CRM

1. 14th
Common
Review
Mission
Odisha
November 2021

2. District CRM Teams
Sundargarh Rayagada
Raghuram Rao Padmini Kashyap
Ram Chahar A. C. Mallick
Mandar Randive Vimlesh Purohit
Suchi Khanna Santosh Ojha
Haifa Thaha Debajit Bora
Rishita Mukherjee T Ankitha
Anil M H Vipin Garg
Shweta Singh Shailey Gokhale
Debasis Swain Subrat Panda

3. Key Indicators
MMR (SRS) IMR Trend (Census & SRS Data)
75
61
46
38
78
63
48
39
55
43
35
30
18
28
38
48
58
68
78
88
2005 2010 2015 2019
Odisha Total Odisha Rural Odisha Urban
S. No. Indicators Odisha India
1 Neo Natal Mortality Rate (NNMR)1 31 23
2 Under Five Mortality Rate (U5MR)1 44 36
3 Still Birth Rate2 10 4
4 Total Fertility Rate (TFR)2 1.9 2.2
5 Sex Ratio at Birth2 933 899
6 TB Annualized total case notification rate (%) 114 163
7 Leprosy Prevalence Rate / 10,000 population 1.45 0.61

4. Top 5 causes & risks of DALYs, 1990-2019
S. No. 1990 2019
Causes of DALYs4
1 Diarrhoeal Diseases 1. Diarrhoeal Diseases
2 Lower respiratory care infection 2. Malaria
3 Drug Susceptible TB 3. Drug Susceptible TB
4 Neonatal preterm Birth 4. Lower respiratory care infection
5 Malaria 5. Ischemic Heart Disease
Causes of Risks4
1 Low Birth weight 1. Low Birth weight
2 Child wasting 2. High Systolic Blood pressure
3 Short gestation 3. Short gestation
4 Unsafe water source 4. High fasting plasma glucose
5 Household air pollution from solid fuels 5. Unsafe water source
Source: 1. Sample Registration Survey (SRS) Bulletin 2018; 2. Registrar General of India (RGI) Statistical Report (SRS) 2018 & 2019; 3.QPR NHM MIS Report [Status as on
01.03.2020 & recent 31.12.2020; 4. Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Seattle, WA: IHME, 2018

5. Sundargarh Rayagada
Heart Diseases: 39.32 % Heart Diseases : 20.64%
Covid-19: 15.01 % Asthma: 9.34%
Paralysis: 13.26 % Pneumonia: 9.06%
Chronic Liver Disease: 7.65 % Paralysis: 8.10%
Cancer: 5.34 % Liver Disease: 7.45%
Transport Accident: 2.62 % Covid-19: 7.29%
T.B: 2.50% Anaemia : 6.41%
Other Accident:2.09% Ulcer, Stomach: 5.81%
Diabetes: 1.55% Cancer: 4.29%
Pneumonia: 1.34% T.B: 4.05%
Anaemia:1.26% Diabetes: 3.37%
*Others (13.1%– 37.9%) and Senility (28.7%-52.6%) removed from Denominator
HMIS – Analysis of Causes of death

6. District Sundargarh

7. District Rayagada

8. Good Practices
Matrujyoti scheme – ensured quality antenatal care including Ultrasonography for
mothers
Advanced Rehabilitation centre and Integrated Physiotherapy Unit
Focus on service support (HR, referral and infrastructure upgradation) through DMF
Daman initiative for combating Malaria
Monthly SNCU performance-based incentive

9. ToR – I (Primary Care)
Checkpoints Status
Conversion of HWCs and
Operationalizing for 12 packages
of Comprehensive Primary Health
Care Services (CPHC), both urban
& rural areas
• Odisha has operationalized 1660 / 5021 AB-HWCs for FY 21-
22 (SHC-3636; PHC-1288 and UPHC-97)
• 7 / 12 packages of CPHC services are being provided
currently and training for expanded package is in the
pipeline
• NCD screening is limited to Hypertension and DM in most
of the facilities
Health promotion and wellness
initiatives
• Wellness calendar is followed in most of the facilities.
However, scope of improvement in wellness activities

10. ToR – I (Primary Care)
Checkpoints Status
Covid 19 – preparedness, response and
challenges with reference to ECRP I and II
• Procurement of 6 bedded prefab units for PHCs is under tendering
• Sites for Pediatric ICUs are identified and procurements ongoing
IT applications in CP/CPHC - status,
utilization and challenges
• NCD-HWC app, AB-HWC portal & ANMOL functional at SHC-HWC. MO-
NCD portal used in PHC&UPHC-HWC.
• Nikshay and IHIP portal not operationalized
• Challenge of internet connectivity in hard-to-reach areas and
application limitations
Referral mechanism – linkages to other levels
of care
• Continuum of care – challenges of direct referrals to DH and downward
referrals
• Telemedicine services utilized primarily for routine illnesses, potential
challenges of overloading the hub and need for sub hubs
• Tele-radiology services restricted to CT scan

11. ToR – II (Secondary Care)
Checkpoints Status
Availability of critical care services and
operational status of critical care areas :
Emergency, SNCU, ICU, OT, LDR, etc at FRUs-
CHC/SDH/DH (both in urban & rural areas)
• Emergency services and critical care services were largely available
at DH level due to lack of specialists at CHC/SDC level facilities
• High LAMA and referral rate for all cases
• Large physical distances between secondary care and tertiary care
services
Diagnostics : Availability, DVDMS / other IT
appn for management, Quality control,
BMMP
• E-Niramaya operational till CHC and in few PHCs
• Diagnostics not completely available as per Free Drugs guidelines
• BMMP outsourced and operational
• State initiative (Nirmal Yojana) for cleanliness and security
operational
Medicines • EDL notified and displayed in all the facilities. Prescription audits
conducted
• Stock outs and expired drugs were observed in few facilities
• Untied funds given to facilities for local purchase as required

12. ToR – II (Secondary Care)
Checkpoints Status
Referral Transport System (Ambulances) Ambulance services including additional Patient Transport Vehicles &
Ambulances from DMF – service optimal and supplemented by DMF
funds
DH Strengthening (including skill based in-
service training - LSAS & CEmONC)
LSAS and CEmONC trained HR – shortages observed
Covid 19 – preparedness, response and
challenges with reference to ECRP I and II
Sites finalized for 50 bedded Prefab Units, Pediatric ICU under
operationalization, RTPCR labs established and LMO under tender
process.
PSA and Medical Gas Pipeline functional
PM-JAY – uptake in public institutions and
challenges
State has its own Insurance scheme named Biju Swasthya Kalyan
Yojana covering OPD and IPD
Central PSU hospitals not fully empaneled

13. ToR – III (Cross Cutting themes)
Checkpoints Status
Quality Improvement • Majority Urban PHCs have been ISO certified
• Existing coverage of NQAS and LaQshya certification of facilities is limited
• Biomedical Waste Management systems in place in all facilities;
• Infection control practices can be further strengthened in health facility,
ambulances and community
• Blood banks were functional as per norms and collection adequate, however
component separation is limited
• There is persistent trend of MP and HBsAg of donated blood last 3 years and higher
detection of Syphilis in 2021

14. ToR – III (Cross Cutting themes)
Checkpoints Status
Human Resource for
Health
• Enabling HR policy with incentive for specialists, however paucity of specialists at
CHC/SDH level facilities
• NHM HR continue to be repurposed for COVID-19 duties
Indian Public Health
Standards
• Gaps in compliance to IPHS standards at all levels
Legal framework, and
accountability
• PCPNDT, MTP, CEA, BMW Rules, Drugs & Cosmetic Act notified, however
implementation needs to be strengthened
Financing • 2nd tranche is yet to be released as utilization is less than 50%
• Good systems for PPP contracting and payments

15. Community Processes &
Comprehensive Primary Health Care
• PHC HWC functional and SHC HWC are work in progress
• Standardized branding for HWCs
• Basic services for RMNCAH, NCD (HT & DM), TB, Leprosy and Malaria provided, UPHCs are providing
comprehensive services
• Referrals for Continuum of Care directly to DH/SDH level. Limited post treatment follow-up for downward
referrals of CBAC
• Wellness activities can be strengthened
• Good coordination with Panchayat, SHGs and ICDS dept including ASHAs, ANMs – Gaon Kalyan Samiti
(GKS), MAS, JAS
• No backlog of ASHA Payments (On an average INR 4500 - 6000 month earned by ASHAs)
• Gaps in infrastructure (electricity, water supply, boundary wall) observed at the HWCs

16. RMNCAH+N - Infrastructure and service
delivery
• Positive response for maternity services, well equipped LR/OTs, MDR and CDR functional and no stock outs
observed for essential drugs in LR. Anti-D and HB IG are available at district
• Under-utilization and operationalization of subdistrict delivery points
• Well functional and operational referral services in both districts - High referrals from peripheral facilities in
Sundergarh to DHH & RGH
• Communication challenges in hard-to-reach areas
• Overcrowding at RGH resulting in early discharge of women - lack of PNC beds
• Need for Obst HDUs and FRUs strategically covering the districts
• Gaps in quality maintenance despite national certification (LaQshya) at DHH-Rayagada, Sundargarh State
certifications pending (DHH/RGH)
• Vehicle not being provided to beneficiaries for drop back under JSSK instead Rs 500/- given (<50% uptake due
to early discharge)

17. RMNCAH+N - Clinical skills, training and
competency
OBSERVATIONS
• Trained staff available at DH level facilities, adhering clinical protocols and documentation practices.
• Limitations in Line listing for high-risk pregnancies & follow-up actions – sub-optimal PMSMA utilization.
• Sub-optimal clinical knowledge and practices with training gaps observed in sub district staff in
Sundargarh.
• Use of Inj. Tramadol during intrapartum and post partum period at Rayagada.
• High percentage of admissions from perinatal asphyxia indicative of poor intrapartum care practices.

18. RMNCAH+N
Newborn and Child health
• SNCUs functional in both districts, provision
of Family participatory care available
• Vacancy in SNCU-Rayagada for MOs, DMF
support is supplementing specialist services
in Sundargarh
• SNCU inborn admissions high (60%), esp.
from birth asphyxia – quality of intrapartum
services low
• High OOPE reported by users for newborn
care services including referral to tertiary
centers (Sundargarh)
Immunization
• Good knowledge of ANMs on vaccination schedule and
placement of vaccines
• ILRs maintained in good condition at most of the sites
• e-VIN not fully functional - indent of vaccine, logistics and
temperature monitoring gaps observed
RKSK services
• Activities of Health & Wellness Ambassador and Health
Messenger under School Health Program were observed at
Rayagada
• Shraddha clinics functional at both districts, however low
footfalls and utilization

19. RMNCAH+N
RBSK and DEIC
• Established services, working well in both districts
• HR gaps observed in Rayagada (Paediatrician & Psychiatrist)
• Pre-discharge screening of SNCU admissions being done at DEICs
NRC
• Antibiotics universally prescribed to all admissions
• Follow up and tracking done telephonically
• Service delivery satisfactory
• Low footfall in NRC due to COVID-19
Family
Planning
• Limited availability and gaps in roll out of DMPA, Chaya
• PPIUCD services – good uptake in both districts
• Limited post LSCS sterilization services (RGH), fixed Day services not fully operational yet
• Poor follow up of users for contraceptive adherence
• Good NSV and PPIUCD services in Rayagada district. Service available even at few SC-HWC.

20. Non-Communicable Diseases
• District NCD clinic functional
• Geriatric ward established and functional at DHHs
• Dialysis Unit in PPP mode functional at district level
• Operational ecosystem for physiotherapy established at different levels of
facilities.
• Planned initiative of ASTHA Gruha for People With Mental Illness (PWMI) in
Sundargarh

21. Non-Communicable Diseases
NPCDCS
• Screening services are limited to
diabetes and hypertension at most of
the observed sites.
• Screening for common cancers was
lacking at most of the facilities
• Lack of follow up and tracking
mechanism for diagnosed cases
• Approx. 20% of dialysis patients were
infected with HCV but not yet linked
to Hepatitis treatment center
(Rayagada).
NOHP
• Challenges in service delivery due to inadequate infrastructure
(dental chairs, etc.) though Human Resource in place.
NMHP
• Need for intensive training of ASHAs in detection and
management- follow-up of care lacking
• Community awareness activities are limited
• Services are restricted primarily at district level and focused on
treatment.
• Non-availability of drugs for sub-district level for follow-up cases
and not linked to telemedicine
• Lack of recovery/ healing plan of existing patients

22. NTEP
Public sector Private Sector
PTER is increased to 1725/L due to implementation of
active case findings through different campaign modes
during 2020 & 2021, however concerns on quality of
sample collected (>50% saliva samples)
Enforcement issues related to mandatory notification
and schedule H1 ( more focus on chemists as
compared to doctors)
Molecular Diagnostics available at District HQ level only
except in 3 districts (Sundargarh, Mayurbhanj and
Ganjam) where available upto block level.
Incomplete mapping of the private health facilities
The referral from general OPDs for TB testing is
significantly below bench mark of 5% & Low cross
referral from other national programs ( like HWCs, NCD
clinics, NRC, ICTC,ART etc (< 1%)
Teething issues with PPSA and the operation model (
field strategy and HR)
Strengthening of Sputum Transportation mechanism

23. Other Communicable Diseases
Malaria
• Test Positive Rate, API and death rate has
significantly decreased since last 5 years.
NVHCP
• Diagnostic and treatment services has been
initiated.
• Screening & linkage of PW for hepatitis B need
to be strengthened
Filaria
• High MF Rate (>1%)
• Districts are under MDA ( old and new)
Dengue
• Major outbreak observed. RRT have been
constituted and responded to control
outbreaks.
NACP
• At several HFs HWs are not aware of PEP
protocol and availability
• Late diagnosis and delayed initiation of ART
due to limited access to ART center ( distance)
observed in one of the district.

24. COVID 19 Vaccination
83
42
71
33
77
33
0
50
100
1st Dose (%) 2nd Dose (%)
COVERAGE
State Sundergarh Rayagada
Observation Recommendation
• Vaccination sites well maintained with appropriate
display of IEC materials, however challenges in
getting a slot in CoWin for 2nd dose reported
Need to improve second dose coverage through
• Focused monitoring for coverage of the campaign
• Training/Retraining of frontline workers on vaccine
hesitancy and ensuring active involvement
• Vaccine coverage of both the districts are below the
state average & Vaccine hesitancy observed in
some pockets
• ‘Har Ghar Dastak’ campaign operational in urban
areas but not much in rural areas

25. Health Finance
• RoPs –Timely disseminated till block level and being used as a guiding document.
• Consolidated ASHA Payment through E-ASHA portal
• Good accounting practices observed (Cash book, Bank reconciliation, fixed assets and staff
register)
• DBT payments coverage is above 80%-JSY, FP, TB schemes, even state sponsored
Sampoorna schemes
• No pendency under State Share and Treasury transfer of GoI funds under NHM & ECRP-II

26. Health Finance
Observations Recommendations
Single Nodal Account: Process started, yet to be
completed
State needs to ensure mapping of PFMS codes and implement SNA
across the districts.
DBT payment is a norm for NHM & State schemes.
However, payments are made monthly leading to delays.
DSC based payments exists only for TB schemes.
1. DBT payments to be made real-time and not monthly.
2. Follow-up actions of failed payments required strengthening.
3. Use of DSC to be ensured for all programmes at all levels
Auditing and internal control mechanisms: In place.
Statutory Audit and Concurrent Auditors appointed.
Timely completion of audit for FY 2020-21 to be ensured.
RKS meetings need to be regularized and their records to
be duly maintained, particularly at the block level.
Minutes of meeting, Signature of competent authorities and ATR of
decisions arrived must be maintained properly.
15th Finance Commission-SLC,DLC constituted, facilities
identified, plan approved by GoI
State to ensure no duplication of activity from various grants viz.
NHM, 15th Finance Commission & PMABHIM grants, DMFF and
ECRP-1 & 2 grants

27. Areas of concern
Delay in funds transfer from State
Treasury to SHS
• Audit Report and Audited UCs from State is yet to
be received for F.Y. 2020-21.
• II Tranche of funds from GoI is pending due to
low expenditure
S. No. Financial
Years
No. of days Average
Delay
(in days)
1 2020-21 0-228 days 58
2 2019-20 5-147 days 64
3 2018-19 6-114 days 51
4 2017-18 8-41 days 21
5 2016-17 13-21 days 17

28. Utilization of Funds
(Rs. In Cr.)
Sr. No. Programmes Outlay (2021-22) Utilization till Sept.2021 % Utilization
1 RCH Flexible Pool 426.63 117.05 27%
2 Health System Strengthening under
NRHM
1,775.32 581.07 33%
3 NUHM Flexible Pool 64.70 21.76 34%
4 Flexible Pool for Communicable
diseases
170.75 39.47 23%
5 Flexible pool for NCDs 87.98 15.26 17%
6 Details of Expenditure under ECRP-
II
789.66 44.28 6%
7 Details of Expenditure under ECRP-I 148.18 146.44 99%

29. Take home message for GoI
Quarterly follow up for ATR of CRM observations
Revision of NRC technical and operational guidelines including budgetary norms
Consider Epidemiology unit at state and district
eVIN operational challenges to be resolved
Option of Aadhar based authentication in addition to DSC for payments
Ambulance norms for difficult and hard to reach areas

30. Well maintained drug stores
Well maintained Drug warehouses

31. IEC Display at facilities

32. Bike ambulances

33. Clean Labor Rooms

34. Community Platform Interactions

35. Community Platform Interactions

36. Maa Gruha

37. Matrujyoti & Sampoorna Kits

38. Oxygen Plant

39. Disability & Elderly Friendly Infrastructure

40. Advance Rehabilitation Center

41. Thank you