Ministry of Health and Family Welfare Government of India. Concurrent Evaluation of National Rural Health Mission. Karnataka

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Ministry of Health and Family Welfare Government of India

Concurrent Evaluation of National Rural Health

Mission

2009

Karnataka

INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (Deemed University)

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INTERNATIONAL INSTITUTE FOR POPULATION

SCIENCES

Vision:

"To position IIPS as a premier teaching and research

institution in population sciences responsive to emerging

national and global needs based on values of inclusion,

sensitivity and rights protection."

Mission:

"The institute will strive to be a centre of excellence on

population, health and development issues through high

quality education, teaching and research. This will be

achieved by (a) creating competent professionals, (b)

generation and dissemination scientific knowledge and

evidence, (c) collaboration and exchange of knowledge,

and (d) advocacy and awareness."

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Ministry of Health and Family Welfare Government of India

Concurrent Evaluation of National Rural Health

Mission

2009

Karnataka

INTERNATIONAL INSTITUTE FOR POPULATION SCIENCES (Deemed University)

MUMBAI – 88

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Suggested citation: International Institute for Population Sciences (IIPS), 2011. Concurrent Evaluation of National Rural Health Mission (NRHM), Karnataka, 2009: Mumbai: IIPS.

For additional information. please feel free to contact:

Director/Project Coordinator (CE-NRHM)

International Institute for Population Sciences

Govandi Station Road, Deonar Mumbai - 400 088 (India)

Telephone: 022-25563254/5, 022-42372642, 42372613 Fax: 022-2556 3257, 25555895

Email: ce_nrhm@iips.net

Website: http://www.iipsindia.org

Additional Director General (Stat.)

Ministry of Health and Family Welfare

Government of India Nirman Bhawan, New Delhi - 110 011 Telephone: 011 - 23061334 Fax: 011 - 023061334 Email: adg-mohfw@nic.in

Chief Director (Stat.)

Ministry of Health and Family Welfare

Government of India Nirman Bhawan, New Delhi - 110 011 Telephone: 011 - 23062699 Fax: 011 - 023062669 Email: cdstat@nic.in Website: http://www.mohfw.nic.in

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CONTRIBUTORS

Manoj Alagarajan

Johnson Thangaraj

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IMPORTANT INSTRUCTIONS TO READERS

This report is based on a sample of selected districts from Karnataka. A combined figure for Karnataka is simply the unweighted average of the information obtained from selected districts. As such, the combined figures may not be representative of the state but provide situation of selected districts only. Readers are advised to take note if comparing with other survey results for the state of Karnataka.

It is also very important to keep in mind that the information collected to compute various indicators refer to different time periods. For examples, information related to any birth occurred after January 1, 2006 was collected. However, the information on ‘place of delivery’, ‘delivery assisted by health personnel’, and ‘JSY beneficiaries’ were collected only for the last birth that occurred after January1, 2006.

The indicators presented in the report are expressed in terms of numbers, averages or percentages. The details of the selection of districts, sampling of health facilities and households are available in this reports. The survey instruments used to collect information are also enclosed in a CD along with this report.

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CONTENTS Page

List of Tables ix

Abbreviations xiv

Acknowledgement xvi

Executive Summary xviii

CHAPTER 1: INTRODUCTION

1.1 Objectives of NRHM……… 1

1.2 Concurrent Evaluation of NRHM………. 2

1.3 Survey design and methodology……….. 2

1.4 Survey instruments……… 5

1.5 Recruitment, training and fieldwork………... 6

1.6 Data processing, validation and quality assurance………. 7

1.7 Chapter scheme………. 7

CHAPTER 2: HOUSEHOLD RESPONSE TO NRHM: KNOWLEDGE, PRACTICE AND HEALTH SEEKING BEHAVIOUR 2.1 Household characteristics………. 8

2.2 Water, sanitation and waste disposal……….. 9

2.3 Awareness of NRHM activities………... 9

2.4 Health seeking behavior……… 10

CHAPTER 3: WOMEN'S RESPONSE TO NRHM 3.1 Profile of the eligible women……… 30

3.2 Utilization of maternal and child health services………... 32

3.3 Birth weight of the child……… 32

3.4 Place of delivery……… 33

3.5 Antenatal, natal and postnatal care received by the women for the most recent birth………... 33

3.6 Immunization among Children……….. 34

3.7 Breastfeeding practices………. 35

3.8 Awareness of women about hygiene and health related matters……….. 36

3.9 Awareness of family planning………. 37

3.10 Knowledge about HIV/AIDS……… 38

3.11 Awareness of ICTC and PPTCT centers……….. 39

3.12 Awareness of ASHA and services received……….. 40

3.13 Awareness of women about VHSCs……… 40

3.14 Awareness of women about VHNDs………... 41

3.15 Awareness of women About NPT kit………... 42

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CHAPTER 4: JANANI SURAKSHA YOJANA (JSY)

4.1 Woman's awareness and source of awareness of the JSY scheme……… 60

4.2 Caste profile of the JSY beneficiaries……….. 61

4.3 Motivator for registering under JSY scheme……… 61

4.4 Place of registration………... 62

4.5 Health workers registered under JSY scheme………... 62

4.6 Timing of registration under JSY scheme………... 63

4.7 Availability of JSY Card……… 63

4.8 Problems faced in the registration………. 63

4.9 Advice received from the ASHA/ANM/HW during Pregnancy/Antenatal Period………. 64

4.10 Place of delivery……… 65

4.11 Profile of the institutional deliveries under JSY………... 66

4.12 Motivation for institutional delivery………. 67

4.13 Types of help received by the beneficiaries for institutional delivery………….. 67

4.14 Mode of payment for JSY money………. 68

4.15 Timing of receipt of JSY money………... 68

4.16 Difficulty faced in getting the Incentive money……….. 69

4.17 Purpose for which incentive money used……….. 69

CHAPTER 5: COMMUNITISATION OF SERVICES 5.1: Rogi Kalyan Samiti (RKS) 5.1.1 Rogi Kalyan Samities in the CHCs has been registered and notified…………... 82

5.1.2 Fund generation and utilisation by Rogi Kalyan Samiti in CHCs and PHCs……. 83

5.1.3 Awareness and utilisation of untied fund at Health Sub-Centre……… 83

5.1.4 Knowledge on Rogi Kalyan Samiti by households……….. 84

5.2: Role of Accredited Social Health Activist (ASHA) 5.2.1 Profile of ASHA……… 92

5.2.2 Training undergone by ASHA……….. 94

5.2.3 ASHA's Awareness about breastfeeding, Diarrhoea, Acute Respiratory Infections, and Major Features of NRHM………..……… 95

5.2.4 Medical Items/Kits Available with ASHA and whether those Items/Kits were Used by ASHA……..………... 96

5.2.5 Activities performed by ASHA………. 97

5.2.6 Incentives received, difficulties faced, and support required to effectively Implement NRHM………. 99

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5.3: Gram Panchayat (GP)

5.3.1 Profile of Gram Panchayats and Distance from the Health Facility………. 113

5.3.2 Establishment of Village Health and Sanitation Committee and Preparation of Village Health Plan………... 113

5.3.3 Problems faced by Village Health and Sanitation Committees and Diseases Prevalent in the Villages……… 114

5.3.4 Problems and support required in implementation of NRHM……… 114

CHAPTER 6: HEALTH SUB- CENTRES (HSCs) AND FUNCTIONING OF ANMs A. State of the health-sub centres 6.1 Characteristics of the Health Sub-Centres……… 123

6.2 Infrastructure and amenities………..……….. 123

6.3 Ante Natal Care (ANC) services and immunization………... 124

6.4 Delivery and other related facilities……….. 125

6.5 Registers availability and modes of maintenance……….……. 125

B. Characteristics and skill-building of ANMS 6.6 Background Characteristics of the ANMs………. 126

C. Performance of ANMS at the facility and in the community 6.7 Untied Funds and Implementation of Programmes……….. 127

6.8 Awareness about Important Activities under NRHM……….. 128

6.9 Ante Natal Care (ANC) and Post Natal Care Services, including Immunization ANC Services……… 128

6.10 Deliveries and Immunizations/Supplements Administered……….. 128

6.11 Women's health: high-risk pregnancies, Diseases/Illness managed…………... 129

6.12 ANMs' interaction with other health functionaries………... 130

CHAPTER 7: PHYSICAL INFRASTRUCTURE AND HUMAN RESOURCES CHAPTER 7.1: DISTRICT HOSPITAL 7.1.1 Physical infrastructure at surveyed District Hospitals……….. 146

7.1.2 Human resources in surveyed District Hospitals……… 147

7.1.3 Training of human resources in surveyed District Hospitals………... 147

7.1.4 Average monthly service outcome at surveyed District Hospitals………. 148

7.1.5 Maintenance of records and Health Management Information System in surveyed District Hospitals………... 148

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CHAPTER 7.2: COMMUNITY HEALTH CENTRE

7.2.1 Population served and accessibility to the Community Health Centres by public

transport……….…... 155

7.2.2 Physical infrastructure at surveyed Community Health Centres……….. 155

7.2.3 Human resources in surveyed Community Health Centres……… 156

7.2.4 Human resources training in Community Health Centres……….. 156

7.2.5 Service outcome at Community Health Centres……….. 157

7.2.6 Maintenance of hospital records and Health Management Information System at Community Health Centres………... 157

CHAPTER 7.3: PRIMARY HEALTH CENTRE 7.3.1 Population served and accessibility to the Primary Health Centres by public transport………... 165

7.3.2 Physical infrastructure at surveyed Primary Health Centres……… 165

7.3.3 Human resources in surveyed Primary Health Centres………... 166

7.3.4 Human resources training in Primary Health Centres……… 166

7.3.5 Service outcome at Primary Health Centres………. 167

7.3.6 Maintenance of hospital records and Health Management Information System at Primary Health Centres………. 167

CHAPTER 8: CLIENTS' RESPONSE TO NRHM 8.1 Response of In-Patients………. 175

8.2 Response of Out-patients……….. 176

Appendix – A Nodal Agency staff involved in Concurrent Evaluation of NRHM……… 191

Appendix – B Technical advisory committee for Concurrent Evaluation of NRHM ………... 193

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LIST OF TABLES AND FIGURES

Table 2.1 Percent distribution of households by selected characteristics……….. 13 Table 2.2 Percent distribution of households by household amenities and assets………….. 14 Table 2.3 Percent distribution of households according to household sanitation practices

and waste disposal……….. 16 Table 2.4 Percent distribution of household respondent according to their knowledge

about health personnel……… 17 Table 2.5 Percentage of households aware about various NRHM activities……….. 18 Table 2.6 Percentage of households reported being aware about ASHA by background

characteristics………. 19 Table 2.7 Percentage of households reported being aware about JSY by background

characteristics………. 20 Table 2.8 Percentage of households according to knowledge of selected diseases………… 21 Table 2.9 Percentage of households according to use of different type of medicines……… 22 Table 2.10 Percentage of households by facilitated in blindness control program………….. 24 Table 2.11 Percentage of households using mosquito net and practices for malaria

prevention for pregnant woman……….. 25 Table 2.12 Percentage of households reporting any member suffered or currently suffering

from tuberculosis and treatment taken……… 27 Table 2.13 Percent distribution of households reported any member suffered or currently

suffering from leprosy and treatment taken……… 28 Table 3.1 Profile of the surveyed eligible by selected background characteristics………… 43 Table 3.2 Percent distribution of currently married women aged 15-49 who had births

during the reference period (January, 2006 to survey date) by number of live births, survival status and sex ratio of the children born……… 44 Table 3.3 Children born during the reference period (January, 2006 to survey date) and

were alive at the time of survey by whether their birth weight was taken, timing of birth weight and reason for not taking birth weight among those who were not weighed………. 45 Table 3.4 Place of delivery and type of assistance for home deliveries for all births during

the reference period……… 46 Table 3.5 Percentage of currently married women aged 15-49 who had received at least

one TT injection during pregnancy, advice on post natal care, family planning, place of delivery and type of assistance at the time of delivery in case of home delivery for the most recent birth………... 47 Table 3.6 Immunization status of the all children born during the reference period and

reason for non-immunization or partial immunization... 48 Table 3.7 Percentage of children aged 12-23 months among children born during last three

years preceding the survey by immunization status……….. 49 Table 3.8 Among the youngest surviving child born during the reference period,

percentage ever breastfed, percent distribution by timing of initiation of breastfeeding, and by duration of exclusive breastfeeding………. 50 Table 3.9 Percentage of currently married women aged 15-49 years by awareness about

hygiene and health related matters………. 51 Table 3.10 Percent distribution of currently married women aged 15-49 by knowledge of

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Table 3.11 Percent distribution of currently married women aged 15-49 years by knowledge about various aspects of HIV/AIDS………. 53 Table 3.12 Percentage of currently married women aged 15-49 years who have heard of

HIV/AIDS by knowledge about ICTC, PPTCT centres and whether they have undergone HIV Test………... 54 Table 3.13 Percentage of currently married women aged 15-49 years by knowledge about

ASHA………. 55 Table 3.14 Percentage of currently married women aged 15-49 years by knowledge about

Village Health Sanitation Committee (VHSC)……….. 56 Table 3.15 Percentage of currently married women aged 15-49 years by knowledge about

Village Health and Nutrition Days (VHND) ………. 57 Table 3.16 Percentage of currently married women aged 15-49 years by knowledge about

Nischay Pregnancy Test (NPT) kit………. 58 Table 4.1 Percent distribution of currently married women aged 15-49 who are aware of

Janani Suraksha Yojana (JSY) scheme and source of information on JSY……... 70 Table 4.2 Out of those women who had given at least one live birth since January 2006,

percentage of women who are JSY beneficiaries by social category………. 71 Table 4.3 Percentage of JSY beneficiaries by motivator for registering under JSY, place of

registration and health worker who registered... 72 Table 4.4 Percentage distribution of the JSY beneficiaries by timing of registration and

availability of JSY card……….. 73 Table 4.5 Percentage of JSY beneficiaries who received advice from ANM/ASHA/Health

Worker during pregnancy/ante natal period and place of delivery……… 74 Table 4.5a Percentage of JSY beneficiaries delivering at home by reasons for preferring for

home delivery………. 75 Table 4.6 Profile of the Institutional deliveries under JSY scheme………... 76 Table 4.6a Difficulties faced in reaching the health facility for Institutional deliveries for

the JSY beneficiaries……….. 77 Table 4.7 Percentage of women who delivered in Institution/facility by problems faced in

reaching the facility and the person who motivated them to go for institution for delivery……….. 78 Table 4.8 Percentage of JSY beneficiaries who delivered in a health institution/facility by

type of help received from the ASHA/ANM/VHSC and others……… 79 Table 4.9 Percentage of JSY beneficiaries by type of payment for incentive money, timing

of receipt of incentive money, person who gave her the incentive money, difficulties faced in getting the incentive money……… 80 Table 4.10 Percentage of JSY beneficiaries by purpose for which incentive money was

used………. 81 Table 5.1.1 Availability and functioning of Rogi Kalyan Samiti (RKS) among surveyed

CHCs………... 85 Table 5.1.2 Source of availability and utility of funds generated by Rogi Kalyan Samiti

(RKS) at surveyed CHC………. 86 Table 5.1.3 Source of funds generated by Rogi Kalyan Samiti (RKS) at surveyed PHC……. 87 Table 5.1.4 Number of ANMs reporting utilisation of untied fund and related issues under

NRHM in the surveyed Health Sub-Centres……….. 88 Table 5.1.5 Grants received and spent by the surveyed Health Sub-Centres……… 89 Table 5.1.6 Percentage distribution of households having knowledge of Rogi Kalyan Samiti

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Table 5.2.1 Percent distribution of ASHA by selected background characteristics………….. 101 Table 5.2.2 Percent distribution of ASHA by type of house and percentage of ASHA

residing in households having basic amenities and using mosquito nets………... 102 Table 5.2.3 Percent distribution of ASHA by population served, distance travelled and time

taken to reach the farthest village, and percentage of ASHA reporting about the person/authority that nominated/recommended/appointed her as ASHA……….. 103 Table 5.2.4 Percentage of ASHA who had undergone ASHA training, topics covered in the

training, duration, place and usefulness of last training, and undergone training on use of Nishchay Pregnancy Test kit (NPT) kit………. 104 Table 5.2.5 Percent distribution of ASHA by awareness about initiation of breastfeeding

and exclusive breast feeding, and percentage of ASHA who were aware about important steps for prevention of diarrhoea, symptoms of pneumonia/ARIs, and major features of NRHM……… 105 Table 5.2.6 Percentage of ASHA who received items and kits, and percentage of ASHA

reporting availability of other items and medicines with them at the time of survey………... 106 Table 5.2.7 Percentage of ASHA reporting the source from where they received NPT kit

and follow-up measure taken after use of NPT kit, and percent distribution of ASHA by number of NPT kits used and whether women are usually able to interpret NPT results………... 107 Table 5.2.8 Percentage of ASHA by the activities performed and percentage of ASHA by

help that she provides to improve sanitation in her communities…... 108 Table 5.2.9 Percent distribution of ASHA by her performance against selected activities

under JSY and family planning during October to December 2008……….. 109 Table 5.2.10 Percent distribution of ASHA by her performance against selected activities

under vector born disease control programme and number of meetings, including village health and nutrition day ……… 110 Table 5.2.11 Incentives received by ASHA under various programmes under NRHM.. 111 Table 5.2.12 Percentage of ASHA reporting various difficulties faced in implementing

NRHM and support that they require to effectively implement various programmes under NRHM………. 112 Table 5.3.1 Profile of the Gram Panchayat... 116 Table 5.3.2 Distance from Gram Panchayat village to nearest health facilities……… 117 Table 5.3.3 Number of Gram Panchayats reported Village Health and Sanitation Committee

(VHSC) and preparing village plan……… 118 Table 5.3.4 Number of Gram Panchayat facing major problems and common diseases as

reported by Village Health and Sanitation Committee and Gram Panchayat functionaries………... 119 Table 5.3.5 Number of Gram Panchayat facing problem in implementing of NRHM and

Support Required……… 120 Table 5.3.6 Number of Gram Panchayat Acknowledging NRHM for Improvement in Health

Facility………... 121 Table 6.1 Number of Health Sub-Centres by selected characteristics, population covered,

accessibility, transport available and other health facilities nearby Health Sub- Centres………... 132 Table 6.2 Number of Health Sub-Centres with selected physical characteristics and

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Table 6.3 Number of Health Sub-Centres by selected environmental risk, sanitation and

health related amenities, including waste management……….. 134

Table 6.4 Number of Health Sub-Centres with selected communication amenities, including mode of payment of bills and having stand-by generators………. 135

Table 6.5 Number of Health Sub-Centres performing selected ANC services performed in nine months prior to the survey……….. 136

Table 6.6 Number of Health Sub-Centres equipped with delivery facilities, including cold chain………... 137

Table 6.7 Number of Health Sub-Centres by type of records/registers maintained and availability at the time of survey……….... 138

Table 6.8 Number of ANMs by selected characteristics……… 139

Table 6.9 Number of ANMs trained on selected family planning methods, ante-natal services, RTI/STIs and immunizations………... 140

Table 6.10 Number of ANMs aware about NRHM, implementation and reporting the impact on their status as ANM………... 141

Table 6.11 Ante Natal Care (ANC), Deliveries and Post Natal Care (PNC) services performed by ANM……… 143

Table 6.12 Average number of women with illnesses, delivery and complicated cases managed by ANMs………. 144

Table 6.13 Number of ANMs/HSCs by activities related to ICDS and ASHA………... 145

Table 7.1.1 Number of surveyed district hospitals with physical infrastructure... 150

Table 7.1.2 Number of human resources in surveyed district hospital……….. 151

Table 7.1.3 Number of surveyed district hospital having human resources trained by type of training……….... 152

Table 7.1.4 Average monthly service outcomes at surveyed district hospital………... 153

Table 7.1.5 Number of surveyed district hospitals by maintenance of records and health management information system (HMIS)……….. 154

Table 7.2.1 Average population served and accessibility to the surveyed CHCs by public transport………... 159

Table 7.2.2 Number of surveyed CHCs with physical infrastructure……… 160

Table 7.2.3 Number of surveyed CHCs with human resources………. 161

Table 7.2.4 Number of surveyed CHCs having human resources trained by type of training 162 Table 7.2.5 Average service outcomes per CHC………... 163

Table 7.2.6 Number of surveyed CHCs by record maintenance/pre-printed cards…………... 164

Table 7.3.1 Average population served and accessibility to the surveyed PHC by public transport……….. 169

Table 7.3.2 Number and percentage of surveyed PHCs with physical infrastructure………... 170

Table 7.3.3 Number of surveyed PHCs with human resources………. 171

Table 7.3.4 Number of surveyed PHCs having human resources trained by type of training.. 172

Table 7.3.5 Average monthly service outcomes per PHC from 1st April -31st December…... 173

Table 7.3.6 Number and percentage of surveyed PHCs with record maintenance/pre-printed cards……… 174

Table 8.1 Background characteristics of in-patients……… 177

Table 8.2 Percentage of in-patients with ailment for which admission is sought in Health Institutions……….. 178

Table 8.3 Percentage of in-patients using different modes of transport to reach Health Institutions……….. 179

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Table 8.4 Percentage of in-patients by duration of stay in Health Institutions………... 180 Table 8.5 Percentage of In-Patients reporting about behaviour of doctor and paramedical

staff………. 181 Table 8.6 Percentage of in-patients reporting cleanliness of health facilities……… 182 Table 8.7 Percentage of in-patients reporting satisfaction with treatment & reasons for not

satisfaction in Health Institutions………... 183 Table 8.8 Percentage of in-patients reporting services available in Health Institutions……. 184 Table 8.9 Background characteristics of the out-patients………... 185 Table 8.10 Percentage of out-patients with ailment for which you visited Health

Institutions………... 186 Table 8.11 Percentage of out-patients using different modes of transport to reach Health

Institutions………... 187 Table 8.12 Number of visits made for current illness………... 188 Table 8.13 Percentage of out-patients reporting about the behaviour of doctor and

paramedical staff……… 189 Table 8.14 Percentage of out-patients reported satisfaction with treatment……… 190 Figure 1.1 Sampling Frame of Concurrent Evaluation of NRHM………... 3

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ABBREVIATIONS

ANC Antenatal Care

ANM Auxiliary Nurse Midwife

AIDS Acquired Immunodeficiency Syndrome APL Above Poverty Line

ARI Acute Respiratory Infection ASHA Accredited Social Health Activist AWC Anganwadi Centre

AWW Anganwadi Worker

AYUSH Ayurveda, Yoga , Unani, Siddha and Homeopathy BCG Bacillus Calmette-Guerin

BEE Block Extension Educator BP Blood Pressure

BPL Below Poverty Line CHC Community Health Centre

CSPro Census and Survey Processing System DBCS District Blindness Control Society DH District Hospital

DOTS Directly Observed Treatment Short-Course DPT Diphtheria Pertussis Tetanus

EAG Empowered Action Group ECG Electro Cardiogram

ECP Emergency Contraceptive Pill EMOC Emergency Obstetric Care FRU First Referral Unit

FP Family Planning

GDMO General Duty Medical Officer GDP Gross Domestic Product

GP Gram Panchayat

HH Households

HPS High Performing State

HIV Human Immunodeficiency Virus

HMIS Health Management Information System HSC Health Sub-Centre

ICU Intensive Care Unit

IEC Information, Education and Communication IFA Iron and Folic Acid

ICTC Integrated Counseling and Testing Centre

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ABBREVIATIONS

IPD In-Patient Department

IPHS Indian Public Health Standard IUD Intra Uterine Device

JSY Janani Suraksha Yojana LHV Lady Health Visitor LPG Liquefied Petroleum Gas LPS Low Performing State MCH Maternal and Child Health MDT Multi-Drug Therapy MHW Male Health Worker MPW Multi Purpose Worker MO Medical Officer

MTP Medical Termination of Pregnancy NBCC New Born Care Corner

NGO Non-Government Organization NPT kit Nishchay Pregnancy Test kit NRHM National Rural Health Mission NSV Non Scalpel Vasectomy OBC Other Backward Classes OPD Out-Patient Department OPV Oral Polio Vaccine ORS Oral Re-hydration Salt OT Operation Theatre PHC Primary Health Centre PNC Post Natal Care

PPH Post Partum Hemorrhage

PPTCT Prevention of Parent to Child Transmission PRI Panchayati Raj Institution

RH Rural Hospital RKS Rogi Kalyan Samiti

RMP Registered Medical Practitioner RTI Reproductive Tract Infection SC Scheduled Caste

SDH Sub Divisional Hospital SBA Skill Birth Attendance SHG Self Help Group ST Scheduled Tribe

STI Sexually Transmitted Infection TAC Technical Advisory Committee TB Tuberculosis

TFR Total Fertility Rate TT Tetanus Toxoid

UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UT Union Territory

VHND Village Health and Nutrition Days VHSC Village Health and Sanitation Committee VIP Ventilation Improved Pit

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Acknowledgement

The Concurrent Evaluation of National Rural Health Mission, conducted during May to August 2009, was a nationwide survey funded by the Union Ministry of Health and Family Welfare. This report is based on the completed work in 7 districts of Karnataka.

We are very grateful to the Ministry of Health & Family Welfare, Government of India for designating the International Institute for Population Sciences (IIPS) as the Nodal agency for the Concurrent Evaluation of NRHM Project and providing an opportunity to work closely with the health and programme officials. In particular, we are thankful to Mr. K. Chandramouli, Secretary, Ministry of Health and Family Welfare, Govt. of India for his support and encouragement. We would also like to thank Mr. Naresh Dayal, Ms. K. Sujatha Rao, former Secretaries -Ministry of Health and Family Welfare, Government of India and Mr. P. K. Pradhan, Special Secretary & Mission Director (NRHM) for their suggestions and support. Our special thanks to Smt. Madhu Bala, the Additional Director General, Dr. Rattan Chand, the Chief Director, Mr. Pravin Srivastava, Deputy Director General, Mr. Rajesh Bhatia, Director, Mr. Biswajit Das, Director, Dr. S.C. Agrawal, Assistant Director and Mr. S. K. Kapoor, Investigator -Statistics Division, Ministry of Health and Family Welfare, Government of India for their active involvement and suggestions. We are grateful to Mr. S.K Das, Dr. V.K. Malholtra, former Additional Director Generals, Ms. Rashmi Verma, former Deputy Director- Statistics Division, Ministry of Health and Family Welfare, Govt. of India for their co-operation and support at the initial stage of this work. We acknowledge the contribution of the Field Agency for their involvement in data collection in the project. Our thanks are due to the members of Technical Advisory Committee (TAC) of Concurrent Evaluation NRHM and especially to its Chairman, Dr. P. M. Kulkarni, Professor, Jawaharlal Nehru University, New Delhi. We gratefully acknowledge the immense contributions of Concurrent Evaluation NRHM project team at IIPS in developing survey instruments, training of field staff, monitoring field work, data processing, preparation of state level fact sheets, and drafting the state level report. Finally, our heartfelt thanks to state and district level health officials and respondents for extending their co-operation by providing us valuable information without which the project would not have been successfully completed.

Co-odirnators/Contributors

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EXECUTIVE SUMMARY

The objective of the Concurrent Evaluation of NRHM is to assess the reach of NRHM activities to the rural communities. The concurrent evaluation was carried out in the state of Karnataka. In this report, we provide key findings on the household and women’s response to NRHM including Janani Suraksha Yojana (JSY), and outcomes of the core strategies of NRHM like communitisation of services and innovations at community level. It also presents functioning of ANMs, ASHA and the status of physical infrastructure and human resources at the health facility levels.

Household response

A total of 8,319 households were covered in the state of Karnataka. A little lower than half of the respondent households were other backward classes (OBCs), 26 percent belonged to scheduled castes and 10 percent belonged to scheduled tribes. About 44 percent of the respondents had no education.

About 54 percent of respondents reported knowing only about ANMs and 39 percent knowing about both ANMs and Male health worker. A little above 3/4th of the respondents were aware about JSY. On the other hand awareness on both RKS and VHSC was very low and reported by only 3 and 18 percent of the respondents respectively. At household level allopathic system of medicine was generally used (99 percent). Only 3 percent and less of the households reported use of homeopathy, siddha and ayurvedic system of medicine. About 71 percent of the households reported availing services from private clinics when needed followed by PHCs (48 percent), CHCs (30 percent), DH/sub-divisional hospitals (23 percent), and HSCs (12 percent). About 74 percent reported going to private clinics followed by 39 percent to district hospital, 34 percent to PHC, 28 percent each to sub-divisional hospital and CHC for treating serious ailments.

At household level, the awareness on Malaria was reasonably high with 68 percent of respondents reported to have knowledge about Malaria, followed by Dengu (17 percent), Kala-Azar (3 percent), Filariasis (1 percent) and Japanese Encephalitis (less than percent). About onef-fifth of the households reported that any member of their households had high fever lasting for more than one month. However, almost all of them had got treated for the high fever and the preferred place for treatment was private clinics (70 percent), followed by PHCs (41 percent), CHCs/RHs (29 percent), and DH/Sub-divisional hospitals (25-26 percent). About half of the households reported that none of their members had used

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mosquito net. Further, about 44 percent of the households reported that pregnant women had slept under mosquito net during last night and 26 percent households reported pregnant women had taken drug to prevent malaria.

In case of blindness, about 11 percent of the households participated in screening camp and of which 55 percent of them had undergone cataract surgery. Tuberculosis was another major disease that had affected about 4 percent of the households and of which about 57 percent of those affected had been treated under DOTS.

Women’s response

The mean and median values of age of eligible women in Karnataka were 30 years. The mean and median values of years of school completion among the surveyed population were 3 and 2 respectively in the state. Nearly two-third of the surveyed Eligible Women got married before age 18. Of the surveyed Eligible Women, about 27 percent had given at least one live birth during the reference period. Majority of these EW who had a live birth during the reference period (over 77 percent) had only one live birth and remaining 23 percent had 2 or more live births. There were 93 females for every 100 male births. About 70 percent of the births were registered. However, the investigator could verify the birth certificates only in about 7 percent cases. Above 2/3rd of the children were weighed and mostly (83 percent) within 24 hours after birth; about 37 percent of the births took place in homes and 16 percent and 8 percent of cases delivered in homes were assisted by doctor and female health workers, respectively. About 57 percent of the women received post natal care advice and about 44 percent of the women received advice on using family planning

About 81 percent of the children age 12-23 months were fully immunized (those receiving BCG, all 3 doses of DPT and Polio and Measles) and only 82 percent of the children were immunized for measles. Breastfeeding was widely practiced (in 98 percent) cases) and about 48 percent of the women breastfed their child within one hour after birth and another about 13 percent did so within 6 hours after birth. About 63 percent of the children were exclusively breastfed up to 6 months.

Women were reasonably aware of preventive ways of diarrhea and action to be taken if any member suffers from either diarrhea or fever or persistent cough. Nearly 3/4th of the surveyed women reported that if anyone in their family had ‘loose motions lasting for more than 24 hours or ‘high fever’ or ‘persistent cough and breathing problems’, they were taken to the nearest government health facility. About 33 percent of the women reported that they

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would give ORS or more fluids (38 percent)) if a family member suffers from ‘loose motions lasting for more than 24 hours’. Only 18 percent of women reported that they would get blood tested for malaria if anyone has ‘high fever’.

While 99 percent of the women were aware of female sterilization, only 11 percent knew about male sterilization. As for knowledge of spacing methods, about 71 percent of the women were aware of oral pills, 61 and 24 percent were aware of IUD and Condom/Nirodh, respectively. Only 3 percent and less than 1 percent respectively, were aware of safe period and withdrawal. About 22 percent of women reported that they would ‘do nothing’ if they had unprotected sex, 23 percent reported ‘would seek advice from doctor’, and 7 percent reported ‘would seek advice from ANMs’ in such situation. Significantly, 36 percent of the women reported that they would ‘take Emergency Contraceptive Pill (ECP)’ if they had unprotected sex. The ideal mean age at first birth reported by the EW was 23 years. A majority (62 percent)) of the surveyed women reported perceived ideal age at first birth to be 19 years or later, nonetheless there were about 26 percent of the women who reported ideal age at first birth as 18 years and another about 8 percent reported it as less than 18 years. As for ideal birth interval between two subsequent births, about 64 percent of the women preferred 24-36 months, 29 percent reported more than 36 months and about 4 percent reported less than 24 months.

About 4/5th percent of the women had heard of HIV/AIDS and its preventive means, but only 27 percent had undergone HIV testing. Further, about 7-9 percent of the women did not know that one can reduce chances of getting HIV/AIDS by ‘having one sexual partner’ or by ‘using condom every time one has sex’ and about 16 percent of the women had no opinion on one’s chances of not getting HIV/AIDS by ‘having one sexual partner’. Further, 57 percent of the women had no opinion on one’s chances of not getting HIV/AIDS by ‘using condom every time one has sex’. Few of the women had misconception of modes of HIV/AIDS transmission routes. For example, 40-42 percent of the women believed that a person can transmit HIV/AIDS by sharing food or by hugging a HIV/AIDS infected person. When asked about the possibility of a pregnant mother transmitting HIV to her child, about 10 percent of the women had said ‘no’ and another 11 percent had no opinion on this. About 31 percent and 16 percent of the women were aware of the ICTC and PPTCT centres respectively and among those who were aware of ICTC centers, majority were aware of the facility where it was located.

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Only a little over one-fourth of the surveyed women were aware of ASHA and of which 42 percent of them knew that ASHA provides common medicines for free to those in need. About 24 percent of the women each reported that ASHA discussed with them on Janani

Suraksha Yojana and institutional deliveries. The other issues discussed by ASHA were

personal hygiene, water safety, safe garbage disposal, ante-natal, natal and post natal care and child care (reported by 20 to 30 percent of women). However, less than 20 percent of the women reported that ASHA discussed with them about construction of household toilets, family planning and DOTS services.

About 11 percent of the women were aware of the VHSCs in the village. Among those who were aware of VHSC in the village, a little under one-fifth reported that the VHSC had constructed community toilets and another 7 percent each reported AHSA had arranged transport for patients and organized health and nutrition days in the village. Of those who were aware, about 2/5th of the women had participated in a VHND organized in their village and of which about half or more women received information on nutrition, family planning advice, Newborn/child care, and child immunization services during the last VHND they attended. Only about 17 percent of the women reported to have received services related to family planning.

Only 6 percent of the surveyed women were aware of NPT kit. Among those who were aware of NPT Kit, about 39 percent knew that it was available free in the public health facility. About 70 percent of them reported that either they or someone known to them had used the same in the past. About 32 percent of the women had received the kit from ANMs and another 11 percent from the PHC. Only 21 percent of the women said that they alone had conducted the test whereas 36 percent reported that they did it with the help from others. About 44 percent of the women were advised for ANC check up after the test result and about 10 percent of the women were advised to use family planning. About 79 percent who registered for ANC and 10 percent women did nothing, as the pregnancy result was negative. There were about 2 percent of the women who terminated the pregnancy and less than two percent of the women started using family planning methods.

Janani Suraksha Yojana (JSY)

Around four-fifth were aware of the JSY scheme; majority of them learnt about it from ‘others’ (58 percent) followed by ANMs (44 percent) and Anganwadi workers (38 percent). Another about 4-5 percent learnt about the scheme from Doctors, Radio/TV/Newspaper and

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ASHA. On the whole, about 44 percent of all women who had a live birth during the reference period were beneficiary under the scheme. Among the JSY beneficiaries 43 percent belonged to Scheduled Caste, 48 percent belonged to Other Backward Classes and the remaining 39 percent belonged to Scheduled Tribes. Nearly 79 percent of JSY beneficiaries reported that it was ANMs in their area who had motivated to go for the scheme. About 47 percent of JSY beneficiaries were motivated by anganwadi workers, 12 percent by family members/relatives, 14 percent by neighbours/friends and about 3 percent of the beneficiaries reported that they were self motivated.

About 62 percent of the beneficiaries reported that their registration under the scheme was done by the ANMs/FHW. This was followed by Anganwadi workers (32 percent) and Doctors (3 percent). Out of the total JSY beneficiaries, about 42 percent were registered during the first trimester, 30 percent were registered during the second trimester and another 28 percent were registered in the 3rd trimester.

Around 85 percent of the JSY beneficiaries did not have JSY card. Even among the rest, 12 percent reported availability of card but could not show to the investigator. Less than 10 percent of the beneficiaries reported to have faced problems in getting the JSY card. Many beneficiaries received advice from the health workers during their pregnancy on number of issues. Such as ‘breastfeeding’, newborn care’, ‘date of next check up’, ‘place of check up’, ‘expected delivery date’, ‘place of delivery’, delivery care’, and/or ‘diet’. A little less than one-fourth of the beneficiaries delivered at homes. About 2/5th delivered at the district hospital or community health center followed by 17 percent delivered at PHCs/HSCs. About 15 percent of the all JSY deliveries were caesarean; About 77 percent of deliveries were conducted in the presence of a doctor; around one-fourth of the women reported that no waiting time at the facility, and 47 percent had to wait for less than one hour, 25 percent waited for 2-3 hours and another about 4 percent waited longer than 3 hours. Only 6 percent of the women reported that the facility was located at a distance of less than 1 kilometer, 20 percent reported it between 1 to 3 kilometers and another 15 percent reported it between 4-6 kilometers. A little less than 3/5th of the women reported that the facility was located at a distance of more than 6 kilometers.

Communitisation of services

Communitization is an important strategy of NRHM to ensure that the programme reaches at the community level. It includes involvement of Panchayat Raj Institutions formation of

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hospital management committee i.e. Rogi Kalyan Samiti and also the provision of community worker known as ASHA at the community level. The main findings are discussed below.

Rogi Kalyan Samities (RKS)

Except one CHC in Bijapur, all the surveyed CHCs in the state had formed Rogi Kalyan

Samities and excluding one RKS formed in Chamarajanagar CHC, all the other had been

registered and notified. None of the surveyed CHCs, barring one CHC in Chamarajanagar, had displayed board showing number of members of Rogi Kalyan Samiti. The provision of ambulance services through RKS was available only in half of the CHCs. The RKS fund had been transferred electronically in 71 percent of the surveyed CHCs. While only one CHC reported to have displayed boards showing the number of meetings, over 85 percent reported availability of meeting minutes. The information about the RKS was also collected from the households. The knowledge of RKS in the surveyed households was less than 6 percent in the state.

Untied fund, Health Sub-Centre and Gram Panchayat

The Health Sub-Centres located in rural areas reported to be facing many difficulties in managing the contingencies arising out of lack of drugs, equipments, and lack of funds for an emergent referral etc. The ANMs also had difficulty in operating the joint account as about 44 percent of ANMs reported of non-availability of Sarpanch when needed and 19 percent reported it was difficult to mutually agree on the areas where funds needs to be spent. Most of the ANMs also maintained record of spending (81 percent). More than 75 percent of Gram Panchayats reported improvement in health condition due to NRHM.

Accredited Social Health Activist (ASHA)

One of the key components of NRHM is to appoint a trained community health activist called ‘ASHA’ in each village of the country. The strategy is that the ASHA will be trained to work as an interface between community and the public health system. Though the study had to select 24 ASHA from each district only fifty eight ASHAs from five districts were selected and interviewed in the state of Karnataka due to availability. The findings are, therefore, based on interviews with 58 ASHA.

Results show that around 1/4th of the surveyed ASHAs were below 25 years of age and around 31 percent of ASHA had completed schooling below 8th. A little lower than 3/4th of

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the ASHA reported residing in semi-pucca houses and another 21 percent in pucca houses. Around 83 percent of ASHA had separate kitchen. As for training, 97 percent of the ASHA were trained in Module 1 and this was 100 percent for Module 2 and above. Around 97 percent of the ASHA reported that the training was useful. Awareness about prevention of diarrhea and acute respiratory infection, and breastfeeding was high among the surveyed ASHAs. While 91 percent of ASHA reported to have received identity card, only 2 percent of ASHA reported to have received special uniform. Availability of ASHA kit was reported by around 36 percent of surveyed ASHA and availability of NPT kit was reported by 45 percent.

Visiting households to attend ANC/immunization session and accompanying women for delivery were reported by 97 percent of the surveyed ASHAs. Almost all ASHAs received incentive for JSY. The average amount received by ASHA per month was around Rs.300/-. Only half of the ASHAs reported that they had received JSY incentive on time. However, all the ASHAs reported receiving JSY incentives by cheque. Unlike all ASHA receiving incentive under JSY, the percentages of ASHAs receiving incentives for family planning and DOTS were far from universal.

About 43 percent of ASHAs reported unavailability of funds on time as an important problem. The second most commonly reported difficulty was lack of adequate training to carry out various activities under NRHM (24 percent). ASHAs (17 percent) also reported that decision making with the community leaders is an important problem. ASHA should be paid a fixed remuneration was the most frequently cited support (reported by 72 percent), followed by more funds for maintenance/effective functioning (reported by 50 %), required by ASHAs to implement NRHM in their communities.

Health Sub-Centres (HSCs) and functioning of ANMs

Salient findings of HSCs/ANMs for Karnataka, based on surveyed 84 HSCs/ANMs are given below:

Overall status of HSC

In Karnataka, a HSC serves a population (average) of about 4,396 persons and 5 villages. The mean distance between the Health Sub-Centre and the farthest village as well as the nearest Primary Health Centre (PHC) was about 7 Kms. About 52 percent of HSCs were reported to be accessible by bus, 86 percent by Jeep or Private vehicle and by 14 percent by

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bullock cart. About 3/5th of the sampled HSCs were functioning in government building. A close to 70 percent of the HSCs had residential facility for staff but only 56 percent of the ANMs reported residing in the official residence. Most HSCs were found not complying with the NRHM norms/requirements as only two HSCs in the district of Bijapur had carried out IPHS facility survey. Majority of the HSCs (80 percent) were easily accessible to the community and about 32 percent served as DOTS centre. About 35 percent of HSCs had separate prominent display boards in local language. Only 4 percent of the HSCs reported segregating bio-medical waste as per the standard colour coding.

Many of the HSCs were found to be equipped with communication facilities but with poor electricity facilities. In all the surveyed HSCs, a little above 2/3rd of HSCs reported to be having telephone connection and all the ANMs in the state had own mobile or telephone connection. A close to half of the sampled HSCs reported to have no electricity connection in all parts of the HSC, and 19 percent had in some parts of the centre. Of the surveyed HSCs, about 44 percent were equipped with delivery facilities and a little less than half of the HSCs (48 percent) were reported to have conducted deliveries. In most of the HSCs there was arrangement available for deliveries between 8PM to 8AM. About 78 percent of the HSCs reported deliveries conducted at night and when required also refer to higher facility. Most of the HSCs (83 percent) maintained all the 14 registers. Among the 84 HSCs, the availability of pre-printed registers for eligible couple, immunization and ANC were reported by 40, 43 and 82 percent of HSCs respectively. Similarly, the availability of pre-printed cards for MCH, immunization and JSY were reported by 60, 69 and 24 percent of HSCs respectively.

Functioning of ANMs: skills, funds, interaction with other functionaries

About 98 percent of ANMs had 10 and more years of complete education. About 57 percent of ANMs had been working at the same place for over five years. As for training, less than 30 percent of ANMs had received training on IUD insertion or removal in the past four years. About 23 percent of ANMs reported to have attended training on skilled birth attendant, 19 percent on IMNCI, and 48 percent on RTIs/STIs.

Of the 84 ANMs interviewed in seven districts, 81 percent of them reported transactions of untied funds. ANMs were also reporting to have faced difficulties in implementation of NRHM programmes and the kind of difficulties faced by ANMs varies from inadequate facilities for institutional delivery and non-cooperation from PRIs (18 percent) each) to non

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availability of funds in time (40 percent). Besides, about 28 percent of ANMs reported difficulties in decision making with community leaders and another 23 percent reported inadequate training for ASHAs. Despite some hiccups that confront their work, majority of ANMs were convinced that NRHM had enhanced their social status in the community (95 percent) and also in the family (70 percent). About 3/4th of the HSCs reported availability of plans and targets of Village Health and Nutrition Days (VHND).

Physical infrastructure and human resources at facility levels

Overall, except few, most of the infrastructures were available in majority of the district hospitals (DH). However, of the total 7 DHs surveyed, IPHS survey had been carried out only in one DH in Raichur. Two DHs (in Davangere and Mandya) were upgraded as per IPHS standard. The number of medical staff in the surveyed DHs was inadequate as many of the surveyed DHs were not having Medical Specialist, Paediatrician, Anesthetist, Radiologist, General Duty Medical Officer, and AYUSH medical officer. The surveyed DHs in all the districts were having staff nurse, Pharmacist and Radiographer but not all the surveyed DHs were having ANMs, Lady Health Visitor, Public Health Nurse, ECG technician and laboratory technicians. The trainings received by both medical staff and para medical staff were inadequate in most of the district hospitals. As for service outcomes at the DHs, on an average monthly 33 JSY cases were registered, 328 pregnant women were given 3 ANC, 135 pregnant women were identified and attended for obstetric complications, 268 deliveries were conducted and 66 caesarean sections were conducted. Average monthly service outcomes in Mysore, Mandya and Davanagere districts were comparatively better as compared to Bijapur, Raichur, Uttara Kannada and Chamarajanagar districts. Overall, the register maintenance was good in the surveyed district hospitals. The availability of infrastructure at the surveyed CHCs was inadequate. Of the total 14 CHCs, IPHS facility survey had been carried out in 3 CHCs and 4 CHCs were upgraded as per IPHS standard. Availability of medical staff was very low in the surveyed CHCs; out of 14 CHCs surveyed only four CHCs had a General Surgeon, 2 CHCs had an Obstetrician/Gynaecologist, one CHC each had a pediatrician and Anaesthetist and 3 CHCs had general duty medical officer of AYUSH. Other than ANMs and Staff Nurse, the availability of para-medical staff was also low in the surveyed CHCs. The training of human resources at CHCs was inadequate. Out of 14, About 5 CHCs were having their medical staff trained in IMNCI, 4 CHCs in RTI/STI, 3 CHCs each in MTP, BEMOC and Minilaprotomy and 2 CHCs each in Anaesthesia, New Born Care and NSV. Similar is the

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scenario with regard to training of para-medical staff in the surveyed CHCs. About 5 CHC were having para-medical staff trained in IMNCI, 8 CHCs in RTI/STI, 4 CHCs each in RTI/STI and Blood Grouping and Matching and another 3 CHCs each were having para-medical staff trained in ultra sound and electro cardiogram (ECG). The average bed occupancy rate at surveyed CHCs was 31 percent and daily OPD attendance was 69 persons. The average monthly deliveries conducted were 27 and JSY deliveries conducted were 16 in Karnataka. Maintenance of registers in the surveyed CHCs was good.

The average population served by the surveyed PHCs in Karnataka was 18,537. The availability of infrastructure at the surveyed PHCs (28) was inadequate in most districts. The IPHS facility survey had been carried out only in 4 PHCs and 6 PHCs were upgraded as per IPHS standard. The availability of medical staff and para-medical staff in the surveyed PHCs was inadequate. The training of human resources at PHCs was inadequate. Out of 28 PHCs surveyed, 8 PHCs reported that their medical staff had undergone training in RTI/STI, 7 PHCs reported training in IMNCI, 4 PHCs in Minilaprotamy, 3 PHCs in new born care, one PHC each in MTP and NSV. The para-medical staff in almost all PHCs of all the districts had not received adequate training except training in skilled birth attendant. As for services outcome, on an average monthly 34 pregnant women were registered for ANC, 18 were registered within first trimester of pregnancy, 21 deliveries and 12 JSY deliveries were conducted in surveyed PHCs. Overall, the register maintenance by PHCs was good.

Client’s response to NRHM

Clients, both in-patients and out-patients who have availed health services, were asked about their satisfaction and quality of care provided in the government health institutions. A total of 388 patients were surveyed in the state of Karnataka. There were 131 in-patients surveyed in Karnataka at the time of their discharge. About 28 percent of the patients stayed in the health facility for more than 5 days. A little lower than half of the patients were discharged within two days. Most of the In-patients interviewed at the District Hospital reported that the behavior of the doctor was good/very good, whereas 83 percent reported that the doctors had discussed about the ailments with them. The opinion of the in-patients about inward facilities was also asked. While majority of the patients (56 percent) reported bath rooms and toilets cleaned once in a day, uniforms and bed sheets were not changed every day in majority of the cases. All the in-patients interviewed in the PHCs, 90 percent of the patients in CHCs and 4/5th of the in-patients in the district hospitals were fully satisfied with the treatment. The three main reasons stated for not being satisfied with the

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facilities were poor quality of services, lack of facilities and bad experience with the doctor. About 63 percent reported availability of medical shops, 85 percent reported pathology/laboratory services, 72 percent reported ambulance services, and another 56 percent reported availability of X-ray services.

There were 257 out-patients surveyed from 7 districts of Karnataka. A little above half of the patients were admitted mainly for ailments such as dental and eye problems, arthritis and mental disorders, followed by 24 percent for infectious diseases and 10 percent for respiratory diseases. About 47 percent of them used public transport, 44 percent used bullock cart/foot and another 41 percent used private vehicles to reach the health facility. About 37 percent of the patients had visited the health facility four and more times for the current illness. At the district hospital level, 88 percent of patients reported good behaviour of the doctor, 61 percent reported friendly or somewhat friendly behaviour of nursing staff and 65 percent reported doctor having discussed about the ailment. The corresponding figures for CHC and PHC were 97, 85, 65 and 94, 72, 73 percent. About 69 percent of the patients reported that they were fully satisfied while availing services at the PHC compared to 74 and 70 percent at the district hospital and CHC levels respectively. Those who had not been satisfied with the treatment cited poor quality of services, bad experience with the doctor and lack of facilities as the most important reasons for their dissatisfaction with treatment provided.

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CHAPTER - 1

INTRODUCTION

The National Rural Health Mission (NRHM) launched in April 2005 seeks to provide accessible, affordable and quality health care to the rural population, especially the vulnerable sections, with special focus on 18 states, including Jammu and Kashmir, Himachal Pradesh and North-Eastern states. The mission proposes to facilitate increased access and utilization of quality health services. This has been carried out by increasing the spending on health and improving the health care services at the community level. The mission undertakes several architectural corrections of the health system to enable and promote policies that strengthen public health management and service delivery within the country. It also envisages revitalizing the local health traditions and attempts to mainstream AYUSH into the public health system by effectively integrating health concerns through decentralized management at local levels. The mission also addresses issues on sanitation and hygiene, nutrition, safe drinking water, gender, social concerns, and inter-state as well as inter-district disparities in health care provision.

1.1 Objectives of NRHM

The main objectives of the National Rural Health Mission (NRHM) are as follows: 1. Reduction in child and maternal mortality.

2. Universal access to public services like food and nutrition, sanitation and hygiene and also access to public health care services with emphasis on services addressing women and children health and universal immunization.

3. Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.

4. Access to integrated complete primary health care.

5. Population stabilization, gender and demographic balance. 6. Regenerate local health traditions & mainstream AYUSH. 7. Promotion of healthy life styles.

In order to achieve the above objectives, the Central Government has adopted 12 core strategies with 5 supplementary strategies, and the plan of action consists of 10 components (NRHM Mission Document: MoH&FW, 2005). It aims to revitalize the institutional frameworks like state and district health societies, and created new structures like state and

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district health missions and Rogi Kalyan Samitis (RKS). It also promoted greater involvement of Panchayti Raj Instititution through the formation of Village and Health Sanitation Committee to oversee and promote the NRHM activities at the Health Sub-centre level. A female accreditated social heath activist (ASHA) has been provided at the village level to take care the local needs of health. ASHA is also required to act as a link between the village community and the Health Sub-Centre. The new innovations also include

Jananni Suraksha Yojana (JSY) for safe motherhood under the NRHM.

1.2 Concurrent Evaluation of NRHM

The objective of the concurrent evaluation of NRHM was to assess the reach of NRHM activities at the health facility levels and among the rural communities. The aim is to get various indicators about implementation of health care which will be helpful to policy makers and programme managers in effective implementation of NRHM. The concurrent evaluation of NRHM was undertaken in 197 districts spread over all 35 states/UTs. The states were grouped into five zones, namely: Central, North, North-east, South, and West (See Appendix for the name of the states in each Zone). The data collection was done by the field agencies under the supervision of zonal agencies. The IIPS acted as a Nodal Agency in the concurrent evaluation of NRHM.

The present report pertains to the state of Karnataka. The concurrent evaluation of Karnataka covered 7 districts namely Bijapur, Raichur, Uttara Kannada, Davanagere, Mandya, Mysore and Chamarajanagar.

1.3 Survey design and methodology

As per the sampling strategy, from each selected district, along with District Hospital (DH), 2 CHCs, 4 PHCs, 12 Health Sub-Centres, 24 villages, 12 Gram Panchayats, 24 ASHAs, 1,200 heads of the household and 1,200 currently married women (15-49) were covered (Figure 1). PHCs were selected from those under the respective selected CHCs; Health Sub-Centres were selected from those under the selected PHCs and so on. In-patients and out-patients were also interviewed to know their opinion about the health services through exit interviews at the health facility levels.

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Figure 1 - Sampling design of Concurrent Evaluation of NRHM

Village 1 1, 2, 3….50 HH Village 2 1, 2, 3….50 HH State Schedule District Hospital Schedule HSC HSC HSC HSC HSC HSC HSC HSC HSC HSC HSC HSC CHC 1 IPD/OPD Exit 5 each CHC 2 Exit IPD/OPD 10 each PHC 1 Exit IPD/OPD 2 each PHC 2 PHC 1 Exit IPD/OPD 2 each PHC 2 Each HSC ASHA 1 Gram Panchayat from SC village ASHA 2

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District Hospital (DH): One DH is selected from each district. Ten in-patients and 10 out-patients were also interviewed from each DH to know their opinion about the health services through exit interview schedules.

Community Health Centre (CHC): As per the sampling strategy, two CHCs from each district were selected. First of all, all CHCs in the district are listed along with their distance from the district headquarter (HQ) irrespective of their first referral unit (FRU) status. If there were more than one FRU, then the farthest was selected, otherwise the only available FRU was selected. Out of the remaining CHCs, one more CHC was selected by arranging the CHCs in increasing order of distance from district HQ and the middle one was selected. In case there are two or more CHCs at the same distance, the one whose name comes first in alphabetic order was selected. If there was no FRU in the district then the one nearest CHC and the one farthest from district HQ was selected. In case there are two or more CHCs at the same distance, the one whose name comes first in alphabetic order was selected. Five in-patients (IPDs) and 5 out-patients (OPDs) were interviewed from each selected CHCs (in case less than 5 in-patients then shortfall was compensated from out-patients).

Primary Health Centre (PHC): Four PHCs were selected from each district, i.e., two each from the CHC catchment area of the 2 selected CHCs. The procedure of the selection of PHCs was based on distance from the CHC and its 24x7 status which similar to the selection of CHCs. If there is more than one 24x7 PHCs, then the farthest was selected, else the only available 24x7 PHC is selected. Out of the remaining PHCs, one more PHC is selected by arranging the PHCs in increasing order of distance from CHC HQ and the middle one may be selected. In case there are two or more PHCs at the same distance, the one whose name comes first in alphabetic order may be selected. If there is no 24x7 PHC under the CHC then the nearest and farthest PHCs were selected. In case there were two or more PHCs at the same distance, the one whose name comes first in alphabetic order was selected. Two IPDs and 2 OPDs were interviewed from each selected PHCs (In case less than 2 IPDs, then the shortfall in IPDs was compensated from OPDs).

Health Sub-Centre (HSC): Twelve Health Sub-Centres from each district were selected i.e. 3 Health Sub-Centres under each PHC excluding the Health Sub-Centre located in the CHC/PHC premises based on distance criteria. One Health Sub-Centre was farthest, one at the middle and one to the nearest of the selected PHC. If there were more than one Health

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Sub-Centre at the same distance, then the one whose name comes first in the alphabetic order was selected. In all, 12 Health Sub-Centre were selected from each selected district.

Gram Panchayat: As per sampling strategy, from each district, the Gram Panchayat which belonged to the Health Sub-Centre Village was selected. As such, 12 Gram Panchayats

were selected which is equal to the number of Health Sub-Centres.

Household and Eligible Woman: A sample of 1,200 households with currently married women (15-49) was covered. Two villages were selected from the catchment area of a selected Health Sub- Centre. Altogether 24 villages were selected from each district. From each village 50 households were selected. In case there was more than one eligible woman, then the pregnant woman or who has delivered during last three years in that order was selected. Else the one whose name appears first in alphabetic order is selected. If the selected village has less than 50 households, a nearby village was linked with the selected village so that the combined number of households (HHs in the selected village + HHs in the link village) was at least in the range of 100-150 households. In case of refusal by selected household, the selected household was replaced by the adjacent household. In case of large villages with more than one Health Sub-Centre, it was advised to cover the catchment area of the selected Health Sub-Centre only. From each village, it was ensured that at least 25 percent of the households were selected from the SC/ST households. A systematic random sampling was adopted with an appropriate interval beginning from the North-West corner of the village.

Accredited Social Health Activist (ASHA): From each district, 24 ASHAs were selected belonging to each selected village. For selecting an ASHA from a village with more than one ASHAs, the names of ASHAs in the village was arranged in alphabetic order and the first available was be selected.

The sample coverage in the state of Karnataka is given below:

Sample coverage

District DH CHC PHC HSC ANMs Village GP ASHA

Household / Eligible Woman IPD/ OPD 7 7 14 28 84 84 168 69 58 8,319 388 1.4 Survey instruments

Bilingual interview schedules, both in English and Kannada language, were used to collect information from households, currently married women (age 15-49) and Gram Panchayat

Figure

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References

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