Study of the performance of 24 X 7 PHCs in the ‘C’ category districts of Karnataka

Dr. R. Balasubramaniam, Sham N Kashyap, Chandrika Shetty
Field Research Team: Mahesh, Kumar, Ravi C S, Ashwath Gowda, Banu, Mamta
Sector: Public health, evaluation of the performance of institution.

Karnataka State Health System Resource Centre (KSHSRC) assigned GRAAM to conduct an in-depth assessment of the factors, positive as well as negative, affecting the performance of 24 X 7 PHCs in the ‘C category’ districts (Bagalkote, Bidar, Vijayapura, Kalaburagi, Koppal, Raichur and Yadgir) of Karnataka and suggest measures, both at policy and operational levels, to improve their performance. The evaluation was conducted on a sample of 37 24×7 PHCs across the 7 ‘C districts. The study used ‘live deliveries reported in PHCs per thousand population per year’ as the primary indicator to assess the performance of 24×7 PHCs. This variable was used to assess and categorize the performance of 24×7 PHCs into 3 categories: High (H), Medium (M) and Low (L).

The major findings of the study are listed below:

  • H level 24×7 PHCs recorded higher numbers of night and complicated deliveries. This proportion was less in M and L level 24×7 PHCs. The average infant deaths in the PHC areas in 2013-14 was 9 in H level PHCs, 7.11 in M level PHCs and 12.38 in L level PHCs. However, these averages weren’t statistically significant to draw conclusions.
  • H level PHCs were able to provide JSY and Madilu kits to beneficiaries in a more timely fashion compared to other levels. Infrastructure and medicine availability (both generic as well as specific to delivery related) did not differ substantially among the three levels of 24×7 PHCs.
  • H level PHCs were significantly better staffed than M and L level PHCs. The proportion of H level PHCs a) having lady doctors, b) having more than 2 doctors and c) having 3 or more staff nurses was higher in comparison to other levels. In 50% of the cases, doctors in H level PHCs were reported to be staying in head-quarters (This ratio was about 22% and 15% respectively).
  • The study found that PHCs with lady doctors had considerably higher average deliveries per thousand per year and hence, this affect was visible in H level PHCs, since the proportion of H level PHCs with lady doctors was high.
  • Staff nurses of H level PHCs were technically more competent in recalling issues to be observed during ANC checkups and were slightly better trained than those in other levels of PHCs.

Based on the results and observations, the following recommendations were made

  • Improving the technical competence of staff nurses with compulsory training in BEmOC and IMNCI and motivating the staff nurses for providing the best services, specifically in deliveries and overnight care.
  • Streamlining job responsibilities of AYUSH doctors, keeping in mind their larger role in the provision of health care.
  • Exploring options for phased regularization of staff nurses and AYUSH doctors.
  • Including number of deliveries as performance criteria with the highest weights, for performance based funding of Untied Grants (as suggested by recent changes in NRHM).
  • Providing at least 3 staff nurses and at least one lady doctor for every PHC, and more importantly, bringing stability in staff patterns and provision of services.