Rapid Appraisal of National Rural Health Mission

District: Gadchiroli
Maharashtra

R. Nagarajan
PRC, Pune

Population Research Centre Ministry of Health & Family Welfare

Gokhale Institute of Politics & Economics (Government of India)
(Deemed to be a University) Nirman Bhavan
Pune – 4111 004 New Delhi – 110 001
September 2009
 Contents

Chapter Title Page

Chapter 1 Background for Rapid Appraisal, State Profile and Study Design 1

Chapter 2 District Profile and Key Findings of the Study 11

Chapter 3 Community Health Centre 30

Chapter 4 Primary Health Centre 43

Chapter 5 Sub Centre 61

Chapter 6 Household Survey 80

Chapter 7 Status and Performance of ASHA 109

Chapter 8 Role, Awareness and Involvement of Gram Panchayat 110

Chapter 9 Quality of Care and Client Satisfaction – IPD Exit Interview 113

Chapter 10 Quality of Care and Client Satisfaction – OPD Exit Interview 126

Appendix-1 State Schedule 138

Appendix-2 District Schedule 142

Appendix-3 Standard of Living Index 161

ii
 Acknowledgements

The study could be carried out successfully only with the help of many individuals. I
take this opportunity to express my gratitude towards them. I am thankful to the Ministry of
Health and Family Welfare, Government of India for assigning this study to the PRC, GIPE.
We are grateful to the authorities of the MOHFW, particularly to Dr. Ratan Chand (Chief
Director, Statistics), Shri Ravi Srivastava (Director, Statistics) and Shri Rajesh Bhatia (Joint
Director, Statistics), for their help and input they provided at various stages of the study.

I am grateful to Professor Rajas Parchure (Offg. Director, GIPE) and Professor Arup
Maharatna (the then Offg. Director, GIPE) and for their valuable support to carry out this
study. I am thankful to the staff of the PRC, Shri Arun Pisal, Shri R.S. Pol and Shri A.P.
Prashik, for managing entire fieldwork, data collection in health facilities and assisting me
throughout to complete the report for the study. I take this opportunity to express my
gratitude to our tabulation staff Smt. Vandana Shivnekar and Smt. Anjali Kale for the help
they provided in data entry, tabulation and computer processing of tables. I am also thankful
to our administrative and accounts staff for their help to carry out the study smoothly.

I would like to thank specially, Shri P.S. Narwade, the District Programme Manager,
NRHM, Gadchiroli for his excellent help and cooperation to carry out the fieldwork in the
district. I also express my gratitude to the officials of the District Hospital, Gadchiroli and of
the selected Community Health Centres and Primary Health Centres and the staff of the Sub
Centres for helping us with providing data on health facilities and supporting us to carry out
the household survey.

We cannot proceed further without acknowledging the sincere efforts of our 16

female field investigators who carried out the difficult job of taking interviews of respondents
in naxalite infested district of Gadchiroli. Last but not least, credit goes to those respondents
who patiently answered to the long questionnaire without any expectation of any kind.

R. Nagarajan
September 2009 Population Research Centre
Gokhale Institute, Pune

iii
 List of Tables

Table Title of the Table Page

The sampling design for the selection of health facilities/households/
1 6
respondents for the rapid appraisal of NRHM
2 Schedules canvassed for the study and survey period 7
List of selected District Hospital, CHCs, PHCs, SCs and Villages for
3 7
the survey in Gadchiroli District as per the sample design
C1 Coverage and availability of infrastructure 34
C2 Position of Medical Staff and Paramedical Staff 36
C3 Availability of specific services in CHC 37
C4 Status of specific interventions 37
C5 Status of residential facilities for Doctors and other staff 37
C6 Availability of laboratory facilities 37
C7 Number of Lab tests done in CHC in last 3 calendar months 38
C8 Number of surgeries performed during 2007-2008 38
C9 Reasons for not conducting surgeries 38
C10 Status of performance of Labour Room during 2007-2008 39
C11 Reasons for not conducting deliveries 39
C12 Status of availability of equipments and drugs 39
C13 Availability of specific services 41
C14 Service outcome (based on data for last three months) 42
P1 Coverage and facilities of Primary Health Centre 48
P2 Primary Health Centres by infrastructure 49
P3 Staff position in Primary Health Centre 50
P4 Status of training of personnel at Primary Health Centre 51
P5 Availability of Labour Room in Primary Health Centre 51
P6 Status of performance of Labour Room during 2007-2008 51
P7 Availability of Laboratory Testing in PHC 52
P8 Number of tests done in PHC in last three calendar months 52
P9 Status of specific interventions 53
P10 Availability of selected equipments in PHC 54
P11 Status of availability of drugs 55
P12A Service outcome (based on data for last three months) 56

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Table Title of the Table Page
P12B Service outcome (based on data for last three months) 57
P12C Service outcome (based on data for last three months) 58
P12D Service outcome (based on data for last three months) 59
P13 Status of record maintenance 60
S1 Sub Centres coverage 67
S2 Sub Centres infrastructure 68
Sub Centres with ANM staying with or away from SC village by
S3 69
distance from Sub Centre and reasons for not staying in Sub Centre
S4 Sub Centres with staff in position 69
S5 Availability of Labour Room in Sub Centre 70
S6A Number of deliveries performed during 2007-2008 70
S6B Sub-Centres with arrangement for deliveries between 8 PM to 8 AM 71
S7A Sub Centres with availability of equipments 71
Percentage of SCs with functional equipments (among the SCs
S7B 72
reported the availability of the equipment)
S8 Status of availability of drugs on the date of survey 73
S9 Status of specific skills and procedures 74
S10 Service outcome (based on data for last 3 months) 75
S11 Status of record maintenance 76
S12A Status of awareness of ANM about JSY scheme 77
S12B Status of procedure under JSY scheme 77
S13 Status of performance of ANM under JSY scheme 78
S14 Status of Untied Grants 79
H1 Characteristics of the respondents 92
H2 Characteristics of the household 92
Percent distribution of households by their waste disposal, stagnation
H3 of waste water and mosquito breeding around the house and system of 93
medicine preferred by them.
Percent distribution of household respondents by their information
H4 about availability of health worker, health facilities and transport used 94
to take serious patients
Percent distribution of household respondents by their knowledge
H5 95
about NRHM, ASHA and her activities, VHND, VHSC and JSY

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Table Title of the Table Page
Percent distribution of JSY beneficiaries by their background
H6 96
characteristics
H7 Timing, person and place of registration for JSY scheme 97
Receipt of JSY card, role of ASHA in getting JSY card and difficulties
H8 97
faced by the beneficiary in getting the JSY card
H9 Role of ASHA during the pregnancy of the beneficiaries 98
H10 Place of delivery and reason for opting institutional delivery 98
H11 Transport of the beneficiaries to reach the health institution 99
Waiting time at the health facility, type of delivery, amount spent at the
H12 health facility and satisfaction regarding services available in the health 100
facility.
Reason for the JSY beneficiary to opt home delivery, in spite of cash
H13 100
incentives being available under the JSY scheme
H14 Cash incentive received by the beneficiary under JSY scheme 101
H15 Utilization of government health facility in last 6 months 101
Characteristics of the respondents who have availed the services in
H16 102
government health facility in last 6 months
Type of health facility visited, purpose of visit and client satisfaction
H17 regarding behaviour of health worker, privacy and availability of 103
medicines
H18 User fees and extra charges 104
H19 Services for the BPL patients 104
Outbreak of selected diseases (Malaria, Measles, Gastroenteritis,
H20 105
Jaundice & Other Diseases) in the respondents’ area in last six months
Action to be taken for selected diseases (diarrhoea, high fever,
H21 persistent cough, loose motion, persistent cough and breathing 106
problems for a child)
H22 Awareness about spacing methods and ideal gap between 1st & 2nd child 107
Awareness about modes of getting AIDS, source of information about
H23 107
AIDS and awareness about VCTC
H24 Suggestions given by the respondents 108
A1 Status of Gram Panchayats covered 111
A2 Level of awareness and involvement of Gram Panchayats 112
EI-1 Background characteristics of the in-patients 119
EI-2 Purpose of admission in the Health Institution 119
EI-3 Waiting time 120

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Table Title of the Table Page
EI-4 Satisfaction regarding waiting time 120
EI-5 Behaviour of staff 121
EI-6 Unique/innovative measure taken to improve the staff behaviour 121
EI-7 Privacy 122
EI-8 Patient-Doctor/Provider Communication 122
EI-9 Cleanliness of the facility 123
EI-10 Satisfaction of patients regarding cleanliness of the facility 124
EI-11 Crowding in the facility 124
EI-12 Amenities provided by the hospital 125
EI-13 Continuity of treatment 125
EO-1 Background characteristics of the patients 130
EO-2 Purpose of visit to the health institution 130
EO-3 Average waiting time (in minutes) for services by type of facility 131
EO-4 Satisfaction regarding waiting time by type of hospital 132
EO-5 Behaviour of staff 133
EO-6 Privacy 133
EO-7 Patient-Doctor/Provider Communication 134
EO-8 Satisfaction of OPD patients regarding cleanliness of the facility 135
EO-9 Satisfaction of OPD patients regarding crowding in the facility 136
EO-10 Continuity of treatment 137

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 Chapter 1

Background for the Rapid Appraisal of NRHM, State Profile and

Study Design

I. Background for the Rapid Appraisal of NRHM

The Government of India, with the objective of meeting the basic requirement of
Health for all, has launched the National Rural Health Mission (NRHM) in April 2005 to
carry out necessary architectural correction in the basic health care delivery system. The
Mission aims at provision of comprehensive and integrated primary healthcare to the people,
especially to the rural poor, women and children. It adopts a synergic approach by relating
Health to determinants of good health viz nutrition, sanitation, hygiene and safe drinking
water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care.
The Plan of Action includes increasing public expenditure on health, reducing regional
imbalance in health infrastructure, pooling resources, integration of organizational structures,
optimization of health manpower, decentralization and district management of health
programmes, community participation and ownership of assets, induction of management
and financial personnel into district health system, and operationalising Community Health
Centres, Primary Health Centres and Sub Centres into functional hospitals meeting Indian
Public Health Standards.

The Mission lists a set of core strategies to meet its goals like decentralized village and
district level health planning and management, appointment of female Accredited Social
Health Activists (ASHAs) to facilitate access to health services. The Mission attempts a major
shift in the governance of public health by giving leadership to Panchayati Raj Institutions in
matters related to health at district and sub-district levels. Another key strategy of the Mission
is decentralization of programmes for district level management of health. Under the scheme,
all existing societies for Health and Family Welfare Programmes, Reproductive and Child
Health and National Programmes for TB, Malaria, Blindness, Filaria, Kala Azar, Iodine
Deficiency and Integrated Disease Surveillance, are integrated into a unified District Health
Mission. Funding for all these programmes is being funnelled into the District Health
Mission, which is empowered to formulate integrated health plan of the district. One of the
core strategies of the Mission is to empower local governments to manage, control and be
accountable for public health services at various levels. The Village Health and Sanitation
Committee, the Standing Committee of the Gram Panchayat, provides oversight of Mission’s

1
all activities at the village level and responsible for developing the Village Health Plan with the
support of the ANM, ASHA, Anganwadi Worker and Self-Help Groups. Block level
Panchayat Samitis co-ordinates the work of the Gram Panchayats in their jurisdiction and
serve as a link to the District Health Mission, which is led by Zilla Parishad and controls,
guides and manages all public health institutions in the district. States are being encouraged to
devolve greater powers and funds to Panchayati Raj Institutions.

Rapid Appraisal of NRHM

In light of the above background and also the fact as the Mission is now in its fourth
year of existence, the Ministry of Health and Family Welfare, Government of India has
undertaken this Rapid Appraisal of the Mission at the state, district and local level through its
18 Population Research Centres (PRC) in 20 states of India. Given the wide scope of the
Mission and diverse nature of its activities, the PRC study on rapid appraisal is restricted to
selected core components that directly address the health and family welfare needs of the
people. It is therefore this rapid appraisal is restricted to the following four core components
of the Mission:
(A) Utilization of Untied Funds at SC, PHC and CHCs
(B) Janani Suraksha Yojana (JSY)
(C) Facility up-gradation under the NRHM
(D) Assessment of health and family welfare situation at the village level

Objectives of the Rapid Appraisal of NRHM

(A) Utilization of Untied Funds
NRHM has drawn a plan of action at all levels of healthcare to build up sustainable
healthcare delivery system, where all citizens have access to affordable and appropriate quality
healthcare. To achieve its goals, NRHM in its strategies, set up a platform for involving the
Panchayati Raj Institutions (PRIs) in primary health programmes and infrastructure. The
Mission also envisages the following roles for PRIs: (i) States are required to commit for
devolution of funds, functionaries and programmes for health to PRIs; (ii) At grassroots level,
Village Health and Sanitation Committee (VHSC) has been formed to decentralize the
planning and monitoring of various programmes; and (iii) For strengthening the health
centres, all the health facilities are provided with Untied Funds.

Untied Funds can be used only for the common good and not for the individual needs,
except in the case of referral and transport in emergency situations. Each Sub Centre will
2
have an Untied Fund @ Rs. 10,000 per annum. Like wise, each PHC and CHC is provided
with Untied Funds of Rs. 25,000 and Rs. 50,000 respectively for local health action. At Sub
Centre level, the fund is deposited in a joint account of the ANM and the woman Sarpanch
or the woman member of Panchayat, but the account will be operated by ANM in
consultation with Village Health and Sanitation Committee and Multipurpose Health
Workers. At the PHC and CHC level, Untied Funds are kept in the bank account of the
concerned Rogi Kalyan Samiti (RKS)/Hospital Management Committee. The funds are spent
and monitored by RKS. This rapid appraisal study attempts to analyze the utilization of
Untied Funds at Sub Centre and PHC level. It will also help to know how actively
PRIs/RKS are involved with the utilization of Untied Funds in right perspective. The specific
objectives of the rapid appraisal under the utilisation of Untied Funds are:
1. To examine the utilization of Untied Funds under different activities at Sub
Centre, PHC and CHC level.
2. To highlight the problems faced by CHC and PHC In-charge and ANMs in
receiving and utilization of funds.
3. To seek the opinions of CHC and PHC In-charge and ANMs regarding the
sufficiency of funds.
4. To study the role of Village Health Committee particularly at Sub Centre level and
Rogi Kalyan Samiti in the utilization of funds at CHC and PHC level.

(B) Janani Suraksha Yojana (JSY)

Janani Suraksha Yojana (JSY), an integral component for safe motherhood under
NRHM, was launched in 2005 with the objective of reducing maternal and neo-natal
mortality. The scheme aims to promote institutional deliveries amongst poor pregnant
women in all the states and Union Territories (UTs) of the country with special focus on low
performing states (LPS). It is a 100 percent centrally sponsored scheme and links cash
assistance with delivery and post-delivery care. In availing institutional delivery services, the
client is usually escorted, would be requiring transport to reach the institution and in case of
complications, referral services would be required. The scheme has considered all these
elements and has made provision for transport including referral and escort and at the same
time invested in improving public health institutions and services through the Reproductive
and Child Health (RCH) Programme interventions. This apart, states have been given
flexibility to evolve public-private partnership (PPP) mechanism and accredit private health
institutions for providing institutional delivery services. The special dispensation for Low
Performing States (LPS) in both rural and urban areas has been made and linked to the
3
ASHA intervention. The LPS are those that have low institutional delivery rates and include
Uttar Pradesh, Uttaranchal, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam,
Rajasthan, Orissa, and Jammu and Kashmir. In the remaining states and UTs, categorized as
High Performing States (HPS), similar provisions have been made wherein Anganwadi
worker or traditional birth attendant or ASHA like activist could be engaged and associated
with the JSY scheme. The JSY focuses on:
(a) Maternal care through micro-planning of birth,
(b) Cash assistance to all eligible mothers for delivery care
(c) Cash assistance for referral transport
(d) Cash assistance to institutions for hiring specialists for Caesarean Section or for the
management of Obstetric complications
(e) Cash benefit to ASHA for facilitating institutional delivery

The specific objectives of the rapid appraisal under the JSY are:
1. To assess the role of ANM/ASHA in providing services to the beneficiaries of the
JSY.
2. To seek the opinions of ANMs/ASHAs regarding the sufficiency of funds and
timely disbursement of funds.
3. To study the role of other health officials in the implementation of the scheme at
district.
4. To review engagement of private sector including accreditation and compensation.
5. To highlight the problems faced by beneficiaries in receiving the services/funds.
6. Analyze nature and scope of IEC interventions for raising awareness of JSY.

(C) Facility Upgradation under NRHM

For meeting the health needs of the rural masses, one of the key strategies of the
NRHM is to strengthen all the health facilities by upgrading them with necessary
infrastructure according to the type of facility (CHC, PHC, SC etc). The main aim is to
strengthen hospital care for rural areas, provide specialized care to the community and also to
improve the standard of quality of care in order to enhance the level of patient satisfaction.
Thus, the rapid appraisal examines as to what extent the SC, PHCs and CHCs have been
upgraded under NRHM. The objectives of the study under this component are:
1. To assess the availability and adequacy of infrastructure, furniture, equipment,
medicines/drugs and vehicle in the upgraded sub centres, PHCs and CHCs.
2. To examine the availability of manpower - medical and paramedical.
4
 3. To assess the type of services and availability of facilities.
4. To assess the clients perception regarding quality of services through exit
interviews.

(D) Assessment of Health and Family Welfare Situation at the Village Level
It has been envisaged under NRHM that indicators of health depend as much on
drinking water, nutrition, sanitation, female literacy, women’s empowerment as they do on
functional health facilities. NRHM seeks to adopt a convergent approach for interventions
under the umbrella of the district plan which seeks to integrate all the related initiatives at the
village, block and district level. Wherever village committees have been effectively constituted
for drinking water, sanitation, ICDS etc., NHRM attempts to move towards one common
Village Health Committee covering all these activities. Panchayati Raj Institutions are being
fully involved in this convergent approach so that the gains of integrated action can be
reflected in district plans. Under NRHM, household surveys through ASHA, AWW will
target availability of drinking water, firewood, livelihood, sanitation and other issues in order
to allow a framework for effective convergent action in the Village Health Plans. Hence, one
of the important objectives of the rapid appraisal is to:

1. Assess the health and family welfare situation in the village in terms of availability
of drinking water, sanitation, functional health facilities, quality of services
provided, nutritional status, women’s empowerment, maternal and child health,
disease prevalence etc.

III. Methodology and Study Design

The rapid appraisal covers all tiers of the public health care delivery system right from
the village level up to the state level. For the sake of objectivity, the rapid appraisal exercise is
organised broadly in terms of policy formulation, programming and implementation for each
of the four components of the Mission listed above.

At the state level, the rapid appraisal exercise focuses primarily on policy formulation
with respect to the above listed four components. At the district and community health
centre level, the rapid appraisal exercise primarily focuses on programming necessary to
translate policy into specific action while at the primary health centre, sub-health centre and
village levels, the rapid appraisal exercise concentrates on the implementation aspects.

5
 A mix of quantitative and qualitative tools is used for the rapid appraisal. At the
village level, a household survey is carried out to assess the health and family welfare situation
as well as to assess the use of public health facilities by the community at large. At the
institution level, the rapid appraisal is based on review and analysis of the available records of
public health institutions and in-depth interviews with the policy makers, programme
managers and service providers at different tiers.

Eleven different schedules/questionnaires are used for the rapid appraisal (Table 2).
Each of these Schedules is further divided into a number of separate Blocks capturing
information on specific areas of interest. Information for one Schedule has been gathered
from a number of different individuals. In every Block, indication about the corresponding
respondent / source of information is given.

Table 1: The sampling design provided by the Ministry for the selection of health facilities /
households / respondents for the rapid appraisal of NRHM

Sl. Facility/ Total /

Selection Criteria Alternate criteria
No. Household district
District In States where the Male and Female DH are separate, SDH or District
1 1
Hospital schedule to be filled for both. HQ Hospital
One CHC to be the farthest from the district HQ. In case no CHC
If the first CHC selected is an FRU then the second is available, the
2 CHC 2
CHC could be any CHC; else the second CHC should largest Block /
preferably be an FRU, if available. Addl. PHC
2 PHCs for each CHC.
3 PHC 4 PHC to be vertically under selected CHC.
Preferably one 24x7, if available.
3 SCs for each PHC.
4 SC 12 All to be vertically under selected PHC.
One SC to be farthest from PHC.
2 villages to be selected from catchment area of SC (if
there is one village under the selected Sub Centre, the
same will be covered).
5 Household 1200 One village to be where Sub-Centre is located and
second village that is farthest from the Sub-Centre.
50 households per village to be randomly selected (total
100 households per SC).
All ASHAs in the selected village to be selected for
6 ASHA
canvassing ASHA Schedule.
Gram Panchayat (GP) Schedule to be canvassed to the
Gram
7 member of GP (including Sarpanch) representing the
Panchayats
selected village.
Patients Exit interview be canvassed for 5-10 IPD and OPD
8 for Exit patients at each of the facility including District Hospital,
Interview CHC and PHC.

6
Table 2: Schedules canvassed for the study and survey period
Schedule Survey Period
Schedule (S) : State Schedule February 2009
Schedule (D) : District Schedule Part A February 2009
Schedule (D) : District Schedule Part B – District Hospital February 2009
Schedule (C) : Community Health Centre Schedule January 2009
Schedule (P) : Primary Health Centre Schedule January & February 2009
Schedule (N) : Sub Centre /ANM Schedule January & February 2009
Schedule (A) : ASHA Schedule --
Schedule (G) : Gram Panchayat Schedule January & February 2009
Schedule (H) : Household Schedule January & February 2009
Schedule (EI) : Exit Interview Schedule for IPD Patients January & February 2009
Schedule (EI) : Exit Interview Schedule for OPD Patients January & February 2009

Health Facilities and the Villages Covered for the Study in Gadchiroli District
District Hospital, Gadchiroli was covered for the study. Two CHCs, 4 PHCs, 12 Sub
Centres and 24 villages were covered in the district as per the sampling design mentioned in
Table 1. The facilities and the villages covered in the district are given below in Table 3. For
household survey, two villages were selected from each selected Sub Centre area. Thus, 24
villages were selected for the household survey. Fifty households were selected from each of
the selected village by following the systematic circular random sampling procedure. For
selecting the households, the total number of households in a village was divided by 50 to
find out the selection interval. After that, the first household situated at the north-west corner
of the village was randomly selected and subsequently every rth household was selected
moving in an ‘anti-clock wise’ direction till 50 households were selected.

Table 3. List of selected District Hospital, CHCs, PHCs, SCs and Villages for the survey in
Gadchiroli District as per the sample design
District
District Civil Hospital: Gadchiroli
Hospital
2 CHCs CHC Dhanora (FRU) CHC Aheri (Farthest)
4 PHCs PHC Rangi (24*7) PHC Pendri (24*7) PHC Mahagaon PHC Kamalapur (24*7)
12 SCs 1. Sode (Farthest) 4. Gatta (Farthest) 1. Devalmari (Farthest) 4. Dhamarincha (Farthest)
2. Nimgaon 5. Chichoda 2. Yelchil 5. Kamalapur
3. Michgaon Bk. 6. Durgapur 3. Mahagaon 6. Guddigudam
24 1. Sode 1. Gatta 1. Devalmari 1. Dhamarincha
Villages 2. Pusavandi (Farthest) 2. Gotta (Farthest) 2. Kolpali (Farthest) 2. Rumalkasha (Farthest)

3. Nimgaon 3. Chichoda 3. Yelchil 3. Kamalapur

4. Bori (Farthest) 4. Markegaon (Farthest) 4. Madhyagudam (Farthest) 4. Khushalgudam (Farthest)

5. Michgaon Bk. 5. Durgapur 5. Mahagaon 5. Guddigudam

6. Gunjanwadi (Farthest) 6. Zadapapda (Farthest) 6. Vadalapath (Farthest) 6. Gola Karanji (Farthest)

7
Field Work
To carry out the study in the district, 16 experienced ad hoc female investigators were
recruited. These selected investigators have earlier worked for the DLHS-3 in Maharashtra
and familiar with the household survey methods. A two day training programme was
organised for them in the Family Welfare Training Centre in Jalgaon. The fieldwork for the
household survey in Gadchiroli district was carried out during the months of January and
February 2009. These 16 investigators were divided into 4 teams and each team was
supervised by one PRC staff. All the household interviews and exit interviews were carried
out by the female investigators and the Facility, Gram Panchayat and ASHA questionnaires
were administered by the PRC staff. During the entire duration of the fieldwork, PRC staffs
were with the field teams and continuously monitored the fieldwork.

Chapter Scheme
The present chapter provides (a) the background for the rapid appraisal of NRHM,
(b) methodology and sampling design for the study, and (c) the state level status of health
infrastructure, formation of RKS, performance under the JSY, and financial mechanism
including transfer of Untied Funds based on the State Schedule. The Chapter two has three
parts. The Part-I presents the current status of NRHM interventions (health infrastructure,
facilities available for delivery, human resources, RKS, JSY and financial mechanisms) in
Gadchiroli district. The Part-II provides the infrastructural facilities and human resources
available in the district hospital. The Part-III presents the key findings of the study. The third
and fourth chapters presents the information on: framework and structure related issues;
infrastructure status; human resources; availability of services, diagnostic facilities, equipments
and drugs; and service outcome statistics for the selected CHCs and PHCs in the district. The
fifth chapter presents the findings based on the Sub-Centre/ANM schedule. Specifically, it
presents the information on population coverage, human resources, infrastructure status,
availability of equipments and drugs, skills and practices of ANM, record maintenance,
functioning of JSY scheme, and utilization of Untied grants. Chapter six presents findings of
the household survey. The findings are presented for background characteristics of the
household, amenities available to the household, awareness of ASHA programme and JSY
Scheme, and feedback from the household about the kind of services availed from a public
health facility, quality of care provided and level of satisfaction from the services provided.
The seventh chapter explains the status of the ASHA scheduled canvassed in the district. The
eighth chapter presents the following information about the Gram Panchayat: population,
households and villages covered; IEC activities; functioning of VHSC, involvement in ASHA
8
programme and JSY scheme; and awareness about NRHM at Gram Panchayat level. Chapters
9 and 10 presents the findings of the exit interview of the IPD and OPD patients respectively
about the quality of services received in the district hospital, CHC and PHC.

II. Status of NRHM interventions at the State Level (based on the State Schedule)
This section presents the information based on the State Schedule colleted from the
State Programme Management Unit for NRHM. The information is presented for the state
level status of health infrastructure, formation of RKS, performance under the JSY, and
financial mechanism including transfer of Untied Funds. The duly filled-in State Schedule is
given in Appendix-1.

Population
Maharashtra with a population of 96.8 million in 2001 is the second most populous
state of India. As per 2001 census, forty-two percent of the total population of the state was
living in urban areas and the remaining 58 percent was residing in rural areas. The rural
population is residing in its 43,722 villages. Ten percent of Maharashtra’s population
belonged to scheduled castes and nine percent belonged to schedule tribes as per 2001
census.

Infrastructure (as on June 30, 2008)

Maharashtra has relatively better network of health services delivery system. The state
has a total of 10,579 SCs, 1,816 PHCs, 365 CHCs, 81 SDHs, and 23 district hospitals to
implement its public health programme at various levels. NRHM is implemented through
these health facilities. Out of the 1,816 PHCs, 397 (22 percent) are designated as 24*7 PHCs.
New buildings are under construction for 650 SCs and 137 PHCs in the state. In the state as a
whole, 446 health facilities are functioning as FRUs (CHC+SDH).

Under the NRHM, every state is required to upgrade their health facilities (PHCs and
CHCs) to the prescribed Indian Public Health Standards (IPHS). The IPHS have been
developed by the Ministry of Health and Family Welfare and circulated to all states. Number
of facilities where IPHS upgradation is completed in Maharashtra is 454 (4.3 percent) for SCs,
293 (16 percent) for PHCs, 106 for FRUs (41 percent), and 78 (100 percent) for CHCs.
Hence, at the lower levels of the health facilities (SCs and PHCs) the ubgradation is not
completed as per the IPHS.

9
Rogi Kalyan Samitis and PPPs
Except very few health facilities, RKSs are registered in all the DHs, SDHs, CHCs
and PHCs of the state. This indicates the state’s initiatives towards the implementation of the
NRHM. The state has also undertaken the Public-Private-Partnership initiative in a bigger
way to implement the JSY scheme by accrediting 1,448 private health facilities for the
implementation of JSY scheme.

Performance under the JSY

To assess the performance of the JSY by caste and APL/BPL categories in public and
private health facilities, the required data are not maintained by the State Programme
Management Unit (SPMU) as per the State Schedule format given by the Ministry. However,
the SPMU provided the total number of registered JSY woman during 2007-08 and number
of these women opted for institutional delivery during 2007-08 by caste. In the state as a
whole, 283,119 women were registered under the JSY and out of these 191,405 opted for
institutional delivery i.e., 40 percent. Among the women registered under the JSY, the
percentage of women opting for institutional delivery among the SCs and STs (42 percent and
44 percent respectively) is more than the General category women (36 percent).

Financial Mechanisms
The state has already merged all the vertical health societies created under different
programmes with the State Health Society under NRHM. All the districts have also merged
the registered health societies. State Health Society maintains a common bank account for all
the programmes. For the year 2008-09, the state has prepared the perspective State Health
Plan. All the 33 districts in the state have prepared the District Action Plans for the year
2008-09 and the District Action Plans have been approved by the State Health Society.

Funds are being allocated to the districts through flexi pool funds, based on size of
districts, and based on previous year’s expenditure. Out of 33 districts, for 32 districts the
funds are being transferred electronically. Out of the 10,579 SCs in the state, 10,535 (99.6
percent) have operational joint bank account of ANM and Sarpanch. Untied Grant for the
current year is transferred to all 446 CHCs and 1,816 PHCs and 10,535 SCs (out of 10579
SCs) in the state.

10
 Chapter 2
District Profile and Key Findings of the Study

I. District Schedule – Part A

Population: As per 2001 census, the total population of the district was 9.70 lakh and
constitutes one percent of the population of the state. Ninety percent of the population in the
district is residing in urban areas and the remaining 10 percent in rural areas. Out of the total
population of the district, 11.2 percent belong to Scheduled Caste and 38.3 percent belong to
Scheduled Tribe.

Infrastructure: The people of the district mainly depend on public health facilities for the
health services. The private health facilities are few in the district. The district has a total of
376 SCs, 45 PHCs, 9 CHCs, 3 SDHs and 1 District Hospital to implement the public health
programme at various levels. Out of the 45 PHCs, 23 (51 percent) are designated as 24*7
PHCs. Three health facilities are functioning as FRUs. The district also has one AYUSH
hospital. New buildings are under construction for 4 SCs in the district. The number of
facilities where IPHS facility survey completed in Gadchiroli is 23 SCs (6.1 percent), 11 PHCs
(24.4 percent), five CHCs (55.6 percent) and all the three SDHs. Number of facilities where
IPHS upgradation completed is 23 SCs (6 percent), 3 CHCs (33 percent), and 3 SDHs (100
percent). In DH, both the IPHS facility survey and upgradation as per IPHS are completed.
The district does not have any private hospitals which are more than 30 bedded. The district
has only one private Nursing Home which is less than 30 bedded. In the absence of private
health facilities, people of the district mainly depend on Government health facilities.

Human Resources: When we compare the ‘number of sanctioned posts’ with ‘total in
position’ among the Medial Officers’ category, we can see that the district is not doing well in
terms of human resource availability. Out of 249 sanctioned medical officers’ posts only 208
(84 percent) are in position. Further, among the general Medical Officers, 28 percent of them
are appointed on contractual position rather than on regular basis. However, among the
ANMS the ‘total in position’ (628) is more than the ‘number of sanctioned’ (421) posts in the
district. The district has appointed large number of ANMs on contractual basis.

11
Rogi Kalyan Samitis: The RKS is constituted in all the functioning health facilities (DH,
SDH, CHC, & PHC) of the district and all of them are registered. This indicates the district’s
initiatives and commitment towards the implementation of the NRHM.

PPP initiatives: The district has also undertaken the Public-Private-Partnership initiative in
to implement the JSY scheme by accrediting 5 private health facilities for the implementation
of JSY scheme. Providing transportation facility for delivery and referral cases are covered
under the PPP initiatives in the district.

Performance under the JSY: The performance of the JSY in the district by caste and
APL/BPL categories in public and private health facilities cannot be assessed as the required
data are not maintained by the District Programme Management Unit (DPMU) as per the
District Schedule format given by the Ministry.

Financial Mechanisms: The district has already merged all the vertical health societies
created under different programmes with the District Health Society under NRHM. The
merged District Health Society is also already registered. The District Health Society
maintains a common bank account for all the programmes. For the year 2008-09, the district
has prepared the District Action Plan and the same has been approved by the District Health
Society. The districts receives the funds from the state based on (i) activity wise, (ii) flexi pool,
(iii) previous year’s expenditure, and (iv) Annual Action Plan. The district receives the funds
through electronic transfer from the state office. Almost all the Sub Centres (374 out of 376)
in the district have operational joint bank account of ANM and Sarpanch and the Untied
Grant was transferred to all these Sub Centres. Untied Funds for the current year was
transferred to all the CHCs, PHCs and SCs in the district.

II. District Schedule – Part B: District Hospital (DH), Gadchiroli.

Location of the Hospital: By using the public transport, it takes one hour to reach the DH,
Gadchiroli, from the nearest CHC and 6 hours from the farthest CHC. The DH is located
three kilometres away from the main bus stand of the town. The DH with bed strength of
226 beds is spread over in 5 acre area in the outskirts of the Gadchiroli town. The hospital is
located away from the residential area of the city and the necessary environmental clearance
was obtained from the Pollution Control Board by the hospital. All the buildings of the DH
are disabled friendly as per the provisions of the Disability Act.
12
Physical Infrastructure: The DH has a registration counter, waiting space adjacent to each
consultation and treatment room, doctors’ duty room, treatment room, isolation room, blood
bank/blood storage unit, pharmacy, ICU, high dependency wards, critical care area,
examination and preparation room. The hospital has the following services: kitchen, Central
Sterile and Supply Department, laundry, medical and general stores, engineering services
backup, ventilation, water coolers/refrigerators, round the clock water supply, overhead water
storage tank with pumping and boosting arrangements, provision for fire fighting, and proper
drainage and sanitation system. The hospital disposes the bio-medical waste through burial.
The bio-medical waste is disposed after segregating the same in three different bins. The
hospital has residential quarters for 16 medical staff and 63 paramedical staff and all these
quarters are occupied. It has a medical records section and disease classification is being
carried out as per protocols. The hospital has telephone, fax, computers and internet facilities.

Obstetrics and Gynaecology Section: The hospital has a separate ward for female patients
with 50 beds. The bed occupancy rate of female wards is only 20 percent. During the last
three calendar months 285 OPD patients were attended in the section and 461 deliveries were
conducted. The hospital has a separate OT for Obstetrics and Gynaecology. The section also
has the facilities to provide services related obstetrics and gynaecology (caesarean section
deliveries, assisted delivery, forceps delivery, MTP, mid trimester abortion, ectopic pregnancy,
retained placenta, eclampsia, PPH, sterilization, hysterectomy, suturing cervical tear and
infertility treatment). The hospital has provided the figures for most of these services during
the year 2007-2008. For instance, the hospital has conducted 1,944 deliveries and 708
caesarean section deliveries.

Surgical Section: The number of surgical OPD and IPD conducted in the section during the
last three months prior to the survey was 1,209 and 908 respectively. Facilities for emergency
surgical services, abdomen surgery and breast surgery are available in the section. However,
the section does not have facilities to conduct pancreas surgery, spleen and portal
hypertension surgery and leprosy reconstructive surgery.

Medical Section: The number of medical OPD and IPD attended by the Section during the
last three months prior to the survey was 14,397 and 966 respectively. The medical section
provides the following services: dermatology and venerology, services under NLEP, pleural
biopsy, pleural biopsy, lumbar puncture, pericardial tapping, and psychiatric services. The

13
medical section does not provide the following services: bronchoscopy, skin scraping for
fungus/AFB, bone marrow biopsy, endoscopic specialised procedures.

Paediatric Section: During the year 2007-2008 the number of paediatric OPD attended in
the section was 12,794 and number of IPD admitted was 3,791. The section has 3 designated
beds for newborns. The number of neonates and other infants & children under five years
admitted in the section during 2007-08 is 1838 and 1953 respectively. The section has the
services to manage asphyxia, malnourished children, neo natal sepsis, dehydration and
diarrhoea cases and respiratory tract/pneumonia cases. The section has the essential
equipments like cradle, incubator, radiant heat warmer, phototherapy unit, bag with mask,
laryngoscope, oxygen mask, suction machine and thermometer with working condition. The
section has the essential drugs like ORS, Vitamin A solution, iron folic acid syrups and
paediatric antibiotics.

Diagnostic Section: The section has conducted OPD diagnostics for 1,138 male patients
and 912 female patients during the last three months prior to the survey. The section has the
services like x-ray, ultrasound and ECG.

Clinical Pathology: The lab has provided 7,834 laboratory services to the patients during the
last three months prior to the survey. Lab has facilities to provide haematology, urine analysis,
stool analysis, semen analysis, CSF analysis, PAP smear, serology and biochemistry. It does
not have facilities for Aspirated fluids (cell count cytology), split skin smear examination for
leprosy, sputum, histopathology, microbiology and physiology.

Human Resources: Out of the 50 sanctioned medical posts in the hospital, 36 (72 percent)
are appointed in regular position. The hospital has not recruited anyone in the contractual
position among the medical staff. The shortage is 20 percent in the category of General Duty
Doctor – out of the 24 sanctioned posts only 19 are appointed. The hospital has a two
sanctioned posts in each of the specialist categories like Gynaecologist, ENT Surgeon,
Ophthalmologist, Orthopaedician and Surgery Specialist. However, in all these five categories,
the hospital has filled up only one post each. Among the paramedical staff, the vacancies are
more than the medical category. Among the Staff Nurses, only 81 out of 131 (62 percent)
sanctioned posts are filled-in and among the Hospital Worker category, only 95 out of 142
(68 percent) sanctioned posts are filled-in. Among the other category of personnel
(technicians and administrative staff), the hospital has almost filled up all the sanctioned
14
positions. Overall, the hospital has the vacancy to the tune of 28 percent in medical category,
38 percent in staff nurse category and 32 percent in Workers’ category.

RKS: The hospital has a registered RKS. The hospital exempts the SC, ST and BPL patients
for the user charges. To avail the exemption, patients have to produce the BPL Ration Card.
Through the user fees the RKS generates additional resources other than government grants.
The user fees are retained within the hospital. However, the hospital has not used the user
fees collected from the patients. The hospital has put up a display board showing number of
members and number of meetings of RKS.

Overall, the hospital has better facilities in Obstetrics & Gynaecology and Paediatrics
sections. Shortage of human resources is more in medical category staff than in paramedical
and other staff.

Comments and Observations

Remarks by MS: “Out of 19 sanctioned posts of Class-I Medical Officers in specialised

categories, only 6 are appointed in regular basis in the hospital. Hence hospital has a huge
shortage on manpower in the specialised categories. Guidelines related to NRHM
programmes and changes in the guidelines are not communicated to us on time”.

Remarks/suggestions for the improvement of services by the observer:

1. The hospital is well constructed as per the norms and has good infrastructure and
equipments. However, the hospital is not fully utilised. Its bed occupancy is low in many
departments.
2. The hospital is located three kilometres away from the town. The patients coming to the
hospital from rural areas first have to get down at the bus stand and have to take another
bus or auto rickshaw to reach the hospital. The frequency of the local buses from the bus
stand to the hospital is also less. People have to depend on private auto rickshaws to
reach the hospital.
3. Ninety percent of the population of the district is living in rural areas and road and
transport facilities are not well developed in the district. People from the rural parts of the
district have the real difficulty to access the health facilities in the district, particularly the
district hospital.

15
4. In Maharashtra, ASHA workers are appointed only in tribal blocks/districts. Though
Gadchiroli is entirely a tribal district, still ASHAs scheme is not functional at the time of
our survey.
5. The funds allotted under the NRHM (JSY and Untied funds) are not reaching on time
from the district to the lower level health facilities and functionaries.

The duly filled-in District Schedule is given in Appendix-2

III. Key Findings of the Study

(A) Community Health Centres

As per the study design, the two CHCs selected for the study are CHC Dhanora
(FRU) and CHC Aheri (FRU & farthest). Aheri is serving for a larger population of 103,759
and Dhanora is serving for a smaller population of 20,780. Both the hospitals are functioning
as FRUs and on 24*7 basis. CHC Dhanora is a 30 bedded (15 beds each for males and
females) hospital and CHC Aheri is 50 bedded (25 beds each for males and females). In both
the hospitals, the availability of paramedical and support staff is better. However, Dhanora is
a low performing hospital compared to Aheri. The BOR of Dahnora is 19 percent and Aheri
is 68 percent.

Dhanora is maintaining the records of JSY beneficiaries, whereas Aheri is not. IPHS
facility survey has been completed in both the CHCs. They receive the grants electronically
from the district. RKS is registered in both the CHCs and their display boards show the
composition of the RKS with the names of the members and number of meetings held. RKS
is generating resources through user fees in both the CHCs. In both the CHCs, there is no
feedback mechanism in place for grievances redressed by RKS.

In both the CHCs, the labour rooms are in use and deliveries are being conducted.
The number of deliveries conducted during 2007-2008 in Dhanora and Aheri is 70 and 275
respectively. Both the CHCs, though they are functioning on 24*7 basis, have not reported
deliveries between 8 pm to 8 am. The number of deliveries took place for the JSY card
holders is 27 in Dhanora and 31 in Aheri.

16
(B) Primary Health Centres

Coverage: Under CHC Dhanora, the selected PHCs are Rangi and Pendri. Under CHC
Aheri, the selected PHCs are Mahagaon and PHC Kamalpur. The number of SCs covered by
these four PHCs varies from 7 to 15 and the population covered varies from 11,348 to
56,781. The distance from the nearest SCs in the coverage areas to these PHCs varies from 2
to 3 kilometres and distance from the farthest SCs varies from 15 to 45 kilometres. Out of the
four PHCs, three (Rangi, Mahagaon and Kamalapur) are having 6 beds each (3 male and 3
female beds each) and the other one (PHC Pendri) has 4 beds (2 male and 2 female). Two
selected PHCs under CHC Dhanora and one PHC under CHC Aheri are designated as 24*7
PHCs. However, in terms of functioning, none of the PHCs are functioning as 24*7 (have 1
MO and 3 or more ANMs/Staff Nurses round the clock). All the four PHCs are equipped to
provide basic obstetrics services.

Infrastructure and Human Resources: Out of four PHCs, three are functioning from a
designated government building and all the three have labour room. One PHC is not
functioning in a government building (Mahagaon) and it does not have a labour room as well.
All the four PHCs have laboratory. Only two out of four PHCs have put up a prominent
display boards regarding service availability in local language. Out of four PHCs, one is not
maintaining the records containing the names of JSY beneficiaries. None of the PHCs have
New Born Care Corner. In three PHCs (Rangi, Pendri and Mahagaon), all the sanctioned
posts are filled in either on a regular or contract basis. In PHC Kamalapur, out of 11
sanctioned posts, only 9 are filled in. Each PHC has a two sanctioned posts of Medical
Officer. Only two PHCs have two sanctioned medical officers each in position with them
whereas the other two PHCs have only one medical officer each with them. As for as
‘sanctioned posts’ and ‘number in position’ are concerned, PHCs are not in bad position.
Except one PHC, the remaining three PHCs have all the sanctioned posts in position.

Status of Training of Personnel at PHC: The staff in three PHCs (Rangi, Pendri and
Kamalapur) have undergone Pre Service IMNCI (Integrated Management of Neonatal and
Child Infections) training. Staff from only one PHC has undergone Skill Birth Attendant
Training. Staff in none of the PHCs have undergone training in Safe Abortion Methods and
New Born Care.

17
Availability and Performance of Labour Room: Three out of four PHCs have labour
rooms and all three of them use the labour rooms for delivery. During 2007-2008, all these
three PHCs together conducted 108 institutional deliveries, seventeen 8 pm to 8 am deliveries
and 56 institutional deliveries for JSY card holders. One PHC which is not functioning in a
designated government building (Mahagaon) is not having a labour room. Hence the PHC did
not conduct any delivery during the year. Overall, the performance of the PHCs in terms of
number of deliveries conducted during the year is very poor.

Status of Specific Interventions: IPHS facility survey has not been done in any of the
PHCs. AYUSH doctor is not available in any of the PHCs. All the four PHCs have registered
RKS. However, only two PHCs have display boards showing the composition of the RKS
with the names of the members and number of meetings held. In none of the PHCs RKS is
generating resources through user fees. All standard treatment guidelines and protocols are
available with the PHCs. Citizens charter is publicly displayed in two PHCs.

Service Outcome: All the four PHCs have reported the JSY cases and institutional deliveries
for JSY cases. All the four PHCs together have registered 72 JSY cases on average per month.
The average number of institutional deliveries reported by the four PHCs together is 50 per
month. Out of these, 32 are JSY cases. It means that, among the institutional deliveries took
place in these four PHCs together during the last three months, 64 percent are JSY cases. All
the four PHCs together have conducted 61 male sterilizations 18 female sterilisations per
month. The average monthly number of outdoor patients reported by the four PHCs is 592,
532, 255 and 410. The caste wise break-up shows that the ST population use the PHC
facilities more than the ‘Other’ caste groups. The average monthly number of indoor patients
reported by the four PHC (6, 21, 10 and 28) indicates the under utilisation of IPD facilities.
The PHC wise performance shows that the PHCs under CHC Aheri have done better
compared to the PHCs under CHC Dhanora.

(c) Sub Centre

Coverage: Twelve SCs are covered for the survey under four selected PHCs. The number of
villages covered by the SCs varies from 2 to 6 and the population covered varies from 376 to
3,627. The average number of villages covered by the SCs is 4.4 and average population
covered is 1,741. Out of the 12 SCs, ASHAs are working/appointed only in three SCs. The

18
number of ASHAs working/appointed under the three SCs is 6 and the average for all the 12
SCs turns out to be 0.5.

Availability of Infrastructure: All the 12 SCs are run from the designated government
building. IPHS facility survey has been done in three fourth of the SCs. Labour room is
available in 11 SCs. None of the SCs have piped water supply. Regular electricity is available
in 10 SCs and telephone is available in 8 SCs. Eleven SCs (92 percent) have labour rooms.
Among the 11 SCs with labour room, nine are using their labour room and two are not using.
The nine SCs with labour room in use together conducted 103 deliveries during the year
2007-2008 and the average turns out to be 11.5 deliveries. The nine SCs which are using the
labour room also conduct the deliveries between 8 pm to 8 am. The performance of the SCs,
in terms of number of deliveries conducted during the year, is very low. Ten SCs have
quarters for ANM. Among the ten SCs with ANM quarters, in nine SCs the ANMs are
staying in quarters and in one SC the ANM is not staying the quarter.

Availability of Staff: The availability of staff in the SCs shows that 11 SCs have both male
and female health workers in position. In one SC, only a female health worker is in position.
In other words, all the 12 SCs are having female health worker in regular position. Three SCs
have contractual ANMs and all these three SCs also have regular female health worker.

Availability of Equipments and Drugs: Only one SC has all the 12 listed equipments
available with it and another two SCs have 10 equipments with them. The remaining SCs
have less than 10 equipments and four of them have six or less than six equipments. Except
few cases, most of the equipments available with the SCs are by and large in working
condition. The availability of drugs shows the mixed picture. Out of 16 drugs, five SCs have
reported the availability of less than 10 drugs on the date of survey. Three SCs have reported
the availability of 12-13 drugs and four SCs have reported 10 drugs.

Specific Skills and Procedures: ANMs in all the 12 SCs reported that they (i) register
pregnancy within three months, (ii) carryout 3 ANC visits as per the RCH schedule, (iii) carry
out specific examinations like Blood Pressure, Haemoglobin and Urine, and (iv) provide
immunisation services. Ten out of 12 ANMs reported that they identify high risk pregnancies
and nine out of 12 reported that they provide TT injection and IFA tablets. None of the
ANMs is carrying out IUCD insertion/removal. None of the ANMs reported that they are
trained on insertion/removal of IUCD A380.
19
Service Outcome: The service outcome data for the last three months show that, on an
average, each ANM has registered 7 ANCs. Out of the total ANCs, the average number
registered by the ANMs in 1st Trimester is 3.4. The average number for the three ANC visits
as per RCH schedule is 3.4 in last three months. During the last three months, on an average,
each ANM has identified 1.2 high risk cases, conducted 3.8 deliveries and referred one
pregnant woman to next higher facility. The number of neonate infections during the last
three months and IUCD insertions are nil in the SCs during the reference period.

Status of Record Maintenance: The record maintenance by each individual SC shows six
registers (Household Survey Register, Antenatal Register, Post Natal Register, Birth and
Death Register, Immunisation Register, and JSY Register) are maintained by all the 12 SCs.
Eligible Couple Register, Meeting Register and Untied Funds Register are being maintained
by 92 percent of the SCs. Three-fourth of SCs maintain Family Planning Register and two
third of the SCs maintain Cash Book.

Awareness about JSY: Awareness about the JSY and the amounts to be given to the
beneficiaries are universal among the ANMs. Only six out of twelve ANMs reported that
there is an increase in the demand for institutional deliveries after the implementation of the
JSY scheme.

Procedure under JSY Scheme: Two third of the ANMs reported that the JSY beneficiaries
are being paid by cheque and remaining one third reported that the beneficiaries are being
paid by cash. Only one third of the ANMs reported that the JSY beneficiaries are paid within
a week after the delivery and rest of the ANMs reported that the beneficiaries are being paid
after one (50 percent) or two weeks (17 percent) later. Nine out of 12 ANMs reported that
the transport support is available under JSY for shifting the pregnant woman from SC to
PHC, in case of emergency. Eleven out of 12 ANMs said that the Register is available with
them to record JSY expenditure.

Performance of ANM under JSY Scheme: All the 12 SCs together have registered 64 JSY
cases during the last three calendar months and the average number per SC turns out to be
5.3 cases. However, three SCs have not registered any JSY cases during the last three calendar
months. The average number of JSY cases resulted in institutional deliveries during the last
three months is 4. The average amount disbursed for JSY cases in last three calendar months
20
by the SCs is Rs. 3,408. During the financial year 2007-2008, the average amount disbursed
under JSY by the SCs for home deliveries and institutional deliveries is Rs. 2,467 and Rs.
2,517 respectively. None of the SCs have made any payment to the ASHAs during the year
2008-2009. It should be noted that only in 3 out of 12 SCs, ASHAs are working/appointed.

Status of Untied Grants: Seven out of 12 SCs have received the Untied Grants. Among
those received the Untied Grants, all of them reported the expenditure from the grants. All
the seven SCs which received the grant are having joint bank account with the Sarpanch/any
other GP functionary. Six out of seven SCs are maintaining the register to record the decision
taken to spend the grant.

(D) Household Survey

Characteristics of the Households: Distribution of the households by social category

shows that 70 percent of the households belong to Scheduled Tribe (ST), 10 percent belongs
to Schedule Caste (SC), 12 percent belong to OBC and 12 percent belong to ‘Other’ castes.
Only about one third of the households have electricity. Only three percent of the households
are living in pucca houses. Toilet facility is available only in 12 percent of the households.
Piped water is used by 28 percent of the households. Only three percent of the households
use LPG/Biogas for cooking. Only 13 percent of the households own a colour/B&W
television and six percent have a mobile phone. Nearly two third of the households (63
percent) belong to BPL category. The BPL status is also reflected in the households with the
low standard of living index (SLI) – 81 percent of the households belong to low SLI. The
characteristics of the households reveal that the extent of deprivation of basic facilities
(electricity, drinking water, housing, toilet facility), is very high in the rural areas of the district.

Waste Disposal, Stagnation of Water and Mosquito Breeding and System of Medicine
Preferred: Method of waste disposal shows that 70 percent of the rural households throw
their waste in the open space and the remaining 30 percent bury in a pit. During the survey, in
9 percent of the households, investigators have observed the stagnation of waster water
around the household. Among the households where the stagnation of waste water was
observed, the investigators have further observed the mosquito breeding in the stagnant water
in most of these households (80 percent). System of medicine preferred by the rural
households reveals that the allopathic medicine is universally preferred (99 percent).

21
Information about Health Workers and Health Facilities: Almost all the respondents
have heard about ANM and Male Health Worker. Further, 93 percent of the respondents
reported that the health worker has visited them in last one month. Ninety five percent of the
respondents further reported that the health workers are available to them when needed.
Respondents were asked about the availability of the health facilities to the households when
required. The responses reveal that the households mainly depend on government health
facility, when needed. Public health facilities like SC, PHC and CHC were mentioned by 47
percent, 60 percent and 14 percent of the respondents respectively.

NRHM, ASHA and JSY: Thirteen percent of the respondents have heard about NRHM.
Only three percent of the respondents have heard about ASHA. One third of the
respondents reported that the Village Health and Nutrition Day (VHND) is being organised
in the village. One fourth of the respondents reported the presence of Village Health and
Sanitation Committee (VHSC) in the village. Sixty percent of the respondents are aware about
JSY scheme. Among those who are aware about the JSY scheme, 13 percent of them reported
that the household is a beneficiary of the JSY scheme. Among the total surveyed households,
8.3 percent (97 out of 1,172) are beneficiaries of the JSY scheme.

JSY Beneficiaries: In Maharashtra, all the Scheduled Castes, Scheduled Tribes and BPL
households are eligible for JSY benefits. Social category of the beneficiaries reveals this as vast
majority of them are Scheduled Tribes (83 percent). The remaining 17 percent of the
beneficiaries are from Scheduled Castes, OBCs (from BPL category) and ‘Other’ categories.
Distribution of beneficiaries by Standard of Living Index (SLI) shows that more than three
fourth of them (78 percent) belong to low SLI households, 20 percent belong to medium SLI
households and 2 percent to high SLI households. Seventy one percent of the beneficiaries
belong to BPL category.

Registration of JSY Beneficiaries: More than half of the beneficiaries (54 percent) heard
about the JSY scheme before being pregnant and the remaining 46 percent heard during
pregnancy. Four fifth of the beneficiaries got registered during the first trimester of the
pregnancy and the rest during 4th and 5th month of the pregnancy. Seventy eight percent of
the beneficiaries were registered by ANM/FHW and 20 percent by Anganwadi worker and
the remaining 2 percent by Doctor/LHV.

22
JSY Card: Only one fourth of the beneficiaries received the JSY card. Among those who
received the JSY card, none of the beneficiaries reported any difficulty in getting the JSY card.

Role of ASHA during the Pregnancy of the Beneficiaries: In Maharashtra, ASAHs are
appointed only in tribal blocks of the state. Though Gadchiroli is a tribal district, among the
24 villages surveyed, ASHAs are appointed only in three villages. The appointed ASHAs in
these three villages have not started functioning at the time of our survey. Due to this,
beneficiaries were not able to answer the questions regarding the role of ASHA during their
pregnancy or we were not able to ask these questions.

Place of Delivery and Reason for Opting Institutional Delivery: Among the
beneficiaries, 29 percent (27 out of 93) delivered in Institutions and the remaining 71 percent
(66 out of 93) delivered at home. Ninety seven percent of these institutional deliveries took
place in public institutions (DH, CHC, PHC and SC).

Transport of the Beneficiaries to Reach the Health Institutions: Out of the 27

beneficiaries who delivered in institutions, only one beneficiary faced difficulty in reaching
health institution due to the non availability of transport. The average distance to the ultimate
place of delivery from the beneficiaries’ residence is about 14 kilometres. Private vehicle was
used by 44 percent of the beneficiaries to reach the ultimate place of delivery, 15 percent used
Government Ambulance and 41 percent reached the facility by walk/bullock cart. For 81
percent of the beneficiaries, mainly family members/relatives (81 percent) had arranged the
vehicle. For 19 percent of the beneficiaries, ANM/Health Worker and Village Health
Committee had facilitated in arranging the transport. The average amount spent by the
beneficiaries on transport to reach the health facility is Rs. 91.1/-.

Reason for Opting Home Delivery: Seventy one percent of the beneficiaries (66 out of 93)
opted for the home delivery in spite of cash incentives being available under the JSY scheme
for Institutional delivery. All these 66 beneficiaries were asked for the reason for opting home
delivery. The major reasons cited by the beneficiaries are non availability of transport (29
percent), more convenience in home delivery (26 percent), and cultural/social reasons (20
percent).

Cash Incentive Received by the Beneficiary under JSY Scheme: Among the
beneficiaries, 97 percent had received the cash incentive under JSY scheme and the average
23
amount received by them is Rs. 523/-. Out of those who received the cash incentive, 80
percent received it in one instalment and 20 percent received it in two instalments. Among
those who received the cash incentive, 12 percent received before delivery, 17 percent
received immediately after the delivery, 25 percent received within a week after the delivery
and 47 percent received much later.

Utilisation of Government Health Facility in Last Six Months: Twenty percent of the
rural households (232 out of 1,172) have availed the health services in government health
facility in last six months. The characteristics of these households reveal that 76 percent are
Scheduled Tribes and Schedule Castes, and 69 percent belong to BPL households. The
percentage of households from low SLI households is 77 percent. The characteristics of the
respondents clearly reveal that most of them come from very poor households. The type of
health facility visited shows that 51 percent visited PHC, 24 percent visited SC, 13 percent
visited District Hospital, and another 12 percent visited CHC.

User Fees and Extra Charges: Among the respondents who have availed the services in
government health facility in last six months, fifty three percent (i.e., 110 out of 210) said that
they were charged user fees by the health facility. Among those who paid the user fees, 94
percent paid for registration, 10 percent for lab test, 2 percent for X-ray, and 16 percent for
medicine, IV set, injection, blood and room charges.

Awareness about Spacing Methods and Ideal Gap between Children: The ideal spacing
between 1st and 2nd child mentioned by the respondents reveals that 53 percent prefer the
ideal spacing to be 3 and more years. Another 38 percent said that the ideal spacing should be
2 years. Only nine respondents mentioned the ideal spacing as one year. The ideal spacing of
3+ years reported by majority of the respondents clearly indicate the need for spacing
methods in our family planning programme. Knowledge regarding the spacing methods
reveals that Oral Pills is known to 86 percent of the respondents followed by IUD (44
percent) and Condom (41 percent). Nine percent of the respondents said that they don’t
know the family planning methods available for spacing.

AIDS and VCTC: Only 44 percent of the respondents are aware about the HIV/AIDS.
Among those who are aware about the HIV/AIDS, 20 percent is aware about the nearby
Counselling Centre/Voluntary Counselling and Testing Centre (VCTC). Among those who

24
are aware about the location of VCTC, most of them (91 percent) reported that that it is
located in the government health facility (DH/CHC/PHC).

Suggestions given by the respondents: The suggestions given by the respondents shows
that respondents generally expect health facility, safe drinking water, pucca road, transport
facility, toilet facility, cleanliness and sanitation for their villages. Some of the respondents
also suggested the regular availability of health workers, medicine and treatment for the
improvement of services in their village. The suggestions given by them reveal the genuine
expectations of the villagers for the improvement of the health and sanitation in their villages.

(E) Gram Panchayat

All the Gram Panchayats have reported that the ANM is regularly available in the
village. Two third of the Gram Panchayats reported that they know the tour plan of the
ANM. All the Gram Panchayats have reported that the Sub Centre is providing timely
services to the patients in the village. Eighty three percent of the Gram Panchayats have
reported the existence of the VHSC in their village. Out of the 15 villages with the VHSC, 14
of them reported the regular meetings of the VHSC in the village. Except one, all the other 17
Gram Panchayats have received the Untied Funds. Only two out of 18 Gram Panchayats
have reported the appointment of ASHAs in their village. Awareness about the benefits under
the JSY scheme was reported by 89 percent of the Gram Panchayats. More than three fourth
of them (78 percent) said that the NRHM has brought improvement in their area. Some of
the improvements reported by the Gram Panchayats due to NRHM are: availability of
funds/facilities under JSY (50 percent), availability of funds for the maintenance of Sub
Centre (29 percent), availability of better facilities in CHCs/PHCs for referred patients (21
percent), and availability of transport facilities for delivery (7 percent). Only few Gram
Panchayats have reported the difficulties in implementing programme activities under
NRHM. Control over funds, more funds for maintenance and effective functioning, and
more training for ASHA and Community members are the kinds of support required by the
Gram Panchayats for implementing the programme under NRHM.

(F) Quality of Care and Client Satisfaction - IPD Exit Interview

Waiting Time: The average waiting time for the patients for the Registration is 17 minutes.
The average waiting time for Registration in DH is more than half an hour, and in CHCs it is
25
7 minutes. After the Registration, the patients had to wait on an average 10-11 minutes for
the Doctor’s call in the hospitals. On an average, the doctors have examined the patients for 8
minutes in CHC and 7 minutes in DH. After the examination it takes 15 minutes to get
admitted to the ward. After admission to the ward, it takes about 8 minutes for the patients to
get the services. The average time for getting discharged for the patients in the hospitals is
about 20 minutes.

Satisfaction regarding Waiting Time: The satisfaction with the waiting time for
registration, doctor’s call, doctor’s examination, admission to ward, getting services, and to get
discharged is assessed with four categories: too long, appropriate, too short and can’t say.
Overall, the dissatisfaction levels are somewhat higher as 13-38 percent of the patients were
dissatisfied for the various types of services in the hospitals. In four out of six services, the
dissatisfaction with the waiting time is more in CHCs than in DH.

Behaviour of Staff: Eighty percent of the patients said that the doctor greeted them in a
friendly manner in the first instance. Regarding the behaviour of doctors, nurses and technical
staff, 71-83 percent of the patients said that their behaviour is good/very kind. Satisfaction
regarding the behaviour of ayah, ward boys and counter clerk appears to be further high as
80-96 percent of the patients said that they are good. Satisfaction of the patients regarding the
behaviour of various categories of staff reveals that 3 to 10 percent of them were not happy.
Dissatisfaction regarding the behaviour of staff is more in the CHCs than in DH.

Privacy: Only 43 percent of patients said that there was privacy in the place of examination.

Patient-Doctor/Provider Communication: The response of the patients with respect to

their interaction with the doctor shows that the patients are not totally happy with it.
Regarding listening to the patient’s ailment, 73 percent of the patients said that the doctor
always listened to their ailment patiently, 17 percent said that the doctor listened somewhat
and 10 percent said that doctor did not listen. Though the majority of the patients (83
percent) said that the either the doctor always/somewhat allowed to ask questions or
responded to questions still 17 percent of the patients said that the doctor did not allow to
ask questions/responded to their questions. Similarly, 20-23 percent of the patients said that
the doctor did not discuss about their ailment with them/talked about their recovery. In four
out of six issues of doctor-patient communication, about 17-23 percent of the patients were

26
not happy with the doctor. However, the analysis of client-doctor/provider communication
clearly indicates that it needs to be improved in health facilities, more so in DH.

Cleanliness of the Facility: Cleanliness of health facilities is assessed through the

frequency of cleaning of floor and toilet/bathroom, changing patient’s uniform and changing
bed-sheets. Cleanliness of floor and toilet/bathroom appears to be poor in CHCs compared
to DH. In DH, all the patients have reported that the cleaning of floor and toilet/bathroom
are done at least once a day, whereas in CHCs only 20 percent of patients said that the floor
cleaning is done less than once a day and 35 percent said that toilet/bathroom cleaning is
done less than once a day. Overall, according to the patients, the cleanliness of floor and
toilet/bathrooms are poor in CHCs compared to the DH. Irrespective of type of facility,
changing patient’s uniform and bed sheets are not a common practice in the hospitals. The
data on frequency of the cleanliness and satisfaction regarding the same clearly shows that
lack of cleanliness is a major issue in CHCs.

Crowding in the Facility: Almost all the patients (28 out of 30) said that they got the cot
immediately after the admission to the ward and 93 percent of them said that the cot was
available to them till the time of discharge. Regarding the adequacy of space in the ward, 10
percent of the patients said that the space is not adequate. One fifth of the patients are not
satisfied with the ward arrangement. For 60 percent of the patients, the space in IPD is
adequate, for 20 percent it is somewhat adequate and for another 20 percent it is inadequate.
The percent of patients reporting that the space is not adequate is more in DH (30 percent)
than in CHCs (15 percent).

Amenities provided by the Hospital: Two third of the patients reported that the health
facilities have accommodation for relatives and ambulance. The percent of patients reported
the availability of canteen and medical shop is 40 percent. Only 20 percent of the patients
reported the availability of telephone and very few (3 percent) reported the availability of
television. As per the reporting of patients, amenities are relatively better in DH compared to
the CHCs.

Continuity of Treatment: Seventy percent of the patients are ‘satisfied’ with their visit to the
facility and 30 percent are ‘somewhat satisfied’ and none of them are ‘dissatisfied’. Satisfaction
by type of hospital shows that all the patients from DH are ‘satisfied’ and from CHCs roughly
half are ‘satisfied’ and half are ‘somewhat satisfied’. All the patients from DH and 85 percent
27
from CHCs said that they would come again to the facility, in case they fell sick. Similarly, all
the patients from DH and 85 percent from CHCs said that they would recommend the
hospital to others.

(G) Quality of Care and Client Satisfaction - OPD Exit Interview

Average Waiting Time for Services: Overall, to get all the OPD services (registration,
doctor’s examination, injection, dressing, getting medicines, and paying bill) it takes on an
average 40 minutes for the patients in the hospitals. The waiting time for the different OPD
services shows that, except for dressing, all the other OPD services take less than 10 minutes
in the hospitals. Average time to get the OPD services is 40 minutes in CHCs followed by
DH (38 minutes) and PHCs (34 minutes).

Satisfaction Regarding Waiting Time: Satisfaction of the patients regarding waiting time
for different services shows that dissatisfaction is not very high as only 6-20 percent of the
patients said that the waiting time is too long for these services. In fact, most of the patients
(60-83 percent) reported that the waiting time for these services is too short. However,
dissatisfaction for the doctor’s examination is more as 70 percent of the patients said that the
examination time is too short. Dissatisfaction for different services shows that the
dissatisfaction is least in DH and higher in CHCs. Though the dissatisfaction levels of OPD
services are not very high (except for doctor’s examination time), even the small level of
dissatisfaction has to be properly addressed.

Behaviour of Staff: Doctors in DH are friendlier with the patients as none of the patients
reported about the unfriendliness of the doctors. Regarding the behaviour of doctors, nurses
and dispenser, 92-97 percent of the patients said that they are good/very kind. However,
seventeen percent of the patients from the DH reported that the behaviour of the nurses was
rude. The figures indicate that, the patients in general, are satisfied with the behaviour of all
categories of staff in the health facilities.

Privacy: On the whole, 73 percent of patients said that there was privacy in the place of
examination. All the patients from DH and CHCs reported the presence of privacy, whereas
only half of the patients from PHCs reported that there was.

28
Patient-Doctor/Provider Communication: Regarding listening to the patient’s ailment, 90
percent of the patients said that the doctor always listened to their ailment patiently. Almost
all the patients said that the doctors did allow them to ask questions and responded to the
questions. Further, ninety percent of the patients said that the doctor discussed about the
ailment with the patients and 78 percent said that doctor talked about the recovery. These
results show that the OPD patients are happy with the communication of the doctors.
Compared to IPD patients, relatively less OPD patients have expressed their dissatisfaction
regarding their communication with the doctors.

Cleanliness of the OPD Facility: Compared to IPD patients, less number of OPD patients
expressed their dissatisfaction regarding the cleanliness. It appears that, cleanliness is an issue
for IPD patients rather than for OPD patients. Because IPD patients stay longer in the
hospital and expect a cleaner environment whereas, OPD patients visit only for a shorter
period and not much bothered about the cleanliness of the OPD area.

Crowding in the OPD Areas: Lot of dissatisfaction exists for crowding/inadequacy of

space in all OPD facilities (OPD Room, Examination Room, Dispensary, Laboratory,
Injection Room and dressing Room) of the hospitals, particularly in CHCs and PHCs. The
percent of patients said that the space is not adequate in OPD Room is 44 percent,
Examination Room is 48 percent, Dispensary is 44 percent, Laboratory is 80 percent,
Injection Room is 63 percent and Dressing Room is 33 percent. Relatively higher percent of
patients from CHCs and PHCs complained about the inadequacy of space in OPD facilities
compared to DH.

Continuity of Treatment: Overall, 87 percent of the patients were ‘satisfied’ with their visit
to the facility and the remaining 13 percent ‘somewhat satisfied’. Compared to IPD patients
(70 percent), more OPD patients (85 percent) were ‘satisfied’ with their visit to the health
facility. Satisfaction by type of hospital shows that all the patients from DH are ‘satisfied’ with
their visit and 85 percent of the patients from CHCs and PHCs are ‘satisfied’. All the patients
from all the hospitals said that they would come again to the facility and also they would
recommend the hospital to others.

29
 Chapter 3
Community Health Centres

Coverage
As per the study design, the two CHCs selected for the study are CHC Dhanora
(FRU) and CHC Aheri (farthest). Aheri is serving for a larger population of 103,759 and
Dhanora is serving for a population of 20,780. Aheri is 120 kilometres away from the District
Hospital and Dhanora is 36 kilometres away. For Aheri, the distance for the farthest PHC is
84 kilometres and for Dhanora it is 58 kilometres. Both the hospitals are functioning as FRUs
and on 24*7 basis.

Availability of Infrastructure
CHC Aheri is a 50 bedded (25 beds each for males and females) hospital and CHC
Dhanora is 30 bedded (15 beds each for males and females) and both are functioning from
own government building. Both the CHCs are having regular electricity supply, generator,
telephone, computer, internet and laboratory. Running vehicle/ambulance is available only in
CHC Dhanora. CHC Aheri has the facilities like ECG, X-Ray, ultrasound, OT, OT for
gynaecology, labour room, separate areas for septic and aseptic deliveries, new born care
centre and pharmacy whereas Dhanora does not have ECG, ultrasound and operation
theatre. Records of JSY beneficiaries are maintained in Dhanora whereas it is not maintained
in Ahere. Both the hospitals have most of the common facilities for the patients (counter near
entrance of the CHC to obtain contraceptives, ORS packets, Vitamin A medicines, separate
public toilets for males and females, suggestion/complaint box, OPD rooms/cubicles,
waiting room for patients with adequate sitting place and drinking water). Emergency
room/casualty and separate wards for male and females are available in both the hospitals. In
both the hospitals, the sewerage system is connected to the soak pit. Both the hospitals are
disposing their bio-medical waste by burying in a pit. As per our observation, the cleanliness
of OPD, compound/premises and rooms/wards are better in both the hospitals.

Human Resources
CHC Aheri has 13 sanctioned posts of medical staff. Out of 13, nine are working in a
regular position and four are vacant. CHC Dhanora has three sanctioned post of medical staff
and all the three are working in a regular position. In terms of paramedical and support staff,
in CHC Dhanora, out of 15 sanctioned positions, 13 are working in regular positions, one is

30
working in contractual position and another one is vacant. In Aheri, out of 19 sanctioned
paramedical posts, 15 are working in regular position, two are working in contractual position
and another two is vacant.

Status of Specific Interventions

IPHS facility survey has been completed in both the CHCs. They receive the grants
electronically from the district. RKS is registered in both the CHCs and their display boards
show the composition of the RKS with the names of the members and number of meetings
held. RKS is generating resources through user fees in both the CHCs and the hospitals use
the money for local purposes. In both the CHCs, there is no feedback mechanism in place for
grievances redressed by RKS. All standard treatment guidelines and protocols are available in
the CHCs. Citizens charter is publicly displayed only in both the hospitals.

Status of Residential Facilities for Doctors and Other Staff

Both the CHCs have residential facility for the Doctors and other staff and the
residences are occupied by the staff. There are no vacant quarters in both the CHCs.

Availability of Laboratory Facilities

Both the CHCs have testing facilities in their laboratory for haemoglobin, urine RE,
blood sugar, blood grouping, blood smear, blood smear examination for malaria parasite,
rapid test for pregnancy, RPR test for syphilis and rapid test for HIV. Both the CHCs do not
have the testing facilities for the diagnosis of RTI/STI. Testing facility for bleeding and
clotting time is available only in CHC Aheri.

Number of Laboratory Tests Done in CHC in Last Three Months

The CHCs maintain the records related to the number of laboratory tests done during
the last three months prior to the survey. As the CHC Aheri is a 50 bedded hospital, the
number of different tests done here is more than in the 30 bedded CHC Dhanora.

Status of Performance of OT during 2007-2008

The performance of the OT shows that Caesarean section deliveries are conducted
only in CHC Aheri and not in CHC Dhanora. Both Dhanora and Aheri CHCs have
conducted the Tubectomy (95 & 133 respectively), Non-Scalpel Vasectomy (231 & 195
respectively), cataract (100 & 221 respectively), MTP (17 & 15 respectively) and surgical cases
(733 & 117).
31
Status of Performance of Labour Room during 2007-2008
In both the CHCs, the labour rooms are in use and deliveries are being conducted.
The number of deliveries conducted during 2007-2008 in Dhanora and Aheri is 70 and 275
respectively. Both the CHCs, though they are functioning on 24*7 basis, have not reported
deliveries between 8 pm to 8 am. The number of deliveries took place for the JSY card
holders is 27 in Dhanora and 31 in Aheri.

Status of Availability of Equipments

Out of 15 equipments listed in the questionnaire, only 8 are available in CHC
Dhanora and 10 in CHC Aheri. The equipments which are not available in both the hospitals
are Cardiac Monitor for OT, Defibrillator for OT, Ventilator for OT and Gloves and Dusting
Machines. In both the CHCs, the available equipments are in working condition.

Availability of Drugs
Out of the 25 listed drugs, CHC Dhanora reported stock out and irregular supply for
4 drugs and CHC Aheri reported stock out and irregular supply for 7 drugs during last six
months.

Availability of Specific Services

Out of the 24 available specific services listed, CHC Dhanora has 18 services and
CHC Aheri has all the 24 services.

Service Outcome
The service outcome statistics was collected from the CHCs for last three months.
Table C14 presents the ‘average monthly figure’ based on the data collected for the last
three months. The caste wise figures are also maintained by the hospitals for all the indicators.
As the CHC Aheri is a 100 bedded hospital, the figures reflect this. In most of the indicators,
the average monthly figures of Aheri are more than the figures for Dhanora which is a 30
bedded hospital. The Bed Occupancy Rate of the CHCs reveals that both hospitals are not
fully utilised. The BOR of Aheri is 68 percent and Dhanora is very low at 19 percent.

CHC-Dhanora: Remarks and Suggestions:

Remarks by MS: ‘We need clear guidelines to spend the NRHM grants. The guidelines
given currently are not clear. Training is necessary regarding the NRHM schemes to all the
32
PHC and SC staff. The hospital is currently 30 bedded and it should be increased to 50
bedded as the demand for health services is more in the area’.

Remarks/suggestions for the improvement of services by the observer: Earlier, the

CHC was functioning as PHC and later upgraded to CHC. However, still the CHC is
functioning in the old PHC building. After its upgradation to the CHC, the new buildings are
not constructed. Hence, the CHC needs the additional buildings and infrastructure as per the
CHC norms.

CHC-Aheri: Remarks and Suggestions

Remarks by MS: ‘We are serving in a remote backward tribal district of the state. Incentive
should be given for the specialist doctors for serving in the backward/tribal areas like this.
Funds for the RKS should be enhanced and clear guidelines should be provided for the
utilisation of the funds. As the performance our hospital is better, we need one more vehicle
for the smooth provision of the services’.

Remarks/suggestions for the improvement of services by the observer: The

performance of the hospital is relatively better. However, out of 13 medical staff sanctioned,
only 9 are currently in position. The vacancies in the medical category have to be filled-up to
enhance the performance of the hospital further.

33
 Community Health Centres

Table C1: Coverage and Availability of Infrastructure

CHC
Coverage and Availability of Infrastructure
Dhanora Aheri
Coverage
Population served by CHC 20,780 1,03,759
Distance & Time Taken to travel to CHC in public Distance Time (in Distance Time (in
transport / available mode from (in Kms) minutes) (in Kms) Minutes)
Nearest PHC in the coverage area 18 30 7 20
Farthest PHC in the coverage area 58 120 84 120
District Hospital 36 60 125 180
Number of beds available
Male 15 25
Female 15 25
Availability of Infrastructure (Yes:1; No: 0) Dhanora Aheri
Status of Building
Own government Building 1 1
Rented premises - -
Other Rent-free Building - -
Electricity in all parts:
No regular electricity supply - -
Regular electricity supply in all parts 1 1
30 or more beds 1 1
Generator 1 1
Telephone 1 1
Computer 1 1
Internet 1 1
Running Vehicle/Ambulance 1 0
Laboratory 1 1
Investigative facilities
ECG 0 1
X-Ray 1 1
Ultrasound 0 1
OT (Operation Theatre) 0 1
OT used for Gynaecology 1 1
Labour Room 1 1
Separate areas for septic and aseptic deliveries 1 1
New Born Care Corner 1 1
Pharmacy for drug dispensing and drug storage 1 1
Counter near entrance of CHC to obtain
1 1
contraceptives, ORS packets, Vitamin A medicines
Separate public utilities (toilets) for males & females 1 1
Suggestion / complaint box 1 1
OPD rooms / cubicles 1 1
Waiting room for patients 1 1
Waiting room have adequate sitting place 1 1
Drinking water available in the waiting area 1 1
Emergency Room / Casualty 0 1
Separate wards for males and females 1 1
Table 1 contd........

34
 CHC
Coverage and Availability of Infrastructure
Dhanora Aheri
Type of Sewerage System
Soak Pit 1 1
Open drain 0 0
Connected to Municipal Sewerage 0 0
Other 0 0
Waste disposal
Buried in a pit 1 1
Collected by an agency 0 0
Incineration 0 0
Thrown in open 0 0
Status of Cleanliness of OPD reported good or fair 1 1
Status of Cleanliness of Compound / Premises
1 1
reported good or fair
Status of Cleanliness of Room/Wards reported
1 1
good or fair
Prominent display boards regarding service
1 1
availability in local language
Names of JSY beneficiaries maintained in record 1 0

35
Table C2: Position of Medical Staff and Paramedical Staff

CHC
Dhanora Aheri
Type of Staff
Numbers Numbers in position Numbers Numbers in position
Sanctioned Regular Contractual Total Sanctioned Regular Contractual Total
Position of Medical Staff (clinical)
General Surgeon 0 0 0 0 1 0 0 0
Physician 0 0 0 0 1 1 0 1
Obstetrician / Gynaecologist 0 0 0 0 1 1 0 1
Medical Officer trained with short
1 1 0 1 1 1 0 1
term obstetrics course)
Paediatrician 1 1 0 1 1 1 0 1
Anaesthetist 0 0 0 0 1 1 0 1
Medical Officer trained with short
1 1 0 1 0 0 0 0
term Anaesthesia course)
General Duty Medical Officer 0 0 0 0 4 3 0 3
Eye Surgeon 0 0 0 0 1 0 0 0
Public Health Nurse 0 0 0 0 2 1 0 1
Position of Paramedical & Support Staff
Lady Health Visitor (LHV) 0 0 0 0 0 0 0 0
Block Extension Educator (BEE) 0 0 0 0 0 0 0 0
ANM 0 0 0 0 0 0 1 1
Staff Nurse 7 6 0 6 12 11 0 11
Dresser 0 0 0 0 0 0 0 0
Pharmacist/Compounder 1 1 0 1 3 2 1 3
Lab. Technician 2 2 0 2 1 1 0 1
Radiographer 1 1 0 1 0 0 0 0
Ophthalmic Assistant 1 1 0 1 1 0 0 0
Statistical Assistant/Data entry operator 1 0 1 1 0 0 0 0
OT attendant 0 0 0 0 1 0 0 0
Ambulance Driver 1 1 0 1 0 0 0 0
Registration Clerk 1 1 0 1 1 1 0 1

36
Table C3: Availability of Specific Services in CHC

CHC
Availability of Specific Services(Yes: 1; No: 0)
Dhanora Aheri
Functioning on 24x7 1 1
Functioning as FRU 1 1

Table C4: Status of Specific Interventions

CHC
Status of Specific Interventions (Yes: 1; No: 0)
Dhanora Aheri
IPHS Facility Survey done 1 1
Funds being electronically transferred from District 1 1
Registered Rogi Kalyan Samiti 1 1
RKS generating resources through user fees 1 1
Money generated by RKS being used 1 1
Display board showing no. of meetings & members of RKS 1 1
Feedback mechanism in place for grievances redressed by RKS 0 0
Citizens Charter publically displayed 1 1
All Standard Treatment Guidelines and Protocols available 1 1

Table C5: Status of Residential Facilities for Doctors and Other Staff

CHC
Residential Facilities (Yes: 1; No: 0)
Dhanora Aheri
For Doctors
Residential Facility for Doctors 1 1
Non-Occupied Residential Quarters 0 0
Reason for non-occupancy being poor condition/insecurity/
- -
lack of electricity and water supply
For Other Staff
Residential Facility for Staff 1 1
Non-Occupied Residential Quarters 0 0
Reason for non-occupancy being poor condition/insecurity/
- -
Lack of electricity and water supply

Table C6: Availability of Laboratory Facilities

CHC
Laboratory Testing (Yes: 1; No: 0)
Dhanora Aheri
Haemoglobin 1 1
Urine RE 1 1
Blood sugar 1 1
Blood grouping 1 1
Blood Smear 1 1
Bleeding time, clotting time 0 1
Diagnosis of RTI/ STIs with wet mounting, grams stain etc. 0 0
Blood smear examination for malaria parasite 1 1
Rapid test for Pregnancy 1 1
RPR test for Syphilis 1 1
Rapid test for HIV 1 1

37
Table C7: Number of Lab. tests done in CHC in last 3 calendar months

CHC
Type of tests done
Dhanora Aheri
Haemoglobin 488 1245
Urine RE 421 654
Blood sugar 13 168
Blood grouping 177 784
Blood Smear 8 224
Bleeding time, clotting time - 32
Diagnosis of RTI/ STIs with wet mounting, grams stain etc. - -
Blood smear examination for malaria parasite 4592 1950
Rapid test for Pregnancy 32 119
RPR test for Syphilis 43 97
Rapid test for HIV 406 563

Status of performance of OT

Table C8: Number of surgeries performed during 2007-2008

Number of surgeries
performed during 2007-2008
Type of surgeries
CHC
Dhanora Aheri
Caesarean Sections 0 34
No. of C-section deliveries for JSY Card holders 0 3
Surgical cases 733 117
Cataract 100 221
Tubectomy 95 133
Laproscopic Sterlisation 0 0
NSV 231 195
Conventional Vasectomy 0 0
MTP 17 15
Laprotomy 0 2

Table C9: Reasons for not conducting surgeries

(if OT available, but surgeries not conducted)

CHC
Reasons for not conducting deliveries(Yes: 1; No: 0)
Dhanora Aheri
Non availability of doctor/anaesthetist/staff 0 0
Lack of equipment/poor physical state of the operation theatre 0 0
No power supply in the OT 0 0
Other 0 0

38
Status of performance of Labour Room

Table C10: Status of performance of Labour Room during 2007-2008

Number of deliveries
performed during 2007-2008
Number of deliveries
CHC
Dhanora Aheri
Total Institutional Deliveries 70 275
Deliveries carried out from 8 pm to 8 am 0 0
Institutional deliveries for JSY card holders 27 31
Number of neonates resuscitated 0 0

Table C11: Reasons for not conducting deliveries

(if Labour room available but deliveries not conducted)

CHC
Reasons for not conducting deliveries (Yes: 1; No: 0)
Dhanora Aheri
Non availability of doctors/staff 0 0
Poor condition of the labour room 0 0
No power supply in the labour room 0 0

Table C12: Status of availability of equipments & drugs

Status of availability of equipments

CHC
Equipments available / working
Dhanora Aheri
(Yes:1; No: 0)
Available Working Available Working
Boyles Apparatus 1 1 1 1
ECG Machine 0 - 1 1
Cardiac Monitor for OT 0 - 0 -
Defibrillator for OT 0 - 0 -
Ventilator for OT 0 - 0 -
Horizontal High Pressure Sterilizer 0 - 1 1
Vertical High Pressure Sterilizer 2/3 drum capacity 1 1 1 1
OT Care Fumigation Apparatus 1 1 1 1
Gloves & Dusting Machines 0 - 0 -
Oxygen Cylinder 1 1 1 1
Hydraulic Operation Table 0 - 1 1
Resuscitation trolley 1 1 0 -
Phototherapy unit 1 1 1 1
MVA syringe 1 1 1 1
Baby incubator 1 1 1 1
Contd…..

39
Status of availability of drugs

CHC reporting stock out or irregular supply of

specific drugs in last 6 months (Yes: 1; No: 0)
Type of Drugs Dhanora Aheri
Irregular Irregular
Stock Out Stock Out
Supply Supply
Iron Folic Acid (IFA) 1 1 1 1
Oral Pills (OPs) 1 1 0 0
IUD 380 1 1 1 1
ORS (Oral Rehydration Salts) 1 1 1 1
ORS with Zinc adjutant as per policy 0 0 1 1
Vitamin A 1 1 1 1
Tab. Fluconazole 1 1 0 0
Tab. Metronidazole 1 1 1 1
Tab. Co-trimoxazole (Kid) 1 1 1 1
Tab. Nefidipine 0 0 1 1
Inj. Oxytocin 1 1 1 1
Inj. Gentamycin 1 1 1 1
Inj. Magnesium Sulphate 1 1 1 1
Tab. Misoprostal 0 0 0 0
Tab. Progestrone 0 0 0 0
Inj. Lignocaine Hydrochloride 1 1 1 1
Inj. Pentazocine Lactate 1 1 1 1
Inj. Adrenaline 1 1 1 1
Cap. Doxycycline 1 1 1 1
Silver Sulphadiazine oint. 1 1 0 0
IV Fluids 1 1 1 1
Inj. Prociane Penicillin 1 1 1 1
Inj. Atropine 1 1 1 1
Syp Amoxycyclin 1 1 0 0
IFA Syrup 1 1 0 0

40
Table C13: Availability of Specific Services (Yes: 1; No: 0)

CHC
Type of Service
Dhanora Aheri
Medicine 0 1
Surgery 0 1
Obstetric & Gynecology 0 1
Pediatrics 1 1
DOTS 1 1
Cataract Surgery 1 1
Leprosy diagnosis management and referral services 1 1
Emergency Services (24 Hrs) 1 1
Mobile Medical Unit 0 1
Separate Neo-natal Care Unit 1 1
Emergency Care for Sick Children 1 1
Full Range of Family Planning Services including Laproscopic ligation 1 1
Safe Abortion Services 1 1
Treatment of STI/RTI 1 1
Blood Storage facility 0 1
Counseling Facility on HIV/AIDS/STD etc 1 1
Voluntary Counselling and Testing Centre (VCTC) 1 1
AYUSH facility 0 1
Primary management of wounds 1 1
Primary management fracture 1 1
Primary management of cases of poisoning/snake, insect, scorpion bite 1 1
Primary management of dog bite 1 1
Primary management of burns 1 1
Management of RTI/STI 1 1

41
Table C14: Service Outcome (based on data for last three months)
Average monthly figure reported in CHC based on last
three months
Indicator
Dhanora Aheri
SC ST Others Total SC ST Others Total
Total ANC Registration 1 3 3 7 0 3 5 9
Total JSY cases registered 1 2 1 4 0 2 3 5
Ist Trimester Registration 0 2 2 4 0 2 3 5
ANC given 3 Checkups as per RCH Schedule 2 8 6 16 2 2 4 8
Out of above, the no. of JSY beneficiaries 2 8 2 12 0 2 3 5
ANC given TT (2nd dose+Booster) 1 2 2 5 1 4 8 13
Out of above, the no. of JSY beneficiaries 1 2 2 5 0 0 0 0
ANC completed IFA Prophylaxis 1 2 3 6 1 1 0.33 2
Out of above, the no. of JSY beneficiaries 1 2 2 5 0 0 0 0
Number of pregnant women identified and
0 1 0 1 4 4 4 12
attended with obstetric complications
Out of these, how many have been referred
0 1 0 1 3 4 3 11
from PHC/SHC
Total Institutional Deliveries 1 5 3 8 2 6 14 22
No. of JSY cases (out of total institutional
1 4 2 6 1 0.33 0 2
deliveries)
No. of infants given BCG 0 7 5 12 4 5 12 21
No. of infants given DPT3 0 1 0.33 1 1 4 11 16
No. of infants given Measles 1 1 3 4 1 2 7 10
No. of infants given Vit. A-first dose 1 1 3 4 1 2 6 9
Children given IFA Syp. (6-60 Months) 0 0 0 0 0 0 0 0
IUD Inserted 0.33 1 1 2 0.33 0 1 1
Total Indoor Patients 16 186 55 257 64 164 166 394
No. of cases referred beyond CHC 0.33 5 0 5 0.33 0.33 1 1
No. of Leprosy cases currently under
0.33 1 1 2 0 0 0 0
treatment
No. of new TB cases enrolled for DOTS 3 14 5 22 2 5 1 7
No. of cases given Blood Transfusion in last 3
0 42
months
Bed occupancy rate in the last 12 months?
19 68
(As on March 31, 2008)
Average Daily OPD Attendance – Total 65 98
Average Daily OPD Attendance - Male 29 37
Average Daily OPD Attendance - Female 27 40
Average Daily OPD Attendance – Children 19 21
Out of the total OPD attendance, specify the
NA NA
referred cases from PHC/SHC

42
 Chapter 4
Primary Health Centres

As per the study design, two PHCs are selected under the each selected CHC. The
selected PHCs are vertically under the CHCs. Under CHC Dhanora, the selected PHCs are
Rangi and Pendri. Under CHC Aheri, the selected PHCs are Mahagaon and PHC Kamalpur.
This chapter presents the information collected from these four PHCs.

Coverage and Facility

The number of SCs covered by these four PHCs varies from 7 to 15 and the
population covered varies from 11,348 to 56,781. The distance from the nearest SCs in the
coverage areas to these PHCs varies from 2 to 3 kilometres and distance from the farthest
SCs varies from 15 to 45 kilometres. Time taken to reach the PHCs from the nearest SCs
varies from 5 to 15 minutes and from the farthest SCs it varies from 20 to 120 minutes.

Out of the four PHCs, three (Rangi, Mahagaon and Kamalapur) are having 6 beds
each (3 male and 3 female beds each) and the other one (PHC Pendri) has 4 beds (2 male and
2 female). Two selected PHCs under CHC Dhanora and one PHC under CHC Aheri are
designated as 24*7 PHCs. However, in terms of functioning, none of the PHCs are
functioning as 24*7 (have 1 MO and 3 or more ANMs/Staff Nurses round the clock). All the
four PHCs are equipped to provide basic obstetrics services.

Infrastructure
Out of four PHCs, three are functioning from a designated government building and
all the three have labour room. One PHC is not functioning in a government building
(Mahagaon) and it does not have a labour room as well. All the four PHCs have laboratory.
Pharmacy for drug dispensing and drug storage is not available in two PHCs. Only two out of
four PHCs have put up a prominent display boards regarding service availability in local
language. Out of four PHCs, one is not maintaining the records containing the names of JSY
beneficiaries. OPD rooms/cubicles and regular electricity supply are available in all four
PHCs. Generator for power backup is available in three PHCs. Although piped water supply
is available in all the PHCs, the hand pumps and open wells in the PHCs run dry during the
summer months. Separate toilets for males and females are available in three PHCs. In three
of these PHCs, suggestion/complaint box is kept. Telephone is available in only one PHC,

43
three has computer and none of them have internet. Type of sewerage in these PHCs is either
a soak pit or open drain. Three PHCs dispose their bio-medical waste by burying in a pit and
one PHC throws it in open. None of the PHCs have New Born Care Corner. Three PHCs
have separate areas for septic and aseptic deliveries. As per our observation, the cleanliness of
OPD, compound/premises and rooms/wards are not good in three out of four PHCs.

Staff Position
In three PHCs (Rangi, Pendri and Mahagaon), all the sanctioned posts are filled in
either on a regular or contract basis. In PHC Kamalapur, out of 11 sanctioned posts, only 9
are filled in. Each PHC has a two sanctioned posts of Medical Officer. Only two PHCs have
two sanctioned medical officers each in position with them whereas the other two PHCs have
only one medical officer each with them. None of PHCs have sanctioned positions of Block
Health Education & Information Officer and Statistical Assistant. As for as ‘sanctioned posts’
and ‘number in position’ are concerned, PHCs are not in bad position. Except one PHC, the
remaining three PHCs have all the sanctioned posts in position.

Status of Training of Personnel at PHC

The staff in three PHCs (Rangi, Pendri and Kamalapur) have undergone Pre Service
IMNCI (Integrated Management of Neonatal and Child Infections) training. Staff from only
one PHC has undergone Skill Birth Attendant Training. Staff in none of the PHCs had
undergone training in Safe Abortion Methods and New Born Care.

Availability and Performance of Labour Room

Three out of four PHCs have labour rooms and all three of them use the labour
rooms for delivery. During 2007-2008, all these three PHCs together conducted 108
institutional deliveries, seventeen 8 pm to 8 am deliveries and 56 institutional deliveries for
JSY card holders. The performance of the three PHC varies in terms of number of
institutional deliveries, 8 pm to 8 am deliveries and institutional deliveries for JSY card
holders. One PHC which is not functioning in a designated government building (Mahagaon)
is not having a labour room. Hence the PHC did not conduct any delivery during the year.
Overall, the performance of the PHCs in terms of number of deliveries conducted during the
year is very poor.

44
Availability of Laboratory Testing in PHC
The laboratory tests that are available in all four PHCs are Blood Smear Examination
for Malaria Parasite and Rapid Test for Pregnancy. Haemoglobin, Urine RE and Blood Smear
tests are available in three PHCs. Blood Sugar and Blood Grouping are available only in one
out of four PHCs. None of the PHC have the testing facility for Bleeding and Clotting Time,
Diagnosis of RTI/STI, RPR Test for Syphilis and Rapid Tests for HIV. The PHCs have
reported the figures for number of laboratories testing done during the last three months.

Status of Specific Interventions

IPHS facility survey has not been done in any of the PHCs. None of the PHCs are
functioning on 24*7 basis (have 1 MO and 3 or more ANMs/Staff Nurses round the clock).
AYUSH doctor is not available in any of the PHCs. All the four PHCs have registered RKS.
However, only two PHCS have display boards showing the composition of the RKS with the
names of the members and number of meetings held. In none of the PHCs RKS is generating
resources through user fees. In three PHCs feedback mechanism is in place for grievances
redressed by RKS. All standard treatment guidelines and protocols are available with the
PHCs. Citizens charter is publicly displayed in two PHCs.

Availability of Specific Services

All the four PHCs have the specific services for primary management of wounds,
fracture, poisoning/snake/insect/scorpion bite and dog bite. Facility for management of
malnourished children, minor surgeries, primary management of burns and Management of
RTI/STI is available in 3 out of 4 PHCs. Management of neonatal asphyxia is available in
only in one PHC. Facility for MTP is not available in any of the PHCs.

Availability of Selected Equipments in PHC

The information collected for the 23 equipments in the PHCs shows that PHC Pendri
has 19 equipments, PHC Rangi has 18 equipments and PHCs Mahagaon and Kamalapur have
17 equipments each with them. The equipments which are not available in any of the PHCs
are Radiant Warmer, Cradle and Auto Analyser. The equipments which are available with the
PHCs are mostly in working condition.

Status of Availability of Drugs

The status of availability of drugs in last six months shows that PHC Mahagaon under
CHC Aheri did not face any stock out or irregular supply in any of the 25 drugs. Kamalapur
45
PHC reported stock out in 8 drugs. The two PHCs under CHC Dhanora faced either the
stock out or irregular supply in several drugs. PHC Rangi reported irregular supply in 13 out
of 25 drugs and PHC Pendri reported stock out in 13 out of 25 drugs in last six months.

Service Outcome
The service outcome statistics was collected from the PHCs for last three months
prior to the survey. Table P12 presents the ‘average monthly figure’ based on the data
collected for the last three months. The caste wise break-up is also maintained by the PHCs
for all the indicators. All the four PHCs have reported the JSY cases and institutional
deliveries for JSY cases. All the four PHCs together have registered 72 JSY cases on average
per month. The average number of institutional deliveries reported by the four PHCs
together is 50 per month. Out of these, 32 are JSY cases. It means that, among the
institutional deliveries took place in these four PHCs together during the last three months,
64 percent are JSY cases. All the four PHCs together have conducted 61 male sterilizations 18
female sterilisations per month. The average monthly number of outdoor patients reported by
the four PHCs is 592, 532, 255 and 410. The caste wise break-up shows that the ST
population use the PHC facilities more than the ‘Other’ caste groups. The average monthly
number of indoor patients reported by the four PHC (6, 21, 10 and 28) indicates the under
utilisation of IPD facilities. The PHC wise performance shows that the PHCs under CHC
Aheri have done better compared to the PHCs under CHC Dhanora.

Status of Record Maintenance

One PHC (Kamalapur) is maintaining all the nine registers for which the information
was collected and another PHC (Rangi) is maintaining eight out of nine registers. PHC Pendri
is maintaining five registers and PHC Mahagaon is maintaining only one Register. JSY
Register and Untied Funds Register are being maintained by three out of four PHCs.

Remarks and Suggestions

PHC: Rangi

Comments by MO: ‘Guidelines to utilise the Untied Funds and RKS funds are not clear.
The same should be provided. The PHC is designated as 24*7. However, the staff are not
provided as per the norm. Unless we get the staff as per 24*7 norms, we cannot effectively
function as 24*7 PHC. As we face the irregular supply of drugs very often, we need an
46
uninterrupted supply of drugs. Currently the PHC vehicle is not on road and it cannot be
repaired. We need a new vehicle’ (PHC Rangi).

Remarks/suggestions for the improvement of services by the observer: Water supply is

not available in the PHC for most part of the year as both the hand pump and the open well
run dry few months after the monsoon season. The PHC has reported an average of only 6
IPD patients per month during the last three months. The terrain is hilly and road and
transport facility are very poor in the area.

PHC: Pendri

Comments by MO: ‘Provide staff as per 24*7 PHC norm. Supply all the drugs regularly as
per the requirement. We are not clear about the guidelines for spending the grants received
under NRHM. New vehicle has to be provided as the existing one is not on road. This is
completely a tribal area, without vehicle it would be difficult to provide the services’ (PHC
Pendri).

Remarks/suggestions for the improvement of services by the observer: Compound wall

is needed for the PHC. The terrain of the area is hilly and dense forest. With the poor road
and transport facilities, people have the difficulty in accessing the PHC.

PHC: Mahagaon

Comments by MO: ‘Our PHC is functioning without a building. We need the building and
staff quarters for the PHC very soon. We are currently functioning from a space provided in a
corner of a temple by the Gram Panchayat’.

Suggestions: The building has to be constructed for this PHC as soon as possible by the
authorities.

47
 Primary Health Centres

Table P1: Coverage and Facilities of Primary Health Centre

CHC 1 (Dhanora) CHC 2 (Aheri)

Coverage and facilities PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Number of Sub-Centres
7 8 15 10
covered by PHC
Population covered 11,348 13,726 56,781 17,632
Distance& time taken to Distance Time (in Distance Time (in Distance Time (in Distance Time (in
travel in public transport (in Kms.) Minutes.) (in Kms.) Minutes.) (in Kms.) Minutes.) (in Kms.) Minutes.)
/ available mode from
Nearest Sub Centre in
3 5 3 15 2 10 0 0
the coverage area
Farthest Sub Centre
15 30 22 60 32 40 45 60
in the coverage area
Nearest CHC 18 30 60 120 7 20 43 45
No. of Beds available
Male 3 2 3 3
Female 3 2 3 3
Total 6 4 6 6
PHC functioning on
0* 0* 0 0*
24x7 basis (Yes:1; No: 0)
PHC equipped to
provide basic obstetric 1 1 1 1
services (Yes:1; No: 0)
PHC with 4-6 beds
1 1 1 1
(Yes:1; No: 0)
∗ These PHCs are designated as 24*7 PHCs. However, in terms of functioning, none of them are
functioning as 24*7 PHC (1 MO and 3 or more ANMs/Staff Nurses round the clock).

48
Table P2: Primary Health Centres by Infrastructure

CHC 1 (Dhanora) CHC 2 (Aheri)

Infrastructure PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
PHC functioning in designated govt. building
1 1 0 1
(Yes:1; No: 0)
Labour Room (Yes:1; No: 0) 1 1 0 1
Laboratory (Yes:1; No: 0) 1 1 1 1
Prominent display boards regarding service
0 1 0 1
availability in local language (Yes:1; No: 0)
Names of JSY beneficiaries maintained in record
1 1 0 1
(Yes:1; No: 0)
Pharmacy for drug dispensing and drug storage
0 1 0 1
(Yes:1; No: 0)
Separate public utilities (toilets) for males and females
1 1 0 1
(Yes:1; No: 0)
Suggestion / complaint box (Yes:1; No: 0) 1 1 0 1
OPD rooms / cubicles (Yes:1; No: 0) 1 1 1 1
Piped Water Supply (Yes:1; No: 0) 1 1 1 1
Electricity Supply
No regular electricity supply (Yes:1; No: 0) 0 0 0 0
Regular electricity supply in all parts(Yes:1; No: 0) 1 1 1 1
Telephone (Yes:1; No: 0) 0 0 0 1
Computer (Yes:1; No: 0) 1 1 0 1
Internet (Yes:1; No: 0) 0 0 0 0
Type of sewerage system (Yes:1; No: 0)
Soak pit 1 1 0 0
Connected to Municipal Sewerage 0 0 0 0
Open Drain 0 0 1 0
Other 0 0 0 1
Waste disposal(Yes:1; No: 0)
Buried in a pit 1 1 0 1
Collected by an agency 0 0 0 0
Incineration 0 0 0 0
Thrown in open 0 0 1 0
Standby facility (generator etc.) available in working
1 1 0 1
condition (Yes:1; No: 0)
Separate areas for septic and aseptic deliveries
1 1 0 1
available? (Yes:1; No: 0)
New Born Care Corner available? (Yes:1; No: 0) 0 0 0 0
Status of Cleanliness of OPD reported good or fair 0 0 0 1
Status of Cleanliness of Compound / Premises
0 0 0 1
reported good or fair
Status of Cleanliness of Room/Wards reported good
0 0 0 1
or fair

49
Table P3: Staff Position of in Primary Health Centre

CHC 1 (Dhanora) CHC 2 (Aheri)

Type of Staff PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur)
Numbers in Position Numbers in Position Numbers in Position Numbers in Position
S S S S
R C T R C T R C T R C T
Medical Officer 2 1 0 1 2 2 0 2 2 0 1 1 2 2 0 2
Pharmacist 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1
Nurses 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1
ANM 1 1 1 2 2 2 0 2 3 3 1 4 1 1 0 1
Lab Technician 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1
Driver 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1
Medical Officer AYUSH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Staff Nurse 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
Lady Health Visitor 2 2 1 3 2 2 0 2 4 3 1 4 2 2 0 2
Lab Assistant 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
Block Health Education
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
and Information Officer
Statistical Assistant 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
S: Sanctioned; R: Regular; C: Contractual; T: Total

50
Table P4: Status of training of personnel at Primary Health Centre

PHC having personnel trained in specific category of

training during 2007 (Yes:1; No: 0)
Training CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Pre Service IMNCI 1 1 0 1
Safe Abortion Methods 0 0 0 0
Skill Birth Attendant Training 1 0 0 0
New Born Care 0 0 0 0

Table P5: Availability of Labour Room in Primary Health Centre

(Yes:1; No: 0)
Labour Room CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Availability of Labour Room 1 1 0 1
Labour Room Currently in Use 1 1 - 1
Reasons for not using Labour Room
Non availability of doctors/staff - - - -
Poor condition of the labour room - - - -
No power supply in the labour room - - - -
Other - - - -

Table P6: Status of performance of Labour Room during 2007-2008

Number of deliveries performed in PHC during

2007-2008
Number of deliveries CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Total Institutional Deliveries 30 29 - 49
Deliveries carried out from
0 0 - 17
8 pm to 8 am
Institutional deliveries for JSY card
40 5 - 11
holders
Number of neonates resuscitated 0 0 0 0

51
Table P7: Availability of laboratory Testing in PHC

(Yes:1; No: 0)
Availability Laboratory Testing CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Haemoglobin 1 1 1 0
Urine RE 0 1 1 1
Blood sugar 1 0 0 0
Blood grouping 0 1 0 0
Blood Smear 0 1 1 1
Bleeding time, clotting time 0 0 0 0
Diagnosis of RTI/ STIs with wet
0 0 0 0
mounting, grams stain etc.
Blood smear examination for malaria
1 1 1 1
parasite
Rapid test for Pregnancy 1 1 1 1
RPR test for Syphilis 0 0 0 0
Rapid test for HIV 0 0 0 0

Table P8: Number of tests done in PHC in last three calendar months

Number of tests done in last 3 calendar months

Type of Test CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) Mahagaon) (Kamalapur)
Haemoglobin 44 19 0 -
Urine RE - 14 23 15
Blood sugar 8 - - -
Blood grouping - 50 - -
Blood Smear - 0 238 -
Bleeding time, clotting time - - - -
Diagnosis of RTI/ STIs with wet
- - - -
mounting, grams stain etc.
Blood smear examination for malaria
3010 3362 0 4880
parasite
Rapid test for Pregnancy 17 5 3 21
RPR test for Syphilis - - - -
Rapid test for HIV - - - -

52
Table P9: Status of Specific Interventions

(Yes:1; No: 0)
Status of Specific Interventions CHC 1 (Dhanora) CHC 2 (Aheri)
PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
IPHS Facility Survey done 0 0 0 0
PHC functioning on 24 x 7 basis (have 1
MO and 3 or more ANMs / Staff Nurses 0 0 0 0
round the clock)
AYUSH doctor providing services 0 0 0 0
Registered Rogi Kalyan Samiti 1 1 1 1
RKS generating resources through user fees 0 0 0 0
Money generated by RKS being used - - - -
Display board showing no. of meetings &
0 1 0 1
members of RKS
Feedback mechanism in place for
1 1 0 1
grievances redressed by RKS
Citizens Charter publically displayed 1 1 0 0
All Standard Treatment Guidelines and
1 1 1 1
Protocols available
Availability of Specific Services
Primary management of wounds 1 1 1 1
Primary management fracture 1 1 1 1
Management of Neonatal asphyxia, sepsis 0 1 0 0
Management of malnourished children 0 1 1 1
Minor surgeries like draining of abscess etc 0 1 1 1
Primary management of cases of
1 1 1 1
poisoning/snake, insect or scorpion bite
Primary management of dog bite cases 1 1 1 1
Primary management of burns 1 0 1 1
Facility for MTP available 0 0 0 0
Management of RTI/STI 0 1 1 1
AYUSH services 0 0 0 0

53
Table P10: Availability of selected equipments in PHC

(Yes:1; No: 0)
CHC 1 (Dhanora) CHC 2 (Aheri)
Equipments available PHC 1 PHC 2 PHC 1 PHC 2
/ working (Rangi) (Pendri) (Mahagaon) (Kamalapur)
Availa- Work- Availa- Work- Availa- Work- Availa- Work-
ble ing ble ing ble ing ble ing
Patient Trolley 1 1 1 1 0 - 0 -
Examination table 1 1 1 1 1 1 1 1
Delivery table 1 1 1 1 1 1 1 1
Wheel chair 1 1 1 1 0 - 1 1
Stretcher/ trolley 1 1 1 0 1 1 1 1
Oxygen Cylinder 1 1 1 1 1 1 1 1
Suction Apparatus 1 1 1 1 1 1 1 1
Infant warmer 0 - 1 1 1 0 1 1
Radiant Warmer 0 - 0 - 0 - 0 -
Cradle 0 - 0 - 0 - 0 -
Autoclave 1 1 1 1 1 1 1 1
Sterlisation equipment 1 0 0 - 1 1 1 1
Bag & Mask 1 1 1 1 1 1 1 1
Laryngoscope 1 1 1 1 1 1 0 -
Oxygen Mask 1 1 1 1 1 1 1 1
Thermometer 1 1 1 1 1 1 1 1
Suction Machine 1 0 1 1 1 1 1 1
Water Purifier 1 1 1 0 1 1 1 1
Microscope 1 1 1 1 1 1 1 1
Haemoglobinometer 1 1 1 1 1 1 1 1
Auto Analyser 0 - 0 - 0 - 0 -
Autoclave 1 1 1 1 0 - 1 1
Resuscitation Equipment 0 - 1 1 1 1 0 -

54
Table P11: Status of Availability of Drugs
PHC reporting stock out or irregular supply of specific drugs
in last 6 months (Yes:1; No: 0)
CHC 1 (Dhanora) CHC 2 (Aheri)
Type of Drugs PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Stock Irregular Stock Irregular Stock Irregular Stock Irregular
Out Supply Out Supply Out Supply Out Supply
IFA tablets 0 0 0 0 0 0 0 0
Iron Syrup 0 0 1 1 0 0 0 1
Oral Pills 0 0 0 0 0 0 1 0
Vitamin A 0 0 0 0 0 0 0 1
Measles Vaccine 1 1 1 1 0 0 0 1
ORS 0 0 0 0 0 0 0 1
Tab. Methergin 1 1 1 1 0 0 0 0
Tab. Albendazole/
1 1 0 0 0 0 0 0
Mabendazole
IUDs 0 0 1 0 0 0 0 0
Inj oxytocin 1 1 0 0 0 0 0 0
Magnesium sulphate 0 0 1 1 0 0 1 0
Tab. Fluconazole 0 0 0 0 0 0 0 1
Partograph 1 1 0 0 0 0 1 0
MVA syringe 0 0 0 1 0 0 1 1
Tab Ciprofloxacin 1 1 1 1 0 0 0 1
Syp Cotrimoxazole 0 0 1 1 0 0 0 1
Syp Paracetamol 1 1 1 1 0 0 0 1
Ringer’s Lactate 1 1 1 1 0 0 0 0
Haemoccele 0 0 0 0 0 0 1 0
AD syringes 1 1 1 1 0 0 1 1
Disposable Gloves 1 1 1 1 0 0 0 1
Bandages 1 1 1 0 0 0 0 0
AYUSH drugs 0 0 1 0 0 0 1 0
DOTS drugs 1 1 1 0 0 0 0 0
MDT drugs, blister
1 1 0 0 0 0 1 0
packs

55
Table P12-A: Service Outcome (based on data for last three months)

CHC 1 (Dhanora)
Average monthly number reported
Indicator
in PHC 1 (Rangi)
SC ST Others Total
Total ANC Registration 1 8 3 12
Total JSY cases registered 0.33 8 1 9
Ist Trimester Registration 1 3 1 5
ANC given 3 Checkups 0.33 2 2 4
ANC given TT1 0.33 4 2 7
ANC given TT2+Booster 0 7 3 10
ANC completed IFA Prophylaxis 1 6 5 12
Total Institutional Deliveries 0.33 6 2 8
No. of JSY cases (out of total institutional deliveries) 1 6 1 7
No. of infants given BCG 0.33 13 2 15
No. of infants given DPT3 0.33 9 3 12
No. of infants given Measles 1 7 2 10
No. of infants given Vit. A-first dose 0 0 0 0
Children given IFA Syp. 0 0 0 0
IUD Inserted 0 1 1 2
Male sterilisation carried out 1 6 1 9
Female sterilisation carried out 0.33 1 1 2
Total indoor patients - - - 6
Total outdoor patients - - - 592
RTI/STI cases treated 0 0 0 0
Number of maternal deaths in 2007-2008 0 0 0 0
No. of cases of obstetric complications referred beyond PHC 1 3 1 5
No. of cataract surgeries carried out 0 0 0 0
No. of new TB cases enrolled for DOTS 0 1 0 1
No. of new leprosy cases registered for MDT 0.33 0.33 0 1
No. of leprosy cases completed treatment for leprosy 0 0 0 0

56
Table P12-B: Service Outcome (based on data for last three months)

CHC 1 (Dhanora)
Average monthly number reported
Indicator
in PHC 2 (Pendri)
SC ST Others Total
Total ANC Registration 0.33 18 2 20
Total JSY cases registered 1 12 1 13
Ist Trimester Registration 0 6 1 7
ANC given 3 Checkups 1 21 1 23
ANC given TT1 0.33 11 2 14
ANC given TT2+Booster 0.33 22 2 24
ANC completed IFA Prophylaxis 0.33 16 1 17
Total Institutional Deliveries 0 3 0.33 3
No. of JSY cases (out of total institutional deliveries) 0 3 0 3
No. of infants given BCG 0 17 2 19
No. of infants given DPT3 1 20 0.33 21
No. of infants given Measles 0 15 1 16
No. of infants given Vit. A-first dose 0 15 1 16
Children given IFA Syp. 0 0 0 0
IUD Inserted 0 5 1 6
Male sterilisation carried out 0 10 0 10
Female sterilisation carried out 0 0 0 0
Total indoor patients - - - 21
Total outdoor patients - - - 532
RTI/STI cases treated 0 11 3 14
Number of maternal deaths in 2007-2008 0 0 0 0
No. of cases of obstetric complications referred beyond PHC 1 3 0.33 4
No. of cataract surgeries carried out 0 0.33 0 0.33
No. of new TB cases enrolled for DOTS 0 0 0 0
No. of new leprosy cases registered for MDT 0 0 0 0
No. of leprosy cases completed treatment for leprosy 0 0 0 0

57
Table P12-C: Service Outcome (based on data for last three months)

CHC 2 (Aheri)
Average monthly number reported
Indicator
in PHC 1 (Mahagaon)
SC ST Others Total
Total ANC Registration 6 26 28 60
Total JSY cases registered 4 22 14 40
Ist Trimester Registration 4 21 25 50
ANC given 3 Checkups 10 24 22 56
ANC given TT1 8 27 21 57
ANC given TT2+Booster 11 32 33 77
ANC completed IFA Prophylaxis 5 7 10 22
Total Institutional Deliveries 5 6 22 32
No. of JSY cases (out of total institutional deliveries) 3 7 7 17
No. of infants given BCG 23 47 53 123
No. of infants given DPT3 13 28 31 72
No. of infants given Measles 13 22 37 72
No. of infants given Vit. A-first dose 13 22 37 72
Children given IFA Syp. 0 0 0 0
IUD Inserted 2 4 1 7
Male sterilisation carried out 1 11 8 20
Female sterilisation carried out 2 4 10 16
Total indoor patients 7 2 1 10
Total outdoor patients 162 58 35 255
RTI/STI cases treated 4 7 5 16
Number of maternal deaths in 2007-2008 0 0 0 0
No. of cases of obstetric complications referred beyond PHC 0 0 0 0
No. of cataract surgeries carried out 0 0 0 0
No. of new TB cases enrolled for DOTS 0 0 0 0
No. of new leprosy cases registered for MDT 0 0 0.33 0.33
No. of leprosy cases completed treatment for leprosy 0.33 0.33 0 1

58
Table P12 D: Service Outcome (based on data for last three months)

CHC 2 (Aheri)
Average monthly number reported
Indicator
in PHC 2 (Kamalapur)
SC ST Others Total
Total ANC Registration 4 13 5 22
Total JSY cases registered 2 6 2 10
Ist Trimester Registration 3 10 4 17
ANC given 3 Checkups 4 13 5 22
ANC given TT1 3 11 4 18
ANC given TT2+Booster 5 13 6 24
ANC completed IFA Prophylaxis 12 12 4 22
Total Institutional Deliveries 2 3 3 7
No. of JSY cases (out of total institutional deliveries) 1 1 3 5
No. of infants given BCG 2 10 7 19
No. of infants given DPT3 7 20 6 34
No. of infants given Measles 7 12 5 24
No. of infants given Vit. A-first dose 7 12 5 24
Children given IFA Syp. 19 34 27 81
IUD Inserted 1 2 1 4
Male sterilisation carried out 2 16 4 22
Female sterilisation carried out 0 0 0 0
Total indoor patients 12 9 7 28
Total outdoor patients 148 104 158 410
RTI/STI cases treated 5 9 7 21
Number of maternal deaths in 2007-2008 0 00 0 0
No. of cases of obstetric complications referred beyond PHC 1 0.33 1 2
No. of cataract surgeries carried out 0 0 0 0
No. of new TB cases enrolled for DOTS 1 1 1 2
No. of new leprosy cases registered for MDT 0 0 0 0
No. of leprosy cases completed treatment for leprosy 0 0 0 0

59
Table P13: Status of record maintenance (Yes: 1; No: 0)
CHC 1 (Dhanora) CHC 2 (Aheri)
Type of Records PHC 1 PHC 2 PHC 1 PHC 2
(Rangi) (Pendri) (Mahagaon) (Kamalapur)
Ante Natal Register 1 0 0 1
Eligible Couple Register 0 0 0 1
Post Natal Care Register 1 0 0 1
Family Planning Register 1 1 0 1
Birth & Death Register 1 1 0 1
Immunisation Register 1 0 0 1
Meeting Register 1 1 1 1
JSY Register 1 1 0 1
Untied Funds Register 1 1 0 1

60
 Chapter 5
Sub Centre

As per the study design, three SCs are to be covered for the survey under each
selected PHCs and one of the three SCs should be farthest from the PHC. Accordingly, we
have covered 12 SCs under four PHCs. The list of selected SCs as per the study design is
given in Table 2 of the introductory chapter.

Coverage by Sub Centres

Table S1 shows that the number of villages covered by the SCs varies from 2 to 6 and
the population covered varies from 376 to 3,627. The average number of villages covered by
the SCs is 4.4 and average population covered is 1,741. The average distance between the
PHC and SC is 15 kilometres and the actual distance varies between 0 and 35 kilometres. The
average time taken to travel in public/available mode of transport from furthest village to SC
is 43 minutes, from SC to PHC is 29 minutes and SC to CHC is one hour. Out of the 12 SCs,
ASHAs are working only in three SCs. The number of ASHAs working under the three SCs is
6 and the average for all the 12 SCs turns out to be 0.5.

Availability of Infrastructure
All the 12 SCs are run from the designated government building. IPHS facility survey
has been done in three fourth of the SCs. Labour room is available in 11 SCs. None of the
SCs have piped water supply. Regular electricity is available in 10 SCs and telephone is
available in 8 SCs. The type of sewerage system of the SCs shows that six SCs have soak pit,
four SCs release their sewerage through open drain and in two SCs it is connected to a
sewerage line. Three fourth of the SCs dispose their bio-medical waste by burying in a pit and
one fourth throw it in open.

Residential Status of ANM

Ten SCs have quarters for ANM. Among the ten SCs with ANM quarters, in nine SCs
the ANMs are staying in quarters and in one SC the ANM is not staying the quarter. The
reason cited by the ANM for not staying in SC quarter is lack of security and non availability
of water/power facility in the SC.

61
Availability of Staff
The availability of staff in the SCs shows that 11 SCs have both male and female
health workers in position. In one SC, only a female health worker is in position. In other
words, all the 12 SCs are having female health worker in regular position. Three SCs have
contractual ANMs and all these three SCs also have regular female health worker.

Availability of Labour Room and number of deliveries conducted

As mentioned above, 11 SCs (92 percent) have labour rooms. Among the 11 SCs with
labour room, nine are using their labour room and two are not using. The nine SCs with
labour room in use together conducted 103 deliveries during the year 2007-2008 and the
average turns out to be 11.5 deliveries. The nine SCs which are using the labour room also
conduct the deliveries between 8 pm to 8 am. The performance of the SCs, in terms of
number of deliveries conducted during the year, is very low.

Availability of Equipments
Only one SC has all the 12 listed equipments available with it and another two SCs
have 10 equipments with them. The remaining SCs have less than 10 equipments and four of
them have six or less than six equipments. Haemoglobinometer is available in all the 12 SCs
and Fetoscope is available in 11 SCs. BP Apparatus and Weighing Machine are available in 10
SCs. Regent Strips for Urine Test is available in nine SCs. Thermometer and Bag & Mask are
available in seven SCs. Sterilizer, Suction Machine, Height Measuring Scale, Cuscos Speculum
and Muscus Extractor are available only half or less than half of the SCs. Except few cases,
most of the equipments available with the SCs are by and large in working condition.
Sterilizer is available in six SCs and in two SCs it is not in working condition.

Availability of Drugs
Availability of drugs on the date of survey was collected from the SCs. The
information was obtained for 16 drugs. The availability of drugs shows the mixed picture.
Out of 16 drugs, five SCs have reported the availability of less than 10 drugs on the date of
survey. Three SCs have reported the availability of 12-13 drugs and four SCs have reported 10
drugs. Oral Pills and Condoms were available with all the 12 SCs. Iron Folic Acid and DDK
were available with 11 SCs. ORS and Disposable Gloves were available in 9 SCs. Partograph
was available in only one SC. The following four drugs were available with less than 50
percent of SCs on the date of survey: Emergency Contraceptive Pill, IUD, Tab Misoprostal
and Partograph.
62
Specific Skills and Procedures
ANMs in all the 12 SCs reported that they (i) register pregnancy within three months,
(ii) carryout 3 ANC visits as per the RCH schedule, (iii) carry out specific examinations like
Blood Pressure, Haemoglobin and Urine, and (iv) provide immunisation services. Ten out of
12 ANMs reported that they identify high risk pregnancies and nine out of 12 reported that
they provide TT injection and IFA tablets. None of the ANMs is carrying out IUCD
insertion/removal. None of the ANMs reported that they are trained on insertion/removal of
IUCD A380. Out of 12, only five ANMs reported that they are trained in syndromic
treatment of RTI/STI.

Service Outcome
The service outcome data for the last three months show that, on an average, each
ANM has registered 7 ANCs. Out of the total ANCs, the average number registered by the
ANMs in 1st Trimester is 3.4. The average number for the three ANC visits as per RCH
schedule is 3.4 in last three months. During the last three months, on an average, each ANM
has identified 1.2 high risk cases, conducted 3.8 deliveries and referred one pregnant woman
to next higher facility. The number of neonate infections during the last three months and
IUCD insertions are nil in the SCs during the reference period. The service outcome data
reveal that the performance of the ANMs varies across the SCs.

Status of Record Maintenance

To know the status of record maintenance, the information was collected for 11
registers from the SCs. It shows that, six registers (Household Survey Register, Antenatal
Register, Post Natal Register, Birth and Death Register, Immunisation Register, and JSY
Register) are maintained by all the 12 SCs. Eligible Couple Register, Meeting Register and
Untied Funds Register are being maintained by 92 percent of the SCs. Three-fourth of SCs
maintain Family Planning Register and two third of the SCs maintain Cash Book. The record
maintenance by each individual SC shows that 6 SCs maintain all the 11 registers, four
maintain 10 registers, 1 maintains 9 registers, and another one maintains 8 registers. The
records maintenance by and large appears to be good in the SCs of the district.

Awareness about JSY

Awareness about the JSY and the amounts to be given to the beneficiaries are
universal among the ANMs. Only six out of twelve ANMs reported that there is an increase
in the demand for institutional deliveries after the implementation of the JSY scheme.
63
Procedure under JSY Scheme
Two third of the ANMs reported that the JSY beneficiaries are being paid by cheque
and remaining one third reported that the beneficiaries are being paid by cash. Only one third
of the ANMs reported that the JSY beneficiaries are paid within a week after the delivery and
rest of the ANMs reported that the beneficiaries are being paid after one (50 percent) or two
weeks (17 percent) later. Nine out of 12 ANMs reported that the transport support is
available under JSY for shifting the pregnant woman from SC to PHC, in case of emergency.
Eleven out of 12 ANMs said that the Register is available with them to record JSY
expenditure.

Performance of ANM under JSY Scheme

All the 12 SCs together have registered 64 JSY cases during the last three calendar
months and the average number per SC turns out to be 5.3 cases. However, three SCs have
not registered any JSY cases during the last three calendar months. The average number of
JSY cases resulted in institutional deliveries during the last three months is 4. The average
amount disbursed for JSY cases in last three calendar months by the SCs is Rs. 3,408. The
performance of SCs/ANMs under JSY varies considerably across the SCs.

During the financial year 2007-2008, the average amount disbursed under JSY by the
SCs for home deliveries and institutional deliveries is Rs. 2,467 and Rs. 2,517 respectively.
Only three SCs have reported the transport costs under the JSY and the average turns out to
be Rs. 125/- per SC. None of the SCs have made any payment to the ASHAs during the year
2008-2009. It should be noted that only in 3 out of 12 SCs, ASHAs are working/appointed.

Status of Untied Grants

Seven out of 12 SCs have received the Untied Grants. Among those received the
Untied Grants, all of them reported the expenditure from the grants. All the seven SCs which
received the grant are having joint bank account with the Sarpanch/any other GP
functionary. Six out of seven SCs are maintaining the register to record the decision taken to
spend the grant. Five out of seven SCs reported that the Sarpanch/others have reviewed the
expenditure records. The seven SCs which received the Grants have reported the following
expenditure from the Untied Grants: purchase of drugs (57 percent), arranging transport (14
percent), water coolers for patients (29 percent), and whitewash/maintenance (71 percent).

64
Remarks by Sub Centres

The remarks given by some of the ANMs regarding the programmes are given below in their
own words (the name of the SC is given brackets):

1. ‘Guidelines regarding how to spend the Untied Fund are not clear to me. SC needs a
compound wall. Drug supply should be regular. As the area is covered with dense forest
and roads are not there for the villages, government should provide a two wheeler to
visit the area’ (SC Nimgaon).

2. ‘JSY fund reaches me very late. Due to this I am not in a position to pay the
beneficiaries on time. Many times, I pay the beneficiaries much later after the delivery.
This makes the beneficiaries unhappy about me. I am not getting the Untied Fund for
the year in one instalment’ (SC Chichoda).

3. ‘I do not receive the JSY money on time from PHC. The bank is 70 kilometres away
from the SC. Due to this the clients and me face lot of difficulty to en-cash the cheque.
Hence beneficiaries should be directly provided with cash’ (SC Durgapur).

4. ‘There is no separate building for the SC. However, SC is functioning from a PHU
(Primary Health Unit). I don’t have a residential quarter in PHU. I should be provided
with a residential quarter as this area doest not have proper transport facility’ (SC
Devalmari).

5. ‘Myself and Sarpanch have opened a joint account with the bank to operate the Untied
Fund. However, after sometime, the Sarpanch has passed away. I am not in a position to
operate the bank account now and nobody from the Gram Panchayat comes forward to
open the account. The unspent balance available in the bank is Rs. 13,743/-. I don’t
have delivery table in the SC, but I am not able to buy now’ (SC Yelchil).

6. ‘Since November 2007, I have not received the money for JSY cases. I am not able to
disburse the amount for the JSY beneficiaries from November 2007’ (SC Dhamarincha).

7. ‘Gram Panchayat is expecting the Untied Funds to be given to them directly. Due to
this, I face difficulty in spending the money (SC Guddigudam)’

65
Suggestions:

1. This SC has five villages under its coverage. The terrain has dense forest and no public
transport available to reach the villages. The ANM visits these villages by her bicycle.
The ANM should be provided with a two wheeler to serve the area effectively (SC
Michgaon).

2. The SC area is dominated by Telugu speaking people. The ANM cannot speak /
understand Telugu. An ANM from the local area who can speak the local language
should be appointed in this SC (SC Devalmari).

3. Untied Fund allotted to the SC is not used for the last two years due to the difficulty in
operating the joint account. Steps should be taken to open a joint account (SC Yelchil).

4. The SC should be provided with water supply and compound wall (Durgapur SC).

5. As the hygiene around the SC is very poor, compound wall is necessary (SC Nimgaon).

6. Currently, PHC Mahagaon is not having a building. It has occupied the delivery room of
the Mahagaon SC for storing its materials. Due to this, the SC is not able to conduct the
deliveries (SC Mahagaon).

7. In many SCs, ANMs are not aware about the transportation assistance available for the
delivery of the JSY beneficiaries under the NRHM. ANMs should be informed about
this scheme.

8. Five SCs have not received the Untied Funds for the year till January-February 2009.
The funds should be sent to the joint account of the ANM and Sarpanch on time so
that they can make the expenditure throughout the year.

66
 Sub Centre

Table S1: Sub Centres Coverage

Sub Centre
Coverage of Sub-Centre CHC 1 (Dhanora) CHC 2 (Aheri) Average
PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) per Sub
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm Centre
Number of villages
3 5 5 6 6 6 3 5 5 2 3 4 4.4
covered by Sub Centre
Population coverage 637 1,990 1,522 1,092 1,140 2,122 2,602 1,260 3,627 1,279 1,837 1,785 1,741.1
Distance between PHC
15 3 16 15 10 4 20 35 0 30 0 30 14.8
and Sub Centre
Time taken (in minutes) to
travel in public transport /
available mode from
Farthest village to
20 60 30 60 60 60 60 60 30 15 30 30 42.9
Sub Centre
Sub Centre to PHC 30 15 45 20 15 10 60 30 0 60 0 60 28.8
Sub Centre to CHC 10 30 30 60 120 180 30 30 20 120 45 30 58.8
No. of ASHAs working in
0 0 0 0 3 0 1 0 2 0 0 0 0.5
the Sub Centre area

67
Table S2: Sub Centres Infrastructure

Availability of Sub Centre % of SCs

Infrastructure in Sub CHC 1 (Dhanora) CHC 2 (Aheri) having
Centres PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) respective
(Yes:1; No: 0) Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamalapur Guddi’dm facility
Functioning in designated
1 1 1 1 1 1 1 1 1 1 1 1 100.0
government building (N120)
IPHS Facility Survey Done 1 1 1 1 0 1 1 1 0 1 1 0 75.0
Labour Room (N141) 1 1 1 0 1 1 1 1 1 1 1 1 91.7
Piped water supply 0 0 0 0 0 0 0 0 0 0 0 0 0.0
Regular electricity supply 1 1 1 1 1 1 1 0 1 0 1 1 83.3
Telephone 1 0 1 1 0 0 1 1 0 1 1 1 66.7
Type of sewerage system
Soak pit 0 1 0 1 0 1 1 0 1 1 0 0 50.0
Connected to any sewerage line 1 0 1 0 0 0 0 0 0 0 0 0 16.7
Open Drain 0 0 0 0 1 0 0 1 0 0 1 1 33.3
Waste disposal
Buried in a pit 1 0 1 1 0 1 1 1 1 1 0 1 75.0
Collected by an agency 0 0 0 0 0 0 0 0 0 0 0 0 00.0
Incineration 0 0 0 0 0 0 0 0 0 0 0 0 00.0
Thrown in open 0 1 0 0 1 0 0 0 0 0 1 0 25.0

68
Table S3: Sub Centres with ANM staying with or away from SC village by distance from Sub Centre and reasons for not staying in Sub Centre
quarter.

Sub Centre
Residential status of ANM CHC 1 (Dhanora) CHC 2 (Aheri) % of
(Yes:1; No: 0) PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Sub
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm Centres
Sub Centre with ANM quarter 1 1 1 1 1 1 0 1 1 1 0 1 83.3
Sub Centre with ANM
Staying in SC’s quarters (N122) 1 1 1 1 1 1 - 0 1 1 - 1 90.0
Staying within SC’s village (N124) - - - - - - - - - - - - -
Staying outside SC’s village(N124) - - - - - - - 1 - - - - 10.0
Reason for ANM not staying on
SC quarter:
Quality of quarter - - - - - - - 0 - - - - -
Family related reason - - - - - - - 0 - - - - -
Security reason - - - - - - - 1 - - - - 100.0
Water/power facility not available - - - - - - - 1 - - - - 100.0

Table S4: Sub Centres with Staff in Position

Sub Centre % of SCs

Availability of Staff CHC 1 (Dhanora) CHC 2 (Aheri) with specific
(Yes: 1; No: 0) PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) staff
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm available
Health Worker Male in position 1 1 1 1 1 - 1 1 1 1 1 1 91.7
Health Worker Female in position 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Additional ANM contractual 0 0 0 0 0 0 1 0 1 0 0 1 25.0

69
Table S5: Availability of Labour Room in Sub Centre

Sub Centre
Labour Room CHC 1 (Dhanora) CHC 2 (Aheri) % of Sub
(Yes: 1; No: 0) PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Centres
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
Availability of Labour Room 1 1 1 0 1 1 1 1 1 1 1 1 91.7
Labour Room currently in use 1 1 1 - 1 1 1 0 0 1 1 1 81.8
Reasons for not using Labour
Room
ANM not staying - - - - - - - 1 0 - - - 50.0
Poor condition/no power/
- - - - - - - 0 0 - - - -
electric supply
No water supply - - - - - - - 0 0 - - - -
Other - - - - - - - 0 1 - - - 50.0

Table S6 A: Number of deliveries performed during 2007-2008

Sub Centre Average

CHC 1 (Dhanora) CHC 2 (Aheri) deliveries
Deliveries performed PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) conducted
per Sub
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm Centre
Total deliveries conducted 6 9 3 - 4 3 8 - - 25 28 17 11.5

70
Table S6B: Sub-Centres with arrangement for deliveries between 8 PM to 8 AM

Sub Centre % of
Arrangement for deliveries CHC 1 (Dhanora) CHC 2 (Aheri) Sub
between 8 PM to 8 AM PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Centres
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
Deliveries conducted at Sub
Centre itself and if required 1 1 1 - 1 1 1 - - 1 1 1 100.0
referred to higher facility
Deliveries not conducted at
Sub Centre but referred to - - - - - - - - - - - - -
higher facility
Referred to Private/NGO
- - - - - - - - - - - - -
facility

Table S7A: Sub Centres with availability of equipments

Sub Centre % of SCs

Availability of the
CHC 1 (Dhanora) CHC 2 (Aheri) with
equipments
PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) equipment
(Yes: 1; No: 0)
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm available
Steriliser 0 0 1 1 1 1 0 0 0 1 1 0 50.0
Haemoglobinometer 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Bag & Mask 1 1 0 0 0 0 1 0 1 1 1 1 58.3
Suction Machine 0 1 0 0 0 1 0 0 0 1 1 0 33.3
Thermometer 0 0 1 1 0 1 0 1 1 1 1 0 58.0
BP Apparatus 1 1 1 0 1 1 0 1 1 1 1 1 83.3
Weighing Machine 0 1 1 0 1 1 1 1 1 1 1 1 83.3
Height Measuring Scale 1 0 1 0 0 1 1 0 0 1 1 0 50.0
Reagent Strips for Urine Test 1 1 1 0 1 0 1 0 1 1 1 1 75.0
Cuscos Speculum 0 1 1 1 0 0 0 1 0 0 1 0 41.0
Mucus Extractor 0 1 1 1 0 0 1 1 0 0 1 0 50.0
Fetoscope 0 1 1 1 1 1 1 1 1 1 1 1 91.7

71
Table S7B: Percentage of SCs with functional equipments (among the SCs reported the availability of the equipment)

Sub Centre % of SCs

Functional equipments CHC 1 (Dhanora) CHC 2 (Aheri) with
(Yes: 1; No: 0) PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) functional
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm equipment*
Steriliser - - 0 1 0 1 - - - 1 1 - 66.7
Haemoglobinometer 1 1 1 1 1 1 1 1 1 1 1 0 91.7
Bag & Mask 1 1 - - - - 1 - 1 1 1 1 100.0
Suction Machine - 1 - - - 1 - - - 1 1 - 100.0
Thermometer - - 1 1 - 1 - 1 1 1 1 - 100.0
BP Apparatus 1 1 1 - 1 1 - 1 1 1 1 1 100.0
Weighing Machine - 1 1 - 1 1 1 1 1 1 1 1 100.0
Height Measuring Scale 1 - 1 - - 1 1 - - 1 1 - 100.0
Reagent Strips for Urine Test 1 1 1 - 1 - 1 - 1 1 1 1 100.0
Cuscos Speculum - 1 1 1 - - 1 1 - - 1 - 100.0
Mucus Extractor - 1 1 1 - - 1 1 - - 1 - 100.0
Fetoscope - 1 1 1 1 1 1 1 1 1 1 1 100.0

72
Table S8: Status of availability of drugs on the date of survey
Sub Centre % of SCs
Type of Drugs CHC 1 (Dhanora) CHC 2 (Aheri) reporting
Available PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) availability of
(Yes: 1; No: 0) drug on date
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
of survey
Iron Folic Acid 1 1 1 0 1 1 1 1 1 1 1 1 91.7
Disposable Delivery Kit 1 1 1 1 1 1 1 1 1 0 1 1 91.7
Oral Pills 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Emergency Contraceptive Pills 0 0 0 1 0 0 0 0 0 1 0 0 16.7
Condoms 1 1 1 1 1 1 1 1 1 1 1 1 100.0
IUD 0 0 0 0 0 0 1 0 0 0 1 1 25.0
ORS 0 1 1 0 1 0 1 1 1 1 1 1 75.0
Tab. Flucanazole Vaginal 0 0 0 1 1 0 1 0 1 0 1 1 50.0
Tab. Misoprostal 0 1 0 0 0 0 0 0 1 0 0 0 16.7
Partograph 0 0 0 0 0 0 0 0 0 0 0 1 8.3
Pregnancy Test Kit 1 1 1 0 0 0 1 0 1 1 1 1 66.7
Syp. Cotrimoxazole 0 1 1 0 1 1 0 0 1 1 0 0 50.0
Syp. Paracetamol 0 0 1 1 1 1 0 1 1 0 1 1 66.7
Vi. A 0 0 0 0 1 1 1 1 1 0 1 1 58.3
Tab. Ciprofloxacin 0 1 1 0 0 1 0 1 1 1 1 1 66.7
Disposable Gloves 0 1 1 1 1 1 1 0 1 1 1 0 75.0

73
Table S9: Status of Specific Skills and Procedures
Sub Centre % of SCs
CHC 1 (Dhanora) CHC 2 (Aheri) reporting
Type of Skill/Procedure
PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) availability of
(Yes: 1; No: 0)
specific skill /
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
procedure
Register pregnancy within
1 1 1 1 1 1 1 1 1 1 1 1 100.0
three months
Carry out 3 ANC visits as per
the RCH schedule (1st : 6th
1 1 1 1 1 1 1 1 1 1 1 1 100.0
month, 2nd : 7th Month, 3rd: 9th
Month)
Carry out specific
examinations like Blood
1 1 1 1 1 1 1 1 1 1 1 1 100.0
Pressure, Haemoglobin and
Urine
Provision of TT, IFA etc. 0 1 1 1 1 1 0 0 1 1 1 1 75.0
Identification of High Risk
0 1 1 1 1 1 1 1 1 1 1 0 83.3
Pregnancies
Is the ANM carrying out
0 0 0 0 0 0 0 0 0 0 0 0 0.0
IUCD insertion/removal
Is IUCD insertion being
- - - - - - - - - - - - -
carried out using IUD A380 *
Is the supply of IUD A380
- - - - - - - - - - - - -
regularly available *
Has the ANM been trained on
the insertion/removal of IUD 0 0 0 0 0 0 0 0 0 0 0 0 0
A380
Is the ANM trained in
syndromic treatment of 0 0 1 0 1 0 1 0 0 0 1 1 41.7
RTI/STI?
Immunisation services 1 1 1 1 1 1 1 1 1 1 1 1 100.0
* Among the SCs where ANM is carrying out IUCD Insertion/Removal

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Table S10: Service Outcome (based on data for last 3 months)

Sub Centre Average

Indicator CHC 1 (Dhanora) CHC 2 (Aheri) per Sub
PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Centre
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
Total ANC registered 4 8 4 4 5 6 13 3 7 14 11 7 7.2
Out of total ANC, number
4 4 2 3 1 3 2 3 5 0 7 7 3.4
Registered in 1st Trimester
No. given 3 ANC visits as
1 1 2 3 1 4 7 2 3 9 5 3 3.4
per the RCH schedule
No. of High Risk Cases
0 0 2 2 0 1 3 3 0 0 3 0 1.2
identified
Deliveries conducted by
2 12 6 1 2 3 8 0 0 6 5 0 3.8
ANM at Sub Centre
Pregnancies referred & attended
by the next higher facility
0 0 2 0 0 4 1 0 4 0 0 1 1.0
No. of neonate infections
0 0 0 0 0 0 0 0 0 0 0 0 0.0
identified and referred
No. of IUCD insertions in
0 0 0 0 0 0 0 0 0 0 0 0 0.0
2007-2008

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Table S11: Status of Record Maintenance
Sub Centre % of SCs
Type of Records
CHC 1 (Dhanora) CHC 2 (Aheri) reporting
maintained
PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) maintenance
(Yes: 1; No: 0)
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm of record
Household Survey Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Ante Natal Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Eligible Couple register 1 1 1 1 1 1 1 1 1 1 1 0 91.7
Post Natal Care Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Family Planning Register 1 1 1 1 0 1 1 1 1 1 0 0 75.0
Birth & Death register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Immunisation Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Meeting Register 1 1 1 1 1 1 1 1 1 1 1 0 91.7
JSY Register 1 1 1 1 1 1 1 1 1 1 1 1 100.0
Untied Funds Register 1 1 1 1 1 1 1 1 1 1 0 1 91.7
Cash Book 0 0 1 0 0 1 1 1 1 1 1 1 66.7

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Table S12 A: Status of Awareness of ANM about JSY Scheme
Number of ANMs
ANM’s awareness about JSY Reporting
Interviewed
Awareness
Aware about JSY 12 12
Aware about amounts to be given to beneficiaries 12 12
ANM reporting increase in demand for Institutional delivery after
12 6
implementation of JSY Scheme

Table S12 B: Status of procedure under JSY Scheme

% of ANMs according to
ANM’s awareness about JSY
response
Funds being paid to beneficiaries by
Cash 66.7
Cheque 33.3
Vouchers -
Average time taken after birth for JSY payment to beneficiary
Less than 1 week………..1 33.3
1- 2 weeks………………2 50.0
More than 2 weeks……....3 16.7
Transport support for shifting of cases available from Sub Centre to
75.0
PHC/CHC
Register available for recording of JSY Expenditure 91.7
Number of ANMs interviewed 12

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Table S13: Status of performance of ANM under JSY Scheme

Sub Centre Average

Performance of ANM under JSY CHC 1 (Dhanora) CHC 2 (Aheri) per Sub
Scheme PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Centre*
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm
Total cases of JSY registered in last
5 10 13 0 3 4 8 0 4 12 5 0 5.3
3 calendar months
Total JSY cases resulted in Institu-
1 7 13 1 2 2 1 11 2 7 0 1 4.0
tional deliveries in last 3 months?
Total cash disbursed in last 3
2,200 8,600 9,100 3,600 0 1,400 0 5,200 4,900 0 0 5,900 3,408.33
calendar months for JSY cases?
Out of total amount disbursed, the
amount disbursed on the following*
Home Deliveries (Rs.) 1,500 3,500 4,000 2,000 3,000 0 3,500 4,500 4,600 0 2,000 1,000 2,466.67
Institutional deliveries (Rs.) 700 7,000 5,600 1,500 2,100 1,400 700 1,400 1,400 0 3,500 4,900 2,516.67
Transport Costs (Rs.) 100 0 900 0 0 0 0 500 0 0 0 0 125.00
Amount given to ASHA (Rs.) 0 0 0 0 0 0 0 0 0 0 0 0 0.00
* Refers to the financial year

78
Table S14: Status of Untied Grants
Sub Centre % of
Status of Untied Grants CHC 1 (Dhanora) CHC 2 (Aheri) Sub
(Yes: 1; No: 0) PHC 1 (Rangi) PHC 2 (Pendri) PHC 1 (Mahagaon) PHC 2 (Kamalapur) Centre
Sode Nimgaon Michgaon Gatta Chichoda Durgapur Devalmari Yelchil Mahagaon Dham’cha Kamlapur Guddi’dm s
Sub Centre received Untied Grant 0 1 1 1 0 1 0 1 1 1 0 0 58.3
Sub Centre reported expenditure
- 1 1 1 - 1 - 1 1 1 - - 100.0
from Untied Grant *
ANM having a joint account with the
- 1 1 1 - 1 - 1 1 1 - - 100.0
Sarpanch/anyother GP functionary *
Sub Centre reporting maintenance of
register to record the decisions taken - 1 1 1 - 1 - 0 1 1 - - 85.7
to spend this amount *
Sub Centre reporting written record
of transactions being carried out on - 1 1 1 - 1 - 0 1 1 - - 85.7
Untied Funds
Sub Centre reporting that
Sarpanch/others ever reviewed the - 0 1 1 - 1 - 1 0 1 - - 71.4
expenditure records *
Sub Centre reporting expenditure
from Untied Grant on the
following:**
Spent on purchase of drugs** - 0 1 1 - 1 - 0 1 0 - - 57.1
Arranging Transport** - 0 1 0 - 0 - 0 0 0 - - 14.3
Paying of Power/Telephone bills** - 0 0 0 - 0 - 0 0 0 - - 0.0
Arranging facilities like Water
- 0 0 0 - 0 - 1 0 1 - - 28.6
Cooler etc. for patients**
Other (like white wash,
- 1 0 1 - 1 - 1 0 1 - - 71.4
maintenance etc.) **
* Among the SCs received Untied Grant.
** Among the SCs reported the expenditure from Untied Grants.

79
 Chapter 6
Household Survey

This chapter presents the findings of the household survey on NRHM. For the
survey, two villages were selected from each selected Sub Centre area. Thus, 24 villages were
selected for the household survey from the 12 Sub Centre areas. Fifty households were
selected from each of the selected village by following the systematic circular random
sampling procedure. For selecting the households, the total number of households in a village
was divided by 50 to find out the selection interval. After that, the first household situated at
the north-west corner of the village was randomly selected and subsequently every rth
household was selected moving in an ‘anti-clock wise’ direction till 50 households were
selected. In the district, from the selected 24 villages, we have covered 1,172 out of 1200
households for the survey with the coverage rate being 98.0 percent.

Characteristics of the Respondents

Table H1 presents the background characteristics of the respondents (head/senior
member of the household). Forty percent of the respondents are aged 40 years and above and
60 percent are aged less than 40 years. Three fifth of the respondents are females and one two
fifth are males. Sixty one percent of the respondents are illiterates. Majority of respondents
are currently married (80 percent) and the rest are unmarried (10 percent), or
divorced/separated (1 percent) or widowed (9 percent).

Characteristics of the Households

Table H2 presents the percentage distribution of the rural households by selected
background characteristics. Distribution of the households by social category shows that 70
percent of the households belong to Scheduled Tribe (ST), 10 percent belong to Schedule
Caste (SC), 12 percent belong to OBC and 12 percent belong to ‘Other’ castes. Distribution
of households by religion shows that 96 percent of the households are Hindus.

Only about one third of the households have electricity. Only three percent of the
households are living in pucca houses. Toilet facility is available only in 12 percent of the
households. Piped water is used by 28 percent of the households. Only three percent of the
households use LPG/Biogas for cooking. Nearly three fourth (72 percent) of the households
own/cultivate agricultural land. Only 13 percent of the households own a colour/B&W

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television and six percent have a mobile phone. The characteristics of the households reveal
that the extent of deprivation of basic facilities (electricity, drinking water, housing, toilet
facility), is very high in the rural areas of the district.

Nearly two third of the households (63 percent) belong to BPL category. The BPL
status is also reflected in the households with the low standard of living index (SLI) – 81
percent of the households belong to low SLI. The SLI is calculated by using the various
household items possessed by the households (Appendix-3). Among the living children born
in these rural households during the last five years, only 22 percent of them were born in
institutions.

Waste Disposal, Stagnation of Water and Mosquito Breeding and System of Medicine
Preferred
Method of waste disposal shows that 70 percent of the rural households throw their
waste in the open space and the remaining 30 percent bury in a pit (Table H3). Percentage of
households throw the waste in open space is more in SC headquarter village (82 percent) than
the households located in other villages (60 percent). During the survey, in 9 percent of the
households, investigators have observed the stagnation of waster water around the household.
Among the households where the stagnation of waste water was observed, the investigators
have further observed the mosquito breeding in the stagnant water in most of these
households (80 percent). There is no difference in the stagnation of waster water and the
instances of mosquito breeding between the households located in the SC headquarter village
and households located in other villages.

System of medicine preferred by the rural households reveals that the allopathic
medicine is universally preferred (99 percent). In addition to this, 17 percent of the
households prefer Ayurveda and four percent prefer traditional healing.

Information about Health Workers and Health Facilities

Almost all the respondents have heard about ANM and Male Health Worker (Table
H4). Further 93 percent of the respondents reported that the health worker has visited them
in last one month. There is no difference in these aspects between the households located in
the SC headquarter village and households located in other villages. Ninety five percent of the
respondents further reported that the health workers are available to them when needed.

81
 Respondents were asked about the availability of the health facilities to the
households when required. The responses reveal that the households mainly depend on
government health facility, when needed. Public health facilities like SC, PHC and CHC were
mentioned by 47 percent, 60 percent and 14 percent of the respondents respectively. Higher
percentage of respondents living in SC headquarter village (65 percent) reported that the SC is
available to them when required than the respondents living in other villages (31 percent).

Respondents were further asked about the health facility for which the serious
patients are taken. Fifty eight of the respondents mentioned that they take the serious patients
to the District Hospital/Sub Divisional Hospital. PHC and CHC were mentioned by 54
percent and 30 percent of the respondents respectively. RMP was mentioned by 31 percent of
the respondents. As the private health facilities are few in the district, the rural households
mainly depend on government health facilities, in times of need.

Mode of transport used to take serious patients when required was asked from the
respondents. Majority of the respondents mentioned that Bus/public transport (53 percent)
and private vehicle (87 percent) are used to take the serious patients, when required. One in
ten respondents reported that the bullock cart is used to take serious patients.

NRHM, ASHA and JSY

Table H5 presents the distribution of respondents by their knowledge about NRHM,
ASHA and her activities, VHND, VHSC and JSY. Thirteen percent of the respondents have
heard about NRHM and there is no difference in this between households located in SC HQ
villages and other villages. For those who have heard about NRHM, Panchayat (35 percent),
radio/television (32 percent), Community Member (27 percent), ‘Others’ (37 percent) and
Newspaper (8 percent) are the sources of information.

Overall, only three percent of the respondents have heard about ASHA. The percent
of respondents heard about ASHA in SC HQ village is 3.3 percent and in other villages it is
2.7 percent. Those who have heard about ASHA were supposed to be asked further about
their awareness/knowledge regarding various activities of ASHA. However we could not ask
these questions to the respondents as the ASHAs are appointed only in three out of 12
villages. Further, the respondents who have heard about the ASHA have not seen her actually
working in the villages. Due to this we had to skip the questions related to ASHA’s activities
to these respondents.
82
 One third of the respondents reported that the Village Health and Nutrition Day
(VHND) is being organised in the village. One fourth of the respondents reported the
presence of Village Health and Sanitation Committee (VHSC) in the village. More
respondents from SC HQ village (36 percent) reported the presence of VHSC than in other
villages (15 percent). More than half of the respondents (56 percent) reported that VHND is
being organised once in a month in the village. The percentage of respondents reporting the
frequency of the VHND is quarterly and annually is 14 percent and 21 percent respectively.
Higher percentage of respondents from SC HQ villages (67 percent) than in other villages (45
percent) reported that the VHND is being organised monthly.

All the respondents were asked about their awareness regarding JSY scheme. It shows
that 63 percent of the respondents are aware about JSY scheme and there is not much
difference in the awareness between respondents from SC HQ villages and other villages.
Those who are aware about the JSY scheme were further asked about their source of
information about the JSY. It shows that the major sources of information about JSY are
ANM (77 percent) and Anganwadi Centre/worker (27 percent).

Those who said that they are aware about the JSY scheme were further asked whether
any one in the household is a beneficiary of JSY scheme. Among those who are aware about
the JSY scheme, 13 percent of them reported that the household is a beneficiary of the JSY
scheme. The percentage of the beneficiary households is slightly more in the households
located in ‘other villages’ (15 percent) than in SC HQ villages (11 percent). Among the total
surveyed households, 8.3 percent (97 out of 1,172) are beneficiaries of the JSY scheme.

JSY Beneficiaries
Selected characteristics of the beneficiaries are presented in Table H6. Age
distribution of the beneficiaries shows that, as expected, half of them are aged 20-24 years.
Thirty six percent of the beneficiaries are aged 25-29 years and five percent are less than 20
years. Parity of the beneficiaries shows that four percent are zero parity women (first time
pregnant women), 66 percent are first parity women and 30 percent are second parity women.

In Maharashtra, all the Scheduled Castes, Scheduled Tribes and BPL households are
eligible for JSY benefits. Social category of the beneficiaries reveals this as vast majority of
them are Scheduled Tribes (83 percent). The remaining 17 percent of the beneficiaries are
from Scheduled Castes, OBCs (from BPL category) and ‘Other’ categories. All the
83
beneficiaries are Hindus. Distribution of beneficiaries by Standard of Living Index (SLI)
shows that more than three fourth of them (78 percent) belong to low SLI households, 20
percent belong to medium SLI households and 2 percent to high SLI households. Seventy
one percent of the beneficiaries belong to BPL category.

Registration of JSY Beneficiaries

JSY first starts with the registration of the pregnant woman for receiving the benefits.
More than half of the beneficiaries (54 percent) heard about the JSY scheme before being
pregnant and the remaining 46 percent heard during pregnancy. Stage of pregnancy when
beneficiary got registered for JSY scheme reveals that four fifth of the beneficiaries got
registered during the first trimester of the pregnancy and the rest during 4th and 5th month of
the pregnancy. Seventy eight percent of the beneficiaries were registered by ANM/FHW and
20 percent by Anganwadi worker and the remaining 2 percent by Doctor/LHV. Place of
registration of beneficiaries show that 41 percent of them were registered in Sub-Centre. The
percent of beneficiaries registered in Anganwadi Centre is 39 percent, at home is 13 percent
and PHC is 6 percent.

JSY Card
Only one fourth of the beneficiaries received the JSY card (Table H8). Among those
who received the JSY card, none of the beneficiaries reported any difficulty in getting the JSY
card.

Role of ASHA during the Pregnancy of the Beneficiaries

In Maharashtra, ASAHs are appointed only in tribal blocks of the state. Though
Gadchiroli is a tribal district, among the 24 villages surveyed, ASHAs are appointed only in
three villages. The appointed ASHAs in these three villages have not started functioning at
the time of our survey. Due to this, beneficiaries were not able to answer the questions
regarding the role of ASHA during their pregnancy or we were not able to ask this question
(Table H9). Due to this, none of the beneficiaries could answer for the specific help provided
by ASHA during last pregnancy and the type of advice received from ASHA during last
pregnancy.

Beneficiaries were further asked about the type of information received during the
antenatal period (micro birth planning) from Doctor/ANM/ASHA. It shows that the percent
of beneficiaries received the information regarding date of next check up is 56 percent, place
84
of next check up is 40 percent, expected date of delivery is 32 percent and place of delivery is
34 percent. Only one beneficiary was told about the referral place, if complications arise.

Place of Delivery and Reason for Opting Institutional Delivery

Among the beneficiaries, 29 percent (27 out of 93) delivered in Institutions and the
remaining 71 percent (66 out of 93) delivered at home (Table H10). Ninety seven percent of
these institutional deliveries took place in public institutions (DH, CHC, PHC and SC). The
major reasons cited by the beneficiaries for delivering in Institutions are: better access to
institutional delivery (70 percent); better care for mother and new born child (30 percent);
money available under JSY scheme (11 percent); and availability of services in the area (11
percent).

Transport of the Beneficiaries to Reach the Health Institutions

Among the beneficiaries who delivered in health institutions, only one fifth of them
received referral slip from ASHA/health personnel to access delivery services (Table H11).
Out of the 27 beneficiaries who delivered in institutions, only one beneficiary faced difficulty
in reaching health institution due to the non availability of transport. The average distance to
the ultimate place of delivery from the beneficiaries’ residence is about 14 kilometres. Private
vehicle was used by 44 percent of the beneficiaries to reach the ultimate place of delivery, 15
percent used Government Ambulance and 41 percent reached the facility by walk/bullock
cart. For 81 percent of the beneficiaries, mainly family members/relatives (81 percent) had
arranged the vehicle. For 19 percent of the beneficiaries, ANM/Health Worker and Village
Health Committee had facilitated in arranging the transport. Only 54 percent of the
beneficiaries reported that they had the money to pay for the transport services. The average
amount spent by the beneficiaries on transport to reach the health facility is Rs. 91.1/-. Only
one beneficiary had received transport assistance under JSY scheme and the amount received
is Rs. 50/-. For 96 percent of the beneficiaries, relatives accompanied them to the health
institution.

Waiting Time, Type of Delivery and Satisfaction Regarding Services

The average waiting time at the facility until someone attended the beneficiary is 15
minutes. Out of 27 beneficiaries 23 had the normal delivery (85 percent), three had assisted
delivery and one had Caesarean delivery. The average number of days spent in the health
facility till discharge is 3.3 days. Thirty seven percent of the beneficiaries had to pay at the
health centre and the average amount turns out to be Rs. 1,094/-. Among the 27
85
beneficiaries, 25 were satisfied with the services available in the health centre and two were
somewhat satisfied.

Reason for Opting Home Delivery

As mentioned earlier, 66 out of 93 beneficiaries (71 percent) opted for the home
delivery in spite of cash incentives being available under the JSY scheme. All these 66
beneficiaries were asked for the reason for opting home delivery. The major reasons cited by
the beneficiaries are non availability of transport (29 percent), more convenience in home
delivery (26 percent), and cultural/social reasons (20 percent). Few other reasons cited are
can’t afford, fear of stitches/caesarean, and indifferent behaviour of medical/paramedical
staff.

Cash Incentive Received by the Beneficiary under JSY Scheme

Among the beneficiaries, 97 percent had received the cash incentive under JSY
scheme and the average amount received by them is Rs. 523/-. Out of those who received the
cash incentive, 80 percent received it in one instalment and 20 percent received it in two
instalments. Among those who received the cash incentive, 12 percent received before
delivery, 17 percent received immediately after the delivery, 25 percent received within a week
after the delivery and 47 percent received much later. For most of the beneficiaries (92
percent), ANM/LHV delivered the cash incentive and for the rest doctor, LHV and
Angawadi Worker delivered the incentive. Place of delivery of cash incentive shows that the
beneficiaries have mainly received the cash incentive at the following places: home (36
percent), Sub Centre (39 percent), PHC (9 percent) and Anganwadi Centre (7 percent). Four
beneficiaries reported that they had faced difficulty in getting the incentive.

Utilisation of Government Health Facility in Last Six Months

This section addresses some of the issues related to the quality of care in government
health facilities. First, to understand the extent of utilisation of the government health
facilities in last six months, all the surveyed households were asked whether anyone from the
household availed the services in any government health facility in last six months. It shows
that 20 percent of the rural households (232 out of 1,172) have availed the health services in
government health facility in last six months. The proportion of households availed the
services in government health facility is slightly more in households located in SC headquarter
villages (22 percent) than in other villages (18 percent). Out of the 232 households that have
availed the services in government health facility we could conduct the interview in 210
86
households (in case the household availed the services for the children below 16 years of age,
the adult household member accompanied the child was interviewed).

The selected characteristics of the patients/respondents who have availed the health
services in government health facilities are presented in Table H16. The age distribution of
the respondents shows that 39 percent are age below 30 years, 9 percent are age 60 years and
above and the rest (52 percent) are in the age range of 30-59 years. Fifty eight percent of the
respondents are females and the rest (42 percent) are males. The socioeconomic
characteristics of the respondents reveal that more than half of them are illiterates (53
percent), 76 percent are Scheduled Tribes and Schedule Castes, and 69 percent belong to BPL
households. The percentage of households from low SLI households is 77 percent. The
characteristics of the respondents clearly reveal that most of them come from very poor
households.

Client Satisfaction
Table H17 presents the type of health facility visited and purpose of visit; and
satisfaction regarding behaviour of health worker, privacy and availability of medicine at the
facility. The type of health facility visited by the respondents show that 51 percent visited
PHC, 24 percent visited SC, 13 percent visited District Hospital, and another 12 percent
visited CHC. The reason reported by the respondents for the visit to the health facility shows
that 63 percent visited for the treatment of minor ailment and the remaining 37 percent for
other services (ANC care, child care, immunization) and ailments.

Regarding the behaviour of the staff at the health facility, 79 percent of the
respondents said that the staff were courteous. Only few (2 percent) respondents reported
that the behaviour of the staff were insulting/derogatory. Eighty two percent of the
respondents said that the doctor/staff at the health facility listened to their complaints, 16
percent said that they have somewhat listened and 1 percent said that they did not listen. One
of the problems often cited for the government health facilities is the lack of privacy for the
woman patients. The problem can be easily addressed with either a simple partition of the
examination room or with a cloth curtain. To know about this, the respondents were asked
whether women patients treated with privacy and dignity. Four fifth of the respondents
reported that women patients are treated with privacy and dignity and 10 percent said that
they are not treated with privacy and dignity.

87
 Regarding the availability of medicines, only 44 percent of the respondents said that
patients with chronic illnesses (like joint pains, heart disease, blood pressure, diabetes etc.) get
medicines regularly from the government health facility. Fifteen percent of the respondents
said that they don’t get medicines and 41 percent said that they don’t know. Respondents
were further asked whether doctor from government health facility do private practice during
or after the duty hours. For this question, 53 percent of them said they ‘don’t know’, one
third said ‘no’, and 13 percent said ‘yes’.

Satisfaction of the respondents regarding the overall services of the government

health facility reveals that 86 percent are satisfied, 8 percent are somewhat satisfied and 7
percent are not satisfied. Satisfaction of the respondents regarding the behaviour of staff at
the government health facility also shows a similar level of higher satisfaction with 87 percent
satisfied, 10 percent somewhat satisfied and 3 percent are not satisfied. Though the level of
satisfaction appears to be higher, even a smaller level of dissatisfaction regarding services and
behaviour of staff has to be looked into.

User Fees and Extra Charges

In Maharashtra, user fees are charged for various services in the government health
facilities with some categories of patients exempted for the charges. In the survey, among the
respondents who have availed the services in government health facility in last six months,
fifty three percent (i.e., 110 out of 210) said that they were charged user fees by the health
facility (Table H18). Among those who paid the user fees, 94 percent paid for registration, 10
percent for lab test, 2 percent for X-ray, and 16 percent for medicine, IV set, injection, blood
and room charges Among those who have paid the user fees, only 31 percent said that they
have received the receipt for the same and the remaining 69 percent said that the receipt was
not given. Among those who paid the user fees, 26 percent said that extra money was charged
from them for the services provided.

Services for the BPL Patients

BPL respondents were asked whether BPL patients provided free/subsidized services
(Table H19). For this question, 62 percent of the respondents said that they are provided
free/subsidized services, 18 percent said that they are not provided free/subsidized services
and 20 percent said that they don’t know. Half of the BPL respondents (52 percent) said that
they don’t face difficulty in getting free/subsidized services whereas; 17 percent said that BPL

88
patients face difficulty in getting free/subsidized services. Only five percent of the BPL
respondents said that the RKS facilitates the paper work for them.

Outbreak of Diseases
All the respondents were asked whether there is any outbreak of malaria, measles,
gastroenteritis, jaundice and other diseases in their area in the last six months (Table H20).
The percentage of respondents reported the outbreak of the above diseases in their area in
the last six month is 38 percent, 7 percent, 6 percent, 2 percent and 1 percent respectively.
These figures should be noted with caution as these are orally reported outbreaks by the
respondents. However, it indirectly indicates that mosquito breeding is a major issue in the
villages as outbreak of malaria is reported by 38 percent of the respondents.

Action to be taken for Selected Diseases

All the respondents were asked about the following: steps for prevention of diarrhoea;
actions to be taken if a family member has a high fever, persistent cough for more than two
weeks and loose motions lasting for more than 24 hours; and action to be taken if a child in
the family has persistent cough and breathing problems (Table H21). For the prevention of
diarrhoea, the proportion of respondents mentioned the hand washing, use of safe food and
water, and use of covered containers is 39 percent, 66 percent and 25 percent respectively.
The proportion of respondents does not know any simple steps for the prevention of
diarrhoea is 30 percent. Actions to be taken for high fever, persistent cough and loose
motions for a family member; and persistent cough and breathing problems for the child in
the family shows that 83-93 percent of the respondents will take the family member /child to
the nearest government health facility followed by 30-35 percentage to the RMP. Taking the
family member/child to the nearest government health facility is the prominent actions
reported by most of the respondents. It indicates the importance of the availability of
government health facility nearer to the people at the times of need. The proportion reported
that they will try with home remedies vary between 22-34 percent for all four diseases. It is
heartening to know that, for the loose motions, even in this backward region, 29 percent of
the respondents said that they will start giving ORS.

Awareness about Spacing Methods and Ideal Gap between Children

The ideal spacing between 1st and 2nd child mentioned by the respondents reveals that
53 percent prefer the ideal spacing to be 3 and more years (Table H22). Another 38 percent
said that the ideal spacing should be 2 years. Only nine respondents mentioned the ideal
89
spacing as one year. The ideal spacing of 3+ years reported by majority of the respondents
clearly indicate the need for spacing methods in our family planning programme. Knowledge
regarding the spacing methods reveals that Oral Pills is known to 86 percent of the
respondents followed by IUD (44 percent) and Condom (41 percent). Nine percent of the
respondents said that they don’t know the family planning methods available for spacing.

AIDS and VCTC

The awareness, modes of getting and source of information for HIV/AIDS are
presented in Table H23. Among the respondents, 44 percent are aware about the HIV/AIDS.
With regard to knowledge about the modes of transformation of HIV/AIDS, the percent of
respondents reported that the unsafe sexual contact, sharing of needles/syringes, blood
transfusion and from mother to child is 92 percent, 54 percent, and 60 percent respectively.
About 8 percent of the respondents aware that HIV/AIDS transforms from infected mother
to child. Few respondents reported the misconceptions like sneezing and insect bite are the
modes of getting HIV/AIDS. Source of information for the HIV/AIDS reveals that health
worker (32 percent) and TV (32 percent) are the important sources followed by posters,
newspapers and radio (10-20 percent). Friends / relatives / neighbours / community etc. (63
percent) are also important source of information to the respondents for HIV/AIDS.

Those who were aware about HIV/AIDS were further asked about their awareness
regarding the HIV/AIDS Counselling Centre/Voluntary Counselling and Testing Centre
(VCTC) nearby. The response shows that, only one fifth (20 percent) of the respondents are
aware about the nearby Counselling Centre/VCTC. Those who are aware about the nearby
Counselling Centre/VCTC were further asked about the location of Counselling
Centre/VCTC. The percent of respondents said that the Counselling Centre/VCTC is
located in PHC is 25 percent, CHC is 22 percent, District Hospital is 20 percent, Sub District
Hospital is 28 percent and Private Hospital is 8 percent. Among those who are aware about
the location of VCTC, most of them (91 percent) reported that that it is located in the
government health facility.

Suggestions given by the respondents

The suggestions given by the respondents for the improvement of services in the
village are given in Table H24. It shows that respondents generally expect health facility, safe
drinking water, pucca road, transport facility, toilet facility, cleanliness and sanitation for their
villages. Some of the respondents also suggested the regular availability of health workers,
90
medicine and treatment for the improvement of services in their village. The suggestions
given by them reveal the genuine expectations of the villagers for the improvement of the
health and sanitation in their villages.

91
 Household Characteristics

Table H1: Characteristics of the respondents

Percent distribution of respondents by background characteristics
Characteristics of the respondents Number Percent
Age
< 30 years 366 31.2
30-39 years 338 28.8
40-49 years 256 21.8
50-59 years 114 9.7
60 years or more 98 8.4
Sex
Male 492 42.0
Female 680 58.0
Years of Schooling
Illiterate 713 60.8
1-5 years 138 11.8
6-9 years 183 15.6
10 years or more 138 11.8
Marital Status
Unmarried 114 9.7
Currently Married 936 80.0
Divorced/Separated 10 0.9
Widowed 110 9.4
Total 1,172 100.0

Table H2: Characteristics of the household

Percent distribution of households by their background characteristics
Characteristics of the household Number Percent
Social Category
SC 116 9.9
ST 815 69.5
OBC 137 11.7
Others 104 8.9
Religion
Hindu 1128 96.2
Muslim 9 0.8
Christian 2 0.2
Others 33 2.8
Households having BPL status 732 62.5
Households living in pucca house 29 2.5
Households with electricity 369 31.5
Households with toilet facility 142 12.1
Households with piped water supply 333 28.4
Households using LPG/Biogas for cooking 40 3.4
Household having own agricultural land /cultivating any agricultural land 845 72.1
Household own a colour/B&W television 153 13.1
Household have a mobile phone 69 5.9
Households with low Standard of Living Index 944 80.5
% of children born in Health Institutions during last 5 years 119 21.7
Total number of households 1,172 100.0

92
Table H3: Percent distribution of households by their waste disposal, stagnation of waste
water and mosquito breeding around the house and system of medicine preferred by them.

Households Households
Waste disposal, stagnation of water and
located in located in
mosquito breeding and system of medicine All
Sub Centre Other
preferred
HQ Village village
Method of waste disposal by the household
Thrown in the open 81.5 59.7 70.4
Buried in a pit 18.0 39.8 29.1
Burnt 0.5 0.2 0.3
Other methods - 0.3 0.2
Stagnation of waste water around the
household (stagnation of waste water observed by 8.8 8.9 8.9
the interviewer)
Instance of mosquito breeding in the stagnant
water (among the households where stagnation of 78.4 81.1 79.8
water is observed)
System of medicine preferred (multiple answer)
Allopathic 100.0 99.7 99.8
Ayurveda 5.2 29.9 17.7
Yoga and Naturopathy 0.0 0.0 0.0
Unani 0.0 0.0 0.0
Siddha 0.0 0.0 0.0
Homeopathy 0.0 0.0 0.0
Traditional Healing 0.9 7.9 4.4
Any other 1.0 1.5 1.3
None 0.0 0.0 0.0
Total number of households 577 595 1,172

93
Table H4: Percent distribution of household respondents by their information about
availability of health worker, health facilities and transport used to take serious patients

Households Households
Information about health workers and health located in located in
All
facilities Sub Centre Other
HQ Village Village
Availability of health workers
Heard about ANM 99.5 99.5 99.5
Heard about Male Health Worker 99.1 99.2 99.1
Visited by a Health Worker in last one month 91.9 94.5 93.2
Health Workers are available when needed 96.7 92.8 94.7
Availability of health facilities to the households,
when required (multiple responses)
RMP 15.8 8.4 12.0
Private Clinic/NGO 14.4 29.2 21.9
Sub Centre 64.5 30.9 47.4
PHC 5.3 68.7 60.2
CHC 7.1 20.2 13.7
Others 0.3 1.7 1.0
Facility for which serious patients are taken,
when required (multiple responses)
RMP/private Clinic 34.8 27.7 31.2
NGO Hospital Clinic 2.8 9.2 6.1
PHC 57.7 49.4 53.5
CHC 35.4 25.5 30.4
District/Sub Divisional Hospital 47.5 68.9 58.4
Others 0.0 0.2 0.1
Mode of transport used to take serious patients,
when required (multiple responses)
Bullock Cart 2.6 18.8 10.8
Bus 59.8 47.1 53.3
Private Vehicle 87.3 86.1 86.7
Ambulance 2.3 11.1 6.7
Others 3.1 0.8 2.0
Total number of household respondents 577 595 1,172

94
NRHM, ASHA and JSY

Table H5: Percent distribution of household respondents by their knowledge about NRHM,
ASHA and her activities, VHND, VHSC and JSY

Households Households
located in located in
NRHM, ASHA and JSY All
Sub Centre Other
HQ Village Village
13.0 13.1 13.1
Heard of NRHM
(75) (78) (153)
If heard of NRHM, source of information about
NRHM (multiple responses)
ASHA 0.0 0.0 0.0
Radio/television 42.7 21.8 32.0
Newspaper 9.3 6.4 7.8
Panchayat 34.7 34.6 34.6
Community Member 18.7 34.6 26.8
Other 22.7 51.3 37.3
3.3 2.7 3.0
Heard of ASHA
(19) (16) (35)
ASHA and her activities, VHND and VHSC
ASHA carry a kit - - -
ASHA provide a common medicines free of cost - - -
ASHA held discussions about hand washing - - -
ASHA held discussions about construction of - - -
household toilets - - -
ASHA held discussions about safe drinking water - - -
Village Health and Nutrition Day being organized 34.9 32.5 33.7
in the village
Presence of Village Health and Sanitation 36.0 14.8 25.3
Committee in the village
Frequency of Village Health and Nutrition Day
Weekly 8.0 11.9 9.9
Monthly 66.5 44.6 55.7
Quarterly 19.5 7.3 13.5
Annual 6.0 36.3 20.9
61.2 64.4 62.8
Aware about the JSY scheme
(353) (383) (736)
If aware about JSY, source of information about
the JSY (multiple options)
Radio/Television 4.2 4.2 4.2
Pamphlets 0.8 2.9 1.9
Hoardings at SC/PHC etc. 3.4 2.9 3.1
ASHA Worker 0.8 0.0 0.4
Anganwadi Centre/Worker 15.9 38.1 27.4
ANM 75.9 77.0 76.5
Doctor 5.9 11.2 8.7
Gram Panchayat 3.4 2.1 2.7
NGOs/SHGs - - -
Other 26.3 32.4 29.5
11.0 15.1 13.2
Household is a beneficiary of JSY Scheme
(39) (58) (97)
Total number of household respondents 577 595 1,172

95
JSY Beneficiaries
Table H6: Percent distribution of JSY beneficiaries by their background characteristics

Characteristics of the JSY beneficiaries Percent

Age
< 20 years 5.2
20-24 years 48.5
25-29 years 36.1
30-34 years 7.2
35-39 years 3.1
40-44 years -
45-49 years -
Parity
0 4.1
1 66.0
2 29.9
3 & 3+ -
Social category
SC 5.2
ST 82.5
OBC 7.2
Others 5.2
Religion of the household
Hindu 99.0
Muslim -
Christian -
Sikh -
Others 1.0
SLI of the household
Low 78.4
Medium 19.6
High 2.1
BPL household 71.1
Place of last delivery (delivery previous to this delivery)
Household 69.1
Health Institution 30.9
Total number of JSY beneficiaries interviewed 97

96
Registration of JSY Beneficiaries
Table H7: Timing, person and place of registration for JSY scheme

Timing, place of registration for JSY scheme and JSY card Percent
Timing of hearing about JSY scheme
Before being pregnant 54.2
During pregnancy 45.8
Stage of pregnancy when beneficiary got registered for JSY scheme
1st month 3.8
2nd month 7.7
3rd month 69.2
4th month 19.2
5th month or later -
Person who registered the beneficiary for JSY scheme
Doctor 1.0
LHV 1.0
ANM/FHW 78.4
Anganwadi worker 19.6
ASHA worker -
Others -
Place where the beneficiary was registered for JSY scheme
District/Sub-district Hospital -
Community Health Centre -
PHC 6.2
Sub-Centre 41.2
Anganwadi Centre 39.2
Private hospital accredited by the government -
At home 13.4
Other places -
Total number of JSY beneficiaries 97

JSY Card
Table H8: Receipt of JSY card, role of ASHA in getting JSY card and difficulties faced by the
beneficiary in getting the JSY card

JSY Card Percent

JSY card received by the beneficiary 23.7
ASHA worker helped the beneficiary in getting JSY card -
Beneficiary faced difficulty in procuring JSY card -
If faced difficulty, type of difficulties faced by beneficiary (multiple options)
Cards were not available -
Formalities for making cards were too cumbersome -
Was asked to pay money for the card -
Other difficulties -
Total number of JSY beneficiaries 97

97
Table H9: Role of ASHA during the pregnancy of the beneficiaries

Role of ASHA during the pregnancy of the beneficiaries Percent

ASHA worker provided specific help during last pregnancy -
Beneficiary received advice from ASHA during pregnancy for the following
(multiple options)
Diet -
Danger signs -
Delivery care -
Breastfeeding -
Newborn care -
Family planning -
Not applicable (ASHA not appointed in the village) 93.8
Information given to the beneficiary (Micro Birth Planning) during
antenatal period by Doctor/ANM/ASHA (multiple options)
Date of next check-up 55.7
Place of next check-up 40.2
Date of expected delivery 32.0
Place of delivery 34.0
Place of referral, if complications arise 1.0
Total number of JSY beneficiaries 97

Table H10: Place of delivery and reason for opting institutional delivery

Place of delivery and reason for opting institutional delivery Percent

Place of delivery
District/Sub-district Hospital 2.2
Community Health Centre 8.6
PHC 5.4
Sub-Centre 9.7
Trust/NGO Hospital 1.1
Private hospital 1.1
Private hospital accredited by the government 1.1
At home 71.0
Total (93)
Reasons for opting Institutional Delivery (multiple reasons)
Money available under JSY scheme 11.1
Better access to institutional delivery 70.4
Better care for mother and new born child 29.6
Services in the area 11.1
Support provided by ASHA 3.7
Availability of transport assistance -
Previous child was born in an institutions 3.7
Other 3.7
Total (27)
Total number of JSY beneficiaries 93

98
Table H11: Transport of the beneficiaries to reach the Health Institution

Process of Transport Percent

Received referral slip from ASHA/health personnel to access delivery
services 18.5
Faced difficulty in reaching Health Institution 3.7
If faced difficulty, type of difficulties faced in reaching the Health
Institution by the beneficiaries (multiple options)
It was late in the night -
Did not have sufficient money -
Transport was not immediately available 100.0
Male members in the household were not present -
ASHA was not readily available -
Others -
Average distance to the ultimate place of delivery from the beneficiary’s 13.8
residence (in kms)
Mode of transport used by the beneficiary to reach the ultimate place of
delivery
Government Ambulance 14.8
Private vehicle 44.4
Vehicle arranged by Local Health Committee -
Other (walking, bullock cart) 40.7
Persons facilitated in arranging the transport
ASHA -
ANM/Health Worker 15.4
Village Health Committee 3.8
Family members/relatives 80.8
Others -
Beneficiary had money to pay for the transport services 53.8
Average amount spent on transport (in Rs.) 91.1
Average amount of transport assistance received under JSY scheme by the
Rs. 50
beneficiary (in Rs.)**
Cases where amount spent on transport is more than the amount received --
Persons accompanied the beneficiary to the Health Institution
ASHA -
Relatives 96.2
Mother/Mother-in-law 3.8
Husband -
ANM/health Worker -
Others 3.8
Total number of JSY beneficiaries 26
** Only one beneficiary had received the transport assistance of Rs. 50/- Others have not received

99
Table H12: Waiting time at the health facility, type of delivery, amount spent at the health
facility and satisfaction regarding services available in the health facility

Waiting time, type of delivery and satisfaction regarding services Percent

Average waiting time at the facility until someone attended the beneficiary
14.5
(in minutes)
Type of delivery (Percent)
Normal 85.2
Assisted (Forceps, Vacuum) 11.1
Caesarean 3.7
Average number of days spent in the facility till discharge 3.3
Percent beneficiary who have to pay at the health centre 37.0
Average amount paid to the health centre (Rs.) 1,094.0
Satisfaction regarding the services available in the health centre (Percent)
Satisfied 92.6
Somewhat satisfied 7.4
Not satisfied -
Reasons for not satisfied with the services in the health centre (Percent)
Staff was rude -
Facility was not clean -
Poor quality of services -
Other -
Total number of JSY beneficiaries 27

Table H13: Reason for the JSY beneficiary to opt home delivery, in spite of cash incentives
being available under the JSY Scheme

Reason for the beneficiary to opt home delivery Percent

Reasons for home delivery (multiple options)
Home delivery is more convenient 25.8
Fear of stitches/caesarean 1.5
Indifferent behaviour of Medical/paramedical staff 1.5
Cultural/social reasons 19.7
Transport not being available 28.8
Can’t afford 1.5
Others 37.9
Total number of JSY beneficiaries under Home Delivery 66

100
Table H 14: Cash incentive received by the beneficiary under JSY scheme

Cash incentive Percent

Number of beneficiary received cash incentive 94
Percent of beneficiary received cash incentive under JSY scheme 96.9
Average amount received by beneficiary as cash incentive (in Rs.) 523.2
Received the cash incentive:
In one go 79.8
In 2 instalments 20.2
In 3 instalments -
Timing of the receipt of the cash incentive by beneficiary
At the time of registration 1.1
At the time of antenatal checkups 2.1
Much before the delivery 7.4
Within a week before the EDD 1.1
Immediately after the delivery 17.0
Within a week after the delivery 24.5
Much later (After one or more than one month) 46.8
Not received yet -
Do not know/husband knows -
Other -
The person who delivered the cash incentive to the beneficiary
Doctor 4.3
LHV 2.1
ANM/FHW 91.5
Anganwadi worker 1.1
ASHA worker -
Others 1.1
Place where the cash incentive received by the beneficiary
District/Sub-district Hospital 2.1
Community Health Centre 1.1
PHC 8.5
Sub-Centre 39.4
Anganwadi Centre 7.4
Private hospital accredited by the government 1.1
At home 36.2
Other place 4.3
Faced difficulty in getting incentive money 4.3
If faced difficulty, type of difficulty faced by the beneficiary
Was asked to pay the bribe -
When paid by cheque/draft -
Other difficulty (had to go several times) 100.0
Total number of JSY beneficiaries received cash incentive 94

Table H15: Utilization of government health facility in last 6 months

Households Households
located in located in
Utilization of government health facility All
Sub Centre other
HQ Village village
Percent of households availed health services in 21.7 18.0 19.8
government health facility in last 6 months (125) (107) (232)
Total number of households 577 595 1,172

101
Table H16: Characteristics of the respondents who have availed the services in government
health facility in last 6 months

Characteristics of the respondent Percent

Age
16-19 years 8.3
20-29 years 30.9
30-39 years 26.5
40-49 years 15.7
50-59 years 9.3
60 years or more 9.3
Sex
Male 41.9
Female 58.1
Years of schooling completed
Illiterate 53.3
1-5 years 12.4
6-9 years 21.4
10+ years 12.9
Marital status
Unmarried 14.3
Currently Married 76.7
Divorced/Separated 0.5
Widowed 8.6
Social category of the household
SC 13.3
ST 62.9
OBC 11.4
Others 12.4
Religion of the household
Hindu 94.3
Muslim 1.4
Christian -
Sikh -
Others 4.3
BPL Household 69.0
Standard of Living Index of the household
Low SLI 76.7
Medium SLI 18.1
High SLI 5.2
Total respondents who have availed the services in government health
210
facility in last 6 months

102
Client Satisfaction

Table H17: Type of health facility visited, purpose of visit and client satisfaction regarding
behaviour of health worker, privacy and availability medicines

Type of health facility visited, purpose of visit and client satisfaction Percent
Type of health institution where service availed
District/Sub District Hospital 13.3
CHC 11.9
PHC 51.0
Sub Centre 23.8
AYUSH -
Purpose of visit to the health facility
Treatment of minor ailment 63.3
ANC care 2.4
Child care 13.3
Immunization 0.5
Other 20.5
Behaviour of the staff at the health facility
Courteous 79.4
Casual/Indifferent 18.7
Insulting/Derogatory 1.9
Listening of complaints by Doctor/staff
Listened to complaints 82.4
Somewhat listened 15.7
Not listened 1.4
Can’t say 0.5
Women patients treated with privacy and dignity
Yes 80.5
No 10.5
Don’t know 9.0
Patients with chronic illnesses (like joint pains, heart disease, blood pressure,
diabetes etc.) get medicines regularly from health facility
Yes 44.3
No 15.2
Don’t know 40.5
Private practice of the doctors during and after the duty hours
Yes 13.3
No 33.3
Don’t know 53.3
Satisfaction with the overall services of the govt health facility
Satisfied 85.7
Somewhat satisfied 7.6
Not satisfied 6.7
Satisfaction with behaviour of staff at the govt health facility
Satisfied 87.1
Somewhat satisfied 9.6
Not satisfied 3.3
Total respondents who have availed the services in government health facility
210
in last 6 months

103
Table H18: User fees and extra charges

User fees and extra charges for the services provided Percent
User fees charged from the users
Yes 52.9
No 47.1
Total (210)
If user fees charged, type of user fees
Registration 93.7
X-ray 1.8
Ultrasound -
Lab test 9.9
Other 16.2
Receipt given for the user fees
Given 30.6
Not given 69.4
Extra money charged for the services provided
Yes 25.5
No 73.6
Don’t know 0.9
Total respondents who have paid the user fees 110

Table H19: Services for the BPL patients

BPL Patents Percent

BPL patients provided free/subsidized services
Yes 62.2
No 18.3
Don’t know 19.5
BPL patients face difficulty in getting free/subsidized services
Yes 17.1
No 52.4
Don’t know 30.5
RKS facilitates the paperwork for BPL patients
Yes 4.9
No 23.2
Don’t know 72.0
Total BPL respondents who have availed the services in government health
82
facility in last 6 months

104
Table H20: Outbreak of selected diseases (Malaria, Measles, Gastroenteritis, Jaundice and
Other Diseases) in the respondents’ area in the last six months

Outbreak of diseases Percent

Outbreak of Malaria in the last six months
Yes 38.1
No 55.8
Don’t know 6.1
Outbreak of Measles in the last six months
Yes 7.3
No 85.4
Don’t know 7.3
Outbreak of Gastroenteritis in the last six months
Yes 5.7
No 86.1
Don’t know 8.2
Outbreak of Jaundice in the last six months
Yes 2.1
No 89.8
Don’t know 8.0
Outbreak of Any Other Diseases in the last six months
Yes 0.9
No 87.2
Don’t know 11.9
Total number of household respondents 1,172

105
Table H21: Action to be taken for selected diseases (diarrhoea, high fever, persistent cough,
loose motion, persistent cough and breathing problems for a child)

Action to be taken for selected diseases (Multiple responses) Percent

Prevention of diarrhoea
Hand washing 39.0
Use of safe food and water 66.0
Use of covered containers 25.0
Proper disposal of garbage 2.2
Other -
Don’t know 30.3
Action to be taken if a family member has a high fever
Get the blood tested for malaria 20.2
Taken to the RMP 36.3
Take to the nearest govt. health facility 92.8
Consult ASHA 0.2
Try home remedies 28.2
Other 3.9
Don’t know 1.8
Action to be taken if a family member has a persistent cough for more than
two weeks
Taken for sputum testing 9.5
Taken to the RMP 35.3
Take to the nearest govt. health facility 89.0
Consult ASHA 0.1
Try home remedies 31.5
Other 3.3
Don’t know 4.6
Action to be taken if a family member has loose motions lasting for more
than 24 hours
Stop giving Oral Fluids/Food etc 2.0
Start giving ORS 28.8
Taken to the RMP 35.0
Take to the nearest govt. health facility 89.8
Consult ASHA -
Try home remedies 34.3
Other 4.1
Don’t know 0.6
Action to be taken if a child in the family has persistent cough and
breathing problems
Try home remedies 22.5
Taken to the RMP 29.5
Take to the nearest govt. health facility 83.4
Consult ASHA 0.3
Other 2.7
Don’t know 11.3
Total number of household respondents 1,172

106
Table H22. Awareness about spacing methods and ideal gap between 1st and 2nd child

Awareness about spacing methods and ideal gap between children Percent
76.3
Aware about the family planning methods
(894)
Ideal gap between 1st and 2nd child
1 year 8.6
2 year 38.2
3 and more years 53.1
Methods available for spacing
IUD 44.0
Oral Pills 85.8
Nirodh/Condom 40.5
Any other 0.1
Don’t know 9.2
Total number of respondents 894

Table H23: Awareness about modes of getting AIDS, source of information about AIDS and
awareness about VCTC

AIDS and VCTC Percent

44.2
Heard of HIV/AIDS
(518)
Awareness about modes of getting HIV/AIDS (out of respondents who
have heard of AIDS)
Unsafe sexual contact 91.9
Blood transfusion 54.4
Sharing needles/syringes 59.5
From mother to child 7.5
Shaking hands -
Sneezing 0.6
Insect bite 1.7
Kissing -
Others 0.2
Source of information for HIV/AIDS (out of respondents who have heard of
AIDS)
Radio 10.0
TV 31.9
Health workers 32.2
Posters 21.0
Newspapers 10.0
Others 62.9
Aware about HIV/AIDS counselling centre/VCTC nearby(out of 19.7
respondents who have heard of AIDS) (102)
Respondents by reported location of HIV/AIDS counselling centre/VCTC
(out of respondents who are aware about HIV/AIDS counselling
centre/VCTC nearby)
PHC 22.5
CHC 21.6
District Hospital 19.6
Sub-District Hospital 27.5
Private Hospital 7.8
Other 1.0
Total number of respondents 102
107
Table H24: Suggestions given by the respondents

Suggestions Number Percent

Govt. Hospital/PHC/SC needed in the village 304 25.9
Safe/clean drinking water needed 286 24.4
Pucca roads needed/roads should be repaired 280 23.9
Toilets needed in the village 175 14.9
Need transport facility 165 14.1
Cleanliness needed in the village 102 8.7
Closed drainage system needed/gutters should be repaired or closed 91 7.8
ANM needed in the village 46 3.9
Medicines should be available regularly 33 2.8
Information about health schemed needed 27 2.3
Behaviour of doctor should be improved 21 1.8
Treatment should be available for all types of diseases 8 0.7
Treatment should be free of cost 1 0.1
HIV/AIDS counselling Centre needed in the village 1 0.1
No suggestions/can’t say/satisfied 301 25.9
Total number of respondents* 1,172 --
* Total may exceed 100 percent due to multiple responses.

108
 Chapter 7
Status and Performance of ASHA

In Maharashtra, ASHA scheme is introduced only in areas where the tribal population
in considerable. Hence, out of 35 districts of the state, ASHAs are appointed only in 15
districts where the tribal population is considerable. Within these 15 tribal districts also,
ASHAs are appointed only in the blocks where the concentration of tribals is more.
Gadchiroli is one of the districts where ASHAs scheme is introduced. As per 2001 Census,
38.3 percent of the population is tribal in Gadchiroli district and the tribals are concentrated
in all the tehsils of the district. Though the ASHA scheme is introduced in the district, it has
not become completely operational in the District. Out of 12 Sub Centres covered for the
study, ASHAs are working/appointed only in three Sub Centres at the time of survey. In the
remaining nine Sub Centres ASHAs are not yet appointed. Even in the three SCs where
ASAHs are appointed, they have not yet started actually functioning in the villages.

Out of the six ASHAs appointed in the villages selected for the household survey we
could contact only two ASHAs and interviewed them As the number of ASHAs
appointed/available/interviewed is less, we are not presenting the tables for ASHA in the
report.

109
 Chapter 8
Gram Panchayat

Gram Panchayat schedule was canvassed to the member of GP/Sarpanch

representing the selected village. It covered the basic information about the Gram Panchayat
(population and households covered), IEC activities carried out, functioning of the VHSC,
implementation of ASHA and JSY, and awareness about the ASHA at the Gram Panchayat
level. Out of 24 villages covered for the survey, we could canvass the Gram Panchayat
Schedule only in 18 villages.

The average population of the 18 villages is 767 with an average SC population of 114
(15 percent) and ST population of 422 (55 percent). The average number of households per
village is 172 with an average of 25 SC and 100 ST households. The average number of BPL
families per village is 114 with an average of 16 SC and 75 ST families.

Regarding the regular availability of ANM, all the Gram Panchayats have reported
that the ANM is regularly available in the village. Two third of the Gram Panchayats reported
that they know the tour plan of the ANM. All the Gram Panchayats have reported that the
Sub Centre is providing timely services to the patients in the village. Only 28 percent of the
Gram Panchayats reported that it had a role in conducting/finalising IEC programme in the
village.

Fifteen out of eighteen Gram Panchayats (83 percent) have reported the existence of
the VHSC in their village. Out of the 15 villages with the VHSC, 14 of them reported the
regular meetings of the VHSC in the village. However, only 40 percent of the Gram
Panchayats reported that VHSC has prepared the Village Health Plan. Except one, all the
other 17 Gram Panchayats have received the Untied Funds.

Only two out of 18 Gram Panchayats have reported the appointment of ASHAs in
their village. Awareness about the benefits under the JSY scheme was reported by 89 percent
of the Gram Panchayats. More than three fourth of them (78 percent) said that the NRHM
has brought improvement in their area. Some of the improvements reported by the Gram
Panchayats due to NRHM are: availability of funds/facilities under JSY (50 percent),
availability of funds for the maintenance of Sub Centre (29 percent), availability of better

110
facilities in CHCs/PHCs for referred patients (21 percent), and availability of transport
facilities for delivery (7 percent). Only few Gram Panchayats have reported the difficulties in
implementing programme activities under NRHM. Some of the reported difficulties are non
availability of funds on time (33 percent), inadequate facilities for institutional deliveries (28
percent), difficulty in decision making with the community leaders (6 percent) and inadequate
training for ASHAs (6 percent).

The Panchayats were asked about the kind of support required to enable them to
implement NRHM more effectively. The kind of support required by the Gram panchayats
are: control over funds (50 percent), more funds for maintenance and effective functioning
(39 percent), and more training for ASHA and Community members (28 percent).

Role, Awareness and Involvement of Gram Panchayats

Table A1. Status of Gram Panchayats Covered

A. Number of Gram Panchayats covered in the district 18

B. Average population of the Gram Panchayat covered
Scheduled Caste 114.2
Scheduled Tribe 421.5
Total 766.9
C. Average number of Households in the Gram Panchayats covered
Scheduled Caste 24.8
Scheduled Tribe 100.7
Total 171.6
D. Average number of BPL families in the Gram Panchayats covered
Scheduled Caste 16.1
Scheduled Tribe 74.8
Total 111.4

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Table A2. Level of awareness and involvement of Gram Panchayats

A1. Percentage of Gram Panchayat reporting regular availability of ANM 100.0

A2. Percentage of Gram Panchayat reporting awareness about ANM Tour Plan 66.7
B. Percentage of Gram Panchayat reporting timely services provided by SC to the patients 100.0
C. Percentage of Gram Panchayat reporting role of Gram Panchayat in conducting /
27.8
finalizing IEC programme in Gram Panchayat
D. Percentage of Gram Panchayat reporting existence of VHSC in their Gram Panchayat 83.3
E. Percentage of Gram Panchayat reporting regular meetings of VHSC 93.3
F. Percentage of Gram Panchayat reporting Village health Plan been prepared by VHSC 40.0
G. Percentage of Gram Panchayat reporting that VHSC has received any Untied Fund 93.3
H. Percentage of Gram Panchayat reporting ASHA workers in position 11.1
I. Percentage of Gram Panchayat reporting awareness of the benefits under JSY scheme 88.9
J. % of Gram Panchayat reporting that NRHM brought about improvement in their area 77.8
K. Percentage of Gram Panchayat reporting conduct of IEC activities during last 6 months 38.9
L. Distribution of Gram Panchayats covered by type improvement reported due to NRHM
Funds available for maintenance of Sub Centres 28.6
Community support is available as ASHA worker 7.1
Funds/facilities are available under JSY 50.0
Better facilities are available for CHCs/PHCs for referred patients 21.4
Transport facilities are available 7.1
Other 7.1
M. Distribution of Gram Panchayats by type of difficulties faced in implementing
programme activities under NRHM
Funds not available in time 33.3
Decision making with the community leaders is difficult 5.6
ASHA has not been adequately trained 5.6
Adequate facilities for institutional deliveries not available 27.8
Any other 5.6
M. Distribution of Gram Panchayats by kind of support required to enable them in
implementing the programme more effectively
More funds are required for maintenance/ effective functioning 38.9
Gram Panchayat should be given direct control over funds 50.0
More training is to be arranged for ASHA and Community members 27.8
Any other -
Number of Gram Panchayats covered in the district 18

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 Chapter 9
Quality of Care and Client Satisfaction
(Based on IPD Exit Interview)

Introduction
As per the study design, 5-10 IPD patients have to be interviewed at each of the
health facility (1 District Hospital, 2 CHCs and 4 PHCs) at the time of discharge. Hence, the
expected number of exit interview in the district varies between minimum of 35 and
maximum of 70. Accordingly, we have interviewed 10 IPD patients from the DH and 10 each
from the two selected CHCs. However, from the four selected PHCs, we could not conduct
any exit interview due to the non availability of IPD patients during our stay in the field. As
the number of patients interviewed is small (10 for DH and 20 for CHCs), a caution is
necessary while interpreting the figures.

Characteristics of the patients interviewed for the IPD exit-interview in DH and

CHCs are presented in Table EI-1. The age distribution of the IPD patients shows that 71
percent of the patients are aged less than 30 years and the remaining 29 percent are aged 30
years and above. The majority of the IPD patients interviewed are females (70 percent),
currently married (80 percent) and from rural areas (83 percent). Purpose of admission in the
health facility shows that 23 percent of the patients were admitted for minor illnesses, 20
percent for the childhood illnesses, 13 percent for family planning surgery, 7 percent for
delivery, 3 percent for cataract surgery, and 33 percent for various other illnesses (Table EI2).
Family planning surgery, delivery and child admitted together add to 40 percent.

Waiting Time
The average waiting time for the patients for the Registration is 17 minutes (Table EI-
3). The average waiting time for Registration in DH is more than half an hour, and in CHCs it
is 7 minutes. After the Registration, the patients had to wait on an average 10-11 minutes for
the Doctor’s call in the hospitals. On an average, the doctors have examined the patients for 8
minutes in CHC and 7 minutes in DH. After the examination it takes 15 minutes to get
admitted to the ward. Here again, the waiting time to admission to the ward is five minutes
longer in DH (18 minutes) than in CHCs (13 minutes). After admission to the ward, it takes
about 8 minutes for the patients to get the services. The average time for getting discharged
for the patients in the hospitals is about 20 minutes and there is no difference in the time to
get discharged between DH and CHCs.

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Satisfaction regarding Waiting Time
Satisfaction of the patients regarding waiting time for different services is given in
Table EI-4. The satisfaction with the waiting time for registration, doctor’s call, doctor’s
examination, admission to ward, getting services, and to get discharged is assessed with four
categories: too long, appropriate, too short and can’t say. Thirteen percent of the patients said
that the waiting time is too long for Registration. One fifth of the patients were dissatisfied
with the waiting time for doctor’s call and admission to ward. Seventeen percent of the
patients were dissatisfied with the doctor’s examination time as they said that the examination
time is too short. More patients from DH (30 percent) were dissatisfied with the doctor’s
examination time than from CHCs (10 percent). More patients from CHCs were dissatisfied
with the waiting time to get the services. Thirty eight percent of the patients reported that the
waiting time to get discharged is too long. In four out of six services, the dissatisfaction with
the waiting time is more in CHCs than in DH. Overall, the dissatisfaction levels are somewhat
higher as 13-38 percent of the patients were dissatisfied for the various types of services in
the hospitals.

Behaviour of Staff
Behaviour of each category of staff (doctor, nurse, technical staff, ayah, ward boy and
counter clerk) is assessed with a four point scale - rude, reasonable, good and very kind (Table
EI-5). Only 80 percent of the patients said that the doctor greeted them in a friendly manner
in the first instance. Regarding the behaviour of doctors, nurses and technical staff, 71-83
percent of the patients said that their behaviour is good/very kind. Satisfaction regarding the
behaviour of ayah, ward boys and counter clerk appears to be high as 80-96 percent of the
patients said that they are good. The figures indicate that all the patients are not satisfied with
the behaviour of all categories of staff in the health facilities. Satisfaction of the patients
regarding the behaviour of various categories of staff reveals that 3 to 10 percent of them
were not happy. Dissatisfaction regarding the behaviour of staff is more in the CHCs than in
DH.

The patients were asked whether the hospital authorities have taken some unique/innovative
measure to improve the staff behaviour in the hospital (Table EI7). For this question, 97
percent of the patients said that no unique/innovative measure was taken to improve the
behaviour of the staff.

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Privacy
One of the criticisms for the services in public health facilities in India is lack of
privacy during the examination, particularly for female patients. This can be addressed easily
by making partitioning of the room or by keeping a curtain at the place of examination. In the
exit interview all the patients were asked whether there was privacy at the place of
examination. On the whole, only 43 percent of patients said that there was privacy in the
place of examination.

Patient-Doctor/Provider Communication
Client-provider communication is one of the important dimensions of the quality of
care. The doctor-patient communication was assessed from the patients in the following
issues: doctor listened to the description of the ailment; doctor allowed to ask questions;
doctor responded to questions; doctor discussed about ailment; doctor talked about recovery;
and doctor gave other advice (Table EI-8). The response of the patients with respect to their
interaction with the doctor shows that the patients are not totally happy with it. Regarding
listening to the patient’s ailment, 73 percent of the patients said that the doctor always
listened to their ailment patiently, 17 percent said that the doctor listened somewhat and 10
percent said that doctor did not listen. Though the majority of the patients (83 percent) said
that the either the doctor always/somewhat allowed to ask questions or responded to
questions still 17 percent of the patients said that the doctor did not allow to ask
questions/responded to their questions. Similarly, 20-23 percent of the patients said that the
doctor did not discuss about their ailment with them/talked about their recovery. Nearly two
third of the patients said that the doctor did not give any ‘other advice’ for them. In four out
of six issues of doctor-patient communication, about 17-23 percent of the patients were not
happy with the doctor. Hospital wise satisfaction regarding the doctor-patient communication
shows that the unhappiness is more in DH than in CHCs. This may be due to the higher
number of patient turnover in DH. However, the analysis of client-provider communication
clearly indicates that it needs to be improved in health facilities, more so in DH.

Cleanliness of the Facility

Cleanliness of health facilities is assessed through the frequency of cleaning of floor
and toilet/bathroom, changing patient’s uniform and changing bed-sheets. Regarding the
frequency of cleaning of the floor, the percentage of patients reported that the cleaning is
done twice in a day is only 3 percent, once in day is 83 percent and less than once in a day is
13 percent. The percentage of patients said that the toilet/bathroom is cleaned twice a day is
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3 percent, once a day is 73 percent and less than once a day is 23 percent. Cleanliness of floor
and toilet/bathroom appears to be poor in CHCs compared to DH. In DH, all the patients
have reported that the cleaning of floor and toilet/bathroom are done at least once a day,
whereas in CHCs only 20 percent of patients said that the floor cleaning is done less than
once a day and 35 percent said that toilet/bathroom cleaning is done less than once a day.

Overall, 60 percent of patients said that patient uniform was not changed during their
hospitalisation. All the patients from DH reported that the patients’ uniform was changed
once a day, whereas only 75 percent of patients reported so in CHCs. It appears that changing
bed sheet is not a common practice in the hospitals as 33 percent of patients reported that the
bed sheet was not changed during their hospitalisation and another 43 percent said that it was
changed less than once a day. Only 23 percent of the patients said that bed sheet was changed
once/twice a day. The performance of the CHCs is worst in this as 45 percent of the patients
from CHCs (10 percent from DH) reported that the bed sheet was never changed. Overall,
according to the patients, the cleanliness of floor and toilet/bathrooms are poor in CHCs
compared to the DH. Irrespective of type of facility, changing patient’s uniform and bed
sheets are not a common practice in the hospitals.

Satisfaction Regarding the Cleanliness of the Facility

The satisfaction regarding the cleanliness of the facility is assessed through three
categories of satisfaction – satisfied, somewhat satisfied and not satisfied (Table EI10). It
shows that only 50 to 63 percent of the patients are clearly satisfied for cleaning of floor,
cleaning toilet/bathroom, changing patients uniform and bed sheets. The remaining patients
are either somewhat satisfied or not satisfied. Dissatisfaction is 33 percent for not changing of
uniform, 25 percent for not changing bed sheets, 21 percent for cleanliness of toilet and 13
percent for cleanliness of floor. Satisfaction by type of facility shows that all the patients in
DH are satisfied with all the aspects of cleanliness whereas 20-39 percent of the patients in
CHCs are not happy with the four areas of cleanliness. The data on frequency of the
cleanliness and satisfaction regarding the same clearly shows that lack of cleanliness is a major
issue in CHCs.

Crowding in the Facility

Crowding in the facility is assessed through availability of cot for the patients,
adequacy of the space in the ward, satisfaction with the arrangement of ward and adequacy of
space in IPD (Table EI-11). Except two, all the patients (28 out of 30) said that they got the
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cot immediately after the admission to the ward and 93 percent of them said that the cot was
available to them till the time of discharge. As the bed occupancy in the hospitals is low,
availability of cot is not a major problem in the hospitals. Regarding the adequacy of space in
the ward, 10 percent of the patients said that the space is not adequate. Overall, one fifth of
the patients are not satisfied with the ward arrangement. For 60 percent of the patients, the
space in IPD is adequate, for 20 percent it is somewhat adequate and for another 20 percent it
is inadequate. The percent of patients reporting that the space is not adequate is more in DH
(30 percent) than in CHCs (15 percent).

Amenities Provided by the Hospital

The availability of amenities in health facilities as reported by the patients are given in
Table EI-12. Two third of the patients reported that the health facilities have accommodation
for relatives and ambulance. The percent of patients reported the availability of canteen and
medical shop is 40 percent. Only 20 percent of the patients reported the availability of
telephone and very few (3 percent) reported the availability of television. Accommodation for
relatives and Ambulance are the most reported amenity (60-70 percent) across the hospitals.
According to patients, Television is the least available amenity in the DH and CHCs. All the
patients from DH reported that the television is not available. As per the reporting of
patients, amenities are relatively better in DH compared to the CHCs. Among those who said
that the particular amenity is available in the hospital were further asked about their
satisfaction regarding the amenity. It shows that that all the patients are satisfied with the
availability of television, canteen, medical shop and accommodation for relatives whereas only
50 percent are satisfied for telephone and 75 percent for Ambulance.

Continuity of Treatment
Patients satisfied with the services will continue to visit the facility. However,
dissatisfied patients may cause harm to the public health programmes/facilities by
discouraging others to go the government facility. Hence, any dissatisfaction may lead to
underutilisation of the facilities and wastage of precious public resources. To understand this,
the patients were asked about their overall satisfaction with the visit to the health facility, their
willingness to visit again and their willingness to recommend the facility to others. Table EI-
13 shows that, overall, 70 percent of the patients are ‘satisfied’ with their visit to the facility
and 30 percent are ‘somewhat satisfied’ and none of them are ‘dissatisfied’. Satisfaction by
type of hospital shows that all the patients from DH are ‘satisfied’ and from CHCs roughly
half are ‘satisfied’ and half are ‘somewhat satisfied’. All the patients from DH and 85 percent
117
from CHC said that they would come again to the facility, in case they fell sick. Similarly, all
the patients from DH and 85 percent from CHC said that they would recommend the
hospital to others.

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 Quality of Care and Client Satisfaction
(Based on IPD Exit Interview)

Table EI-1: Background characteristics of the in-patients

Background Characteristics of the In-Patients Percent

Age
< 20 years 6.7
20-29 years 63.3
30-39 years 13.3
40-49 years 3.3
50-59 years 3.3
60 years or more 10.0
Sex
Male 30.0
Female 70.0
Marital status
Unmarried 16.7
Currently married 80.0
Divorced/Separated -
Widowed 3.3
Residence
Rural 83.3
Urban 16.7
Type of Health Facility
District Hospital 33.3
CHC 66.7
PHC -
Total number of in-patients interviewed 30

Table EI-2: Purpose of admission in the Health Institution

Type of Health Facility (Percent)

Purpose of admission in Health Institution
DH CHC PHC All
Minor illness 40.0 15.0 - 23.3
FP surgery - 20.0 - 13.3
Delivery 10.0 5.0 - 6.7
Cataract surgery 10.0 - - 3.3
Child admitted 10.0 25.0 - 20.0
Other 30.0 35.0 - 33.3
Total number of in-patients interviewed 10 20 - 30

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Table EI-3: Waiting time

Type of Health Facility

Average waiting time for: (Average waiting time in minutes)
DH CHC PHC All
Registration 37.0 6.5 - 16.6
Doctor's call 10.0 11.8 - 11.2
Doctor's examination 6.7 8.0 - 7.6
Admission to ward 18.2 13.7 - 15.2
Getting services 6.2 8.4 - 7.6
To get discharged 18.3 20.0 - 19.4
Total number of in-patients interviewed 10 20 - 30

Table EI-4: Satisfaction regarding waiting time

Type of Health Facility

Waiting time for/Satisfaction
DH CHC PHC All
Registration
Too long 10.0 15.0 - 13.3
Appropriate 70.0 45.0 - 53.3
Too short 20.0 40.0 - 33.3
Can't say - - - -
Doctor's call
Too long 20.0 21.1 - 20.7
Appropriate 80.0 52.6 - 62.1
Too short - 26.3 - 17.2
Can't say - - - -
Doctor's examination
Too long - 26.3 - 20.7
Appropriate 70.0 63.2 - 62.1
Too short 30.0 10.5 - 17.2
Can't say - - - -
Admission to ward
Too long 10.0 26.3 - 20.7
Appropriate 60.0 63.2 - 62.1
Too short 30.0 10.5 - 17.2
Can't say - - - -
Getting services
Too long - 22.2 - 14.3
Appropriate 60.0 50.0 - 53.6
Too short 30.0 27.8 - 28.6
Can't say - - -
To get discharged
Too long 33.3 40.0 - 37.5
Appropriate 66.7 60.0 - 62.5
Too short - - - -
Can't say - - - -
Total number of in-patients interviewed 10 20 - 30

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Table EI-5: Behaviour of Staff

Type of Health Facility (Percent)

Staff Behaviour
DH CHC PHC All
Doctor greet in a friendly manner
Yes 100.0 70.0 - 80.0
Somewhat - - - -
No - 30.0 - 20.0
Behaviour of Doctor
Rude - 5.0 - 3.3
Reasonable - 20.0 - 13.3
Good 80.0 70.0 - 73.3
Very kind 20.0 5.0 - 10.0
Behaviour of Nurse
Rude - 15.0 - 10.0
Reasonable - 10.0 - 6.7
Good 100.0 75.0 - 83.3
Very kind - - - -
Behaviour of Technical Staff
Rude - 12.5 - 7.1
Reasonable 16.7 25.0 - 21.4
Good 83.3 62.5 - 71.4
Very kind - - - -
Behaviour of Ayah
Negligent - 6.3 - 4.2
Arrogant - 12.5 - 8.3
Indifferent - - - -
Good 100.0 81.3 - 87.5
Behaviour of Ward Boys
Negligent - 13.3 - 8.0
Arrogant - 13.3 - 8.0
Indifferent 10.0 - - 4.0
Good 90.0 73.3 - 80.0
Behaviour of Counter Clerk
Negligent - - - -
Arrogant - - - -
Indifferent - 5.3 - 3.6
Good 100.0 94.7 - 96.4
Total number of in-patients interviewed 10 20 - 30

Table EI-6: Unique/ innovative measure taken to improve the staff behaviour

Type of Health Facility (Percent)

Staff Behaviour
DH CHC PHC All
Unique/innovative measure taken to improve
the staff behaviour 10 10 - 20
Yes - 5.0 - 3.3
No 100.0 95.0 - 96.7
Don't know - - - -
Total number of in-patients interviewed 10 20 - 30

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Table EI-7: Privacy

Type of Health Facility (Percent)

Privacy
DH CHC PHC All
Patients reporting presence of privacy at the place
40.0 45.0 - 43.3
of examination
Total number of in-patients interviewed 10 20 - 30

Table EI-8: Patient-Doctor/Provider Communication

Type of Health Facility (Percent)

Patient-Doctor/ Provider Communication
DH CHC PHC All
Doctor listened to description of ailment
patiently
Yes, somewhat - 25.0 - 16.7
Yes, always 90.0 65.0 - 73.3
No 10.0 10.0 - 10.0
Doctor allowed to ask question
Yes, somewhat - 30.0 - 20.0
Yes, always 80.0 55.0 - 63.3
No 20.0 15.0 - 16.7
Did not interact with doctor - - - -
Doctor responded to question
Yes, somewhat - 30.0 - 20.7
Yes, always 77.8 55.0 - 62.1
No 22.2 15.0 - 17.2
Doctor discussed about ailment
Yes 70.0 85.0 - 80.0
No 30.0 15.0 - 20.0
Doctor talked about the recovery
Yes 70.0 80.0 - 76.7
No 30.0 20.0 - 23.3
Doctor gave 'other advice'
Yes 20.0 45.0 - 36.7
No 80.0 55.0 - 63.3
Total number of in-patients interviewed 10 20 - 30

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Table EI-9: Cleanliness of the facility

Type of Health Facility (Percent)

Type of facility/ Frequency of cleaning
DH CHC PHC All
Floor
Thrice a day - - - -
Twice a day - 5.0 - 3.3
Once a day 100.0 75.0 - 83.3
Less than once a day - 20.0 - 13.3
Not applicable - - - -
Toilet/Bathroom cleaning
Thrice a day - - - -
Twice a day - 5.0 - 3.3
Once a day 100.0 60.0 - 73.3
Less than once a day - 35.0 - 23.3
Not applicable - - - -
Changing patient's uniform
Twice a day - - - 5.0
Once a day - 21.1 - 20.0
Less than once a day 100.0 15.8 - 15.0
Not changed - 63.2 - 60.0
Not applicable - - - -
Changing bed-sheets
Twice a day 20.0 - - 6.7
Once a day 20.0 15.0 - 16.7
Less than once a day 50.0 40.0 - 43.3
Not changed 10.0 45.0 - 33.3
Not applicable - - - -
Total number of in-patients interviewed 10 20 - 30

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Table EI-10: Satisfaction of patients regarding cleanliness of the facility

Type of Health Facility (Percent)

Type of facility/ Satisfaction
DH CHC PHC All
Floor cleaning
Satisfied 100.0 45.0 - 63.3
Somewhat satisfied - 35.0 - 23.3
Not satisfied - 20.0 - 13.3
Toilet/ Bathroom cleaning
Satisfied 100.0 36.8 - 58.6
Somewhat satisfied - 31.6 - 20.7
Not satisfied - 31.6 - 20.87
Changing patient's uniform
Satisfied 100.0 47.1 - 50.0
Somewhat satisfied - 17.6 - 16.7
Not satisfied - 35.3 - 33.3
Changing bed sheets
Satisfied 100.0 33.3 - 57.1
Somewhat satisfied - 27.8 - 17.9
Not satisfied - 38.9 - 25.0
Total number of in-patients interviewed 10 20 - 30

Table EI-11: Crowding in the facility

Type of Health Facility (Percent)

Crowding in the facility
DH CHC PHC All
Availability of cot
Immediately 90.0 95.0 - 93.3
Not immediately but same day 10.0 5.0 - 6.7
Next day - - - -
After more than a day - - - -
Never got the cot - - - -
Availability of cot/bed till the time of
discharge
Yes 80.0 100.0 - 93.3
No 20.0 - - 6.7
Adequacy of space in the ward
Adequate 80.0 70.0 - 73.3
Somewhat adequate 10.0 20.0 - 16.7
Not adequate 10.0 10.0 - 10.0
Satisfaction with the ward arrangement
Satisfied 70.0 40.0 - 50.0
Somewhat satisfied 10.0 40.0 - 30.0
Not satisfied 20.0 20.0 - 20.0
Adequacy of space in IPD
Adequate 60.0 60.0 - 60.0
Somewhat adequate 10.0 25.0 - 20.0
Not adequate 30.0 15.0 - 20.0
Total number of in-patients interviewed 10 20 - 30

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Table EI-12: Amenities provided by the hospital

Percentage of in-patients reporting Type of Health Facility

availability/ % reporting DH CHC PHC All
satisfaction % No. % No. % No % No.
Availability of amenities
Television 10.0 1 - - - - 3.3 1
Canteen 100.0 10 15.0 3 - - 43.3 13
Medical shop 70.0 7 25.0 5 - - 40.0 12
Telephone - - 30.0 6 - - 20.0 6
Accommodation for relatives 70.0 7 60.0 12 - - 63.3 19
Ambulance 70.0 7 65.0 13 - - 66.7 20
Satisfaction among those who said
the amenity is available
Television 100.0 1 - - - - 100.0 1
Canteen 100.0 10 100.0 3 - - 100.0 13
Medical shop 100.0 7 100.0 5 - - 100.0 12
Telephone - - 50.0 3 - - 50.0 3
Accommodation for relatives 100.0 7 83.3 10 - - 89.5 17
Ambulance 87.5 7 69.2 9 - - 76.2 16

Table EI-13: Continuity of treatment

Type of Health Facility (Percent)

Continuity of treatment
DH CHC PHC All
Overall satisfaction on visiting to facility
Dissatisfied - - - -
Somewhat satisfied - 45.0 - 30.0
Satisfied 100.0 55.0 - 70.0
Reason of dissatisfaction
Lack of facilities - - - -
Bad experience with doctor - - - -
Poor quality of services - - - -
Charges are exorbitant - - - -
Other - - - -
Would like to come again in case fell sick
Yes 100.0 85.0 - 90.0
No - 15.0 - 10.0
May come/unsure - - - -
Whether recommend this hospital to other
Yes 100.0 85.0 - 90.0
No - 15.0 - 10.0
Total no. of in-patients interviewed 10 20 - 30

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 Chapter 10
Quality of Care and Client Satisfaction
(Based on OPD Exit Interview)

As per the study design we have to interview 5-10 OPD patients at each of the
selected health facility (1 District Hospital, 2 CHCs and 4 PHCs) at the time of their exit from
the hospital. Hence, the expected number of OPD exit interview in the district varies between
minimum of 35 and maximum of 70. We have conducted 10 OPD interviews from DH, 20
from the two selected CHCs and 39 from the four selected PHCs. As the number of patients
interviewed is small (10 for DH, 29 for CHCs and 39 for PHCs), a caution is necessary while
interpreting the figures.

Characteristics of the patients interviewed for the OPD exit-interview are presented in
Table EO-1. The age distribution of the OPD patients shows that 32 percent of the patients
are aged less than 30 years and the remaining 68 percent are aged 30 years and above.
Thirteen percent of the patients are aged 60 years and above. The majority of the OPD
patients interviewed are females (62 percent), currently married (81 percent) and from rural
areas (81 percent). Purpose of visit to the health facility shows that 52 percent of them visited
for availing treatment for minor illness, one fourth of them for child illness, and remaining 23
percent for various other illnesses (Table EO-2). Purpose of OPD visit by type of facility
shows that minor and child illnesses (65 to 75 percent) are the two major reasons for the visit
to the health facilities.

Average Waiting Time for Services

Overall, to get all the OPD services it takes on an average 40 minutes for the patients
in the hospitals (Table EO-3). Average time to get the OPD services is highest in CHCs (40
minutes) followed by DH (38 minutes) and PHCs (34 minutes). The waiting for the different
OPD services shows that, except for dressing, all the other OPD services take less than 10
minutes in the hospitals. The average waiting time for the Registration is 5.4 minutes. The
average waiting time for Registration in DH is higher (8 minutes) than in CHCs (6 minutes)
and PHCs (5 minutes). After the Registration, the patients have to wait on an average 7
minutes for the examination of the doctor. The average waiting time for Doctor’s
examination is higher in DH (18 minutes) than in other hospitals (5 minutes). For getting

126
injection, patients have to wait on an average 6.6 minutes in the hospitals. Getting medicines
takes on an average 6.5 minutes in the hospitals.

Satisfaction Regarding Waiting Time

Satisfaction of the patients regarding waiting time for different services is given in
Table EO-4. The satisfaction with the waiting time for registration, doctor’s examination,
injection, dressing, getting medicines, and paying bill is assessed with four categories (too
long, appropriate, too short and can’t say). It shows that dissatisfaction is not very high as
only 6-20 percent of the patients said that the waiting time is too long for these services. In
fact, most of the patients (60-83 percent) reported that the waiting time for these services is
too short. However, dissatisfaction for the doctor’s examination is more as 70 percent of the
patients said that the examination time is too short. Dissatisfaction for different services
shows that the dissatisfaction is least in DH and higher in CHCs. Though the dissatisfaction
levels of OPD services are not very high (except for doctor’s examination time), even the
small level of dissatisfaction has to be properly addressed.

Behaviour of Staff
Behaviour of each category of staff (doctor, nurse, technical staff, ayah, ward boy and
counter clerk) is assessed with a four point scale - rude, reasonable, good and very kind (Table
EO-5). Nine percent of the patients said that the doctor did not greet them in a ‘friendly
manner’ in the first instance, 25 percent said that the doctor greeted them in ‘somewhat
friendly manner’ and 66 percent said that the doctor greeted them in a ‘friendly manner’.
Doctors in DH are friendlier with the patients as none of the patients reported about the
unfriendliness of the doctors. Regarding the behaviour of doctors, nurses and dispenser, 92-
97 percent of the patients said that they are good/very kind. However, seventeen percent of
the patients from the DH reported that the behaviour of the nurses was rude. The figures
indicate that, the patients in general, are satisfied with the behaviour of all categories of staff
in the health facilities.

Privacy
In the exit interview, all the OPD patients were asked whether there was privacy at
the place of examination. On the whole, 73 percent of patients said that there was privacy in
the place of examination. All the patients from DH and CHCs reported the presence of
privacy. However, only half of the patients from PHCs reported that there was privacy at the
place of examination.
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Patient-Doctor/Provider Communication
The response of the OPD patients with respect to their interaction with the doctor
shows that the patients have lot of concern about this. Regarding listening to the patient’s
ailment, 90 percent of the patients said that the doctor always listened to their ailment
patiently, 10 percent said that the doctor listened somewhat and none of them said that
doctor did not listen. Almost all the patients said that the doctors did allow them to ask
questions and responded to the questions. Further, ninety percent of the patients said that the
doctor discussed about the ailment with the patients and 78 percent said that doctor talked
about the recovery. These results show that the OPD patients are happy with the
communication of the doctors. Compared to IPD patients, relatively less OPD patients have
expressed their dissatisfaction regarding their communication with the doctors.

Cleanliness of the OPD Facility

Satisfaction of the patients regarding the cleanliness of the OPD facilities (OPD
room, examination room, dispensary, laboratory, injection room and dressing room) is
presented in Table EI-8. It shows that, overall, 75-94 percent of the patients felt that the
OPD facilities are clean and only very few patients said that the facility is not clean. Except
few, all the patients from DH and PHCs reported that the OPD facilities are clean. Compared
to IPD patients, less number of OPD patients expressed their dissatisfaction regarding the
cleanliness. It appears that, cleanliness is an issue for IPD patients rather than for OPD
patients. Because IPD patients stay longer in the hospital and expect a cleaner environment
whereas, OPD patients visit only for a shorter period and not much bothered about the
cleanliness of the OPD area.

Crowding in the OPD Areas

Compared to cleanliness, lot of dissatisfaction exists for crowding/inadequacy of
space in all OPD facilities (OPD Room, Examination Room, Dispensary, laboratory,
Injection Room and dressing Room) of the hospitals, particularly in CHCs and PHCs. The
percent of patients said that the space is not adequate in OPD Room is 44 percent,
Examination Room is 48 percent, Dispensary is 44 percent, Laboratory is 80 percent,
Injection Room is 63 percent and dressing room is 33 percent. Relatively higher percent of
patients from CHCs and PHCs complained about the inadequacy of space in OPD facilities
compared to DH.

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Continuity of Treatment
Table EI-13 shows that, overall, 87 percent of the patients were ‘satisfied’ with their
visit to the facility and the remaining 13 percent ‘somewhat satisfied’. Compared to IPD
patients (70 percent), more OPD patients (85 percent) were ‘satisfied’ with their visit to the
health facility. Satisfaction by type of hospital shows that all the patients from DH are
‘satisfied’ with their visit and 85 percent of the patients from CHCs and PHCs are ‘satisfied’.
All the patients from all the hospitals said that they would come again to the facility and also
they would recommend the hospital to others.

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 Quality of Care and Client Satisfaction
(Based on OPD Exit Interview)

Table EO-1: Background characteristics of the patients

Background Characteristics of the Out-Patients Percent

Age
< 20 years 4.3
20-29 years 27.5
30-39 years 26.1
40-49 years 14.5
50-59 years 14.5
60 years or more 13.0
Sex
Male 62.3
Female 37.7
Marital Status
Unmarried 10.1
Currently Married 81.2
Divorced/Separated -
Widowed 8.7
Residence
Rural 81.2
Urban 18.8
Type of Health Facility
District Hospital 14.5
CHC 29.0
PHC 56.5
Total out-patients interviewed 69

Table EO-2: Purpose of visit to the Health Institution

Type of Health Facility (Percent)

Purpose of visit to the Health Institution
DH CHC PHC All
Minor Illness 40.0 50.0 56.4 52.2
FP Services - - - -
Antenatal Care - - 5.1 2.9
PNC - - - -
Eye Check-up - - 2.6 1.4
MDT-DOTs - 5.0 2.6 2.9
Child Illness 50.0 15.0 23.1 24.6
Other 10.0 30.0 10.3 15.9
Total out-patients interviewed 10 20 39 69

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Table EO-3: Average waiting time (in minutes) for services by type of facility

No. of patients Average waiting

Average waiting time for:
availed the service time (in minutes)
A. District Hospital
Registration 10 8.0
Doctor’s examination 10 18.0
Injection 1 5.0
Getting medicines 10 4.6
Dressing - -
Paying bill 5 2.0
Total time taken for OPD services - 37.6
B. CHC
Registration 20 5.8
Doctor’s examination 20 5.5
Injection 6 9.5
Getting medicines 20 9.3
Dressing - -
Paying bill 2 10.0
Total time taken for OPD services 40.1
C. PHC
Registration 39 4.6
Doctor’s examination 37 4.9
Injection 9 4.9
Getting medicines 38 5.5
Dressing 5 11.4
Paying bill 11 2.5
Total time taken for OPD services 33.8
D. All
Registration 69 5.4
Doctor’s examination 67 7.0
Injection 16 6.6
Getting medicines 68 6.5
Dressing 5 11.4
Paying bill 18 3.2
Total time taken for OPD services 40.1

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Table EO-4: Satisfaction regarding waiting time by type of hospital

No. of Satisfaction
patients (% of patients)
Waiting time for:
availed the
Too Long Appropriate Too Short Can’t Say
service
A. District Hospital
Registration 10 - 60.0 40.0 -
Doctor’s examination 10 50.0 40.0 10.0 -
Injection 1 - 100.0 - -
Getting medicines 10 - 30.0 70.0 -
Dressing - - - - -
Paying bill 5 - - 100.0 -
B. CHC
Registration 20 10.0 10.0 80.0 -
Doctor’s examination 20 15.0 10.0 75.0 -
Injection 6 33.3 16.7 50.0 -
Getting medicines 20 15.0 20.0 65.0 -
Dressing - - - - -
Paying bill 2 50.0 - 50.0 -
C. PHC
Registration 38 5.3 2.6 92.1 -
Doctor’s examination 37 8.1 8.1 83.8 -
Injection 9 - 11.1 88.9 -
Getting medicines 38 10.5 26.3 63.2 -
Dressing 5 20.0 20.0 60.0 -
Paying bill 11 - 18.2 81.8 -
D. All
Registration 68 5.9 13.2 80.9 -
Doctor’s examination 67 16.4 13.4 70.1 -
Injection 16 12.5 18.8 68.8 -
Getting medicines 68 10.3 25.0 64.7 -
Dressing 5 20.0 20.0 60.0 -
Paying bill 18 5.6 11.1 83.3 -

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Table EO-5: Behaviour of Staff

Type of Health Facility (Percent)

Staff Behaviour
DH CHC PHC All
Doctor greet in a friendly manner
Not friendly - 10.0 10.8 9.0
Yes, somewhat 30.0 20.0 27.0 25.4
Yes 70.0 70.0 62.2 65.7
Behaviour of Doctor
Rude - - - -
Reasonable - 20.0 2.7 7.5
Good 50.0 70.0 83.8 74.6
Very kind 50.0 10.0 13.5 17.9
Behaviour of Nursing Staff
Rude - - - -
Reasonable - 5.0 2.6 3.0
Good 85.7 95.0 82.1 86.4
Very kind 14.3 - 15.4 10.6
Behaviour of Dispenser
Rude - 5.0 - 1.4
Reasonable - 10.0 5.1 5.8
Good 100.0 85.0 87.2 88.4
Very kind - - 7.7 4.3
Behaviour of Technician
Rude - - 2.6 1.4
Reasonable - 5.0 5.1 4.3
Good - 65.0 35.9 39.1
Very kind - - 7.7 4.3
Did Not Interact / Not applicable 100.0 30.0 48.7 50.7
Total out-patients interviewed 10 20 39 69

Table EO-6: Privacy

Type of Health Facility (Percent)

Privacy
DH CHC PHC All
Patients reporting presence of privacy
100.0 100.0 51.3 72.5
at the place of examination
Total out-patients interviewed 10 20 39 69

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Table EO-7: Patient-Doctor/Provider Communication

Type of Health Facility (Percent)

Patient-Doctor Communication
DH CHC PHC All
Doctor listened to description of ailment
patiently
Yes, somewhat - 10.0 12.8 10.1
Yes, always 100.0 90.0 87.2 89.9
No - - - -
Doctor allowed to ask questions
Yes, somewhat - 25.0 17.9 17.4
Yes, always 90.0 75.0 82.1 81.2
No 10.0 - - 1.4
Doctor responded to questions
Yes, somewhat - 30.0 12.8 15.9
Yes, always 80.0 70.0 87.2 81.2
No 20.0 - - 2.9
Doctor discussed about the ailment
Yes 90.0 85.0 92.3 89.9
No 10.0 15.0 7.7 10.1
Doctor talked about the recovery
Yes 90.0 65.0 82.1 78.3
No 10.0 35.0 17.9 21.7
Doctor gave ‘other advice’
Yes 10.0 40.0 43.6 37.7
No 90.0 60.0 56.4 62.3
Total out-patients interviewed 10 20 39 69

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Table EO-8: Satisfaction of OPD patients regarding cleanliness of the facility

No. of patients Cleanliness

Satisfaction regarding availed the (% of patients)
service Not Clean Partially Clean Clean
A. District Hospital
OPD Room 10 - - 100.0
Examination Room 10 - - 100.0
Dispensary 10 - - 100.0
Laboratory 1 - - 100.0
Injection Room 1 - - 100.0
Dressing Room - - - -
B. CHC
OPD Room 20 - 25.0 75.0
Examination Room 20 - 20.0 80.0
Dispensary 20 - 15.0 85.0
Laboratory 6 - 33.3 66.7
Injection Room 7 - 14.3 85.7
Dressing Room 2 - 50.0 50.0
C. PHC
OPD Room 39 2.6 15.4 82.1
Examination Room 38 2.6 53 92.1
Dispensary 39 2.6 - 97.4
Laboratory 4 - - 100.0
Injection Room 8 - - 100.0
Dressing Room 6 16.7 - 83.3
D. All
OPD Room 69 1.4 15.9 82.6
Examination Room 68 1.5 8.8 89.7
Dispensary 69 1.4 4.3 94.2
Laboratory 11 - 18.2 81.8
Injection Room 16 - 6.3 93.8
Dressing Room 8 12.5 12.5 75.0

135
Table EO-9: Satisfaction of OPD patients regarding crowding in the facility

Crowding
No. of patients
(% of patients)
Satisfaction regarding availed the
Not Somewhat
service Adequate
Adequate Adequate
A. District Hospital
OPD Room 10 - 40.0 60.0
Examination Room 10 - 40.0 60.0
Dispensary 10 10.0 80.0 10.0
Laboratory - - - -
Injection Room 1 - 100.0 -
Dressing Room - - - -
B. CHC
OPD Room 20 25.0 50.0 25.0
Examination Room 20 35.0 .35.0 30.0
Dispensary 20 30.0 20.0 50.0
Laboratory 8 12.5 12.5 75.0
Injection Room 8 25.0 125 62.5
Dressing Room 3 - 33.3 66.7
C. PHC
OPD Room 39 35.9 15.4 48.7
Examination Room 39 30.8 15.4 53.8
Dispensary 39 33.3 17.9 48.7
Laboratory 2 - - 100.0
Injection Room 10 10.0 20.0 70.0
Dressing Room 6 66.7 16.7 16.6
D. All
OPD Room 69 27.5 29.0 43.5
Examination Room 69 27.5 24.6 47.8
Dispensary 69 29.0 27.5 43.5
Laboratory 10 10.0 10.0 80.0
Injection Room 19 15.8 21.1 63.2
Dressing Room 9 44.4 22.2 33.3

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Table EO-10: Continuity of treatment

Type of Health Facility (Percent)

Continuity of treatment
DH CHC PHC All
Satisfaction with the visit to the health facility
Dissatisfied - - - -
Somewhat satisfied - 15.0 15.4 13.0
Satisfied 100.0 85.0 84.6 87.0
Reason for dissatisfaction, if dissatisfied
Lack of facilities - - - -
Bad experience with the Doctor - - - -
Poor quality of services - - - -
Charges are exorbitant - - - -
Other - - - -
Visit again to the facility (if fell sick)
Yes 100.0 100.0 100.0 100.0
No - - - -
May come/unsure - - - -
Recommend this hospital to others
Yes 100.0 100.0 100.0 100.0
No - - - -
Total out-patients interviewed 10 20 39 69

137