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Performance Review

of

Primary Health Center,Sille, East Siang District,

Arunachal Pradesh

Co-managed by

Future Generations Arunachal,Arunachal Pradesh

&

Department of Health & Family Welfare,Government of Arunachal Pradesh

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Contents

1 Introduction 1

2 Background 3

3 Performance Review

a. Curative Services 6

i. Outpatient Attendance

ii. Inpatient Services

b. Maternal & Child Health 8

i. Antenatal Care

ii. Childhood Immunization

iii. Family Planning

c. Laboratory Services 12

d. Ambulance & Referral Services 14

e. Outreach Activities 14

i. Immunization Camps

ii. School Health Programs

iii. Malaria Control Programs

f. Data Management 18

g. Community Mobilization 18

h. Infrastructure Strengthening 19

i. Human Resources Management 21

j. Community Training Center 21

k. Project Management & Monitoring 22

4 Conclusion 24

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Introduction

The National Rural Health Mission (NRHM), launched in 2005 to provide accessible,

affordable and reliable healthcare to the rural population, envisaged convergence of

various existing standalone health programmes, decentralization of the planning

process with special emphasis on bottom-up approach in decision making and

creating better linkages and cooperation among various social sector departments. It

also provided much-needed flexibility to the state governments to introduce context-

specific innovations to improve health service delivery systems.

The Government of Arunachal Pradesh introduced the concept of Public-Private

Partnership (PPP) in which one of the Primary Health Center (PHC) in each of the 16

districts is being co-managed with selected non-governmental organizations (NGOs).

Along with three other NGOs, Future Generations Arunachal (FGA) is also

participating in the PPP project and managing the PHC at Sille in East Siang district

since January 2006.

FGA was registered with the Government of Arunachal Pradesh as a society in 1997

and has since been working for sustainable and equitable development in the state. It

uses a process of community change called SEED-SCALE which works on the

foundation of four principles:

Building from success (rather than on problems); Evidence-based decisions (rather than based on opinion); Three-way partnerships (among bottom-up, top-down and an outside-in

partners);

Behavior change (rather than infrastructure or other more tangible outcomes)as the outcome of development.

Using this principle, FGA has been working on fields ranging from health, livelihood,

conservation and local governance with the communities to meet its objectives.

Volunteer village women have been trained on basic health care and development,

who now work as Village Welfare Workers (VWWs). They, in turn, have formed

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Womens Groups. In addition, men have formed themselves into Farmers Clubs and

young people into Youth Groups. These groups lead the communities in taking

actions based on local needs.

The management of the PHC at Sille was started building on the success of FGAs

community works in the area, especially on basic home-based health care with the

VWWs. The main thrust, in consonance with the organizations working principle has

been mobilizing the communities to participate in the health care activities and

demonstration of the health facility as a capacity building institution.

Since 2006, lots of improvements in the availability of health service facilities are

seen in the Sille area. Health indicators have dramatically improved. Pregnant

women attending antenatal clinics have increased. Number of institutional

deliveries is one of the highest in the district next only to General Hospital in

Pasighat. Childhood immunization is excellent. There has been no death due to

malaria in the last three years a significant fact as malaria was the number one

killer in the area in the past. The Rogi Kalyan Samiti (RKS) is actively

participating in the day-to-day management of the center. There is increasing

feeling of ownership by the community members as is evident from their

voluntary contributions to the center and periodic review meetings with them.

This brief report reviews the performance of the PHC, Sille in meeting the

requirements of the government as stated in the Memorandum of Understanding

(MoU) and meeting the organizational objectives of FGA.

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Background

Sille is a small village in East Siang district (Fig. 1) , 20 km from Pasighat, the

district headquarters. The PHC at Sille is one of the oldest health facility in the

district and caters to 6 major villages Sille, Oyan, Mangnang, Baro-Mile, Sika-

Bamin and Sika-Tode. There is also a high concentration of population in newer

settlements like the Sille Bazar, Oyan Charali, Donyi-Polo Tea Estate and

Jampani. In addition, agricultural workers attached to each of the main villages

and a big floating population, mainly of roadside workers, constitute significant

population using the services of the PHC.

Figure 1. Location of Sille

The inhabitants belong to the Adi and Mishing communities. In addition, there

are non-tribal populations in newer settlements as businessmen, agricultural

workers and laborers. Most of the local population are engaged in agricultural

works.

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The next level of health care facility the Community Health Center at Ruksin is

14 kilometers whereas the General Hospital at Pasighat is 25 kilometers. Two

Sub-centers at Mangnang and Sika-Tode are attached to the PHC. The

population in the main villages and their distance from the PHC is shown in the

following table (Table. 1). It needs to be pointed out that the floating population,

that of agricultural workers and non-tribal populations are not included here.

Table 1 Population and Distance of Catchment Villages

Prior to the year 2006, the PHC was providing skeletal curative services. There

was neither laboratory services nor immunization services. The center was not

equipped to conduct deliveries. There was inadequate skilled manpower though

Grade IV staff exceeded the need. The communities looked on with passive

helplessness.

When FGA took over the responsibility of managing the PHC on January 4,

2006, the community members were mobilized to lend helping hands to rebuild

the center. With active cooperation of the circle administration, the villagers

volunteered their time and resources to give the building a new look, creating a

conducive atmosphere for the newly recruited staff to start working. A new order

Sl No Village Population Distance from

PHC

Sille 1939 1 km

Oyan 3158 3 km

Mangnang 573 12 km

Baro-Mile 316 8 km

DPTE 692 6 km

Sika-Bamin 960 7 km

Sika-Tode 775 8 km

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of health care service was thus initiated in the area. The staff started working to

turn the PHC into a model health care center in the state.

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Performance Review

Curative Services

In spite of FGAs established approach in facilitating preventive and promotive

health, curative service has remained the main thrust in the PHC, Sille. This

comprises of outpatient services, inpatient services and dressing rooms with

facilities for minor surgery. The most important change, however, has been the

way the patients are treated, starting from greeting them to sending them off.

Outpatient Attendance

A sudden increase in the outdoor attendance is seen in 2006. A total of 13,023

new patients were registered during the year (Fig. 2). Prior to January 2006, the

average attendance has been around 18001. The number of patients attending the

OPD has started decreasing thereafter, apparently due to decrease in morbidity in

the area. Decrease in morbidity was because of active outreach programs andcapacity building measures, which will be discussed subsequently.

1 OPD register of August-December, 2005.

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Figure 2 OPD attendance

Inpatient Services

No patient was admitted to the indoor wards in 2006. Such admissions were

started during 2007 with 82 patients in the year. It increased to high of 385

patients in 2009, but has started decreasing again, with 287 patients in 2010. Till

May 2011, 190 patients were treated as indoor patients in the PHC (Fig. 3).

Figure 3 Indoor patient admission

_________________________________________

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At present, the PHC provides inpatient care with 10 beds 5 for male and 5 for

female patients.

Figure 4 Indoor Ward

Mother & Child Health

Antenatal care

As there was no provision for antenatal care prior to 2006, it took more time to pick

up. Only 26 pregnant women were registered in 2006. It increased to 194 the next

year and peaked at 269 in 2008 (Fig. 5). There has been decrease in the registration in

the following two years. This could be due to more eligible couples adopting family

planning methods in the area.

Figure 5 Antenatal registration & registration during 1st trimester

The number of pregnant women registered during the first trimester, however, has

been steadily increasing. While only 7.7% of the pregnant women who attended

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ANC registered themselves in the first semester in 2006, it has increased to 68.3% in

2009 and to 85.1% in 2011 (Fig. 6). There has, therefore, been increase in awareness

about the need for proper anti-natal care among the women.

Figure 6 Antenatal registration during 1st trimester

The number of pregnant women receiving first dose of tetanus toxoid (TT1)

corresponds with that of antenatal clinic registration. It started with only 24 in 2006

and peaked at 208 in 2008 (Fig. 7). With the decrease in antenatal clinic attendance,

there has been a decrease in pregnant women receiving TT1 as well.

Figure 7 TT1 &IFA for 100 days

The same trend can be seen as far as institutional deliveries is concerned. Only 17

babies were delivered in the PHC in 2006. It increased to 91 babies in 2008 and

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decreased again with corresponding decrease in ANC attendance (Fig.8).

Figure 8 Institutional Deliveries

The percentage of pregnant women attending ANC and opting for institutional

deliveries is steadily increasing over the years (Fig.9). The overall rate of institutional

delivery for the PHC catchment area is calculated to be 33.7 % (232 out of 958). It is

marginally better than 31% institutional delivery rate for Arunachal Pradesh but much

better than 19% for women in rural areas in india2.

2 NFHS-3.

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Figure 9 Institutional Delivery Percentage

Incidentally, the first baby born in the PHC after

FGA took over the management from the district

authority was on January 26, 2006 when the

renovation works were still going on (Fig. 10).

Prior to this, deliveries were not conducted in the

center.

Child

Immunization

The number of children immunized with BCG, DPT, OPV and measles has seen an

increased trend from 2006 to 2008. Since then, the number has been more or less

constant (Fig. 11). Maintaining a constant trend in spite of decreasing numbers of

deliveries indicate increasing proportions of the babies getting immunized against

Figure 10 First Baby delivered in PHC in 2006

_______________________________________

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vaccine-preventable diseases. It is, however, difficult to confirm this as the number of

infants during each month of the periods is not available.

Figure 11 Childhood Immunization

Family planningFamily planningFamily planningFamily planning

As has been mentioned above, the decreasing number of antenatal

attendance and institutional deliveries since 2008 points to more

eligible couples using family planning methods. This has been seen to

be true. Intrauterine device (IUD) was inserted only on 4 new women in

2006. It increased to 25 new women in 2009. However, use of oral pills

and condoms has been increasing (Fig. 12). During 2011, 8 emergency

contraception pills were distributed when it was made available.

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Figure 12 Use of Family Planning Methods

Laboratory servicesLaboratory servicesLaboratory servicesLaboratory services

The laboratory in the PHC is equipped with calorimeter, refrigerator

and centrifuge apart from other required equipments. The following

services are provided in the laboratory:

Routine blood examination Slide test RMT for Malarial

Parasite

Urine - routine examination Stool - ME & RE Sputum for AFB Blood grouping/Rh typing Blood sugar Figure 13 Laboratory

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VDRL Widal test Blood urea

Blood creatinine Liver Function Test

The increasing number of tests for hemoglobin over the years (Fig. 14) is

indicative of increasing utilization of the laboratory.

Figure 14 Tests for Hemoglobin

A decreasing trend in the number of tests for malaria parasite is

observed. Starting with 4417 tests in 2006, it increased to 5742 in 2008

and again decreased to 2117 in 2010 (Fig. 15). This is due to decreasing

case burden of malaria as will be discussed later.

Figure 15 Tests for Malarial Parasite

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Ambulance & Referral ServicesAmbulance & Referral ServicesAmbulance & Referral ServicesAmbulance & Referral Services

As the old jeep ambulance handed over by the district medical authority

broke down too often, FGA procured a Tata Sumo ambulance for use in

the PHC during 2007. Since then, it has been used to fetch patients from

the villages to the PHC and take referred patients from the PHC to the

Community Health Center at Ruksin or to the General Hospital in Pasighat.

The ASHAs have been involved in requisition process from the patients in

the villages.

Outreach activitiesOutreach activitiesOutreach activitiesOutreach activities

FGA had started its health and empowerment works in Sille area in 1997.

The approach was to train selected village women on basic home-based

health care and development, who then became the Village Welfare

Workers (VWWs) and organized the villagers to take actions to improve

their lives. With the launching of NRHM, these VWWs have appropriately

been selected to work as Accredited Social Health Activists (ASHAs) and

have continuing to be the key persons to help carry out all the outreach

activities by the PHC.

Immunization CampsImmunization CampsImmunization CampsImmunization Camps

The PHC organizes immunization camps every Saturday in

one of

the

villages

by turn,

so that

each

village gets coverage

once a month. General

health awareness

Figure 16 Immunization Camp

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campaigns are part of such camps.

School Health ProgramSchool Health ProgramSchool Health ProgramSchool Health Program

School health programs are being carried out regularly since July 2007.

The government schools in the catchment areas have allotted one period

per week for health education which are taken by either a doctor or a

nurse. In addition, occasional health education sessions are arranged in

the Vivekananda Kendriya Vidyalaya, Oyan. Regular general health

check-ups are carried out in all the schools.

Figure 17 School Health Education program

Malaria control programs

Since malaria has been major health menace in the area, a pilot project to contain the

disease was started in Mangnang village in 2008. The villagers were given

chemoprophylaxis during summer months, starting in the month of April till

September. Though malarial cases could not be controlled that year, no death was

reported. Since then, such chemoprophylaxis has been extended to other villages as

well. As a result, there has been constant decrease in the suspected cases as indicated

by decreasing numbers of tests for malarial parasite (Fig. 15).

In absolute numbers, positive cases of both PV and PF have decreased over the years

(Fig. 18)

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Figure 18 Malaria positive cases

The percentage of both PV and PF positivity also have decreased after initial increase

in 2007. However, the trend in 2011 indicate an increase in the positivity percentage

(Fig. 19). Initial increase was due to more cases being tested for malarial parasite.

The increase in 2011, on examination of the register, has been found to be due to

more positive cases among the agricultural workers and patients from the

neighboring villages like Rani which are not officially covered by PHC, Sille. These

areas have not been paid adequate attention as far as awareness activities were

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concerned. A proper slide survey is being carried out in the agricultural fields and a

strategy to contain the disease among the agricultural laborers are being worked out

at present.

Figure 19 Percentage of positivity for malarial parasites

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Data Management

On the premise that decisions have to be made based on evidence, data management

system in the PHC has been strengthened. A population register for each of the

villages and major settlements are maintained in the PHC. The register lists each

individual, dedicating a full for each household, which are numbered for easy

identification.

Based on the population register, one file for each household has been opened with a

sheet for each individual member in the file. These registers are linked to the OPD

registration system and the sheets in the files are used to note medical records by the

Medical Officers. Thus, a robust medical records system has been developed.

Community Mobilization

The programs of FGA since 1997 in Sille area has been to mobilize the communities

to take locally relevant actions to improve their lives. The management of PHC in

2006 started with this practice

when the villagers as well

government employees from

the surrounding areas

gathered in large numbers to

voluntarily participate in the

renovation and cleaning

activities of the PHC. People

volunteered with their time

and in-kind donations. The same has been the case in the renovation of the Sub-

center in Mangnang.

Figure 20 Volunteers constructing fencing

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One of the first major steps was to ensure 24-hours water supply by installing water

tank and connecting it with the main supply tank. Later, tiles were fitted in the labor

room and laboratory. A generator house and a garage for the ambulances were

constructed. Adequate spaces in the patients waiting areas were created, with a

complaint box. Boards were fitted to display health education materials, relevant

data and other services information.

Sub-centers:

Along with the PHC, two Sub-centers Mangnang and Sika-Tode, were handed

over to FGA for management. While there was no infrastructure at all at Sika-Tode,

the building at Mangnang was in a dilapidated condition. It was renovated with

active participation by the community members and made functional in January

2006 itself. It is manned by an ANM and a Health Assistant and has been providingbasic curative as well as preventive services. The services at Sika-Tode has been

started in 2009 after renovation of an abandoned building belonging to the

agriculture department.

Human Resources Management

Figure 23 PHC building under renovation

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The PHC, Sille has been constantly manned by adequate staff as recommended by

the government from the beginning of the project, despite major challenges in

retaining skilled manpower. There has been rapid turn-over of staff, mostly ANMs.

In a span of a little more than five years, 4 doctors have left the center after being

absorbed by the government.

The first batch of staff were

given extensive induction

training and subsequent new

recruits too are provided with

periodic orientations. The

doctors and nurses have been

sent to the Comprehensive

Rural Health Project (CRHP),

Jamkhed in Maharashtra for

training and to the SEARCH,

Gadchiroli for exposure visits so

that they are aware of the social determinants of health and the needs to address

them in addition to clinical care in a PHC setting.

The Medical Officers and the nurses also participate in all the trainings organized by

the Department of Health and Welfare from time to time.

Community Training Center

The feasibility and need to use the health care facilities as community training

centers on health and hygiene is being demonstrated in the PHC, Sille. Starting from

May 2007, three women are being trained to become Village Welfare Workers

(VWWs) every month. These women come from other parts of the state like

Sangram and Palin in Kurung Kumey district, Bameng and Poube in East Kameng

Figure 24 Orientation Training for PHC staff

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and Ziro in Lower Subansiri district in addition to those from the villages of East

Siang district.

Starting in May 2008,

another program to

train one woman from

each household in the

PHC catchment area

on basic health care

and hygiene, called

Mothers Training, has

been started. Every fortnight, new batches of six women from six villages attend the

PHC everyday to learn from the medical staff there. This program has contributed

immensely in reducing the burden of patients as most minor ailments are being taken

care of by these trained women at home.

Project Management & Monitoring

The project is managed by the Executive Director assisted by a Project Coordinator

based in FGAs branch office at Oyan. The day-to-day affairs of the center are

managed by the Medical Officer Incharge (MO i/c) as per the decisions made by the

Rogi Kalyan Samiti. An elaborate system to ensure accountability in managing the

various resources of the center has been put in place. Materials are procured as per

the indent placed by the MO i/c based on the stock position of various items. A copy

of the mandatory periodic reports to the governments are also sent to the Executive

Director, which are used to monitor the performance of the staff.

A system for community monitoring also has been put in place. Half-yearly review

meetings are held with the representatives of the villagers the Panchayat leaders,

Gaon Buras and other village elders in the areas.

Figure 25 VWW training

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Conclusion

The Government of Arunachal Pradesh introduced the concept of Public-Private

Partnership (PPP) in order to improve the rural health service delivery in the state.

One Primary Health Center (PHC) in each of the sixteen districts is being co-

managed with selected non-governmental organizations (NGOs). Future

Generations Arunachal (FGA), a society registered with the Government of

Arunachal Pradesh and working for a sustainable and equitable development of the

state since 1997, is participating in the project and managing the PHC at Sille in East

Siang district since January 2006.

In consonance with FGAs approach to health care one of capacity building rather

than mere service delivery has been the guiding principle in managing the PHC.

The communities are being actively involved in decision making and management of

the center. The center is also being used as training of village women on basic home-

based health care.

Curative services facilities in the PHC has been improved manifold. As a result, a

steady increase in patient attendance in the outpatient department was observed till

2008 and has started decreasing thereafter reflecting decreased patient load. This was

due to extensive outreach and capacity building activities resulting in decreased

morbidity and care of minor ailments at home itself by trained women. Inpatient

services, started in 2007 also peaked during 2009 and has started decreasing

thereafter.

Since there was no antenatal service prior to 2006, it started picking up slowly with

only 26 registrations during the year. Registration rapidly increased to 269 in 2008

and started decreasing again. This decrease also is explained by concomitant family

planning services more eligible couple accepting some form of contraception.

However, the proportion of pregnant women getting themselves registered in the first

trimester is increasing. This indicates increased awareness among them about the

needs for antenatal care.

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The number of institutional deliveries in the PHC, Sille has been among the highest

in the district. Such deliveries increased till 2008 and a marginal drop is observed

after that. This drop corresponds to decreased antenatal registration. Again, the

percentage of pregnant women opting for institutional deliveries is increasing (14.9%

in 2007 to 47.8% till May 2011).

Childhood immunization with primary vaccines also follow the trends of antenatal

registration and deliveries. The percentage of children immunized shows steady

increase.

More and more eligible couples are seen to be using contraception methods over the

years. Oral pills are seen to be most popular followed by condoms.

Clinical investigation support services have been strengthened with a wide range of

essential services being provided in the laboratory. User fees are levied on selected

tests.

A new ambulance has been procured to improve referral services. The ASHAs have

been made integral part of such services.

Outreach programs include weekly immunization camps, school health programs

and malaria control programs. These programs have resulted in increased

immunization coverage and better health awareness among the communities.

Malaria cases have been drastically reduced and there has been no death due to the

disease.

A systematic management of medical information system as well as other relevant

data and mobilization of communities to participate in the management of the PHC

are the special features noted. The feeling of ownership that the communities have

contributed to the success of the management.

The renovation of the PHC building and improvements in other required

infrastructures have been other notable features after FGA took over the

management of the PHC.

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Apart from making essential medicines and supplies available, the required

manpower strength has been consistently maintained, providing 24 x 7 OPD

emergency services and 6 days a week OPD services.

The management and monitoring by FGA is done under the overall supervision of

the Executive Director with his central office in Itanagar and the branch office at

Oyan, where a Project Coordinator is based.

The PPP project in East Siang district has resulted in upgradation of infrastructural

facilities, strengthening of management systems, increasing community participation

and sense of ownership. This has resulted in improved curative, preventive and

promotive health services. Community capacity building activities in the form of

VWW training and Mothers Training

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For details, contact:

Future Generations Arunachal,Vivek Vihar, H-Sector,

Itanagar 791 113,Arunachal PradeshTel. 0360-2215355

Fax 0360-2291767e-mail: kanno@future.org; web: www.future.org