National Rural Health Mission Andhra Pradesh 3 rd Common Review Mission

1. National Rural Health MissionAndhra Pradesh3rd Common Review Mission 4th-10 November 2009

2. Team members • Dr Himanshu Bhushan, MoHFW • Dr Rajasekhar.V, NHSRC, New Delhi • Dr Arun Agarwal, PGI, Chandigarh • Dr Rajiv Tandon, USAID • Dr K.S. Jacob, MSG, NHRM

3. Districts visited • Visakhapatnam • Vizianagaram The CRM team expresses profound thanks to the state and district officials for their courtesy and support

4. Commitment is at the Highest level

5. De-Briefing Meeting with Hon’ble CM

6. Facilities visited- Visakhapatnam • DMHO office • District Hospital: Anakapalle • Area hospital: Narasipatinam • CHC: Aganampudi, Aruku valley • 24x7 PHC: Anandapuram, Revidi, Kasimkota, Ananthagiri • PHC: Lambasingi, Pendurthi, • Sub-centres: Rajapakala, Rampuram • AWC: Srirampuram, Jogampatti • Village: Pedabarada, • 104 service delivery site: • 108 site: Anandapuram • Nutrition project site: Jogampatti

7. Facilities visited- Vizianagaram • DMHO office • District Hospital: Vizianagaram • MCH hospital: Ghosha hospital (APVVP) • CHC: Bogapuram (APVVP), S.Kota • 24x7 PHC: Kotavalasa, L.Kota, P.M.Palam • PHC: Kotam, • Sub-centres: Thatipudi, Bodhavaram • AWC: Rangapuram, Bodhapuram • VHSC: Rangapuram

8. Positive findings • Good coordination between district admin and DMHO • Appreciable inter sectoral coordination between DHMO, DRDA, IMA, NGOs and ICDS at district level • Citizen’s charters displayed at considerable number of facilities • Good and clean infrastructure including toilets up to PHC Level was seen even in tribal and remote areas. • Essential drugs available at all facilities. • 104 giving good out-reach services • SERP/IKP Project doing income generating activities and nutritional supplementation through village level organizations

9. Positive findings • Well Managed HIV and RNTCP programs • Well established Eye care surveillance and good quality Dental Care services available at designated facilities. • Adequate supply and re-impregnation of bed nets in Malaria endemic districts along-with RDK. • Bio medical waste management is outsourced from CHC and above and fairly doing well

10. Positive findings • Considerable increase in institutional deliveries • JSY beneficiaries getting payment thru cheque at most of the facilities • Target for Family Planning being achieved, on the spot financial re-imbursement being done. • Vaccines available at all levels and alternate delivery of cold chain is functional. • Sub-center ANMs regularly making list of beneficiaries to be vaccinated during immunization session. • AYUSH doctors are providing good services at PHC and CHC. All required medicines are available. • Compulsory induction training of 2-4 weeks for all medical officers joining government service

11. Positive findings • DPMU and district health officials functioning as a team • RKS/HDS,VHSC constituted, operational and good utilization of funds. • Untied funds being utilized at all facilities. • Regular online transfer of fund up to PHC. • Expenditure being reported on Tally Software. • Auditors appointed for concurrent audit. • Good training and orientation of ASHAs.

12. Observations • Mis-Match between location of facilities and required services at some places • Lack of coordination between APVVP and DHS on Facility up-gradation and required services • Mis-Match between placing and requirement of specialists, equipments etc at some places. • Most Operation Theatres and Labor Rooms equipped but neo-natal care equipment inadequate.

13. Observations • No District Specific Action Plans for operationalizing FRUs and PHCs with timeline • Important skill based trainings such as LSAS, EmOC, SBA, IMNCI, NSSK etc either not launched or very slow progress. • Inadequate monitoring of program implementation by the district program officers • Inadequate funds/vehicle/POL for monitoring visits at block level

14. Observations • Generators, POL and Cold Chain Maintenance variable. • Malaria workers not being utilized for all vector borne diseases. • Disease surveillance and reporting at CHC and above is weak • Diagnosis of Smear negative cases have declining trend compared to smear positive cases • District Internal evaluation report on RNTCP was not shared with the team for triangulation • Late detection of new leprosy cases • Biomedical waste management at PHC level is weak

15. Observations • Comprehensive VHND services lacking. • Most of 2nd ANMs are deputed to 104 fixed day health services (mobile) affecting routine sub-center function . • Nutritional Supplementation through SERP/IKP Project is too complex and involves lot of HR compared to no. of villages and beneficiaries covered. • VHSC Grants are not distributed uniformly and being divided as per the population of village. • No uniform record and ledger maintenance for financial transactions below district level. • Capping of ASHA incentives.

16. Recommendations Organizational Structure and Cadre Management : • Different division of health such as Directorate of health services, APVVP, DME, CFW needs unification and better coordination. • Effective and rational policies for career progression at all levels like GDMOs, specialists, nursing, and other cadre • All district and state program officers including DPMU and SPMU to be trained and involved in program and finance management including disease control programs • Public health specialists and PDC trained persons to be utilized in program implementation and supervision • Merging of vertical program societies with state and district health societies

17. Recommendations Human resources and Infrastructure: • Rational deployment of specialist staff • Filling up of vacant posts at all levels particularly Malaria RNTCP, RCH etc • Specific plans for tribal and remote areas for improved service delivery • Classify the facilities under difficult ,most difficult and inaccessible areas and Incentivize accordingly. • Implementation of Standard Financial Guidelines for maintenance of ledgers and records below district level. • Retraining for use of equipment and new diagnostic and treatment procedures • AMC should be the part of Equipment maintenance for all critical services like MH, CH, immunization etc. Including Generators and Cold chain equipment . • Cross sharing of work of laboratory technicians recruited from different programs

18. Recommendations RCH program: • District nodal officer for MCH services be designated • District specific action plans for operationalising FRUs and PHCs with time line • Facilities with adequate case load be identified and strengthened • Special thrust needed on placing the protocols of maternal and new-born care in labour room. • Urgent dissemination and orientation on protocols of maternal, new-born and child services needs to be undertaken for medical officer and other service providers. • All skilled based trainings to be implemented and scaled-up • Tracking of missed out and left out cases for ANC and immunization be ensured • ASHA incentive should not be capped

19. Recommendations Disease Control Programs: • RNTCP working well but need strengthening at some places • Malaria workers should be used for all vector borne diseases • NLEP needs focus in places where rise in diagnosis of deformity cases found • Reorientation of health care providers and community screening for leprosy • Strengthening of disease surveillance mechanism above PHC levels • Eye care facilities at CHCs need better focus. • Using HIV/STI Counselors for other conditions especially nutrition.

20. Recommendations Trainings: • In-service training, particularly skill based training like LSAS, EMOC, SBA, IMNCI, NSSK needs immediate implementation with quality protocols • SIHFW, DTO, professional bodies to be involved in ensuring training quality • All district hospitals be designated and strengthened for conducting training

21. Recommendations Out-Reach Services : • Immunization Day, VHND, weekly Out-Reach sessions, 104 and other out-reach activities needs further rationalization and duplication should be avoided. • Sub-Center activities by ANMs must be ensured. • Comprehensive VHNDs be organized and monitored.

22. Recommendations Nutrition: • SERP Project is a very elaborate and good activity for social and financial upliftment but nutritional activities need appropriately evaluated for sustainability, costing and needs synchronization with ICDS and needs review before scaling-up.

23. Recommendations Monitoring: • State and district level quality assurance committees to be constituted and made functional. • Regional directorate to be strengthened with adequate staff for effective supervision and monitoring. • PHC/CHC medical officers District program officers including DPMs and SPMs should monitor programs implementation with defined checklists. • Adequate funds/vehicles/POLs to be ensured for monitoring visits.

24. Community Monitoring • Transparency in public health through social audit • like citizen’s charter • Display of JSY beneficiaries list

25. THANK YOU