Tamil Nadu Overview w Visit Profile Two Districts-Thiruppur & - - PowerPoint PPT Presentation

VI VI Common R Revie iew M Mis ission F Fin indin ings

Tamil Nadu

Overview w

Visit Profile

• Two Districts-Thiruppur & Cuddalore- GH-3, DH-2, CHC-4, PHC-

8, HSC-12, & 7 Villages.

• CRM team- 12 members from different organization, supported by

state and district officials. State Profile & Performance

• One of the best performing- already achieved the NRHM/RCH

goals.

• IMR-24 (SRS 2011); MMR-97 (SRS 2009); TFR-1.7 (DLHS-III).
• Service Delivery Indicators improved exponentially under NRHM.
• Institutional delivery- 245%;
• IPD services-205% during 2005-12 period;

Best Practices/ s/ I Innovations

• 1. Public Health Cadre.
• 2. Tamil Nadu Medical Service

Corporation (TNMSC) & TAMPCOL for AYUSH.

• 3. Maternal & Child Health Innovations-

i. Injectable Iron Sucrose , ii. Birth Companion Program , iii. Maternity Picnic and Bengal Ceremony , iv. Congenital Fetal Abnormality Detection, v. Non-Pnuematic Anti Shock Garment (NASG)

4. Well Functional & Co-located AYUSH services. 5. Mortuary Van Services. 6. State Health Data Resource Centre. 7. Involvement of District Collectors in NRHM through sensitization and performance rewards. 8. Program specific ASHAs to bridge specific gaps. 9. NCD Clinics.

• 10. Palliative Care treatment.
• 11. Community Monitoring.

Recommendation- Innovation Cell at State level to document

• utcomes of innovations.

Public H Heal alth I Infrastructure

OBSERVATIONS

• Over the years State strengthened primary care infrastructure. Most institutions

in govt. buildings. (75% of HSC in govt. buildings).

• Limited shortfall in primary care institutions (PHC+CHC+DH). 33% shortage
• f HSC as per population norm.
• Infrastructure development by PWD- Executive Engineer looking after 3-4
• districts. No involvement of Health Department in the whole process.
• New constructions done nearby to the existing structure without integration.

RECOMMENDATIONS

• Infrastructure development should integrated - good architecture design.
• Infrastructure development team should be formed at district level- comprises
• f district health officials, PWD engineers and architect, helping with design,

construction and supervision.

• State needs to assess utilization of residential accommodation by PHC/CHC

staff and ensure stay of staff nurse in the PHC premise if MO is staying

• utside.

Supportive Services

OBSERVATIONS

• Laboratory, radiography investigations, medicines and equipments, diet are

available free of cost. Citizen Charter, Signage system and bio-medical waste management available in all facilities.

• No OOP found for drug, diet, and other ancillary services except for the drop-back

for mothers.

• Quality Management Systems (ISO/NABH)- Quality of services provided by the

facilities has improved significantly. RECOMMENDATIONS

• Security needs to be strengthened, stay arrangements for ASHA and patient

relatives required.

• Injection rooms need separate beds and curtains for both male and female patients .
• Waste segregation at source needs to be strengthened . Deep burial for final

disposal of sharps.

• Ensure- Grievance redressal in all facilities & patient information kiosk at-

SDH/DH.

• Ensure- Common signage boards in all SDH/DH indicating services in each

building.

• Strengthen- Quality Assurance Cell at State level and Quality Assurance team at

District level for speedy implementation of quality management system.

Outreac ach & & P Pat atie ient T Tran ansport Se Servic ices

OBSERVATIONS

• Sub Centers -good infrastructure, no 2nd ANM. Deliveries reduced- 7.2% in 2005-

06 to 0.4% in 2011-12.

• MMU: Available in each block with dedicated staff. Visit schedule prepared &

followed.

• Emergency transport : Provisioned through EMRI. Wide range of emergencies

rescued most being accidental followed by obstetric. Inter-facility transfers is being provided and has a large share of obstetric emergencies. RECOMMENDATIONS

• Service delivery reduced from HSC; advisable to strengthen HSC to reduce
• vercrowding at the PHCs and to streamline referrals.
• Additional plans for service provision and screening of NCD can be tested at HSC.
• Strengthen IEC/BCC activities at HSC esp. Family Planning counseling.
• Ensure supply of family planning consumables & Pediatric IFA tab/syrup at the

HSC level. Hb estimation should be done from all HSCs.

• Improve the frequency, range and quality of services rendered by MMU’s to the

tribal areas and assess impact.

• IEC/BCC activities need to be done to improve utilization of EMRI services for
• bstetric and newborn rescue especially from rural and remote areas which is very

low currently ( 13%)

Hu Human an R Resources

OBSERVATIONS

• Good Progress noted.
• Two cadres: Public Health & Medical and Rural Services employed in public health system.
• Additional support- Psychiatrists, Dentists etc in districts.
• Vacant positions are still there in both directorates- Specialists (Obs, Paed, Anes) have higher
• vacancies. Others include- MPW (HIs), MCH Officer, MMU MOs, Sector Health Nurse &

Nursing Assistant,

• Adequate institutions for production of Human Resources for Doctors, Paramedical &

AYUSH Cadre.

• Arrangements made for rational deployment, retention & promotion and skill development for

Human Resources in the State. Residential facilities available for MOs but utilisation is low. RECOMMENDATIONS

• Delegate recruitment responsibility to recruit contractual MOs, specialist at the District level.
• Some of the training institutes should be strengthened for MPW training to ensure availability.
• Payment of Grade IV staff should be raised up to the daily wage norms.
• Limited promotions opportunities for the doctors and nurses in Directorate of Public Health &

Preventive Medicine; need to have more career progression opportunities for retention.

• More absorption and career progression opportunities for AYUSH contractual staff - Multi-

skilling.

RC RCH

OBSERVATIONS

• All PHCs - 24x7 services with new born corner, 3 Staff Nurses trained in SBA, F-IMNCI,

NSSK, IMEP. All PHC MO – trained in short term anaesthesia skills and EmOC..

• EmOC-42 L-II MCH Centers and 18 MCH hospitals, 29 well functional DH and 232 SDH.
• Blood Banks- SDH/DH. Blood Storage -few PHC, CHC (50.6%) ,SDH (16.4%), DH (6.9%).
• Abortion Services- Ist trimester – Few PHCs (5%), all CHCs, SDH, DH and MCH centres .

IInd trimester – all DH &MCH centers, half of the SDH and 20% of CHCs.

• 47 Sick newborn Care Units located at medical colleges, DH & large SDH.
• Adolescent Health Program - through 17 Medical colleges by establishing Teen Clinics.
• More focus towards sterilizations and spacing methods form a miniscule proportion of CPR.

RECOMMENDATIONS

• Ensure- Web listing of JSY beneficiaries & JSSK entitlements display in all facilities.
• Strengthen Drop-back and collect proper data for further improvement.
• Monitor- Injectable iron sucrose beneficiaries for outcomes and new born from SNCU for
• survivals. Sensitization of providers in appropriate use of non-pneumatic anti-shock

garment.

• Ensure- Safe abortion services through MVA at designated service delivery points.
• Adolescent health needs to be established in all districts at the CHC/SDH/DH level.
• Focus more on spacing methods and PPFP services need to be strengthened.
• Ensure display of uniform SOP’s related to RMNCH at various levels of facilities.

Dis Diseas ase C Control l

OBSERVATIONS

• JE & Dengue has emerged as a newer challenge.
• Limited involvement of PHC MOs in Disease control activities.
• Started program for non-communicable disease screening. Mass CA Cervix

detection & Breast Cancer Screening done in the last year. RECOMMENDATIONS

• Acceleration of anti malaria activities for- surveillance and management.
• Malaria Drugs & Mosquito nets should be available in facilities.
• Line list lymphoedema and hydrocele cases to help in morbidity management.
• Sentinel surveillance system for Dengue/Chikungunya and JE needs to be

established in endemic districts.

• Data should be used at all levels for program improvement.
• District and Block officers’ needs to be motivated to conduct local review

meetings more frequently.

• To improve TB case detection Factory Health Inspectors need to be involved

for referral of cases to the public health facilities.

• Intensive IEC efforts needs to done to educate community about the

availability of free TB treatment in the facilities.

Commun munit ity Process esses, es, S Social D Det eterminants & s & Gender er

OBSERVATIONS

• ASHA program not universal but to bridge specific gaps- Program specific ASHAs.
• ASHA training on module 6 and 7 and relevant for program specific training going
• n.
• ASHA support structure- one supervisor for 10 ASHAs per block is under

implementation.

• VHNSC- Main expenditure is done on public Health activity such as sanitation

drive, school health activities, ICDS activities, house hold survey etc.

• Good integration between various other departments observed.
• Modified School Health Program which focuses on prevention, early intervention

and strengthening the health status of the children. RECOMMENDATIONS

• Enhanced incentives to the ASHAs working in the tribal areas.
• Provision of uniform for identity and recognition in the community.
• Training and activities of program specific ASHAs needs to be monitored clearly to

document evidence of this innovative program.

• Ensure Form F is available and is filled after each USG and monitor for

compliance.

• Sensitize providers on gender issues and display VISHAKHA guidelines at all

facilities.

Progr

• gram Manage

geme ment

OBSERVATIONS

• A good integration of the NRHM with Directorate s noted.
• No separate staff recruited for State Program Management Unit and from the

regular service; program officers are managing the components of the NRHM.

• There is no provision of program management unit at district & block.
• Deputy Director Health Services acts as District Program Manager. There is

no provision of district accounts manager. Block Medical Officer acts as Block Program Manager and implements NRHM activities with the help of

• ther regular staff.
• Tamil Nadu has strong supportive supervision and monitoring system in place.

RECOMMENDATIONS

• One District Program manager to coordinate with different cadres.
• One Administrator trained in Hospital Administration at major hospitals.
• One Accountant and M&E officer at block level and one Data Entry Operator

at facility level.

• All administrative and managerial staff needs refresher training.

Knowl wledg edge M e Managem emen ent

OBSERVATIONS

• Skill based trainings- Medical College, DH & few SDH. Knowledge-based trainings –

6 regional training institutes & IPH Poonamallee.

• Rich history of ICT innovations in health care- currently 28 different information
• systems. Some of the local information systems are extension of the national

information systems with focus on local requirements i.e. PICKME & MCTS.

• State Health Data Resource Centre [SHDRC] to integrate most the data sources and

build a data ware house for data driven planning, monitoring and evaluation.

• There are multiple systems with multiple forms and lacking integrations with no

flexibility to the users for data entry, analysis and report generation. Very limited analysis functions are available in the software applications used. RECOMMENDATION

• SHDRC -it should be made clear that integration should be done through inter-
• perability of different system rather through manual integration of reports.
• Comprehensive capacity building & change management is required for improving

adoption of the existing systems.

• It is also recommended that each system needs to relook at its reporting system and

remove duplication and process errors through business process reengineering.

• It is also important that each facility should publish its annual/ monthly performance in

the facility premise for transparency and accountability.

• Refresher training for older nurses and ANMs can be taken up by the State.
• Evaluation studies to be undertaken to know the gaps in training and its effectiveness.

Financial Manage geme ment

OBSERVATIONS

• E-Transfer of funds was being taken up to Block level.
• SHS had regularized the placing of Statutory Audit Reports in the GB meeting.
• Staff has developed positive attitude to improve the Financial Management.
• The Positions of the District Accounts Managers is vacant in 30 Districts.
• Frequent diversion of funds from one pool to another at State Health Society

level.

• Decrease in Financial Absorption capacity under the two major pools (RCH

and MFP) in respect of last year.

• AMG funds have been given to Non functional HSCs.

RECOMMENDATIONS:

• The position of District Accounts Manager needs to be filled up.
• Create to position of Block Accountants with defined action plan to fill up the

positions.

• Payment to JSY beneficiaries on camp basis.
• Defined Action plan to improve the Fund Absorption capacities.
• Improve community participation in RKS/PWS meetings.
• Improve Internal Audit Mechanism.
• Avoid diversion of funds.

Thank You