density of Population
860
Source: Census of India 2011

2127789
96.26
1100
1501

Alappuzha district was formed on 17th August, 1957 and consists of six taluks Cherthala, Ambalappuzha, Kuttanad,
Karthikappally, Chengannur and Mavelikkara. There are 12 Blocks, 91 Villages, 73 grama panchayats and 5
Municipalities. It is the smallest district in Kerala with a total area of 1414 sq. kms forming 3.64 percent of the total
state area and so the second most densely populated district (1501 persons per sq.km). The district head quarters is
located at Alappuzha. It is one of the most literate districts with a literacy rate of 96.26 percent. The health service
delivery in the public sector is rendered through 1 District Hospital, 1 Women and Children Hospital, 1 General
Hospital, 7 Taluk Hospitals, 16 CHCs, 56 PHCs, 366 SCs, 2 TB Centres and 1 other hospital.

Key health and service delivery indicators:

The decentralized health care delivery system in the state has helped to achieve low levels of fertility and mortality.
The CBR in the state is 15.2, and the TFR is 18 as per the latest report of SRS (2011). Child Mortality rate (3)
U5MR (13), IMR (12), NMR (7), Peri-natal MR (10), Still BR (6) are the lowest for any state in the country. As per
the DLHS-3 estimate the mean number of children ever born in the Alappuzha district is 1.8 children. Census data
based indirect estimate of CBR shows that the fertility declined from 15.2 births per 1000 population in 1994-2000
to 12.8 by 2004-10. TFR is 1.5 (2001). Census data based estimates of sex ratio at birth is 951 female children per
1000 male children as against 918 during the period April-September 2013. Service delivery statistics available from
HMIS (April-September 2013) shows that in Alappuzha district the proportion of deliveries shared by public and
private hospitals is 47 and 53 percent respectively. The proportion of C-Section to total deliveries is 53 percent in
Public hospitals and 48 percent in private hospitals. First semester ANC registration is about 79 percent and more
than four-fifths of the women registered for ANC receive 100 IFA tablets. All the children born are given BCG and
OPV0 vaccine at birth.

Health Infrastructure:

District Hospital Mavelikara is easily accessible from the nearest road. It functions in a group of independent
Government building(s). At a first glance on entering the hospital complex, one gets a view of buildings at the time
of Maharajas of Travancore and also some present day hospital buildings. So the various departments are put up in
separate buildings in one compound at this hospital. In the Medical Superintendents words who is a resident of the
same town, the building where the medical ward is put up was built in 1890 when it began functioning as a General
Hospital. Later about 70 years or so it started functioning as a Taluk Head Quarter Hospital. But recently
Government of Kerala has upgraded it into a District hospital. So in the true sense, when one assesses the facilities
required for a District Hospital, it falls short of the requirements. The Medical Superintendent says that with the
upgradation, the public demand for services have increased but the hospital lacks both infrastructure and human
resources to function as a District Hospital. A proposal has been moved to the Government for the construction of a
five storeyed building to bring all the services under one roof as any other District Hospital in the state and the

Page 6 of 20

hospital management committee is awaiting sanction. There is no staff quarters. Power backup supply is available
only in the Theatre and labour room.
The maternity section and the administrative wing are put up in a new building. These buildings are in good
condition. The wards in the old buildings are maintained neatly though it is very difficult to maintain. The labour
room is neat with attached toilet and new born care unit is within the labour room itself with all necessary
equipments except Ventilators. Using NRHM funds in the third floor of the new building an operation theatre has
been setup recently. There is no Blood Bank. The Blood Storage Unit is non-functional. So it is outsourced.
Kurathicad CHC is easily accessible from the nearest road, functioning in a Government Building and in good
condition. Staff quarters is available for medical officers, JPHN, LHS,HS and Clerk. The CHC has no delivery point.
Clean wards separate for males and females are available. It is 25 bedded CHC, separate toilet for males and
females. Adequate water and electric supply is ensured in the facility. Citizen Chart is displayed in the CHC.
.Complaint or suggestion boxes are available.
Chettikulangara PHC This PHC is under Kurathicad CHC. Catchment population of the area is 42134. Facility is
easily accessible and functioning in Government building and in good condition. No staff quarters are available.
Electricity is there but with no power back up. Water supply is there. BP instrument and Stethoscope, adult weighing
machine and infant weighing machine and needle and Hub cutter is available and functional. Facility for oxygen
administration is there. Autoclave is not functional. No laboratory services are in the PHC.EDL and computerised
inventory management is not doing.
Nadakavu SC - This sub centre is under Chettikulangara PHC. Catchment population of the area is 5213. At the day
of visit JPHN, JHI and ASHA workers were present in the SC. It is 2 km away from PHC and is 13km away from
CHC and more than 16km from District Hospital, Mavelikara and 5km from Kayamkulam Taluk Hospital. It is
functioning in a room of a rented building which has no ventilation and water supply and has electricity but without
backup. Approach roads have no directions to the SC. No quarters are available to ANM or ANM is not residing at
the SC. No complaint /suggestion box is available. Since it is a room in a shop no burial pit for biomedical waste
management.

6 Human Resources:
District Hospital Mavelikara In this hospital upgraded to DH level, human resource shortage has been reported.
All the sanctioned posts are suitable for a Taluk level hospital. No change in the staff pattern has been made along
with upgradation to DH. Out of 2 sanctioned post of Senior consultants and Paediatrician one post each is vacant. 2
General Surgeons, 2 Specialists, 2 Gynaecologists, 2 Ophthalmologists, 2 Orthopaedicians, 2 ENT Specialists, 2
Dental specialists, 9 MOs, 44 SNs, 1 JPHN (regular) and 2 JPHNs under NRHM, 3 LTs, 4 Pharmacists, 1 LHV, 2
Radiographers, 2 ECG Technicians, 2 Ophthalmic Assistants, and 1 Dental Technician forms the Human Resource of
this DH.
Gaps
Service delivery at the Orthopedic, PP Unit, Paediatric wing and Gynaec wing are mostly affected by lack of
sufficient staff. The hospital is presently managing with RSBY support.
The JPHNs who are given multiple responsibilities, find it difficult to cater to the needs of the people in the
municipality area.
Page 7 of 20

 Lack of trained staff is also seen. As per the details provided by the PRO, only 1 doctor is trained in EmOC
and BeMOC. Only 2 SNs have received training in PPIUCD and 1 doctor in IUCD.
As the SNCU is coming up, more SNs are needed at the SNCU and NBSU
In Kurathicad CHC staffing pattern has been reported to be adequate with 3 MOs, 4 SNs, 6 ANMs, 1 LT, 1
Pharmacist, 1 LHV, 1 HS, 1 PHNS, 1 HI, 4 JHIs, 2 Nursing Assistants, 1 HA, 2 JPHNs for School Health
Programme doctors and 4 staff nurses and separate staff for NCD Clinic: 1 MO, 1 DEO, 1 Dietician and, 2 SNs.
Remuneration of NRHM staff is reported to be less. Training status of the staff presently employed is less. As it not a
delivery point staff who have undergone training required to handle maternal health are not posted and among the
MOs posted, in general medicine, adequate training has been reported
Chettikulangara PHC HR at the PHC is 3 medical Officers, one staff nurse, 8 JPHN, one pharmacist, 2 LHV.
None are trained in the last year except one got training in IUD insertion.
Nadakavu SC - One JPHN and one JHI are in the sub centre. JPHN knows how to measure BP. Skill of the JPHN in
measuring BP is also good. There is no equipment in the subcentre to measure haemoglobin, urine albumin and
protein. JPHN has the skill for identifying high risk pregnancy. JPHN does not know about partograph as delivery
services are not there.

Other health System inputs

District Hospital Mavelikara- District Hospital, Mavelikara provides following services: surgery, medicine,
ophthalmology, ENT, Anesthesia, Orthopedics, Paediatrics, Psychiatry, Dental, NSV(family planning) services and
gynaecology. It is 347 bedded hospital with a large number of OPD ( Q1-71078 and Q2-63511 ) and IPD (Q12276, Q2- 2144) during the 2013-14.
There is no case of severely anemic women and maternal death.. So there is no register available regarding the
above. Foetal Doppler/ CTG, MVA equipment, CT Scanner , Ultrasound Scanner (general) are not available at the
facility , All other equipments including OT equipments are available and functional. EDL is available and displayed
in the pharmacy. Computerised inventory management system has been started but is not completed. The process is
going on and will be completed soon. IFA Tablets, Zinc tablets and Vitamin A are out of Stock. Tablets Misoprostol
is out of stock so it is locally purchased. Sanitary napkins are not in stock. All other essential drugs are available and
distributed to the patients. Equipment maintenance is very difficult for want of staff. Grievance redressal mechanism
is there. Tally is not implemented.
Gaps
Difficulty in getting medicines in time and as per demand from the KMSCL. So the hospital manages with
HMC fund. Delay in time between demand and supply is the main reason.
Space in the laboratory is inadequate. Endoscopy service not available,
Kurathicad CHC - . In the first quarter 4253 out patients utilized the services given by the facility and 5524 in the
second quarter. 21 in-patients were there in the first quarter and 32 in the second quarter. The expected pregnancies
in the catchments area of the facility is 182 in both the quarters and the women tracked in MCTS are 69 and 38
respectively. Line listing of severe anaemic women has been initiated at subcentre level. High risk pregnancies are
identified and referred to the DH Mavelikara.
Page 8 of 20

BP apparatus, Stethoscope, needle cutter, emergency tray with emergency injections are available and functional.
There is no functional ILR, Deep freezer and semi auto analyser. There is functional autoclave but not in good
working condition. EDL is displayed in the pharmacy. Some kind of intolerance is felt among children when they
consume IFA tablet blue. IFA syrup with dispenser and zinc tablets are out of stock. Supply of sanitary napkins is not
in the CHC, PHC or in the subcenters.
A good lab facility is available in the CHC except the testing of CBC and RPR. Microscope, Hemoglobinometer,
centrifuge, reagents and testing kits are available and functional in the laboratory. Leptospirosis and Dengue fever,
Platelets testing are conducted in the CHC if needed. Only one staff in the lab and daily 150 -200 patients tests
referred from the OP are made. So there is shortage of staff. 70 Patients were there in the IPD last month. She is able
to handle the IP cases only.
The necessary registers like OPD, IPD, ANC, Indoor bed head ticket, Family Planning, Immunization etc are
available and correctly filled in the facility. A separate register is not kept for microplan for immunization.
Gaps identified
Supply of drugs for smooth functioning of projects from the KMSCL is problematic. Only 50 percent of
demand is met and that too quite late after request. So the facility is forced to manage the drug supply so as
to run the NCD clinics by using the HMC funds.

AYUSH services are not offered in any of the selected facilities

Chettikulangara PHC OPD attendance during April-June is 7552 and that of July-September is 9186. There is no
IP facility in the centre. Neither a maternal death nor a neonatal death was reported in two quarters. OPD register
ANC register PNC register, equipment register, stock register and sub stock register is being maintained. JSY
payments are made at delivery points. So no separate register is kept for JSY payments.
One infant death was reported at the centre. Number of VHND meeting during six months is 11. Service delivery
data submitted for MCTs updation is 12 each in the two quarters.
Nadakavu SC - Haemoglobinometer or any other hemoglobin estimation are not available. Available and functional
equipments at the centre are Blood sugar testing kits, BP instrument and stethoscope and adult weighing machine
and infant weighing machine is not functioning. Needle and Hub cutter is available and functional. IFA tablets,
Vitamin A syrup and ORS packets are the only drugs available at the centre. There was no stock of IFA tablets up to
last week. Not only supply of IFA tablets is a big problem, but the quality of them keeps the beneficiary away from
consuming it. Beneficiaries consume IFA tablets from private hospitals or medical stores. JPHN are still entering
data of consumption of IFA tablets in the HMIS portal even if there is no supply from the centre. Pregnancy testing
kits and EC pills are available but OCPS or sanitary napkins are not available in the centre. IFA for adolescent girls is
not in stock.

8
8.1

Maternal health
ANC and PNC

Page 9 of 20

District Hospital Mavelikara - ANC1 registration in the two quarters April-June and July to September is about 55
and 60 respectively. The ANC3 coverage is 40 in Q1 and 42 in Q2 and the corresponding ANC4 coverage is 41 and
34 respectively. No severely anaemic cases were found among pregnant women, but 86 pregnant women with
hypertension were detected at the institution in the first quarter of the financial year 2013-14.The IFA tablets for
pregnant women were out of stock. With regard to PNC services, women are compulsorily asked to stay back 48
hours after delivery
Kurathicad CHC As per the data available from the MCH registers the number of ANC1 registration during Q1 is
84 and Q2 is 90. The ANC3 registrations are 75 and 66 respectively in the two quarters. The ANC4 registrations are
62 and 54 respectively in the two quarters. Women were given IFA tablets are 76 in Q1 and 69 during Q2
Chettikulangara PHC Number of estimated pregnancies in last two quarters is 99 each. MCTs entry on
percentage of women registered in the first trimester is 77 and 79 respectively in the two quarters. IFA tablets were
given to 100 and 106 pregnant women in the respective quarters. First trimester registration of ANC in quarter 1 is
100 and that of quarter 2 is 108. ANC3 coverage in first quarter is 92 and that of second quarter is 101. ANC4
coverage is not counted. IUD insertions are doing in the PHC.
Nadakavu SC - Number of estimated pregnancies in last year is 24. First trimester registration of ANC in quarter 1
is 12 and that of quarter 2 is 12 ANC3 coverage in first quarter is 12 and that of second quarter is 6. ANC4 coverage
is 12 and 5 respectively. There is a register for VHND plan and is updated. EC register, MCH register and stock
register are updated. Due lists are not maintained. There is no line listing of severe anaemia cases as there is no case.
List of families with 0-6 years children are available. JPHN has awareness on referral PHC and FRU. Since medical
officers are doing IUD insertions, JPHN has no knowledge on inserting it. She correctly knows administration of
vaccines, provides guidance or support for breast feeding, identifies signs of Pneumonia and dehydration, She has no
knowledge on IMEP protocols or functionality of AVD system.

8.2 Institutional deliveries

District Hospital Mavelikara - It is a delivery point with 158 deliveries in the first quarter and 207 deliveries in the
second quarter. Out of which, 86 were C- section deliveries in the first quarter and 129 in the second quarter. The
proportion of C-section to total deliveries in this hospital is higher compared to the proportion in the district when
HMIS data is analysed (56 to 60 percent in the facility as against 50 percent and less in the district). Ten obstetric
complications managed in the first quarter and 15 in the second quarter. 194 cases of RTI/STI treated in the first
quarter and the same cases treated are 208 in the second quarter.
Kurathicad CHC No delivery facility
Chettikulangara PHC - No delivery facility
Nadakavu SC No delivery facility
8.3 Maternal death Review
District Hospital Mavelikara- No Maternal death has been reported during the past year. The MO is well aware of
the maternal death review and the guidelines to be followed in case of a maternal death.
8.4 JSSK
District Hospital Mavelikara According to the Medical Superintendent of the hospital, under JSSK, free
entitlements are provided to the beneficiaries. Free and cashless delivery , free C-section, free drugs and
Page 10 of 20

consumables, free diagnostics through tie up with private clinics, free diet during stay at the hospital through
outsourcing to Kudumbasree and free provision of blood through out sourcing are provided. As referral transport Rs.
500/- is paid to women. So the system of recording referral transport is restricted to recording of payments made.
Mavelikara District Hospital hospital has a system to monitor the activities under JSSK. Patient feed back survey is
carried out. IEC activities are reported to be organized. 108 Ambulance is at present available but managing
emergency cases is difficult. So a strong demand for an Ambulance has been reported. With implementation of
JSSK, the number of deliveries does not appear to have increased. Once the woman reaches the hospital all the
services are free.
Findings of exit interviews - JSSK
In general JSSK beneficiaries are educated to 10-12 years and majority of them come from BPL families. They come
to hospital for delivery by auto or car. They receive Rs. 500/- after delivery for transport. Food is available for all
beneficiaries and they are satisfactory in quantity and quality of the food. Food for three days is available for normal
delivery. But we met women who was awaiting her PPS and staying in the hospital without food. There is a
tendency for shifting delivery from private hospital to government hospital especially in case of caesarean section,
since cost of CS is very large at private hospital. Women in Kerala prefer to take extra care during pregnancy and
delivery. So they go for private hospitals or do private consultations. Out of pocket expenditure of the women is
mainly due to these private consultations. Lab tests and diagnostic tests at the time of private consultations cost a
high expenditure for these women. One scan costs Rs.400 and women do scanning at least two times in their
pregnancy period. Lab tests costs around Rs. 2000 for some women.
Gaps
No Help Desk has been set up under JSSK. So during the beneficiary interviews we could identify a woman
who missed her privilege of free diet.
The hospital is yet to display contact details and set up grievance redressal mechanism
Out of Pocket expenditure were found when the JSSK beneficiaries were interviewed. It occurred at the time
of ANC as the women did her scanning outside the hospital as per doctors advice.
Corrective actions suggested by the team
Informed the Medical Superintendent about setting up a Help Desk and monitoring the activities so that all
the services are properly monitored and no woman misses her right to avail free services under JSSK.
So we recommended the Medical Superintendent to advise the gynaecologists to ask the patients to do all
diagnostic tests in the hospital itself although we cannot stop private consultation as it is the right of the
patients to take an extra care during their pregnancy and delivery period.

8.5

JSY

Page 11 of 20

District Hospital Mavelikara JSY payments are usually made before discharge and payments are made by cheque.
Since all women stay back for 2 days after delivery, JSY payments are also processed within the time they stay at the
hospital. Still there are women who have not received their payments.
Kurathicad CHC - JSY Register is maintained and updated up to 23/11/2012. Pending payments have been reported
as women delay in collecting their money
Chettikulangara PHC JSY register is maintained and updated. JSY payments are made at the delivery points and
incentives to the concerned ASHAs are only given from this centre.
Nadakavu SC - JSY payments are made at the delivery points and 7 women were registered.

Child health

9.1 SNCU
District Hospital Mavelikara SNCU is being set up. All the equipments have been received.
Kurathicad CHC Not a delivery point
Chettikulangara PHC Not a delivery point

9.2 NRCs
No separate Nutrition Rehabilitation Centre is present in any of the facilities visited or any other facility selected

9.3 Immunization
District Hospital Mavelikara The facility has carried out immunization sections in two days in a week (each Wednesday and Friday). 1065 and
1014 immunizations were made during the first and second quarter respectively. No vehicle service to carry out
vaccine is available. Facility has adequate supply of alternate vaccine. The ORS + Zinc and Vitamin A are out of
Stock.
Kurathicad CHC There is no good room for immunization, staff room is insufficient and the immunization is also
given at this room. - A total of 431 children are fully immunized in the first quarter and it is 442 in the last quarter.
220 children are given Vitamin A in the first quarter and it is 1068 in the last quarter. No maternal, neonatal, still
births are reported in the area of the facility in the last two quarters. Two infant deaths are reported in the area of
facility during the last two quarters.
Chettikulangara PHC Number of children fully immunized and measles coverage is 71 in the 1 st quarter and 87
in the 2nd quarter. Vitamin A was given to 554 and 413 and ORS was given 12 and 15.
Nadakavu SC - Immunizations are taking on PHC and the sub centre has no facility for stocking of vaccine. The
JPHN knows how to administer vaccines, provide guidance or support for breast feeding, able to identify signs of
Pneumonia and dehydration. JPHN has no knowledge on IMEP protocols or functionality of AVD system. Number
of children fully immunized and measles coverage is 5 in the 1 st quarter and 10 in the 2nd quarter. Vitamin A was
given to 25 and 10 in the respective quarters and ORS was given to 3 and 5 children. IFA syrup was given to 70
children in 1st quarter and no stock in the second quarter.

Page 12 of 20

9.4 RBSK
RBSK known as Arogyakiranam in Kerala has been inaugurated only during October 2013. Arogyakiranam or
RBSK staff training has started.

10 Family planning
District Hospital Mavelikara - In this financial year there is no supply of OCPS, ECPills and Condoms. All other
Family Planning services are provided from this facility. About 41 MTP cases of first trimester were conducted in the
facility during the last two quarters. Counseling and follow up were given to eligible women by Medical Officer,LHI
and JPHNS.BCC/IEC activities to high light the benefits of FP especially spacing methods were developed by the
facility.
Kurathicad CHC - . IFA tablets are given to women. In the first quarter 76 pregnant women received IFA tablets
and it is 69 for the second quarter. 14 and 6 IUD insertions have been reported. In the first and second quarters 17
and 15 tubectomies have been reported respectively. No vasectomy is conducted in the facility. The staff in the
facility is able to correctly insert IUCD and able to administer vaccines.
Chettikulangara PHC IFA tablets, Vitamin A syrup and ORS packets are the only drugs available at the centre.
There was no stock of IFA tablets upto last week of the monitoring period. Number of IUD insertions is 15 in the
first quarter and 14 in the 2nd quarter. No of women who accepted post partum FP services is 23 and 25. Wednesday
is the immunization day and cold chain equipment is functional and trained paramedical staff is available for handle
cold chain equipment. Through school health programme, IFA tablets are supplying. IUCD is achieved only at 39
percent. Lab services, X-ray services and scan services are items in which the patients are charged fees which lead
to high load to high out of pocket expenses at ANC period because majority are doing these items in private
facilities.
Nadakavu SC - IUD insertions are being done in the PHC. Medical officers are doing IUD insertions, JPHN has no
knowledge on inserting IUDs. Number of IUD insertions from the area is only 1in the first quarter and 3 in the 2 nd
quarter.

11 ARSH
District Hospital Mavelikara -This hospital has not established a separate ARSH clinic. It manages only those
cases that come in the OP wing. Also through outreach programmes, counseling service is offered.
Kurathicad CHC - No separate ARSH clinic. School health programmes are conducted at anganwadi and schools.
Two JPHNs for school health are posted in the CHC
Chettikulangara PHC - No separate ARSH clinic

12 Quality in health services

12.1 Infection Control
District Hospital Mavelikara Sanitary rounds are held weekly. The Medical Superintendent reports that
maintaining and cleaning the old buildings is a herculean task. Head Nurse is in charge of general cleanliness of

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wards and Theatres. The floor and the periphery are cleaned frequently. To reduce infection, fumigation is done and
autoclaves are functional. There is no laundry and clothes are washed by dhobis.
Kurathicad CHC Cleaning is done twice a week. All equipments are sterilized. Through source reduction
techniques adopted frequently by the health volunteers, JPHN and JHI, infection is controlled. No fumigation is
done and autoclave not used. Area concentrated survey conducted for identification of dengue fever.
Chettikulangara PHC Autoclave machine or fumigation or any other measure of infection control is not adopted.
One Part time sweeper is available for cleaning.

12.2 Biomedical Waste Management

District Hospital Mavelikara - The staff knows the importance of segregation of waste in colour code bins and so
they segregate it. The whole biomedical waste is given to IMAGE and waste management is in adherence to IMEP
protocols. Incineration mechanism for waste management is not available in the facility.
Kurathicad CHC - IMEP protocols are not followed here and waste is not segregated in colour coded bins.
Chettikulangara PHC IMEP protocols are not followed here and waste is not segregated in colour coded bins.
Nadakavu SC - Waste is disposed in PHC.

12.3 IEC
District Hospital, Mavelikara - IEC Display on various services at the facility is satisfactory. Timings of health
facility, services available, EDL, JSSK entitlements, Immunization schedule, JSY entitlements and essential contact
details are displayed. Citizens charter and Protocol posters were not to be seen anywhere. But at the community
level it needs to be improved with more display of JSSK and JSY entitlements
Kurathicad CHC
- A citizen charter is available in the facility. Timing of the facility and list of services are also shown along with
that. The availability of specialized doctors in the OP days are not shown anywhere in the facility. Protocol posters,
JSSK entitlements, JSY entitlements are not shown. Immunization schedule is shown in the facility. Regular
fumigation, drug storage facilities are adequate. Laundry/washing services, dietary services, equipment maintenance
and repair mechanism, grievance redressal mechanisms are not available in the facility. Tally is not implemented for
accounting purposes.
Chettikulangara PHC The approach road has just one sign board showing direction to the facility. Citizens
charter is displayed. Timings of facility is displayed but services available could not be seen anywhere. EDL is not
displayed. Few JSSK banners and JSY entitlements are displayed but it needs to be reworked. Immunization
schedule could be seen in the PHC
Nadakavu SC - Since there is no space, there is no IEC displays except on timings of sub centre. .No complaint box
is available.

13 Clinical Establishment Act

PIP approval status for CEA implementation, Any issues

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14 Referral transport and MMUs

District Hospital Mavelikara Ambulance Service is available in the hospital. Since the Ambulance 108 under
NRHM is in service only in 2 districts Alappuzha and Thiruvananthapuram, DH Mavelikara has service of 108
available.
Kurathicad CHC - There is no facility for travelling assistance for referral linkages. One woman was transported
from home to the facility during last quarter and other government vehicles are being used in certain situations for
travelling.
Chettikulangara PHC No referral transport is available here
Nadakavu SC - Referral linkages are not available in the Sub centre. Community processes

15 Community Processes
15.1 ASHA
District Hospital Mavelikara There are 20 ASHAs working in the area. Since it is a municipality area there is
deficit in number of ASHAs. Asha drug kits are available and regularly replenished and ASHA payments are made
regularly.
Kurathicad CHC - ASHAs required and sanctioned is 36, out of which 34 are presently in service. No inadequacy
has been reported.
Chettikulangara PHC Number of ASHA required is 40 but 32 is available.
Nadakavu SC - Nadakavu SC - Number of ASHAs working in the sub centre is 6.

15.2 Skill development

District Hospital Mavelikara - All ASHAs have received trainings modules
Kurathicad CHC - All ASHAs are trained upto 7 th module. They attend meeting every month. WHNDs are
organized with ASHAs help.
Chettikulangara PHC All ASHAs got training in 6th module. HMIS and MCTS data are updated.

15.3 Functionality of the ASHAs

District Hospital Mavelikara ASHAs are regular in their duties.
Kurathicad CHC - There is a general complaint that ASHA payment is quite low. All ASHAs are regular in their
duties except a few.
Chettikulangara PHC Number of ASHA required is 40 but 32 is available. They got training in 6th module. HMIS
and MCTS data are updated.
Nadakavu SC - JPHN and ASHA work together in ANC care, immunization, source deduction, filed visits etc.
Since a majority of the children are taking their immunization in private hospitals, ASHA are not getting their
incentives.

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16 Disease control programmes

16.1 Malaria
District Hospital Mavelikara - In this area 2 cases of Malaria identified this financial year.JHI handle the above
cases .Rapid Malaria test is available and sufficient drug for Malaria.
Kurathicad CHC - No cases of malaria were reported. Facility has drugs for treatment
Chettikulangara PHC No malaria cases and 3 dengue cases and 6 chicken pox cases are in the last quarter

16.2 TB
District Hospital Mavelikara - TB not treated in this facility
Kurathicad CHC About 8 and 6 cases of TB were reported duringQ1 and Q2 respectively. There is a TB Cell in Mavelikara and cases
are referred as per need. Sufficient drugs for TB are available. No separate staff for managing TB but JHI and JPHN
manage DOTS. .
Chettikulangara PHC TB cases treated in quarter 1is 7, quarter 2 is 6, No separate staff is available for TB cases.
Sufficient drug is available .
16.3 Other Communicable Disease
NLEP

District Hospital Mavelikara NLEP not treated

Kurathicad CHC - No Leprosy cases

17 Non Communicable Diseases

District Hospital Mavelikara - There is no NCD clinic in the facility because the hospital located in the
municipality area.
Kurathicad CHC - NCD clinic is functioning in a good manner. One doctor, one dietician, one data entry operator
and two staff nurses are in the NCD clinic. Diabetes and Hypertension are identified more. Number of persons screed
in the NCD clinic are 5368 during Q1 and 11142 during Q2. 60 cases of diabetes in Qi, 136 during Q2 have been
identified. High BP hve been identified among 76 patients (Q1) and 73 patients(Q2). Cardio Vascular problems are
referred to higher facility. As per the diagnosis, dietician suggests food to be taken and those to be avoided. Health
education classes are organized,
Chettikulangara PHC No separate register is not maintaining for non-communicable diseases. PHC is running
NCD clinics. Sufficient strips for testing sugar level in glucometer are not available and insulin is also in shortage.

18 Good Practices and Innovations

District Hospital Mavelikara
Out Patient wing functions well. Delivery service offered is good with JSSK entitlements. 24 hour casuality
is well accepted by people. Outreach activity is also well accepted.

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 Palliative care project is running successfully. Monthly 40 cases are managed through 8-10 visits. One
Nurse under regular and NRHM each are dedicated to the service. Mostly stroke patients, malignancy cases,
are attended.
Kurathicad CHC Palliative Care is one good program done by the facility. There is one trained Staff Nurse dedicated for
providing palliative care. Santhvanam Vehicle is being rented for palliative care. Weekly 2 visits are made.
There is good support from the community. The Medical officer also accompanies in case of need.
Weekly meetings are held in the CHC to identify problems in the community especially if there is any
communicable disease reporting.
Source reduction activities are organized to tackle spread of communicable diseases.
NCD services are provided quite satisfactorily.
Chettikulangara PHC According to the Medical Officer of the centre, managing the staff for doing their work and
improving their efficiency is the first step to resolve common programmatic issues. This manpower management was
done by self assessment of the staff and corrected their faults through discussions. Centre constructed a waiting shed
and seating arrangements and arranged a token system for the patients. Timings are made for Palliative care and
home visits to care for the disabled and bed ridden patients have been planned.

19 HMIS and MCTS

District Hospital Mavelikara - Medical record librarian prepares the data manually and report is sent to DMO and
DHS monthly. All details including OP, IP, OT, RTI STI, NSV, CD, NCD and deaths, animal bites and snake bites,
etc. are collected and sent to DHS and DMO monthly
Kurathicad CHC The JPHNs are given charge of uploading data in HMIS and tracking mothers in MCTS. The uploaded data are
complete. LHI verifies the data before uploading. Updation of dat in MCTS is not complete. Lack of computer
hinders HMIS and MCTS data uploading. JPHNs requested for a computer. One complaint from the JPHNs is when
JPHN under NRHM covers one ward, the regular JPHNs have to cover 2 wards apart from other numerous
responsibilities.
Chettikulangara PHC The JPHNs are given charge of uploading data in HMIS and tracking mothers in MCTS.
No due list and work plan for MCTS
Nadakavu SC - No due list and work plan for MCTS. She contacts all women through her own mobile phone.

20 Untied Fund and AMG

District Hospital Mavelikara
HMC fund for 2013-14 was received in August 2013 but not utilised but the record has been updated.

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Kurathicad CHC - A sum of Rs 50000 was received as Untied fund for the CHC on 3/9/2013. Now PRO has taken
charge and he will be managing the fund utilization and record maintenance correctly. AMG fund has not been
received. WHSC fund (RS 10000 each for 19 wards) has been fully utilized. All registers are available, updated and
filled correctly.
Chettikulangara PHC A sum of Rs 25000 was received as Untied fund for the PHC for this financial year.AMG
has not been received. Rs. 100000 has been received as Hospital management fund (RKS). Rs. 80000 has been
received as sub centre fund for the PHC. A separate utilization record for each fund is not maintained in the PHC. All
expenses are met from the same fund without any specific criterion. Nearly 68 percent of the total fund has been
utilized in this financial year.
Nadakavu SC - Untied funds expenditure is updated till 23.5.2013. Since there was no JPHN for three months and
new JPHN took her charge in August. Untied fund is not spending due to non transfer of account from old JPHN to
new JPHN. Annual Maintenance grant is not receiving as SC is functioning in rented building.

21 Supervisory Visits
District Hospital Mavelikara - DMO visit has been recorded on 11th January 2013. The epidemiologist visited the
hospital on 20th Febuary 2013. Junior Medical Officer from DMO Office visited on 22 nd February and 19th June
2013.
Kurathicad CHC - A doctor from Family planning, Government of India visited the facility for supervision.
Deputy DMO DPM, RCH Officer and Mass Media MCH Officer visited the CHC in connection with the Mass NCD
Screening programme on 4th October 2013.
Nadakavu SC - In June DPHN officer and LHS, are visited the sub centre. LHI and HI are visiting once in a month.
MO officer is visiting the subcentre once in a month

22 Household Visits
Nadakkavu Sub Centre area, Mavelikara
Knowledge and awareness among mothers with 0-6 years children
Awareness on breastfeeding initiation within an hour after birth is universal in the area of Nadakkavu sub centre.
Such awareness is gathered through the respondents parents and grandparents. Only 37 percent of the mothers
initiated breastfeeding within an hour of birth. The rest of the women delivered through C-section and initiation of
breastfeeding delayed due to that. Universal knowledge exists on exclusive breastfeeding for six months and
continued breastfeeding till two years among the mothers. Among the interviewed women, 75 percent continued
breastfeeding after 2 years of delivery. General awareness exists about the initiation of complementary feeding
practices after six months of age to the child. Almost every woman initiated CF to the child around six months of
age. Entire women are aware of the initiation of ORS + Zinc whenever it seem to be necessary and about the danger
signs of diseases and whom to approach on recognizing the danger signs. Three forth of women know about the
availability of ORS + Zinc with ASHAs. Infants are treated as precious and are taken to the medical doctors even
with minute signs of diseases.
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Pregnant women
Nadakkavu SC area, Mavelikkara
MCP card is regularly filled up in the area of Nadakkavu sub centre. The quality and regularity of ANC is adequate.
They are aware of the birth preparedness and JSY but not about JSSK. Only 30 percent of pregnant women are aware
about JSSK programme and most of them gathered sufficient information from the health facility. Nearly 30 percent
of the women got safe motherhood booklet and have the telephone number of call center for referral transport. Entire
women have good contact with ASHAs and keep the telephone numbers of ASHAs or JPHNs. These women have a
vague idea about high risk pregnancies and 60 percent of them answered that they got guidance along with birth
preparedness but not about referral transport facilities in case of high risk pregnancy. Low quality care is pointed by
these women for not opting government facilities for delivery services. Two women re-opted private facility after
taking initial ANC care from the government facilities.

23 Key Conclusions and Recommendations

The present report is based on monthly monitoring activities initiated by Ministry of Health and Family Welfare,
Government of India. Alappuzha district forms the area of present study. The health facilities selected in Alappuzha
district are District Hospital Alappuzha, Kurathicad CHC, Chettikulangara PHC, and Nadakkavu SC.
Strengths
Good quality care is provided to the people under all the institution selected for monitoring.
Palliative Care is one good initiative at the PHC and CHC level
NCD clinics are functioning well and services are provided quite satisfactorily in all the facilities with NCD
clinics.
DH Mavelikara, an upgraded hospital offers good quality services especially maternal and child care

Weakness and Recommendations

With the upgradation of THQH to DH Mavalikara, the public demand for services have increased but the
hospital lacks both infrastructure and human resources to function as a District Hospital. So shortage of staff
and infrastructure need to be addressed. support.
The JPHNs who are given multiple responsibilities, find it difficult to cater to the needs of the people in the
municipality area So posting of JPHNs as per required number has to be given priority.
Difficulty in getting medicines in time and as per demand from the KMSCL. So the hospital manages with
HMC fund. Delay in time between demand and supply is the main reason. This issue has to be taken care of.
Mainstreaming AYUSH has to be considered

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 Under JSSK free and cashless normal and C-section delivery, free drugs and consumables, diagnostics
through tie up with private clinics, diet during stay at the hospital are provided . But Help Desk has to be set
up under JSSK to ensure free service to all so that the finding from exit interview which identified that some
women miss these services does not happen again. The hospital is yet to display contact details and set up
grievance redressal mechanism
Out of Pocket expenditure found from exit interviews of JSSK beneficiaries at the time of ANC during
private practice has to be eliminated. Proper sensitization at community level should solve the problem.
No separate Nutrition Rehabilitation Centre is present in any of the facilities visited or any other facility
selected
In PHC, Lab services, X-ray services and scan services are items in which the patients are charged fees which
lead to high load to high out of pocket expenses at ANC period because majority are doing these items in
private facilities.
ARSH clinics should be set up.
IEC activities w.r.t JSSK need to be stepped up as many women are ignorant about the JSSK entitlements.
Biomedical waste management should be as per the guidelines in the CHC, PHC and SC

24 Annexure
Performance Indicators 2013-14 April - September
Indicators
Alappuzha District
Percentage of First trimester ANC to total ANC
78.5
Percentage JSY registration to total ANC
68
Percentage women given 100 IFA tablets to total
registrations
84.2
Percentage of deliveries in Public hospitals to total
Institutional deliveries
52.5
Percentage of deliveries in Private hospitals to total
Institutional deliveries
47.4
Percentage of C-Section deliveries in Public hospitals
to total Institutional deliveries in Public hospitals
46.9
Percentage of C-section deliveries in Private hospitals
to total Institutional deliveries in private hospitals
53.2
Sex Ratio of live births
918
Source: HMIS 2013-14

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