State Level Consolidated Report of Bihar

Transcription

1 State Level Consolidated Report of Bihar Findings of Community Monitoring for Improving Informed Choice and Quality of Care in Family Planning Centre for Health and Social Justice, New Delhi Page 1

2 Content Page number 1 Family Planning in India 3 2 The Process 3 3 Methodology Adopted 4 4 Major Findings -District Wise 6 5 District Level Dialogues and Sharing 8 6 State Level Score Card 10 7 District wise Findings of Community Monitoring Process 11 8 Conclusion 20 9 Annexure of Media Coverage of District Level Dialogue 21 Content List of Acronyms ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWW Anganwadi Worker CHSJ Centre for Health and Social Justice CHC Community Health Centre CBM Community Based Monitoring CMO Chief Medical Officer CSO Civil Society Organisation FGD Focus Group Discussion GOI Government of India IUD Intra Uterine Device MOIC Medical Officer in-charge NRHM National Rural Health Mission PRI Panchayati Raj Institution PHC Primary Health Centre OCP Oral Contraceptive Pills Page 2

3 1. Family Planning in India Family planning within the context of health is one of the flagship programmes of the Government of India (GoI). India started its national family planning programme in 1951 which has a long and chequered history. There was an obsessive fear of explosive population growth which led to the introduction of coercive components like targets, incentives and penalties for the community as well as the health worker. However, the programme was often reduced to provision of female sterilisation. In rapidly conducted sterilisation camps the quality of surgical procedures was poor. After signing on to the Program of Action of the International Conference on Population and Development (PoA- ICPD, 1994), the GoI made many changes in the way the family planning programme was designed and implemented. Method specific targets were abandoned; standard operating procedures and quality assurance mechanisms were introduced. Today the GoI has shifted its programme focus from female sterilisation to an approach focusing more on birth spacing and temporary methods. However, India is a large country and the manner in which programmes are delivered on the ground can be very different from the policy intentions. There is need to understand whether couples especially women can access high quality family planning services according to their needs and choice which is the true intention of the family planning programme. 2. The Process Community based monitoring (CBM) methodology has been developed within the auspices of the National Rural Health Mission to understand the communities experience of service delivery. It is also seen as an integral component of community participation as well as of accountability mechanisms, and is aimed at improving the quality of services demanded by the community and delivered by the health system. CBM methodology has been used in this initiative since it increases participation of the community and civil society organisations (CSOs). In an effort to strengthen people s access to quality family planning services and build understanding on quality of care in family planning, five CSOs undertook community based monitoring on family planning services in selected villages in five districts of Bihar Pradesh, Bhagalpur, Nawada, Nalanda, Kishanganj and Patna. The CBM exercise included discussions with women where the experience of women who are intended as well as actual beneficiaries of the family planning programme was understood. Interviews were conducted with a selected group of ASHAs in each district and the Medical Officer and ANM of one Block in each district were also interviewed. The district level public dialogues based on the findings of CBM has been undertaken in five districts of Uttar Pradesh during last two months focussing on informed choice and quality of care in family planning. In district level Jansamvad, score cards with findings and experiences of family planning users were shared with community, health service providers, Panchayati Raj Institution (PRI) members and media. Objectives: The main objectives of the study are: To monitor compliance of quality standards in family planning services. To advocate for improvement of quality and fulfillment of reproductive rights. 3. Methodology Adopted In each of the four districts of Bihar, one village each from five panchayats in one block in the district were selected for the study. The entire survey in five districts was done by women selected from the Page 3

4 community in the villages. These women were given orientation on the objectives and provided trainings on data collection. Table 1 enumerates district wise block and village names. Table 1: District wise block and village name District Block Panchayat Village Bhagalpur Nathnagar Kajrailee Kajrailee Gorachakki Gorachakki Noorpur Noorpur Sardarpur Nishambe Rampurkhurdi Rampur Kishanganj Kishanganj Belwa Belwa Mahingaon Nuniabasti Chakla Phoolwari Gaijpara Salki Tengarmani Teusa Teusa Nalanda Hisua Arpi Arpi Kapsima Kapsima Purna, Purna, Akbarpur Akbarpur Indot Indot Nawada Hilsa Khanpur Khanpur Manwa Manwa Sindholi Sindholi Dihri Dihri Bagodar Bagodar District Selection Criteria As per 2001 Census, majority of the population (70.7 per cent) of Kishanganj is minority communities. Sex ratio was 940 female per thousand male and literacy rate was per cent (lower than the state and national average). Health facilities are inadequate and outreach of quality family planning services to the Muslim communities is sparse. As per DLHS III and NFHS III, district Nawada has poor health indicators with high MMR and IMR. This is also one of the drought prone districts in the state of Bihar. Bhagalpur is a flood prone district and smacks of poor health indicators. Nalanda is a district with a considerable amount of inflow of State Government resources in terms of social development and welfare. Given this background, selection of these districts was done to investigate the adherence to standards in family planning programme set by the government. The list of organisations that participated in collecting data for the study is given in Table 2. Table 2: List of organisations: Sl. No. District Name Organisation Name 1 Bhagalpur Arthik Atma Nirbharta Samajik Vikas Abhikaran (AANSVA) 2 Kishanganj RAHAT 2 Nawada Society for Development Action (SDA) 3 Nalanda IRADA Page 4

5 Selection criteria of villages and study population Table 3: Selection criteria of study population USERS COMMUNITY PROVIDERs FACILITY 50 interviews with women in each district who have used either Intrauterine device (IUD), oral contraceptive pill (OCP) or sterilisation, injectables as a method of family planning in last two to three years Two focus group discussions (FGDs) with women in 5 villages in one district. The inclusion criteria comprised of following: o Pregnant women o Newly married o Women who have children of one to two years o Women who used the family planning methods within a year o Age group for selection is 19 to 45 years of age Interview with Medical Officer of Primary Health Centre (PHC) Interviews with ASHAs of all 5 selected villages Observation of one PHC using a checklist Interviews and FGDs: Two FGDs (12-15 women per focus group discussion) (total 10 FGDs per district) One interview with ASHA in each village (five ASHAs per district) 10 interviews (with users) in every village (50 interviews per district) One facility survey (PHC) in one district One interview with Medical Officer in Charge (MOIC) in one district Case stories (no number is defined) In each districts, two FGDs were held in each of the five selected villages along with interviews with the ASHAs of each village and Medical Officer. A PHC was observed in five blocks of five districts as a facility observation. A total of 50 FGDs conducted across the five selected villages. Score Card Preparation After gathering the information through the FGDs, interviews with family planning users, interviews with ASHAs and MOIC, and facility observation, scores were given to each of the conducted inquiry, and a community scorecard was processed. Data triangulation was done by identifying and clubbing the responses from various tools under the themes/issues that were identified from the reference guidelines, documents and manuals consulted for developing the tools. Under each theme, questions and sub questions were developed and each question had an indicative response: Yes or No. In case of a negative response, the score given was zero and in case of a positive response, the scoring was one. Cumulative scoring was calculated for each of the themes and later percentage was calculated and colour coding was developed in order to obtain final results in the form of a traffic light. Reverse scoring was done in case of questions related to coercion. Thus, percentages were calculated for each of the indicators, 100 percent being the most desirable condition. For the purpose of translating the results into traffic lights, below 50 percent (poor) was put under red colour, results from percent (average) under yellow colour and results above 80 percent (good) were green coloured. The issues considered for preparing these report cards are enumerated in Table 4 and 5. Page 5

6 Table 4: Issues for community report card Theme Client identification Counseling Information and choice Quality of services Follow up and management Coercion/incentives Source of Information 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews Table 5: Issues for facility/provider report card Theme Source of Information Knowledge of methods MO Interview, Facility Checklist, ASHA Interviews Counseling and IEC MO Interview, Facility Checklist, ASHA Interviews Basket of options MO Interview, Facility Checklist, ASHA Interviews Facility preparedness MO Interview, Facility Checklist, ASHA Interviews Quality of clinical services MO Interview, Facility Checklist, ASHA Interviews Follow up and management MO Interview, Facility Checklist, ASHA Interviews Target/ Incentives MO Interview, Facility Checklist, ASHA Interviews 4. Major Findings Family Planning Users Interviewed (District wise) Table 6 shows the number of family planning users that were interviewed. Community meetings and focus group discussions were conducted in each of the five villages and interviews with the women contraceptive users (married women who have used or IUD, or contraceptive pill or sterilisation as a method of family planning) from were identified during the FGDs and also from the records maintained by ASHAs. Interviews were conducted with women users and women who are expected to be visited by service providers for family planning counselling and services in the district. Women participants participated in a FGDs in Nalanda and Kishanganj Districts Page 6

7 Table 6: Family planning users that were interviewed Districts Sterilisation IUD Oral Contraceptive Pills (Mala D) Injectables Condom Total Bhagalpur Kishanganj Nalanda Nawada Total Counselling and Information Sharing The service providers accepted that there was lack of counselling from the providers side. The service providers also accepted that they only emphasised on female sterilisations in order to meet their target set by State Government and other spacing/family planning methods were not given as a choice to the community. ASHAs who were present in the Jansamvads told that they were never provided any kit or Information Education and Communication materials of different family planning methods to demonstrate among community. The service providers accepted that there was no regular supply of family planning services to the facility. The community enquiry and providers and facility enquiry process describe a similar kind of trend. The community data shows there is little work done by providers to identify potential family planning users. In all the districts, family planning providers never identify the newly married couples and also fail to understand the need of the newlyweds for spacing methods. They only focus on women who already have two or more children. ASHAs never provide any detailed information on spacing methods except seterilisation. Across the five districts, sterilisation users were not counseled about the side effects/health problems that could occur due to sterilisation. All of them informed that they had not been counseled about other methods of family planning. The female sterilisation users reported that none of them had been informed about the family planning insurance scheme in case any health problem occurred after sterilisation operation. Very few women reported that the consent forms of sterilisation operation were read out to them and they were made to understand what was written in the consent forms. In Nawada district, two sterilisation users reported that they were scolded during sterilisation operation. In Bhagalpur district, two sterilisation failure cases were documented. Problems of Health Service Providers In district level public dialogue, ASHA workers said none of the authorities helped them to redress the grievances of the community. ASHAs also shared that their problems were never heard by higher authorities. Medical Officers in-charge accepted that there was a target for sterilisation. The target set from 200 to 400 in all the five districts in a year. ASHAs stated that they did not distribute spacing methods in their village. From the interviews with users and FGD with community, it came out that ASHAs only tried to lay emphasis on female sterilisations. No other methods were given as a choice to the community. From the interviews with ASHAs, it came out that the highest number of family planning users had used sterilisation as a family planning method. Page 7

8 From the facility survey, it came out that the Primary Health Centres in five study districts were not well equipped to provide family planning services and no family planning counselors were available in the PHCs across the five districts of Bihar. There was no regular supply of family planning services to the facility. Health service providers accepted that the health system had been facing a dire lack of health staff and they had to provide different types of services by engaging limited number of staff. Follow-up Mechanism The follow-up mechanism was also very poor in all the districts. The women said that ASHAs did not pay visits after the selection of any family planning methods by women. ASHAs hardly came if the family planning users felt any discomfort after using any of the methods. Basically, family planning services are a matter of self choice and should be put into use through proper motivation and counseling and not as a matter of compulsion as there is dearth of staff. The providers lack proper skills of counseling and also lack in skills of carrying out the pre conditional physical and pelvic examinations before insertion of IUD and sterilisation. The health authorities admitted that there was a need for good Information Education and Communication (IEC) services related to family planning. In district level Jansamvads, service providers accepted that they should be trained on family planning counseling and how to provide proper information to the users. District Level Dialogues and Sharing In district level public dialogues, ASHA workers said none of the authorities helped them to redress the grievances of the community. ASHAs also shared that their problems were never heard by higher authorities. Medical Officers in-charge accepted that there was a target for sterilisation. The target was to sterilise one percent (0.05%) in every 200 people. Page 8

9 Photographs of District Level Jansamvad in Nalanda and Kishanganj District Page 9

10 Table 7: State Level Score Card of Bihar Indicators Districts Colours Community Enquiry BHAGALPU R KISHANGA NJ NAWAD A NALANDA RED YELLOW GREEN Client identification 12.9% 12.5% 19.37% 11.66% Counseling 34.5% 32.8% 19.5% 8.6% Information and Choice 63% 82.5% 65.26% 65% Quality of clinical 50% 60.9% 46.4% 27.45% services Follow-Up Management 44% 26.3% 26.6% 6.1% Element of Coercion 88.9% 95.8% 88.3% 0% Providers and Facility Enquiry Knowledge of Method 88.8% 57.7% 57.9% 28.9% Counseling and IEC 64% 54.4% 67.9% 30.6% Basket of Choice 60% 62.5% 83.3% 33.3% Targets/Incentive 59.2% 46.3% 55% 21.8% Facility Preparedness 50% 33.3% 55.8% 60% Quality of Clinical 76.5% 43.9% 42.85% 14.28% Services Follow-up Management 57.1% 73.7% 21.8% 21.8% Red <50% of cumulative score Poor Yellow 50-80% of cumulative score >80% of cumulative score Good Page 10

11 Table 8: District-wise findings of the community monitoring process INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA Counseling and Information Sharing Out of 150 women who participated in FGDs, 135 reported that the ASHAs do not come to their villages regularly. If we look at the data, there is a poor level of counseling (only 34.5%) among users by the family planning service providers and client identification is also very poor in the district. The service providers never counsel newlywed women for family planning.. Out of seven IUD users, four stated that no pelvic examination was done before inserting IUDs to them. Out of thirty five, only fifteen sterilisation users were informed about the possible effects on their health after the operation. Out of thirty five sterilisation users, sixteen women were not counseled about the side effects/health problems that could occur due to sterilisation. Out of 160 women who participated in FGDs, 81% (130 women respondents) reported that the ASHAs do not come to their villages regularly. There is a poor level of counselling of users by the family planning service providers, and client identification is also very poor. Out of 10 IUD users, 90% (9 IUD users) stated that no pelvic examination was done before inserting IUD. None of the sterilisation users were informed about the possible effects on their health after the operation. Out of 10 sterilisation users, 60% (6 sterilisation users) were not counselled about the side effects/health problems that could occur due to sterilisation. Due to high rate of ontraceptive failure, there is a lack of faith in communities on family planning methods. None of the women who opted for sterilisation reported that they had been informed about the family planning insurance Out of 114 women who participated in FGDs, 69 reported that the ASHAs do not come to their villages regularly. There is a poor level of counseling among users by the family planning service providers and client identification is also very poor. It has come out that the service providers never counsel newly married couples on various family planning methods. They rather focus on the women for sterilisation who already have two or more children. No pre medical examinations were done before inserting IUD s to the users. Among sterilisation users, all the thirty two women stated that only blood and urine test was done before the sterilisation operations. Out of thirty two sterilisation users, seven women were not counseled about the side effects/health problems that could occur due to sterilisation All the thirty two sterilisation users had given written consent for sterilization operation and none of All 106 women (participated in the FGDs) reported that the ASHAs do not come to their village regularly. No pre medical examinations have been done before using any methods of family planning All the fifteen sterilisation users were not counseled about the side effects/health problems that could occur due to sterilisation and all of them informed that they had not been counseled about other methods of family planning. None of the 15 female sterilisation users reported that they had been informed about the family planning insurance scheme in case any health problem occurs after sterilisation operation. Two women out of fifteen sterilisation users reported that they were scolded during sterilization operation. None of the sixteen IUD users have reported that pelvic examinations were done before inserting the IUDs Page 11

12 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA scheme in case any health problem occurs after sterilisation operation. None of the 10 IUD users interviewed reported that they had been counselled about the benefits of IUD, and all the IUD users reported that they had not received any counseling on side effects/health problems that could occur after IUD. Only 1 out of 12 OCP users had ever been counseled on the side effects of contraceptive pills, and no examination was done prior to the prescription for oral contraceptive pills the women reported that the consent form was read out to them and made them understand what was written there. None of the five IUD users have reported that their pelvic examinations were done before inserting the IUDs None of the sixteen IUD users interviewed, reported that they had been counseled about the benefits of IUD and all the 16 IUD users reported that they had not received any counseling on side effects/health problems that could occur after IUD. All the fifteen setrilisatioon users stated that only blood test was done before the NSV operation.. None of the female sterilisation users reported that they had been informed about the family planning insurance scheme in case any health problem occurs after sterilisation operation. None of the users were told about any other methods other then female sterilisation by ASHA. None of the 18 users had ever counseled on the side effects of contraceptive pills and no examination was done prior to the prescription for oral contraceptive pills. None of the users had ever been told what to do after finishing a packet of pills Page 12

13 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA Information and Choice All the thirty five sterilisation users had given written consent for sterilization operation and only two of the users reported that the consent form was read out to them and made them understand what was written there. Out of thirty five, only sixteen sterilisation users informed that they were also counseled about other family planning methods. Out of 10, only 30% (3 sterilisation users) informed that they were counseled about other methods of family planning. All 10 sterilisation users had given written consent for sterilisation operation; however, only 10% (1 sterilisation users) of the users reported that the consent form was read out to her and that she was helped to understand what was written there. Out of 32 sterilisation users, twenty five sterilisation users informed that they were not counseled about other methods of family planning rather than fesmale sterilisation. None of the female sterilisation users reported that they had been informed about the family planning insurance scheme in case any health problem occurs after sterilisation operation. None of them were given the sterilisation certificate till the date of interview. ASHAs never provided any detail information on spacing methods except seterilisation. ASHAs never provide any detailed information on spacing methods except seterilisation. Only one woman out of fifteen sterilisation users has given written consent for sterilization operation and none of the women have reported that the consent forms were read out to them and made them understand what was written there. Service providers never counsel newly married couples on various family planning methods. They rather focus on the women for sterilization who already have two or more children. Follow-up management From the FGD data, it has come out that ASHAs do not pay visits after the selection of any family planning methods by the women. ASHAs donot come if the family planning users feel any discomfort after using ASHAs do not pay visits after the selection of any family planning methods by the women. ASHAs do not come if the family planning users feel any discomfort after using any method. All 10 sterilisation users stated Out of thirty two sterilisation users, only four stated that after the operation, every fifteen minutes their blood pressure was checked Only four out of thirty two sterilisation users were told about any other methods other then female sterilisation by ASHAs. All the thirty two setrilisatioon Out of fifteen sterilisation users, none of them stated that their blood pressure was tested every fifteen minutes after the operation. All the sixteen IUD users mentioned that after insertion of IUD they had not been questioned about any feeling Page 13

14 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA any method. All the 35 setrilisatioon users stated that only tablets were provided after the NSV operation.. None of the women who opted for sterilisation reported that they had been informed about the family planning insurance scheme in case any health problem occurs after sterilisation operation. None of them were given the sterilisation certificate till the date of interview. All the 35 sterilisation users stated that ASHAs had come to their house one week after the operation. None of seven IUD users were asked about any feeling of discomfort after the IUD insertion. Out of seven IUD users, only one had reported that ASHA had come to visit them after three to six weeks of IUD insertion None of the seven IUD users interviewed, reported that they had been counseled about the benefits of IUD and all the IUD users that only tablets were provided after the Non Scalpel Vasectomy operation. Out of 10 sterilisation users, 6 stated that ASHAs had come to their house one week after the operation. None of 10 sterilisation users were given the sterilisation certificate till the date of interview. All 10 IUD users mentioned that after insertion of IUD they were not asked about any feeling of discomfort. None of the 10 IUD users reported that ASHA had come to visit them 3-6 weeks after IUD insertion. Out of 10 IUD users, 3 users did not receive any prescription or written slip describing the date of insertion and duration of the insertion. Out of total 12 OCP users, only one did not face any problems in accessing OC pills and ASHA told them what they should do if they forget to have tablets. users stated that only tablets were provided after the NSV operation.. None of the female sterilisation users reported that they had been informed about the family planning insurance scheme in case any health problem occurs after sterilisation operation. Only four sterilisation users stated that ASHAs had come to their house one week after the operation. All the five IUD users mentioned that after insertion of IUD they had not been questioned about any feeling of discomfort. None of the five IUD users had reported that ASHA had come to visit them after three to six weeks of IUD insertion Out of five IUD users, only one IUD user was asked about her health status prior to IUD insertion. None of the five IUD users interviewed, reported that they had been counseled about the benefits of IUD and all the IUD users reported that they had not received any counseling on side effects/health problems that could occur after IUD. None of the five IUD users had of discomfort. Only one out of sixteen IUD users had reported that ASHA had come to visit them after three to six weeks after insertion of IUD None of the sixteen IUD users had received any prescription or written slip describing the date of insertion and duration of the insertion All the 18 OCP users faced problems to access OC pills and ASHA never told them what they should do if they missed to have tablets Page 14

15 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA reported that they had not received any counseling on side effects/health problems that could occur after IUD. Out of seven IUD users, 3 users did not receive any prescription or written slip describing the date of insertion and duration of the insertion. Only one, out of five OCP users had ever counseled on the side effects of contraceptive pills and 4 users reported that no examination was done prior to the prescription for oral contraceptive pills. Out of total five OCP users, two women reported that they did not face any problems in accessing OC pills and ASHA told them what they should do if they forget to have tablets. received any prescription or written slip describing the date of insertion and duration of the insertion. Only one, out of four OCP users had been ever counseled on the side effects of contraceptive pills and no examination was done prior to the prescription for oral contraceptive pills. All the four OCP users did not face any problems to access OC pills and ASHA told them what they should do if they forget to have tablets Element Coercion of The community reported that they were not forced to take any methods, but the ASHAs The data obtained from service providers say that there is little coercion among family planning The data obtained from service providers say that there is little coercion among family planning users All 106 women reported that (FGD) they were coerced and given incentives to adopt Page 15

16 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA and ANMs always try to target women who already had more than two children. In Bhagalpur districtout of 35 sterilisation users, only 16 were told about other family planning methods by service providers. users in the village; however, the data show that the providers only tried to give emphasis on female sterilisations and other methods were not given as a choice to the community. in the village; however, the data show that the providers only tried to give emphasis on female sterilisations and other methods were not given as a choice to the community. family planning methods All the 49 users that were interviewed (Copper T-16, Mala D-18, Female Sterilisation-15) said that they were coerced in one form or other. Basket Choice of The providers only tried to give emphasis on female sterilisations and other methods were not given as a choice to the community. Out of 10, only 30% (3 sterilisation users) informed that they were counseled about other methods of family planning. ASHAs only tried to give emphasis on female sterilisations. None of the other methods were given as a choice to the community. From the interviews with ASHAs, it has come out that only method they provide information to the community is sterilisation. The data from community enquiry also shows that ASHAs only tried to give emphasis on sterilisation. Challenges and Gaps at facility level From the facility survey, it came out that only emergency contraceptive pills were available in the PHC and there was no space for proper storage of the methods. Primary Health Centre which was not well equipped to provide family planning From the facility survey, it came out that there were spacing method like contraceptive pills were not available in the PHC and there was no space for proper storage of the methods. There was no lady doctor and no Non-Scalpel Vasectomy (NSV) specialist was available in There was no lady doctor and no Non-Scalpel Vasectomy (NSV) specialist was available in the PHC. Primary Health Centre which was observed was not well equipped to provide family planning services. There was separate room for the women to take rest after operated. It was found that there was no family planning counselor in Primary Health Centre which was observed was not well equipped to provide family planning services. It was found that there was no family planning counselor and no stock of family planning methods was available. There was no lady doctor and no Non-Scalpel Page 16

17 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA Challenges and Gaps at Providers Level services. It was also observed that only emergency contraceptives pills were available in the PHC. During facility observation, it was noticed that, there was no regular supply of family planning services to the facility. Two out of five ASHAs stated that they did not distribute spacing methods in their village. From the interviews with users and FGD with community, it came out that ASHAs the PHC. Primary Health Centre observed was not well equipped to provide family planning services. There was separate room for the women to take rest after an operation. It was found that there was no family planning counsellor in PHC. During facility observation, it was noticed that there was no regular supply of family planning services to the facility. The infrastructure of Sub Centre and PHC level could not provide privacy to female contraceptive clients. That is why the women do not prefer visit to government hospitals. Two out of five ASHAs stated that they did not distribute spacing methods in their village. From the interviews with users and FGD with community, it came out that ASHAs only tried to give emphasis on the PHC. All the ASHAs said that they know only about female sterilizations among all the family planning methods None of the ASHAs told that they were ever provided any demonstration kit of different family planning methods to Vasectomy (NSV) was available in the PHC. During facility observation, it was noticed that, there was no regular supply of family planning services to the facility. Sterilisation targets were given to ASHAs, 12 cases per year and Anganwadi workers were also given targets for sterilisation, five women in a year. If they cannot fulfill the targets they were Page 17

18 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA only tried to give emphasis on female sterilisations. No other methods were given as a choice to the community. From the interviews with ASHAs, it came out that highest number of family planning users had used sterilisation as a family planning method. The ASHAs who were interviewed reported that they did not have enough stock of spacing methods to distribute among women in the villages. All of the ASHAs were given targets to bring in sterilisation cases. Two out of five ASHAs indicated that they did not have any demonstration kit of different family planning methods to demonstrate among community. From the interview with ASHAs, it came out that highest number of female sterilisations. No other methods were given as a choice to the community. From the interviews with ASHAs, it came out that the highest number of family planning users had used sterilisation as a family planning method. All the ASHAs were given targets to bring in sterilisation cases. Out of five ASHAs interviewed, two were not given any training on family planning. Out of five ASHAs, one ASHA stated that she did not provide any advice on family planning. None of the ASHAs said that they were ever provided any demonstration kit of different family planning methods to demonstrate among community members. From the interview with ASHAs, it came out that the highest number of demonstrate among community. During facility observation, it was noticed that, there was no regular supply of family planning services to the facility. ASHAs were provided only two or three strips of OCP which contains 28 tablets and that is not enough to meet the need of spacing methods in a village. Medical Officer in Charge stated that there was a target for sterilisation. The target was one percent in every 200 population. threatened to throw out from the service. All the ASHAs said that they know only about female sterilizations among all the family planning methods None of the ASHAs told that they were ever provided any demonstration kit of different family planning methods to demonstrate among community. ASHAs were provided only two or three strips of OCP which contains 28 tablets and that is not enough to meet the need of spacing methods in a village. Medical Officer in Charge stated that there was a target for sterilisation. The target was one percent in every 200 population. Page 18

19 INDICATORS BHAGALPUR KISHANGANJ NAWADA NALANDA family planning users of last year used sterilisation as a family planning method. The Medical Officer in Charge stated that there was a target for sterilisation family planning users of last year used sterilisation as a family planning method. The Medical Officer in Charge stated that there was a target for sterilisation. During the interview with the Medical Officer in Charge, it was found that prior to undertaking the surgery for sterilisation, women were not provided instructions according to the government directive for such procedures. Most of the women got copper T inserted by ASHAs, who were not trained. From the FGD, it came out that ANMs were not regularly present at the facility. ANMs do not pay attention to promoting contraceptives. Page 19

20 Conclusions The score card is reinforcing community enquiry and service provider s enquiry findings. The findings from provider and facility observations clearly show that there is a strong gap in service delivery of family planning. During district level public dialogues, the service providers accepted that there was lack of counselling from the providers side. The service providers also accepted that they only emphasised female sterilisations in order to meet the targets set by the State Government and that other spacing/family planning methods were not given as a choice to the community. The community enquiry and providers and facility enquiry process describe a similar kind of trend. The community data also shows there is little work done by providers to identify potential family planning users. In all the districts, family planning providers never identify the newly married couples and also fail to understand the need of the newlyweds for spacing methods. They only focus on women who already have two or more children. ASHAs never provide any detailed information on spacing methods except seterilisation. Proper counselling with informed choice and strong follow-up mechanism should be an integral part of family planning services. Though these criteria are mentioned in family planning guidelines but there is no evidence that these are followed in field level implementation.

21 Annexure: Media Coverage of District Level Jansamvad Page 21

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