REGIONAL RESOURCE CENTRE FOR NE STATES

KHANAPARA, GUWAHATI DATE – 17 Feb to 19th Feb 2014

RMNCH+A GAP ANALYSIS REPORT District – Lohit, Arunachal Pradesh

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TEAM MEMBERS

Mr.Manash Mohan State Facilitator ,AP

Mr. Devajit Bora Consultant, Community Mobilization, AP

Mr.Narendra Jangra Consultant, UNICEF

District Visited

1. Lohit

Executive summary

Lohit is an administrative district in the state of Arunachal Pradesh in India. The district

headquarters are located at Tezu. As of 2011 it is the third most populous district of Arunachal

Pradesh (out of 16), after Papum Pare and Changlang. This area was one of the last territories to be

brought under British control after the punitive Abor and Mishmi Expedition in the first decade of

the 20th century.

Gaps and findings of sub center assessment- All visited Health Sub centers were functioning in

government buildings. The condition of buildings were good. only one third of the visited SCs were

having 24 x7 Water supply and electricity backups. Half of the visited SCs were having habitable

staff quarters for ANMs and at 33% of the sub centers having ANMs residing in their quarters.

Availability of RMNCH A essential commodities i.e IFA tabs, IFA syrup, Vit. A soln, etc. was major

matter of concern. Huge training gap was existing among the available HR for the provision of

RMNCH+A services in the district.

Gaps and findings of Non FRU institutions- Most of the non FRU facilities visited were having

govt building in good condition. Most of the specialist positions at CHC level were vacant as

compared to IPHS standard while at PHC level staff was adequate except SNs & LTs. While the

training gap was wide for various types of training at all level. Radiant warmer was available at all

NBCC without any training as how to operate radiant warmer. Availability of essential RMNCH A

commodities was poor which needs immediate attention for strengthening of supply chain

management system. Implementation of referral transportation under JSSK was very poor.

Gaps and Findings of FRU/ DH- most of the specialist positions at DH was filled except General

surgeon, C-sections are being conducted at the facility. SNCU was under construction. Blood

storage unit was not functional due non availability of license. PNC ward was un-clean. Cold chain

was not maintained properly.

ASHA Payment: Irregular payment of ASHA incentives was found during the visit.

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JSSK, JSY & community level assessment- In community, awareness was good regarding JSY

scheme and its incentives while knowledge & awareness was very poor about various

entitlements under JSSK scheme though JSSK entitlements were displayed at most of the

PHC/CHCs visited. Late payments of JSY incentive was reported. Pickups and drop back of delivery

cases was reported very poor as they have to arrange for transportation with Out of Pocket

expenditure. Poor implementation of JSSK. CHC Namsai is taking user fees for laboratory testing

from pregnant lady.

One Maternal Death is reported by District during Year 2012-13.

Pregnancy Care:

The performance of the district in the area of pregnancy care is poor as compared to other

districts in State. Overall, Chongkham & Namsai are good performing block and Legank is

worst performing block.

The total registered pregnancies are 167% against the estimated, duplication of reporting can

be the reason.

Only 27.7% of the registered pregnancies have been registered early

One-third of PWs having 3 ANC checkups

Line listing of high risk pregnancies was not available at any of the health facility visited.

Child Birth:

The performance in the ‘Child birth’ domain is also poor as compared to other districts in State

yet the district has improved slightly in 2013-14 up to 3rd quarter as compared to the previous

year performance.

Overall, block Chongkham is the worst performing of the five blocks.

Post Natal Care:

Much improvement is needed in the area of postnatal care. Only11% of the reported deliveries

are seen within 48 hours.

99.2 % of mothers are discharged before 48 hrs after institutional delivery.

HBNC reports are not available

Child Health:

While the coverage of BCG vaccine and DPT1 are more than 100 %.

Awareness and practice of early breast feeding is good. Awareness of community for ORS+ Zinc,

Pneumonia and JSSK is very poor

Inadequate supply of IFA syrup, Albendazole Susp, Vit.A solution, etc.

Reproductive Health:

The performance of the district in RH is dismal uniformly across all blocks.

PPIUCD services are not provided at DH

Met need for FP is low as compared to the estimated no. of eligible couples in the district.

Health System Assessment:

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Supply Chain Management: Availability of essential RMNCH+A commodities was very poor at

the visited health facilities including at community level i.e. SC levels. Supply at Sub Health

Centers and ASHAs are replenished at PHC level while PHCs were also with stock out of

essential drugs supplies. So, procurement system and supply chain needs to be strengthened on

priority basis to ensure regular supply. Online stock position monitoring system can be devised

and implemented in the state.

Human Resource Management: all delivery points should be equipped with trained

manpower with necessary skills.

Emergency transportation: Facility ambulance were used for emergency transportation

purpose. But its utilization was poor due to poor road and network connectivity.

Implementation of entitlements under JSSK: Under JSSK Drugs and consumables were

procured at district level and supplied to the facilities while other entitlements under JSSK

were poorly implemented in the districts. Beneficiaries has to bear out of pockets for referral

transport & necessary lab tests.

Capacity building roll out of trainings: Major training gap was found for various types of

trainings among HR deployed at all levels. If capacity building of available HR is improved

through provision of appropriate training, quality services can be provided with efficient

utilization of available resources.

Lohit : District Profile:

Administration

The district headquarters are located at Tezu. Lohit District is situated in the foot hills of eastern part

of the Himalaya with a geographical area of 5212 sq. km, surrounded by Anjaw District in the East,

Changlang District and Assam in the South, Part of Lower Dibang Valley District in the North, Assam

State and part of Lower Dibang Valley District to the West.

The district is divided into 2 sub-divisions (Teju & Namsai) and 8 administrative circles, namely, Teju,

Sunpara, Namsai, Chongham, Wakro, Lekang, Piyong & Lathao. There are four Arunachal Pradesh

Legislative Assembly constituencies located in this district: Tezu, Chowkham, Namsai, and Lekang. All

of these are part of Arunachal East Lok Sabha constituency.

HIGHLIGHTS OF LOHIT DISTRICT

I T E M S P A R T I C U L A R S

Blocks 5

Villages 225

Town(Census Town) 2 (Tezu & Namsai)

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Number of Household

I) Total 41,793

ii) Rural 32,494

iii)Urban 9,299

Lohit district experiences vast topographical and altitudinal variations that range from 140 to 686

meters above Mean Sea Level. The District is named after its principal river LOHIT, which flows

through Eastern Tibet and enters India in Kibithoo area, and enters Lohit district at PARASHURAM

KUND, a famous place of pilgrimage for the Hindus. Demographic Profile

According to the 2011 census Lohit district has a population of 145,538, roughly equal to the nation of

Saint Lucia. This gives it a ranking of 601st in India (out of a total of 640). The district has a population

density of 28 inhabitants per square kilometer (73 /sq mi). Its population growth rate over the decade

2001–2011 was 16.44%. Lohit has a sex ratio of 912 females for every 1000 males, and a literacy rate

of 68.18%.Lohit is the home of the Adi, Zekhring, Khampti, Deori, Ahom, Singpho, Chakma and Mishmi

tribes. A small group of Tibetan refugees have settled in Lohit since the 1960s. The Zekhring are

Tibetan Buddhists; the Khampti,Chakmas and Singpho are Theravada Buddhists, and the Mishmi are

mainly Animists.The Chakmas inhabit a land which is surrounded in all side by two mighty rivers, the

Kamlang to the north and Guri Kamlang to the south

Demographic Profile–

Background characteristics

Lohit Arunachal Pradesh

Census 2011

Census 2001

Census 2011

Census 2001

Geographic Area (in Sq. Kms)

5,212 5,212 83,743 83,743

Total population 1,45,538 1,24,991 13,82,611 1097968

Male Population 76,559 67,105 7,20,232 579941

Female Population 68,979 57,886 6,62,379 518027

Population density per Sq.Km

28 24 17 13

Population (0-6 yrs) – Total

23,901 25,026 202759 205871

Population (0-6 yrs) – Male

12,159 12,947 103430 104833

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Source- Census-2011

Map of Lohit District

Health Facilities:

Health Facilities in District: The District has 1 District Hospital, 3 Community Health Centers, 6 PHCs

and 19 Sub Centers spread over 5 blocks

Details of Public Health facilities in the district

Type of the Health Facility Total No. of the functional

Health facilities

Sub Centre 19

Primary Health center 6

Population (0-6 yrs) – Female

11,742 12,079 99,329 101038

Literacy rate Average 68.18 58.73 66.95 54.74

Sex Ratio 912 863 920 901

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Community Health center 3

District Hospital 1

Source- State Profile Report

The block-wise health facilities- listed in the table below

Table9 Block wise availability of Health Facilities

Block DH

SC CHC PHC

Tezu-Sunpura 1 0 2 5

Wakro 0 0 1 2

Chongkham 0 1 0 3

Namsai 0 1 2 5

Lekang 0 1 1 4

Total 1 3 6 19

Delivery Points

Though the District has 1 District Hospital, 3 Community Health Centers, 6 PHCs and 19 Sub Centers

spread over 5 blocks, the district has total 11 Delivery Point, at the 1 DH, 3CHCs, 6 PHCs & 1SC. 82

percent of the delivery points were covered during DGA exercise.

Status of Delivery points

Sr. No Name of the Block L3 L2 L1

Type of Facility

1 Tezu-Sunpura 1 0 2 DH

2 Wakro 0 1 1 PHC & SC

3 Chongkham 0 1 0 CHC

4 Namsai 0 1 2 CHC & PHC

5 Lekang 0 1 1 CHC & PHC

District Gap Analysis:

During the District Gap Analysis following facilities were covered :

Type of the Health

Facility

Total No. of the

functional

Health

facilities

Facilities

Assessed

Facility name

Sub Centre 19 5 Medo, Kumari,

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Sitapani, Monmow

Primary Health centre 6 4 Wakro, Loiliang,

Lathao & New Mohong

Community Health

centre

3 3 Chowkham, Namsai &

Mahadevpur

District Hospital 1 1 DH-Teju

In addition to the facilities, ASHAs and Beneficiaries were also covered during the DGA.

Overall status of health facilities in the district: Infrastructure: Accessibility of all PHCs and all SCs: The distance of the health facilities assessed from the district HQ is depicted in the graph below. Most of the health facilities were more than 50 Km far away from the district Headquarter. Geographical accessibility of Sub-centers and PHCs from Headquarter (in percentage)

16.7

21

16.7

5.3

66.7

73.7

0 10 20 30 40 50 60 70 80

PHCs

SCs

>50 Km 30-50 Km <30 Km

Status of building:Most of the health facilities were functioning in govt. building. Three fourth of the

available building were in good conditions while among rest facility were upgraded to the higher

facility with same available infrastructure. Two-third of the visited health facilities were havening

habitable staff quarters for Medical officers & half of the visited facilities were having habitable

quarters for Staff nurses.

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Availability of residential quarter at DH, PHC, and CHC Level

87.5

75

62.5

50

0

10

20

30

40

50

60

70

80

90

100

Govt building Building in good condition Habitable Staff Quarters MOs

Habitable Staff Quarters SNs

All visited Health Sub centers were functioning in government buildings. The condition of buildings

were good. While, only one third of the visited SCs were having 24 x7 Water supply and electricity

backups. Half of the visited SCs were having habitable staff quarters for ANMs and at 33% of the sub

centers having ANMs residing in their quarters.

Only 40 percent of the ANMs at visited SCs were trained in Skill Birth Attendant (SBA) & cold chain

maintenance during immunization. Only one-fifth of the ANMs were trained in NSSK.

Availability of running water and electricity:

Graph 3 Sub-Health Centers (L1-Facilities) –Physical Infrastructure

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District Hospital and CHC Chongham were having 24 x7 electricity and water supply as well as

functional toilets in the Labour room while CHCs in block Namsai & Lekang were facing problems for

24 x7 water supply and 24 x7 electricity power back.

Availability of running water and electricity

Block DH/ CHC Availability

24*7 Water Supply

24*7 Electricity Supply

Functional Toilets in LR

Tezu-Sunpura

1 1 1 1

Wakro 0 NA NA NA

Chongkham 1 1 1 1

Namsai 1 1 0 0

Lekang 1 0 0 1

All of the PHCs assessed were equipped with 24 x7 water supplies and functional toilets in Labor room

(LR)

Block Total PHCs Availability

24*7 Water Supply in LR

Functional Toilets in LR

Tezu-Sunpura

1 1 1

Wakro 1 1 1

Chongkham NA NA NA

Namsai 1 1 1

Lekang 1 1 1

Human Resource -

HR Position-As per revised Indian Public Health Standard (IPHS) norms for DH, 1-O&G specialist, 1-

Pediatrician & 1- Anesthetist were posted at DH. C-sections were also conducted at DH with well-

equipped OT.

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Critical HR position at DH:

HR Position at District Hospital

S.No Personnel Current Availability at District Hospital

IPHS Norm

1 Surgery Specialists 0 2

2 O&G specialist 1 2

3 Pediatrician 1 2

4 Anesthetist 1 2

5 Casualty Doctors / General Duty Doctors 7 9 (At least 4 female

allopathydoctos)

6 Staff Nurse 11 50 (including 5 ward incharge)

7 Laboratory Technician ( Lab + Blood storage) 3 5

8 Radiographer 2 3

9 Pharmacist 4 5

Critical HR position including specialist at CHC:

Sr.

No.

Personnel IPHS Norm CHC-

Namsai

CHC-

Mahadevpur

CHC-

Chowkhem

1 Medical officer* 9 8 3 5

2 ANM 1 4 3 5

3 Staff Nurse 7 5 3 3

4 Pharmacist /

compounder

1 1 1 1

5 Lab. Technician 1 1 1 1

*it also includes 5 specialist positions & 1 AYUSH MO

All category of staff positions were filled while specialist positions were vacant at all visited CHCs.

HR Position at PHC Level

The availability of HR against IPHS norms in the 4 PHCs assessed is as follows:

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Sr. no.

Personnel IPHS Norms

PHC-Wakro

PHC-Loiliang

PHC-Lathao

PHC-New Mohong

1 Medical Officer 2 2 1 2 2

2 Pharmacist 1 0 1 1 1

3 Nurse - Midwife (Staff Nurse)

3 0 0 1 2

4 Health Worker (Female)

1 9 3 3 1

5 Laboratory Technician

1 1 1 1 0

6 Health Educator 1 0 0 0 0

MO positions were filled at most of the visited PHCs but 50% of Staff Nurse Positions were vacant at

the PHCs visited.

HR availability at Sub Health Center level: The SCs visited all had ANMs and two-thirds had MPWs.

In terms of NRHM’s Programme Management staff, the positions are fully filled and there is no net HR

deficitTraining Status of HR- The training status is reflected in the table below. Critical gap exists at

various levels and various categories of Health care providers, especially in the areas of FP, IMNCI, E-

IMNCI, RTI/STI, BEmOC, NSSK etc.

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Training status of key of District:

Training DH-Teju

CHC-Namsa

i

CHC-Chowkha

m

CHC-Mahadevpu

r

PHC-Wakr

o

PHC-Latha

o

PHC-Loilian

g

PHC-New

Mohong

EmONC 1 0 0 0 0 NA NA NA

LSAS 0 0 0 0 NA NA NA

BeMONC 0 3 0 1-MO 1 0 0 0

MTP/MVA 1-MO

0 1 2-MO 0 0 0 0

NSV 0 0 0 0 0 0 0 0

F-IMNCI 0 0 0 0 0 0 0 0

Mini Lap-Sterilizations

0 0 0 0 0 0 0 1-MO

Laparoscopy- Sterilizations

0 0 0 0 0 0 0 0

Blood storage 1-SN 0 0 0 0 NA NA NA

IMEP 0 0 0 0 0 0 0 0

PPIUCD 0 0 0 0 0 NA NA NA

SBA 0 0 2-MO, 1-SN, 1-ANM

2 SN 0 0 0 1-SN

IMNCI 0 0 0 1-MO 1 0 0 0

NSSK 0 0 2-MO, 1-SN, 1-ANM

1-MO, 1-SN 0 0 0 0

IUCD 1-MO, 1-ANM

0 1-MO 1-MO, 2 SN 1 2 1-MO, 3- ANM

0

Immunization & cold chain

1-HA

1-HA 0 1-HA 2 3 1-MO, 1- ANM

1-MO

RTI/STI 0 0 0 1-MO 1 1 1-MO 1-MO

Equipment: The availability of equipment at various levels is reflected in the following graphs

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Status of equipment at SC

Status of equipment at PHC and CHC Level

Commodities:

The availability of RMNCH+A essential commodities is reflected in the graphs below. In terms of major

stock outs the following are the observations:

Essential Drug list (EDL) was not displayed at any health facilities visited

Stock outs of major RMNCH+A essential drugs i.e. IFA large tab, IFA Blue tab, IFA Syrup, Vit. A

solution, zinc Sulphate dispersible tablets etc. was observed at all health facility visited.

Tab. Misoprostol was not available at any of the SC visited.

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Community level assessment:In community, awareness was good regarding JSY scheme and

its incentives while knowledge & awareness was very poor about various entitlements under

JSSK scheme though JSSK entitlements were displayed at most of the PHC/CHCs visited. Late

payments of JSY incentive was reported. Pickups and drop back of delivery cases was reported

very poor as they have to arrange for transportation with Out of Pocket expenditure.

Quality of care by ASHA:

Of the 225 ASHAs selected in the district, all were trained in module 6-7 first round. ASHAs

were aware of their roles and responsibilities i.e. community mobilization on VHNDs,

awareness generation, HBNC etc.

All ASHAs were provided with drug kits but supply of near to expire drugs were observed

during field visit.

Late payment of JSY incentive and non-payment of other ASHA incentives were reported during

the field visit. The district was responsible for delayed release of fund to all health facilities for

ASHA incentive.

Health System Management:

Supply Chain Management: Availability of essential RMNCH+A commodities was very poor at

the visited health facilities including at community level i.e. SC levels. Supply at Sub Health

Centers and ASHAs are replenished at PHC level while PHCs were also with stock out of

essential drugs supplies. So, procurement system and supply chain needs to be strengthened on

priority basis to ensure regular supply. Online stock position monitoring system can be devised

and implemented in the state.

Human Resource Management: all delivery points should be equipped with trained

manpower with necessary skills.

Emergency transportation: Facility ambulance were used for emergency transportation

purpose. But its utilization was poor due to poor road and network connectivity.

Implementation of entitlements under JSSK: Under JSSK Drugs and consumables were

procured at district level and supplied to the facilities while other entitlements under

JSSK were poorly implemented in the districts. Beneficiaries has to bear out of pockets for

referral transport & necessary lab tests.

Capacity building roll out of trainings: Major training gap was found for various types of

trainings among HR deployed at all levels. If capacity building of available HR is improved

through provision of appropriate training, quality services can be provided with efficient

utilization of available resources.

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Pregnancy Care:

The performance of the district in the area of pregnancy care is poor as compared to other

districts in State. Overall, Chongkham & Namsai are good performing block and Legank is

worst performing block.

One-third of PWs having 3 ANC checkups

Line listing of high risk pregnancies was not available at any of the health facility visited.

Recommendations:

o Strengthening of regular outreach activities in coordination with ICDS deptt. At VHND

platform and supportive supervision to ensure improved service provision.

o Improving the skills of the ASHAs/ ANMs and ensuring early pregnancy testing,

including regular supply of PTKs so that ANC services can be started through early

registration.

o Listing of villages where ANC is low and ensuring adequate supportive supervision visits

o Strengthening of IEC and communication strategy and involvement of the Faith Based

Organizations in the effort

o Tracking High Risk pregnancies and inclusion of review of the high risk pregnancy list as

a standing agenda in all the district and sub-district reviews

Child Birth:

The performance in the ‘Child birth’ domain is also poor as compared to other districts in State

yet the district has improved slightly in 2013-14 up to 3rd quarter as compared to the previous

year performance.

Overall, block Chongkham is the worst performing of the five blocks.

While CEmOC services are available in the DH, there is a need to strengthen the BEmOC services

at CHC/PHC level and the SBA training to SNs/ANMs.

Recommendations:

o Capacity building of contractual staff in SBA/ BEmOC training of staff at CHC/PHC level

(L2).

o Listing of villages with large number of home deliveries and rapid training of ANMs

catering to these villages at the earliest

o Ensuring institutional delivery for the high risk pregnancies- many villages are

inaccessible and provision for maternity waiting homes may be included in the PIPs.

o Equip ASHAs with disposable delivery kits to assist home deliveries.

Post Natal Care:

Much improvement is needed in the area of postnatal care. Only11% of the reported deliveries

are seen within 48 hours.

99.2 % of mothers are discharged before 48 hrs after institutional delivery.

HBNC reports are not available

Recommendations:

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o Though HBNC training to ASHAs has been given, though there is need for handholding

and mentoring of ASHAs for the roll out of HBNC.

o Strengthening of HBNC review at all level with strong reporting system.

o Motivation of ASHAs for regular HBNC visits through regular payment of incentives.

o Use of RMNCH A counselor at high case load facilities for counselling on PNC, Newborn

care, Immunization, FP etc.

o The district also does not have a SNCU nor any stabilization units and the NBCC non-

functional due to lack of training in use of radiant warmer in many of the visited

facilities.

Child Health:

While the coverage of BCG vaccine and DPT1 are more than 100 %.

Awareness and practice of early breast feeding is good. Awareness of community for ORS+ Zinc,

Pneumonia and JSSK is very poor

Inadequate supply of IFA syrup, Albendazole Susp, Vit.A solution, etc.

Recommendations:

o There is a need for regular monitoring and validation of data

o Given than the API in the district is >10, and the district is endemic for Pf, there is a need

to have a better understanding of the malaria cases and related deaths among children.

o Ensure proper implementation of RBSK through adequate & regular supply of RMNCH A

essential supplies.

o Focused IEC/ IPC plans to include component of ORS-Zn.

Reproductive Health:

The performance of the district in RH is dismal uniformly across all blocks.

PPIUCD services are not provided at DH

Met need for FP is low as compared to the estimated no. of eligible couples in the district.

Recommendations:

o PPIUCD can be started at DH

o Motivation to ASHAs for Inter-Personal Communication (IPC) for FP and social

marketing of OCPs, condoms, ECs etc.

o ASHAs should be paid regular incentives for mobilization of beneficiaries for

permanent sterilization.

o IEC/BCC needs to be strengthened to create awareness and generate demand for

FP services.

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GRAPHICAL PRESENTATION:

PHOTO GALLERY:

Manmow SC Dumping pit

Fixed day for JSY Payment at DH Tezu

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Non Implementation JSSK,user charge for Pregnant lady At CHC Namsai

At

Blood bank in DH Tezu

DH Tezu Labour Room

PHC Lathao Labour Room

ARSH Clinic CHC Chowkham

Male Ward at DH Tezu

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JSSK IEC at DH Tezu

New Building under construction PHC New

Mohong

Generator Room Constructed under RKS

fund PHC Lathao

JSY payment register PHC New Mohong