Evaluation of 24x7 PHCs in 7C Districts of North Karnataka 1 - - PowerPoint PPT Presentation

Evaluation of 24x7 PHCs in 7C Districts of North Karnataka

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Agenda

• Background of the study
• Findings

– Snapshot of performance – Snapshot of resources – Contextual factors – Aiding and Hindering factors

• Analysis
• Recommendations

Background

• Primary health centres upgraded to work 24x7
• Increased emphasis on maternal and child health
• Increased human resources: 3 staff nurses, 3 doctors
• Higher priorities for delivery and related services
• Process began in 2008.
• Higher priority to PHCs in North Karnataka

– Regional disparities, backwardness and distribution of PHCs are important parameters

Objectives and methodology

• Snapshot of functionality of 24X7 PHCs
• Aiding and hindering factors for performance
• Operational and policy level changes
• Use existing frameworks for analysis -

WHO's six blocks

• Understand the influence of contextual

factors

• Use a 'small n' framework

WHO's 6 Building Blocks

However, performance affected by systemic factors as well as contextual factors

Performance of 24x7 PHC

• Performance

– IMR, MMR – OPD – In Patients – Delivery – Emergencies – Other services – Fund disbursal

• Systemic factors

– Infrastructure – Medicine – HR – Funds

• Contextual factors

– Competence – Access and coverage – Stability of staff – Disease intensity – Social & demographic issues

'deliveries per thousand population per year' is the primary indicator to assess the performance of 24x7 PHCs

Methodology, field sites and tools

• Small n, and hence

associations rather than strict correlations

• Cross tabulation of

different explanatory variables with PHC levels

7C districts

• Bagalkot (5)
• Bijapur (6)
• Bidar (5)
• Gulbarga (6)
• Yadgir (5)
• Raichur (5)
• Koppal (5)

– Interviews with Doctors, Staff Nurses, Pregnant women and mothers – Group discussions

Tools

– PHC

• bservations

– Document

• bservations

3 categories of performance

– High level (15) – Low level (13) – Median level (9)

Findings – Snapshot of performance

District PHCs in HMIS (sample in brackets) Deliveries per thousand per year (based on HMIS data) Deliveries per thousand per year (sampled PHCs) Max Min Avg

• St. dev

H M L 1 2 3 4 5 6 7 8 9 Bagalkot 46 (5) 15.61 5.27 3.61 15.08 5.82 0.95 Bidar 48 (5) 18.01 5.11 4.38 18.26 5.82 3.77 Bijapur 64 (6) 19.82 6.54 5.53 19.93 4.69 1.28 Gulbarga 76 (6) 18.6 7.44 4.21 19.29 9.35 0.38 Koppal 42 (5) 29.38 3.13 8.32 5.13 21.57 7.16 3.45 Raichur 46 (5) 20.77 0.95 6.82 3.74 21.68 9.52 3.31 Yadgir 42 (5) 44.82 10.66 8.01 41.26 11.35 2.6 Total 364 (37) 44.82 7.1 5.3 22.27 7.53 2.32

• Deliveries observed in the chosen PHCs indeed reflect the respective

level of performance reported in each of the districts

• This indicator is also known as CBR.
• CBR in the region is between 19 – 22.
• About 1/3rd of the deliveries are covered by 24x7 PHCs

Population and distance of PHCs

• Population and distance to taluk HQnot

linked with performance

Population covered H M L Total 1 2 3 4 5 0-9999 1 1 10000-19999 4 1 2 7 20000-29999 4 5 4 13 30000-39999 4 2 2 8 40000-50000 2 1 2 5 >50000 3 3 Total 15 9 13 37

Distance to Taluk Hospital Number of PHCs in each level Total H M L 1 2 3 4 5 5-14 2 4 1 7 15-24 5 1 6 12 25-34 3 2 3 8 35-44 5 3 8 45-54 2 2 Total 15 9 13 37

Snapshot of PHC services

• OPD, In patient rates and
• ther services in general are

higher in H level PHCs. – Doesn't hold good uniformly

District H M L 1 2 3 4 Bagalkot 118.78 28.88 13.84 Bidar 48.27 8.06 34.54 Bijapur 23.13 29.74 21.54 Gulbarga 26.14 26.66 20.93 Koppal 43.58 80.41 54.80 Raichur 37.34 16.51 10.31 Y adgir 69.81 46.34 18.47 Total 50.48 32.56 25.18 District H M L 1 2 3 4 Bagalkot 17.67 18.00 63.33 Bidar 12.83 13.83 15.71 Bijapur 26.11 50.63 8.42 Gulbarga 82.88 19.50 32.33 Koppal 38.08 52.50 35.38 Raichur 139.13 56.67 37.75 Yadgir 123.08 42.92 19.42 Total 60.38 36.02 32.02 Services provided H M L 1 2 3 4 Emergency services (April+July) 11.93 9.22 7.46 Lab tests performed (Average) 687.90 619.61 465.31 Number of PHCs providing services (2013-14) Family planning camps 9 3 4 ENT Camps Eye camps 3 2 1 Provision of birth certificates 15 8 13 Death Certificates 3 1

Deliveries

• PHCs that facilitated higher

number of deliveries also tend to have higher number

• f night deliveries and

complicated deliveries.

• Uniformly applicable in all

districts

H (15) M (9) L (13) T

• tal (37)

5 10 15 20 25 30 35 40 45 50 48.5 18.22 6.38 26.34 22.03 7.11 2.15 11.42 4.67 1.78 0.46 2.49

Patterns in deliveries in 24x7 PHCs

Monthly deliveries Night deliveries Complicated deliveries

24x7 PHC Delivery category Monthly averages

District Average Monthly Deliveries H M L 1 2 3 4 Bagalkot 14.50 13.00 4.75 Bidar 35.00 14.50 8.25 Bijapur 50.50 10.75 2.50 Gulbarga 49.50 20.00 1.00 Koppal 40.25 6.50 5.50 Raichur 55.75 24.50 14.75 Yadgir 93.00 44.00 6.00 Total 48.50 18.22 6.38

Mortality

• Average infant deaths in the PHC areas in H level PHCs is

9, in M level PHCs it is 7.11 and in L level PHCs, it is 12.38

• 1 L level PHC reported that no infant deaths occurred in its

area.

• Majority of H level PHCs (57%) and M level PHCs (66%)

reported infant deaths in the range of 1- 10.

• About 46% of L level PHCs had infant deaths in the 11 – 30

range.

Deaths PHC Level Total deaths H M L Infants (PHC Area) 126 64 164 351 Mothers (PHC Area) 5 1 3 9

Provision of JSY and Madilu Kit

• Based on 5 random

samples in each PHC

• H level PHCs

provide more timely services than others.

• Roughly, 25% of

eligible JSY beneficiaries and 31% of Madilu kit beneficiaries yet to receive entitlements

PHC Level Timeliness in provision of JSY Total Given on time Delayed provision Not provided yet (Oct 2014) Not applicable 1 2 3 4 5 6 H 31 (41.33%) 29 (38.67%) 12 (16% ) 3 (4%) 75 M 8 (18.18%) 16 (36.36%) 20 (45.45%) 44 L 6 (9.52%) 44 ( 69.84%) 13 (20.64%) 63 Total 45 (24.72% ) 89 ( 48.90%) 45 (24.72%) 3 (1.65%) 182

PHC Level Timeliness in the provision of Madilu Kit Total Given on time Delayed provision Not provided yet (Oct 2014) Not applicable 1 2 3 4 6 7 H 37 (49.33% ) 18 ( 24%) 15 (20% ) 5 ( 6.67%) 75 M 14 (31.82%) 19 (43.18% ) 10 (22.73%) 1 (2.27% ) 44 L 7 (11.11% ) 16 (25.40%) 32 (50.79%) 8 (12.70% ) 63 Total 58 (31.87% ) 53 ( 29.12%) 57 (31.32% ) 14 (7.69% ) 182

Provision of resources

• Infrastructure and

medicine provision did not show significant differences

• Bidar in general lagged

behind other districts.

• Most PHCs had at least
• ne doctor
• Presence of lady doctors

was crucial

Doctors H M L Total 1 2 3 4 5 No doctor 2 2 1 3 7 7 17 2 9 2 4 15 3 3 3 Total PHCs 15 9 13 37 Presence of lady doctor Number of PHCs Total H M L 1 2 3 4 5 No 4 4 9 17 Yes 11 5 4 20 Total 15 9 13 37

No Yes T

• tal

2 4 6 8 10 12 14 16 8.03 14.95 11.68

Influence of lady doctors on deliveries in PHCs

Presence of lady doctor Avereage deliveries per thousand per year

Human Resources

• 25 out of 37 PHCs had 3 or more

staff nurses – 13 out of 15 H level had more than 3 staff nurses

• Other staff vacancies not directly

related to PHC performance

• ANM vacancy high

SN H M L Total 1 2 3 4 5 1 2 2 2 2 5 3 10 3 9 4 8 21 4 4 4 Total 15 9 13 37 District Vacant ANM positions No vacancies 1-2 3-4 1 2 3 4 Bagalkot 2 3 Bidar 2 2 1 Bijapur 2 2 2 Gulbarga 4 1 1 Koppal 2 3 Raichur 1 2 2 Y adgir 1 2 2 Total Result 14 15 8 Positions Number of PHCs having vacant positions H M L 1 2 3 4 Lab Technician 3 2 2 MHV(more than 2) 5 4 4 LHV 2 3 1 Pharmacist 1 2 3

Funds received

District Overall funds received (in categories) in 2013-14 No funds < 50000 50001-100000 100001-150000 > 150000 Total 1 2 3 4 5 6 7 Bagalkot 2 3 5 Bidar 5 5 Bijapur 1 1 1 3 6 Gulbarga 1 5 6 Koppal 5 5 Raichur 1 4 5 Yadgir 2 3 5 Total 1 1 5 7 23 37

• Funds received in 2 tranches: July and Nov-Dec
• Koppal PHCs didn't receive the full amount.
• Tangadagi in Muddebihal of Bijapur: No funds received
• 7 PHCs couldn't identify which funds have been received
• Funding patterns based on district

decisions rather than performance

• 2 PHCs from Sedam taluk of

Gulbarga; K R Palli and Yadaga received their final tranches of funds in February and March 2014.

• PHC staff doesn't relate fund

release and expenditures with PHC action plans

Contextual factors

H M L 2 4 6 8 10 12 14 7 2 2 14 8 10

Head-quarter stay of Doctors and Staff Nurses

Doctor Staff Nurse

PHC performance level Number of PHCs

H M L All PHCs 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 6 5 4 15 24 13 21 58 1 1

Deliveries conducted by PHC staff

ANM Staff Nurse Doctor

Observation issues H (15) M (9) L (12) Total 1 2 3 4 5 Weight and HB test 14 8 12 34 Blood pressure 15 8 12 35 Observation of fetal movement 12 5 7 24 Providing T.T injection 14 8 9 31 Identifying other complications and suggesting referrals 10 4 6 20 RH Typing 8 3 5 16 Checking for Veneral diseases (VDRL tests) 13 4 8 25 Linking to ICTC/PPTCT centre 9 4 9 22 Providing IFA tablets 14 6 11 31 Arranging for possible blood donor in cases necessary 1 2 3 Managing severe anemia (through injections or blood transfusion) whenever necessary 13 6 7 26

H M L 1 2 3 4 5 6 7 8 9 10 10 7 5 5 2 7

IFA tablets provided in first trimester

No Yes

PHC performance levels Number of instances

Training programme Number of PHCs with trained Staff nurses H M L Total 1 2 3 4 5 Integrated Skill Development Training 7 3 4 14 Immunization programme training 7 4 4 15 Safe Birth Attendance training 13 8 8 29 Infant Safety Training programme 10 5 10 25 Basic Emergency Obstetric Care (BEmOC) 4 1 5 Integrated Management of Neonatal and Childhood illness (IMNCI) 11 4 7 22

Job security was an important vexing issue in the minds of staff nurses

Social and demographic issues

• Addiction to alcohol and tobacco.
• Open defecation and unhealthy sanitation practices
• Preference for male child
• Child marriage (among SCs and STs) ,
• Extreme poverty and illiteracy
• Multiple pregnancy and child marriages
• Severe anemia among women
• Limited penetration of family planning
• Spread of Tuberculosis
• RMPs

District Respondents under different 'age at marriage' groups Total <13 13-17 18-22 23-27 1 2 3 4 5 6 Bagalkot 2 16 2 20 Bidar 6 14 20 Bijapur 1 7 15 23 Gulbarga 1 3 19 1 24 Koppal 1 19 20 Raichur 18 2 20 Yadgir 2 18 20 Total Result 2 21 119 5 147

District Number of families in different size categories 2-3 4-5 6-7 8-10 >10 Total 1 2 3 4 5 6 7 Bagalkot 3 6 3 2 6 20 Bidar 2 5 7 3 3 20 Bijapur 1 8 5 2 7 23 Gulbarga 1 7 5 11 24 Koppal 7 3 5 5 20 Raichur 5 2 4 8 1 20 Yadgir 1 9 2 3 5 20 Total 13 44 29 34 27 147

Family size and child marriage

• Substantial evidence of child marriage.
• 73 respondents stated age of marriage as exactly 18
• 42% of Hhs with family size larger than 7

Contextual factors

• Staff nurse duration of continuous service higher

in H level PHCs

• Locations where H Level PHCs were located had

higher proportion of private clinics (with doctors). RMPs were not reported

Distance to private clinic/hospitals Number of PHCs at each level Tota l H M L 1 2 3 4 5 0-5 12 8 4 24 5-10 2 1 3 6 10-15 2 2 25-30 1 3 4

Performance level of PHCs Average duration of continuous service Doctor Staff nurse 1 2 3 H (15) 3.73 7.40 M (9) 4.11 6.22 L (12) 5.33 6.08 Total (36) 4.36 6.67

Contextual factors: Health workers

• ANM vacancy equally high in all PHC levels
• ASHAs cover higher populations in L level PHCs

and handle more monthly cases. However, marginal financial gains lesser

District V acant ANM positions No vacancies 1-2 3-4 1 2 3 4 Bagalkot 2 3 Bidar 2 2 1 Bijapur 2 2 2 Gulbarga 4 1 1 Koppal 2 3 Raichur 1 2 2 Y adgir 1 2 2 Total Result 14 15 8

Parameters PHC Performance level Total H M L 1 2 3 4 5 Average duration of service 5.43 4.89 5.75 5.40 Population covered 1136.14 1138.11 1825.83 1373.11 Monthly cases handled 21.14 13.22 30.75 22.40 Monthly honorarium received 1642.86 1944.44 2016.67 1848.57

PHC utilization patterns

• Client satisfaction not
• exceptional. However,

better in H level PHCs.

• Doctors' perception of

PHC usage by different classes favorable for H level PHCs

Economic categories % of people accessing OPD services in the PHC % of people opting to deliveries in the PHC H M L Total H M L Total 1 2 3 4 5 6 7 8 9 Rich 34.73 28.89 31.92 32.32 46.87 38.89 25.92 37.57 Middle 70.00 60.00 61.92 64.73 75.67 63.33 52.92 64.68 Poor 91.00 87.78 86.15 88.51 92.00 86.11 80.77 86.62

H M L 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 25.00% 43.00% 31.00% 70.00% 57.00% 63.00% 5.00% 0.00% 4.00%

Satisfaction levels of PHC clients

Unsatisfactory Satisfactory Good

Aiding and hindering forces

Aiding Forces Hindering Forces Other factors 1 2 3 2 or more doctors serving in the PHC Social issues: preference for the male child, neglect of women's health, large family size, lack of safe sanitation, multiple pregnancy, substance abuse Population coverage of the PHCs Presence of lady doctor High prevalence of diseases like TB and Anemia Distance to taluk head-quarters, connectivity issues to PHCs Head quarters stay of doctor (and availability for night services) High prevalence of RMPs Infrastructure and medicine availability in the PHC Presence of 3 or more staff nurses W

• rk place issues like job security
• f staff nurses and AYUSH

doctors V acancy in positions other than Doctors and Staff Nurses Training and technical competence (with good understanding of issues to

• bserve during ANC, anticipating

complications) of staff nurses Cooperation and participation of communities in PHC activities Longer duration of service of nurses

Recommendations

• Staff nurses

– BemOC, IMNCI – Complication tracking mechs – Incentivizing deliveries – Phased regularization

• Medical officers

– Head quarters stay – Incentives for lady doctors – AYUSH doctors: regularization?

• 24x7 PHCs

– Deliveries as a major performance criterion – Special grants/upgradation of H level PHCs – 3 SN and 2 doctors (with HQ stay) – Stability in staff patterns – Enforcement of anti-quackery act – Social determinants of health as target indicators for BRGF/SAGY

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