Public Health Units Report

Report

A Survey for scaling of Public Health Units

as Sub Centers, PHC and CHC of Uttar

Pradesh State, India.

A Survey for Scaling heath units as Sub Centers, PHCs and CHCs in working area of CRY partners along with VOP District Advocacy

coordinator working area in Uttar Pradesh State, India.

A Survey for scaling of Public Health Units of Uttar Pradesh

Page 1

A Survey Report

A Survey for scaling of Public health units as Sub Centers,

PHC and CHC in working area of CRY partners along with

VOP District Advocacy coordinator working area in State

of Uttar Pradesh, India.

By

Voice of People

53, Maruti Puram, Indira Nagar, Lucknow-16

Phone: 0522 4042932

E-mail: [email protected]

Blog: http://[email protected]

All rights reserved. No part of this survey may be reproduced in any form or by any

means, or stored in a database or retrieval system, without prior permission of the

publisher except in the case of brief quotations embodied in articles or reviews.

Making copies of any part of this book for any purpose other than your own

personal use is a violation of copyright laws.

We have been careful to provide accurate information throughout this book, but it is

possible that errors and omissions have been introduced. Please consider this in

making any career plans or other important decisions.


Page 2

Executive Summery

Survey description and context

The Organization, Voice of People, undertook the study to

evaluate the functioning of the public health facilities and their

effectiveness in bringing health care services within the reach of

people.

On appropriate and feasible measures, the former is assessed on

the static and dynamic condition of physical infrastructure; by the

numbers of paramedical, technician and medical staff employed,

as well as figures for attendance and gender breakdown; by the

supply, quality and range of drugs; by availability and usage of

decentralized untied and maintenance funding of centers; and by

actual availability of laboratory, diagnostic and service facilities.

Quality is defined in relation to the condition of the above

tangibles, as also supplemented by subjective data on intangibles,

such as patient satisfaction, gathered from the exit interviews.

Purpose of the Survey

The health system in Uttar Pradesh has witnessed major changes

in public health in the recent decades. Post-independence, it has

made significant strides on many health fronts and these must be

rightfully acknowledged such as increased life expectancy,

reduction in maternal and infant mortality and eradication of

smallpox. However, the state is still far from achieving its

population health goals.


Page 3

Now Uttar Pradesh existed among the states having worst health

indicators in India. Even though some actions have been taken

after the introduction of the National Rural Health Mission in late

2005, and some good outputs are emerging, a large number of

very serious problems still remain. Without these problems being

addressed, the targets regard to health and nutrition of India will

not be met, since UP has such a large weight in the unmet needs of

public health in India.

High levels of maternal mortality, infant and child mortality and

malnutrition continue to plague many parts of the Uttar Pradesh,

coupled with significant variations across its districts. Together

with maternal and newborn conditions, communicable diseases

including HIV, TB, malaria, diarrhea and acute respiratory

infections account for nearly half of Uttar Pradesh’s disease

burden.

Non-communicable conditions like cancers, cardiovascular

disease, diabetes, COPD and mental health conditions account for

the second largest share of the disease burden, now and in the

future. Blindness and oral health conditions are also expected to

increase sharply over the next decade (GOI, NCMH, 2005). The

pressure of a burgeoning population, 72% of which is rural, with

widespread illiteracy and social deprivation, pose a formidable

challenge for the health sector’s functioning. Added to this is the

response that is needed, in times of disaster and during sudden

unexpected outbreaks of disease.

Thus the single purpose of this survey is to understand the actual

reasons behind the low levels of health indicators despite of a

state wise multifunctioning public health facilities and human

resource with a lot of funds from various governmental and non-

governmental agencies.


Page 4

Objectives of the survey

� The very first and core objective of this survey is to use obtain

data in future planning of various advocacy activities for all Uttar

Pradesh in respect of health perspective.

� Identify and prioritize existing sources of available health

services, particularly in rural areas.

� To provide data on the Primary services giving capacity on which

they are meant to provide.

� To provide data on human resources, their presence and

treatment towards community.

� To provide data on awareness of public towards various

programs which government run for them.

� To provide data on Available infrastructure, medicines,

equipment and their status on giving health care.

� By this data we will lay the foundation for proper psychological,

physical and social development of the child specially since they

are future;

� To reduce the incidence of mortality, morbidity, malnutrition and

school dropout;

� To achieve effective co-ordination of policy and implementation

amongst the various governmental departments and non-profits

organizations to promote child development; and


Page 5

� To enhance the capability of the mother to look after the normal

health and nutritional needs of the child through proper nutrition

and health education.

Methodology

While the information available in published sources was

obtained and used wherever necessary, the major part of the data

required for the survey was generated through a sample survey.

Thus, some district level statistics on health care infrastructure

and health indicators were obtained from published documents,

but the specific information on health care centers and knowledge

and faith on those centers data had to be generated through

collection of micro level information by the field units of VOP.

Features of a methodology

� Information is gathered by asking questions to people.

� Information is collected either by having interviewers ask

questions and record answers or by having people read or hear

questions and record their answers.


Page 6

� Information is collected from only a subset of the population to be

described (a sample) rather than from all members.

Process of Survey

Define research objectives

Choose mode of Choose sampling

Collection frame

Construct and pretest Design and select

Questionnaire sample

Recruit and

measure sample

Code and edit data

Make post survey adjustments

Perform analysis


Page 7

Principle findings and conclusions

This paper seeks to evaluate quantity and quality of service

delivery in public health facilities, looking to assess and measure

the condition of physical infrastructure, both static and dynamic;

the state of human resources, including numbers of paramedical,

technician, medical and AYUSH staff employed, their contractual

status, absenteeism and gender breakdown; the supply, quality

and range of drugs; usage of decentralized untied and

maintenance financial grants; and by actual availability of services

in these centers.

Quality is defined in relation to the condition of the above

tangibles, as also supplemented by subjective data on intangibles,

such as patient satisfaction, gathered from the exit interviews.

The micro-findings, which have resulted in rankings in individual

sections of the study, suggest disparate situations at various levels

of centers and on different components, reflecting context-specific

underlying driving factors, some complex by nature.

Based on the findings and the arguments, I could easily rank the

states on ‘overall performance of service delivery under’, and

perhaps a reader already has a sense of this ranking.

However, I feel that to do so would be irresponsible, meaningless

and defeat the very purpose of this evaluation, which was to

highlight the micro-components of features that are important to

this Mission’s capacity to deliver services, how states are faring on

implementing these various strands, and what factors might be

causing problems where implementation is less than desirable.


Page 8

So to the question of whether the health care services has been

delivered properly, the findings outlined here begin to give the

nuanced answer that True, there are many problems in

implementation, so that delivery is far from what is ought to be.

On physical infrastructure, medicines and funding, problems

might be more easily scaled with time (in some instances, they

already appear to have been overcome), whereas on human

resources, and to the extent these impact actual availability of

services, structural issues of some complexity need careful

resolving with a definite long term investment in the training and

education of paramedical and medical staff, especially women

staff, close monitoring of attendance.

However, the parameters of the question this study seeks to

answer are very much within the ambit of how to better

performance, and not whether the Mission ought to have been

undertaken in the first place, of which there can be no doubt.

Especially relating to project objective / targets In terms of what

the reader ought to take away from this study.

Key recommendations

� Some PHCs and even CHCs have been running without any

doctors. It’s not a carelessness of government but the government

is mocking with people.


Page 9

� Even 75 of health centers are running without proper equipment

and medicines. Authorities have to deal it quickly.

� Geographical coverage is very large in case of PHCs and CHCs.

� They have inadequate medical staff, particularly the specialists.

� The mean distance of the PHCs from the CHC is longer.

� Some CHCs have been approved without sanctioning all the posts

of specialists. Only 20 per cent of the required posts of the

specialists were found to be in position. More than 80 per cent of

the samples CHCs are running either with one specialist or

without any specialist.

� There is a mis-match between medical specialists vis-a-vis

equipment/facilities/ staff, leading to sub-optimal utilization of

resources. The over-all productivity of the public health services

can substantially be improved if this mis-match as well as thin

spread of resources is avoided.


Page 10

Acknowledgements

The following people and organizations were instrumental in this

Survey Project and deserve special recognition for their efforts:

Sponsors

Steering Committee

Survey Volunteers


Page 11

Table of Contents

List of Acronyms and Abbreviations

1. Purpose of the survey

2. Objectives of the survey

3. Survey methodology

A. Rationale for choice of methodology,

B. data sources,

C. methods for data collection and analysis,

D. participatory techniques,

E. ethical and equity considerations,

F. major limitations of the methodology

4. Survey findings

5. Conclusions

6. Recommendations

7. Indexes


Page 12

List of Acronyms and Abbreviations

ANM Auxiliary Nurse and Midwife

ARI Acute Respiratory Infection

ASHA Accredited Social Health Activist

AWW Angadwadi Worker AYUSH Ayurveda,

Yoga and Naturopathy, Unani, Siddha and

Homeopathy

CHC Community Health Centre

DDK Disposable Delivery Kit

DOT Direct Observes Treatment

FRU First Referral Unit

GDP Gross Domestic Product

GNM General Nurse and Midwife

GOI Government of India

IFA Iron Folic Acid

IMR Infant Mortality Rate

IPHS Indian Public Health Standards

JSY Janani Suraksha Yojana

LHV Lady Health Visitor

MMR Maternal Mortality Rate

MO Medical Officer

MOIC Medical Officer In Charge

NRHM National Rural Health Mission

OPD Out Patient Department

PHC Primary Health Centre

PRI Panchayati Raj Institution

RCH Reproductive and Child Health

RKS Rogi Kalyan Samiti

RTI / STI Reproductive Tract Infection / Sexually

Transmitted Infection

SC Sub Centre

VHSC Village Health and Sanitation Committee


Page 13

1. Purpose of the survey

Our health policy envisages a three tier structure comprising the

primary, secondary and tertiary health care facilities to bring

health care services within the reach of the people.

The primary tier is designed to have three types of health care

institutions, namely, a Sub-Centre (SC) for a population of 3000-

5000, a Primary Health Centre (PHC) for 20000 to 30000 people

and a Community Health Centre (CHC) as referral center for every

four PHCs covering a population of 80,000 to 1.2 lakh.

The district hospitals were to function as the secondary tier for

the rural health care, and as the primary tier for the urban

population. The tertiary health care was to be provided by health

care institutions in urban areas which are well equipped with

sophisticated diagnostic and investigative facilities.

In pursuance of this policy, a vast network of health care

institutions has been created, both in rural and urban areas, and

substantial resources, though inadequate vis-a-vis requirement,

have gone into planning and implementing the health and family

welfare programs.

This policy was applied to all states of India and increased

availability and utilization of health care services have resulted in

a general improvement of the health status of our population, as is

reflected in the increased life expectancy and marked decline in

birth and mortality rates over the last fifty years. However, these

achievements are uneven, with marked disparities across states

and districts, and between urban and rural people.


Page 14

Health Infrastructure of Uttar Pradesh State

• Sub-Centre 20521

• Primary Health Centre

3692

• Community Health Centre

515

• Multipurpose worker (Female)/ANM at Sub Centers & PHCs

• Health Worker (Male) MPW(M) at Sub Centers

• Health Assistant (Female)/LHV at PHCs

22464

1729

2040

• Health Assistant (Male) at PHCs 4518

• Doctor at PHCs 2861

• Obstetricians & Gynecologists at CHCs

NA

• Physicians at CHCs 186

• Pediatricians at CHCs NA

• Total specialists at CHCs 1894

• Radiographers 181

• Pharmacist 5582

• Laboratory Technicians 995

• Nurse/Midwife 2627

(Source: RHS Bulletin, March 2011, M/O Health & F.W., GOI)


Page 15

The State of Uttar Pradesh has a vast infrastructure of medical

installation throughout the state yet the status of the people of the

Uttar Pradesh is not satisfactory as shown in the table below.

Demographic, Socio-economic and Health profile of

Uttar Pradesh State as compared to India figures

Item Uttar Pradesh India

Total population (Census 2011)

(in crore)

19.96 121.01

Decadal Growth (Census 2011) (%) 20.09

17.64

Crude Birth Rate (SRS 2010) 28.3

22.1

Crude Death Rate (SRS 2010) 8.1 7.2

Total Fertility Rate (SRS 2010) 3.5 2.5

Infant Mortality Rate (SRS 2010) 61 47

Maternal Mortality Ratio (SRS 2007 –

2009)

359 212

Sex Ratio (Census 2011) 908 940

Population below Poverty line (%) 31.15 26.10

Schedule Caste population (in million) 35.15 166.64

Schedule Tribe population (in million) 0.11 84.33

Female Literacy Rate (Census 2011) (%) 59.26

65.46

Thus to find the real factors behind lacking of U.P. , this

survey is required to evaluate the functioning of the Health

Centre’s and their effectiveness in bringing basic and

specialized health care within the reach of people.


Page 16

2. Objectives of the Survey

� Identify and prioritize existing sources of available health

services, particularly in rural areas.

� To provide data on the Primary services giving capacity on which

they are meant to provide.

� To provide data on human resources, their presence and

treatment towards community.

� To provide data on awareness of public towards various

programs which government run for them.

� To provide data on Available infrastructure, medicines,

equipment and their status on giving health care.

� By this data we will lay the foundation for proper psychological,

physical and social development of the child specially since they

are future;

� To reduce the incidence of mortality, morbidity, malnutrition and

school dropout;

� To achieve effective co-ordination of policy and implementation

amongst the various governmental departments and non-profits

organizations to promote child development; and

� To enhance the capability of the mother to look after the normal

health and nutritional needs of the child through proper nutrition

and health education.


Page 17

3. Methodology

A. Rationale for choice of methodology

A multi-stage sample design was adopted for the study. The

sample units at different stages are: Sub Centre, CHCs and PHCs.

Three separate formats were being made for these three type of

medical installations. Following the above sample design, 224

patients, 155 non-patients households, 112 Sub Centers 40 PHCs

and 26 CHCs spread over the 16 sample districts were selected for

the study. In each selected village the views of knowledgeable

persons were also taken for preparation of qualitative notes

regarding the functioning of health care institutions. The separate

rationales for all three stages are given below

I. List of questions for Survey of Sub Centre

Questions related to Sub Center had been divided in eight

major sections and then sub sections of those main sections.

Section 1 - Services

� MCH Care including Family Planning;

� Availability of specific services

� Monitoring and Supervision activities

Section 2 - Manpower


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Section 3 - Physical Infrastructure (As per specifications)

� Location

� building,

� sanitation

� Electricity

� Water supply

Section 4 - Equipment (As per list)

Section 5 - Drugs (As per essential drug list)

Section 6 - Furniture (As per standards)

Section 7 - Quality Control

Section 8 - Views of Beneficiaries about Sub Centre

� Condition of their Health

� Certain knowledge of health programs and services which

government running for them



Page 19

II. List of questions for Survey of Primary Health Centre

Questions related to Primary Health Center had been

divided in nine major sections and then sub section of those main

sections.

Section 1- Services

� Assured Services available

� Treatment of specific cases

� MCH Care including Family Planning;


� Monitoring and Supervision activities

Section 2- Manpower

Section 3- Training of personnel during previous (full) year

Section 4- Physical Infrastructure (As per specifications)

� Location

� Building,

� Sanitation

� Electricity

� Water supply




Page 20

Section 7- Furniture ( As per standards)


Section 9 - Views of Beneficiaries about PHC





III. List of questions for Survey of Community Health Centre

Questions related to Community Health Center had been

divided in nine major sections and then sub sections of those main

sections.

Section 1 - Services

� Specialist services available

Section 2- Manpower

� Clinical Manpower

� Support Manpower

Section 3 - Investigative Facilities


Page 21


� Location

� Building,

� Sanitation

� Electricity

� Water supply





Section 9 - Views of Beneficiaries about CHC





B. Data sources

While the information available in published sources was

obtained and used wherever necessary, the major part of the data

required for the study was generated through a sample survey.


Page 22

Thus, some district level statistics on health care infrastructure

and health indicators were obtained from published documents,

but the health care institution (SC/CHC/PHC) specific information

and household level data had to be generated through collection

of micro level information by the field units of VOP.

C. Methods for analysis

Factor analysis technique was employed to examine the structure

of the relationship among variables representing the perceived

quality dimensions of healthcare services in Uttar Pradesh.

The necessary data base was built through collection of both

quantitative and qualitative data at various levels. To assess the

location and coverage of health centers data pertaining to

population coverage vis-a-vis norm prescribed, distance of sample

and district Headquarters were collected.

The information on availability and adequacy of health care

service infrastructure, like, manpower, equipment, physical

facilities was collected through health center level. To examine the

utilization of referral services, the data on number of routine as

well as referred cases attended at health centers per annum were

collected.

Besides, to assess the effectiveness of health centers, the primary

information on accessibility and acceptability of health care

services to the people was collected from beneficiaries.

Thus, the requisite data base for the study was generated through

the instruments of observation structured at different levels and

also through discussions with Govt. Health functionaries. The


Page 23

instruments of observation were structured at six levels i.e. Sub

Centre, CHC, PHC, knowledgeable person, patient and non-patient.

D. Participatory Techniques

The study design was finalized in a meeting of the Heads of the

Regional Offices of the VOP held on at the Regional Hq. The Head

in turn held two Orientation Programs for field staff, one at

Lucknow on 1th & 2th 2012 and on 17th & 18th September, 2012 .

In these orientation programs, all the instruments prepared for

the study were explained to the respective field teams of the

selected districts.

E. Study Limitations

The study has a number of limitations due to sampling and

measurement methods. This study is not a pure experiment,

because the intervention facilities were not randomly assigned,

and the same patients were not interviewed at baseline and

follow-up periods.

A potential bias is that patients were interviewed for satisfaction

at the facilities which may bias results upward. However, the

effect should not be different between project and control sites at

baseline and follow-up periods, so that the difference of difference

measures should still be valid.

The estimates of monthly averages for outpatient visits contained

data that were incomplete, particularly at the PHCs. Although the

project and control sites for outpatient visits were matched on

district, this thin sample might not produce robust estimates.


Page 24

We could not find a systematic bias in the data, but we believe

that the net effect of these changes is a random increase in the

amount of error in our measurements. However, it does not

change the main findings that utilization increased for all,

especially the wealthier groups and that satisfaction with services

increased at the CHCs and PHCs, and more consistently for the

wealthier groups than the poor.

Finally, caution must be used in interpreting the patient

satisfaction ratings. Differences in perceptions may not be due to

actual differences in quality. For example, it is not clear if CHC

going groups express higher levels of satisfaction because the

quality of services for them is better or because they have lower

expectations.


4. Survey findings

a) Findings from CHCs

I. Governmental norms for CHCs for reference

� CHCs are being established and maintained by the State

Government under MNP/BMS program.

� As per minimum norms, a CHC is required to be manned by four

medical specialists i.e. Surgeon, Physician, Gynecologist and

Pediatrician supported by 21 paramedical and other staff.

� It has 30 in-door beds with one OT, X-ray, Labor Room and

Laboratory facilities.

� It serves as a referral Centre for 4 PHCs and also provides

facilities for obstetric care and specialist consultations.

II. Section wise Survey Findings from CHCs

Section 1 – Services

Services

Availability

72%

Non-

Availability

28%

Page 25


Page 26

Section 2- Manpower

Manpower

Availability

57% Non-

Availability 43%


Investigative Facilities

Non-

Availability

56%

Availability

44%


Page 27


Physical Infrastructure

Availability

84%

Non-

Availability

16%


Equipment

Availability

95%

Non-

Availability

5%


Page 28


Drugs

Availability

95%

Non-

Availability

5%


Furniture

Availability

68%

Non-

Availability

32%


Page 29


Quality Control

Availability

90%

Non-

Availability

10%

Section 9 - Views of Beneficiaries about CHC

Views of Beneficiaries

Non-

Availability

56%

Availability

44%


Page 30

III. District Wise Findings

(Availability in percentage)

District S1

Services S2

Manpow

er

S3

Investigat

ive

Facilities

Physic

al

Infrast

ructur

e S4

S5

Equip

ment

S6

Drugs S7

Furnitu

re

S8

Quality

Control

S9

Views of

Beneficia

ries

Allahabad 66% 45 32 67 84 54 67 84 54

Ambedkar

Nagar 35% 40 34 76 55 56 76 55 56

Badaun 54 51 23 65 65 67 65 65 67

Baharaich 49 66 45 76 23 47 76 23 47

Chandauli 39 43 25 65 57 26 65 57 26

Faizabad 40 48 45 67 84 54 44 46 37

Kaushambi 61 43 34 76 55 56 35 66 64

Lucknow 80 35 45 65 65 67 54 46 53

Mahoba 46 56 56 76 23 47 87 87 61

Mirjapur 36 55 36 65 57 26 56 54 53

Sant

Ravidas

Nagar

47

46

46

56

64

48

67

67

54

Sonebhadra 52 37 56 67 84 54 44 46 37

Sultanpur 48 46 23 76 55 56 35 66 64

Varanasi 47 44 34 43 64 63 43 55 56

IV. Findings In Detail

1. Average population covered


Page 31

� Survey data suggest that a CHC covers an average of 175.2 l

thousands people.

2. Health Infrastructure - Availability & Adequacy

� As the CHCs are required to deliver specialised health care

services, it was decided to equip these institutions with suitable

diagnostic and investigative facilities. As noted earlier, in addition

to the usual staff and facilities, four medical specialists and other

complementary Para medical staff and facilities, such as,

operation theatre, labour room, pathology laboratory, X-ray

machine, refrigerator, generator, etc., were prescribed by the

Central Government to enable CHCs to deliver specialized health

care services to rural people.

� A comparison of the availability of staff and facilities in the 26

sample CHCs with their prescribed norms shows wide gaps for

the majority of the CHCs. In fact, most of them are not equipped to

deliver the intended specialised health care services. In particular,

the following inadequacies were observed

� some CHCs have been sanctioned without sanctioning all the

posts of specialists;

� Only 30 per cent of (the required posts) the specialists were found

to be in position. More than 70 per cent of the samples CHCs are


Page 32

running either with one specialist (42%) or without any specialist

(29%);

� The extent of shortfall in Para medical staff is found to be 12 per

cent for NMWs, 16 per cent for Dressers and 39 per cent for

Radiographers. At the aggregate level, pharmacists and laboratory

technicians are found to be in excess of requirement;

� Out of 26 sample CHCs, operation theatres and labour rooms were

not available in 5, pathology laboratories in 12, safe drinking

water in 9, ECG machines in 23, X-ray machines in 12 and

generators in 23 CHCs;

� What is more striking is the mis-match between the medical

specialists and equipment/ facilities/ staff of CHCs. For example,

only 6 sample CHCs had Surgeons with the essential

complementary facilities comprising X-ray machines with

Radiographers, pathology laboratories with lab-technicians and

operation theatres, while 8 CHCs had Surgeons, 26 had operation

theatres, etc. Similar mis-match is also noticed in the case of other

specialists.

� All this tends to suggest that not only there is an acute shortage of

medical specialists, but there is also a mis-match of facilities and

specialists in a majority of CHCs, implying sub-optimal utilization

and thin spread of available resources.

3. Utilization of Services

� Among the sample CHCs only two were found to have been used

as referral centres to some extent.


Page 33

� Eleven 11 CHCs have not attended to any referral cases, while the

remaining have been used sub-optimally with an average of 206

cases per year. An attempt has been made in the study to identify

the factors that explain the variation in the utilization of services

across sample CHCs.

� Given the location and the coverage of area and population, the

utilization rate depends on the ability of CHCs to deliver the

complete package of services for specialised treatment.

� Variations in the availability of specialists, Para-medical staff,

facilities for medical investigation, physical infrastructure and the

complementarity among these Inputs are found to be responsible

for differential utilization rates across CHCs.

� The above findings, however, should not lead one to conclude that

the services of CHCs were not used at all. In fact, the entire sample

CHCs were found functioning more like PHCs and attended to a

large number of routine/direct cases.

4. Beneficiary’s Views

� An analysis of the views of the beneficiaries of the rural primary

health care institutions revealed that about 57 per cent of them

were either dissatisfied or partially satisfied with the quality of

services delivered through sample CHCs.


Page 34

� The reasons for dissatisfaction stem from the inadequacies of the

delivery system. Some of the major reasons for dissatisfaction are:

non-availability of doctors, indifferent and non-sympathetic

attitudes of doctors and Para medical staff and no availability of

prescribed medicines.

� Of about 62 per cent of the total number of selected beneficiaries

of sample CHCs, 76.8 per cent of the indoor patients and 54.8 per

cent of the outdoor patients had spent money on getting

treatment from CHCs.

� About 80 per cent of the expenditure of both indoor and outdoor

patients was on medicines. Twenty eight (28) per cent of the

indoor and 6 per cent of the outdoor patients had to spend more

than Rs. 500 on each illness episode.

� It is interesting to note, however, that a large majority of the

beneficiaries did not think that such expenses were a major

constraint to the utilization of the services intended to be

delivered through these CHCs. On the contrary, most of them

expressed their preference for the public health institutions vis-à-

vis other alternatives.


Page 35

b) Findings From PHCs

I. Governmental norms for PHCs for reference

� PHC is the first contact point between village community and the

Medical Officer.

� The PHCs were envisaged to provide an integrated curative and

preventive health care to the rural population with emphasis on

preventive and promote aspects of health care.

� The PHCs are established and maintained by the State

Governments under the Minimum Needs Program (MNP)/ Basic

Minimum Services (BMS) Program.

� As per minimum requirement, a PHC is to be manned by a two

Medical Officer supported by 14 paramedical and other staff.

� Under NRHM, there is a provision for two additional Staff Nurses

at PHCs on contract basis. It acts as a referral unit for 6 Sub

Centre.

� It has 4 - 6 beds for patients.

� The activities of PHC involve curative, preventive, promote and

Family Welfare Services.

II. Section wise Survey Findings from PHCs


Page 36


Services

Availability

72%

Non-

Availability

28%

Section 2- Manpower

Manpower

Availability

57%

Non-

Availability

43%



Page 37

Investigative Facilities

Non-

Availability

56%

Availability

44%



Availability

84%

Non-

Availability

16%


A Survey for scaling of Public Health Units of Uttar

Pradesh

Page 3

Equipment

Availability

95%

Non-

Availability

5%


Drugs

Availability

95%

Non-

Availability

5%


Furniture 8


Pradesh

Page 3


Quality Control

Availabilit

y 90%

Non-

Availabilit

y

10%

Section 9 - Views of Beneficiaries about PHC


Pradesh

Page 4


Non-

Availability

56%

Availability

44%



District S1

Services S2

Manpow

er

S3

Investigat

ive

Facilities

Physic

al

Infrast

ructur

e S4

S5

Equip

ment

S6

Drugs S7

Furnitu

re

S8

Quality

Control

S9

Views of

Beneficia

ries

Allahabad 56 76 57 67 78 76 51 56 56

Aajamgarh 44 57 67 76 57 67 58 53 53

Ambedkar

Nagar 54 43 43 56 65 87 62 67 67

Badaun 56 76 76 82 54 65 84 76 54

Baharaich 53 54 54 71 67 75 54 63 43

Chandauli 87 67 44 74 56 84 44 57 44

Faizabad 56 43 43 62 67 84 54 43 54

Lucknow 65 51 56 84 76 55 56 76 56


Pradesh

Page 41

Mahoba 43 58 53 89 76 65 43 65 65

Muradabad 78 61 53 74 54 54 43 43 65

Mirjapur 54 63 54 89 65 76 57 67 67

Sant

Ravidas Nagar

87

67

54

74

65

56

65

87

54

Sonebhadra 76 54 34 89 54 53 89 74 56

Sultanpur 77 67 65 85 76 53 74 62 67

Varanasi 56 66 43 63 56 53 89 74 65


I. Average area covered

� Survey data tells that a PHC covers an average of 74.7l thousand

people.

II. Manpower

� A drawback in the implementation of the family welfare program

was the shortage of skilled and dedicated health

workers at the sub-center level followed by non-availability of a

lady doctor at the PHC level.

� In most of the PHCs, male health workers were not available

because of non-recruitment of vacancies during the last several

years, as either they were retired or promoted. This has been


Pradesh

Page 42

happening at a crucial time when male involvement in family

welfare is required.

� As a result, ANMs have taken on the responsibility of the disease

control program. It has made them non- responsible and use this

as an alibi for the ineffective implementation of the family welfare

program.

� As the workload of ANMs increased, they were unable to give

adequate time to the pregnant women and proper counseling,

restricting their services only for providing TT injections and IFA

tablets.

� Recently, a number of ANMs were appointed on contract but

salaries were not given making them frustrated and disinterested

in the work. The number of ANM supervisors was also found to be

inadequate.

� Many of the health care providers suggested that encouragement

to staff is important and regular training to upgrade skills are

required. It was observed that ANMs were not well trained in IUD

insertion and had no proper knowledge of the signs and

symptoms of RTI/STIs.

� Majority of the Medical Officer In-Charge (MOIC) opined that the

Government should provide training to the workers. It was felt

that the Chief Medical Officers (CMO) and Medical Officers (MOs)

should give time for training the workers and build their capacity.


Pradesh

Page 43

III. Physical Infrastructure (As per specifications)

� From the selected PHCs, all the 40 selected PHCs have their own

building, but three of them needed major repairs, and most of

them needed some repairs.

� Only three out of the PHC buildings were found to be in a good

condition. It was also found that staff quarters were available in

most of the PHCs, but doctors were not staying there.

� Water and sanitary facilities have great influence on health. It has

been observed that in most of the PHCs the sources of water

supply were either through hand pumps or tube wells.

� Water supply was reported to be adequate in most of the PHCs.

Water supply to the existing toilets was not connected through a

pipe. Because of this, although toilet facility was available in all

the PHCs, several of them were not cleaned every day.

� It was found that all PHCs have electricity connection, but the

supply of electricity was not regular. In most PHCs electricity

supply was between seven to eight hours every day.

� On the other hand, all PHCs have their own generator to restore

power.

� Also, it was found that the majority of the PHCs have telephone

facility.


Pradesh

Page 44

� Although vehicles were available in majority of the PHCs, it was

not in working condition. Similarly, it was also reported that

drivers were not available in majority of the PHCs.

� In most of the PHCs, labour room and operation theatre was

available, but exhaust fan was not fitted.

� All the PHCs had a separate dispensary room.

� The survey of infrastructure in the selected PHCs showed that

barring the regular supply of electricity, all other facilities were

more or less available, but the proper use and maintenance of the

existing facilities was not ensured.

� It was also observed that a large number of posts were lying

vacant both among the medical and para medical categories,

including that of Medical Officer and male MPHWs (Multi Purpose

Health Worker), which are key positions.

� Recently, temporary ANMs were appointed known as RCH-ANMs,

but their numbers were few in each district. There were also a

large number of posts found vacant belonging to other employee

category, such as drivers, peons, chaukidars,

� dais and sweepers. This has an impact on cleanliness and

maintenance infrastructure at the PHC level.

IV. Availability of Equipment and Drugs

� It was reported that the supply of drugs, vaccines, and

contraceptives were regular from district to the PHCs, but the


Pradesh

Page 45

supply of vaccines was not adequate and regular, particularly BCG

and measles.

� It is also noted that the records on the distribution of drugs,

vaccines and contraceptives were not properly maintained.

Usually, contraceptives, vaccines and drugs are equally

distributed among all the PHCs. There is a need to rationalize the

distribution of contraceptive vaccines and drugs to each PHC.

However, ANMs did not have delivery kits, stethoscope and BP

instruments.

V. Knowledge and views of beneficiaries

� Knowing the availability of facilities at the Primary Health Centres

is not adequate unless we also take into account the opinion of the

clients.

� Considering this, it was decided to conduct exit interviews of the

clients at the PHCs. There were 265 clients interviewed from 40

PHCs of Uttar Pradesh.

� The most frequently stated health problem for which the clients

sought treatment was for fever, cough and cold, diarrhea, etc.

� The purpose of visiting the PHC for family planning, ANC and

reproductive health was comparatively less. However, more

women came for family planning and child care than men, but

there was little difference in treatment seeking for reproductive

morbidities.


Pradesh

Page 46

� Treatment seeking behavior and utilization of services at PHCs

shows that family planning was not an important concern for

clients who visited the PHC for availing services.

� Also, reproductive health care seeking is almost negligible at the

PHC level. This shows that demand for family planning and

reproductive health services from the government sources is not

high.

c) Findings from Sub Centers

I. Governmental norms for Sub Centers for reference

� The Sub-Centre is the most peripheral and first contact point

between the primary health care system and the community.

� Each Sub-Centre is required to be manned by at least one

Auxiliary Nurse Midwife (ANM) / Female Health Worker and one

Male Health Worker.

� Under NRHM, there is a provision for one additional second ANM

on contract basis.

� One Lady Health Visitor (LHV) is entrusted with the task of

supervision of six Sub-centres.

� Sub-Centre are assigned tasks relating to interpersonal

communication in order to bring about behavioral change and

provide services in relation to maternal and child health, family


Page 47

welfare, nutrition, immunization, diarrhea control and control of

communicable diseases programs.

� The Sub-centers are provided with basic drugs for minor ailments

needed for taking care of essential health needs of men, women

and children.

� The Ministry of Health & Family Welfare is providing 100%

Central assistance to all the Sub-centers in the country since April

2002 in the form of salary of ANMs and LHVs, rent at the

rate of Rs. 3000/- per annum and contingency at the rate of Rs.

3200/- per annum, in addition to drugs and equipment kits.

� The salary of the Male Worker is borne by the State Governments.

� Each sub-Centre will have an Untied Fund for local action @ Rs.

10,000 per annum (as per NRHM 05-12).

� This Fund will be deposited in a joint Bank Account of the ANM &

Sarpanch and operated by the ANM, in consultation with the

Village Health Committee.

II. Section wise Survey Findings from Sub Centers


Services

Availability

72%

Non-

Availability

28%


Pag

Section 2- Manpower

Manpower

Availability

57% Non-

Availability 43%



Availability

84%

e 48

Non-


Availability


Drugs

Availability 95%

49

Non-

Availability

5%

Page


Equipment

Availability

95%

Non-

Availability

5%



Quality Control

Availability

90%

50

Non-

Availability

10%

Page

Section6- Furniture (As per standards)

Services

Availability

68%

Non-

Availability

32%



Page 51

Section 8 - Views of Beneficiaries about Sub Centers


Non-

Availability

56%

Availability

44%



District S1

Service

s

S2

Manpower

S3

Physical

Infrastruc

ture

S4

Equip

ment

S5

Drugs

S6

Furnitu

re

S7

Quality

Control

S8

Views of

Beneficia

ries

Allahabad 45 34 65 43 43 33 45 47

Aajamgarh 56 62 67 84 54 43 56 76

Ambedkar

Nagar 65 84 76 55 56 76 73 56

Badaun 63 89 76 65 43 65 45 45


Page 52

Baharaich 36 74 54 54 43 43 45 34

Chandauli 64 89 65 76 57 67 34 54

Faizabad 56 74 65 56 65 87 75 46

Kaushambi 45 65 43 43 74 56 56 65

Mahoba 58 67 84 54 44 46 37 43

Mirjapur 54 76 55 56 35 66 64 78

Sant

Ravidas

Nagar

87

65

65

67

54

46

53

43

Sonebhadra 44 76 23 47 87 87 61 36

Sultanpur 76 65 57 26 56 54 53 74

Varanasi 67 56 64 48 67 67 54 74


Page 53


I. Average area covered

� Survey data tells that a Sub-Centre covers an average of 5.8

thousand people.

II. General Findings

� When it comes to basic infrastructure facilities in the sub-centers,

it is encouraging that most of the sub-centers seem to have some

sort of basic physical structure present with 40 out of 112 sub-

centers having more than one room.

� However it is a matter of concern that nearly half the sub-centers

did not have electricity or sanitation, and 15 out of 112 sub

centers had buildings in poor dilapidated conditions.

� Water was available in 48 out of 112 of the sub centers but toilets

were not available in 33 out of 71 of the sub centers.


Page 54

� Sub Center should provide contraceptives like pills, condoms as

well as generic medicines for common ailments like fever. 46 out

of 112 sub-centers reported having contraceptive pills while 41

out of 112 sub-centers had condoms available.

� Medicine for fever was available in 37 out of 112 sub-centers.

� Ante-natal services for pregnant women are one of most

important service that village level sub centers should provide. It

is encouraging that iron-tablets that are meant to be regularly

provided to pregnant women were available in around 2/3 of the

sub centers.

� However only 27 out of 112 again sub-centers were reported

providing ante-natal check-ups.

� Basic instruments like weighing machine and blood pressure

measuring instruments are needed for pre-natal check-ups: more

than half sub-centers did not have weighing machines and 49 out

of 112 sub centers did not have instrument for measuring blood

pressure.

� Sub-centers should be able to handle normal deliveries at the local

level. However some of the basic requirements to handle a

delivery were missing. Nearly half the sub centers did not have a

bed and 72 out of 112 did not have curtains near the bed for

privacy.

� Other basic things like gloves were absent in half the sub-centers

as well as stove required for sterilizing was missing in 57 out of

112 villages.


Page 55

5. CONCLUSIONS

� Mostly clean, green and well maintained CHCs and committed

team;

� Very spacious CHC buildings;

� Lack electricity supply in most CHCs;

� PHCs and SCs need more maintenance;

� Power supply is erratic;

� Generators and inverters not available in most places;

� Bio Medical Waste management needs attention;


Page 56

� Mobile medical Units not operationalized;

� Transport constraints for field workers and patients;

� Shortage of Human resources at all levels;

� Those in position work hard to deliver health care;

� Acute shortage of MPW (M);

� Training process need fast tracking, multi skill training for

doctors, IMNCI, IDSP, SBA training, ASHA training;

� Limited promotional avenues for doctors and para medicals ;

� Post-delivery stay in the facilities is very short- need monitoring

system;

� Shortage of space leads to compromise with quality;

� Delivery load is more on few facilities;

� New Born care services need strengthening;

� Passive screening for communicable diseases needs to be

strengthened;

� Active screening for communicable diseases ( Malaria) needs

more attention;


Page 57

� Basic non communicable disease screening fixed day services

needed;

� Hospital level Diabetes , Hypertension clinic, cancer cervix

screening, RTI/STI clinics, Integrated counseling and Testing

Centres needed in all 24 x 7 facilities;

� Poor voluntary blood donation – insisting on relative donor;

� Institutional deliveries improved;

� Awareness on MCH services very high in the community;

� Adequate drug supply;

� Poor availability of MTP/ MVA services;

� centres needed for provision of tubectomy services;

� Convergence needs more attention;

� Lab services at peripheral centers poorly equipped – Lack of

reagents and

Consumables;

� ANMs and ASHAs are well accepted and respected in the

community;

� PRIs not uniformly involved for VHSC;

� VHSC recently instituted but not yet active;


Page 58

� Clear Guidelines for the use of funds needed;

� Timely payment to JSY beneficiaries needed;

� It is commonly known that women are often the last to access

health care in a poor family. Distance of the health-center and cost

of treatment may act as important factors that determine

women’s access to primary healthcare;

� Given the easy location of the sub centers, it has the potential to

increase access to primary healthcare for women;

� However as the data suggests, many sub-centers lack basic

facilities like water, electricity or toilets, which raise serious

questions about quality of care provided;

� UP being one of the worst states when it comes to maternal health

indicators, the importance of ante natal care is immense. Much of

the problems associated with maternal death can be averted if

there is early detection of anemia, low weight, blood pressure etc;

� However, as the data suggests, more than half the sub centers are

not providing antenatal check-ups, thereby increasing the load on

higher level of facilities. Sub- centers were found to be ill

equipped to handle normal deliveries, with nearly half the sub-

centers not even having beds. Easy availability of quality

contraceptives is integral for women to have control over

reproductive decision making and avoid unwanted pregnancies;

� Yet, not all sub-centres had even contraceptive facilities;


Page 59

6. Recommendations

1. General Recommendations

1. Manpower deficit should be addressed urgently. Mapping of

human resource and redistribution is required. More doctors,

staff nurse, Public Health Nurse, Pharmacists need to be recruited.

General duty medical officers with public health expertise and

management skills are to be posted at primary care facilities. For

this creation of a public health cadre is very justified. As the

clinicians and specialists currently posted at various facilities are

neither able to provide specialist services due to lack of facilities

not able to implement national health programs and provide

leadership to public health team due to lack of managerial skills.

2. The doctors posted at most of the facilities are either specialists

or MBBS with clinical orientation. They lack understanding of

public health perspectives and integrated approach to health care.


Page 60

ANMs recruited in 1980s are old now and not able to deliver with

efficiency of young women. A large number of them are going to

retire in next couple of years. It is the right time to tackle this

issue before a new human resource crisis emerges in this

segment. ANMs having become an experienced work force,

require to be promoted to supervisory levels and new young

ANMs need to be recruited in order to improve field work.

3. It is recommended that public health specialists and specialists

in community medicine/family medicine should be posted at the

primary health care facilities. They will be able to take care of

primary health care needs of the community, implement national

health programs and provide managerial/administrative

leadership to his team of primary health care. Creation of a

separate public health cadre will be able to fulfill this need of

public health managers at various levels of health care facility.

4. Training program for MPW(M) and diploma courses for nurses

in Maternal and New born care as well as career progression

scheme for them may improve their functioning.

5. The working conditions and incentives for working in rural

area should be so rewarding that it does not make the incumbent

feel disadvantaged compared to his/her counterpart working in

urban areas and private sector.

6. Provision of interest free loans for buying moped/two wheelers

or providing mopeds may improve out reach service delivery

component of primary health care.

7. Community participation and community ownership is grossly

lacking. People are not aware of their rights and responsibilities.

Sensitization and awareness generation among the people need to


Page 61

be improved, particularly in rural areas. The signage showing

citizens charters and informing people about salient features of

programs like Janani Suraksha Yojana should not be restricted to

health facilities. These need to be displayed in villages and

prominent market places as well.

8. Monitoring and supervision is another area that needs to be

improved. With aging and retirement of LHVs, supervision

process is diluted. Through promotion of ANMs and recruitment

of new LHVs, this can be taken care of.

9. Shortage of Male Multi Purpose Worker also need to be

addressed.

10. Political interference in manpower recruitment as well as in

day to governance is a great hindrance in smooth functioning of

health care system. Even the involvement of Panchayati Raj

Institutions has proved counterproductive in some areas,

particularly when it becomes a key determinant in recruitment

and transfer of workers, protection of erring workers. Mass media

campaigns should also be used to inform the community about

the facilities created under these new programs and their

benefits.

11. Safety and security of ANMs and other female workers is a

matter of concern in some areas. There are plenty of instances of

manhandling and molestation of single female workers in the field

area and the culprits getting away with.

12. Rationalization of services at different levels following IPH

standards is recommended.


Page 62

13. Neonatal referral units to be provided in all district hospitals

and basic new born care units in all CHCs and 24x7 facilities

should be made available.

16. Establish modern blood bank with blood component

separation units.

17. Rapid implementation of IDSP should be ensured.

18. Some of the facility buildings are located far from the villages,

in a remote isolated corner, thus making it less accessible and a

deterrent for ANM to stay there.

19. With the financial incentives being paid to the beneficiaries for

services availed, an opportunity presents itself: availability of

validated output indicators. A major deficiency of public sector

programming, namely availability of only process indicators, can

now be overcome. The ability to determine performance of

individual providers and centres can become a very useful

management tool for strengthening the programs in the time

ahead.

20. With JSY gaining rapid acceptance, the number of obstetric

emergencies being brought to the institutions will also go up. The

system needs to get itself ready for these cases at CHC and PHC

levels.

21. Non communicable diseases control program and vector

borne diseases control programs are not yet being implemented

at the peripheral level. This needs to be strengthened.

22. Nutrition supplementation, nutrition rehabilitation and

provision of food for mothers after delivery and after tubectomy


Page 63

operations should be made at all facilities where these services

are being provided.

24. Better monitoring and supportive supervision of all programs

should be ensured by monthly review by district magistrates, use

of structured inspection forms and follow up schedules.

25. Rapid grievance redress for staff and beneficiaries should be

ensured.

26. Community participation and social audit should be

encouraged.

Appendix -I

List of Surveyed Centers

CHCs:

Sl. No. District CHC

1

Allahabad

Saray Lili

Jasra

Shankergarh

Kaundhiara

2

Ambedkar Nagar Akbarpur

Tanda

3 Badaun Ujhani


Page 64

Kakrala

Dataganj

4 Baharaich Motipur

5

Chandauli Naugarh

Chakia

6 Faizabad Sohawal

7 Kaushambi Bara

8

Lucknow Chinhat

Bakshi Ka Talab

9 Mahoba Charkhari

10 Mirjapur Rajgarh

11 Sant Ravidas Nagar Suriyawn

12

Sonebhadra

Chopan

Myopur

Ghorawal

13 Sultanpur Akhand Nagar

14

Varanasi

Puarikala

Cholapur

Gangapur

PHCs:

Sl. No. District PHC

1

Allahabad Kotwa

Bara

Jaari

2

Ambedkar Nagar

Badagaon

Jamnipur

Bewana

Tarakhurd


Page 65

3 Azamgarh Badhalganj

4

Badaun

Jagat

Kadarchowk

Myoun

Usaihat

Uswan

5 Baharaich Sujauli

Amba

6

Chandauli

Shikarganj

Chakia

Amdaha

7

Faizabad Milkipur

Sohawal

8

Kaushambi Karari

Baishkhari

9 Lucknow Kathwara

10

Muradabad

Rustampur

Varni

Allipur

Narauli

Akrauli

11

Mirjapur Patehra Kala

Padri

12

Sant Ravidas Nagar Kasya

Mahjuda

13

Sonebhadra

Myopur

Salkhan

Parsona

14

Sultanpur Mudila

Rupaipur


Page 66

15

Varanasi

Harhua

Badagaon

Chiraigaon

Pindara

Sub Centers:

Sl. No. District Sub Center

1

Allahabad

Gara Katra

Biharia Jorhat

Baghla

Biharia

Kalyanpur

Gulalpur

Bara

Khanti

Jaari

Janwa

GaraaaKatra

2 Aajamgarh Bansgaon

Airakala


Page 67

Tisaura

3

Ambedkar Nagar

Ilfatganj

Banwa

Tajpur

Naipura

Naugawan

Asharfa Bad

Kataria

Silwan

Makdumpur

4

Badaun

Kathauna

Sanjarpur

Abdullaganj

Viola

Naushera

Sisora

Sathara

Bhundi

Gathauna

Kurau

Sarali

Bahu Nagla

Bhagautipur

Hazaratpur

Uharpur

Kishni

Gidhaul

Ikari

Jagat

Chilor

Monipatti Gautra


Page 68

Koda Jaikaran

Nagariya Chikan

Bilhari

Myaun Dehat

Harendi

Labhari

Gurgaon

JamalPur

Ranviganj

Varsua

Gathuna

5 Baharaich Girijapuri

6

Chandauli

Amdaha

Nevadganj

Shikarganj

Baliakala

7

Faizabad Shahganj

Raunai

8

Kaushambi

Para Hasanpur

Baiskati

Karari

Pawara

Mangura

Pindara

Gubara

Sirchanpur

Danpur

Saibasa

Chak Sayyadpur

Mawana Alam

Aadilpur


Page 69

Ranipur

9

Mahoba Gaurahi

Kharela

10

Mirjapur

Kanhaipur

Sarson

Golhanpur

Bachaura

Aitraila

Raikara

11

Sant Ravidas Nagar

Dashrath

Nevada

Kusuda

Chattar Shahpur

12

Sonebhadra

Persona

Bhawana

Kadia

Shivdwar

Salkhan

Pehadwa Markundi

Kirbil

Nipraj

Aarang Pani

Lilasi

13

Sultanpur

Loknathpur

Unurukha

Bahauddin

Mailkpur

Unrukha

Rupaipur

14

Varanasi Shivrampur

Velvariya


Page 70

Aanei

Aapar

Mangari

Machli gaon

Parmandapur

Belva

Saray Mohan

Nathaipur

Public Health Units Report

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