status of frus and their critical...
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4
Status of FRUs and their Critical Determinants
4.1 Background
The critical requirements to make a FRU fully functional are Emergency Obstetric Care
(EmOC) services, with all types of surgeries, blood transfusion facility, care for new
born babies, and 24 hour round the clock delivery services. There are certain specific
issues in operationalisation of FRUs, which include accessibility to suitable infrastructure
which include operation theatres, labor rooms and water supply, on the logistics side;
shortage or lack of emergency drugs, lack of blood transfusion facilities, lack of skilled
manpower particularly anesthetists and gynecologist.
The number of FRUs operationalized in Gujarat state has shown an upward trend since
the year 2009- 10. In comparison to only 98 operationalized FRUs in 2009-10, there are
143 FRUs operationalized in the current year (2011-12). The number of fully functional
FRUs has also improved from 58 in 2009-10 to 110 in 2011-12. One of the tremendous
improvements made by the state government in FRUs is at all the non- functional FRUs
are now converted to Partial functional by providing Blood Transfusion and New born
care facility, a major emphasis was given on making the partially functional FRU to fully
functional which can provide all facilities available at FRUs to the patients. It can be seen
from the graph that the total partial functional FRUs has improved from 40 in the year
2009-10 to around about 37 in the year 2010-11 and has considerably improved in the
year 2011-12, though it has increased from 37 to 53, but this is due to the reduction in the
number of non functional FRUs, all of the 20 non-functional FRUs in the year 2010-11
have been made partially functional in the year 2011-12. This is a remarkable
180
160
140
120
100
80
60
40
20
achievement made by any state government in India so far. The graph below shows the
comparison of FRU status for the past three years.
FIGURE 4.1 STATUS OF FRUs SINCE 2009 IN GUJARAT
133
156
163 163
136
98
110
99
2009-10 2010-11 2011-12
58 53
40 37 35
20
0 State Total
FRUs
State Total
Operationlise FRUs
Total Fully Functional
FRUs
Total Partialy
Functional FRUs
0
Total Non Functional
FRUs
4.2 Analysis of FRUs in terms of the Functioning status
In order to evaluate the status of the FRUs in terms of its functioning, a center wise check
list was prepared which evaluated the FRUs on the following parameters:
1. Availability of C-Section delivery services
2. Availability of Blood Transfusion Facility
3. Availability of Facility based New Born Care
Based on the above three parameters, the FRUs were indicated to be fully functional,
partially functional or Non- Functional on the following criteria.
• Availability of all 03 facilities = Fully Functional
• Availability of any 02 services = Partially Functional
• Availability of any 01 services = Partially Functional
• Non- availability of all 03 services = non- functional.
TABLE 4.1 CRITERIA FOR SETTING FRU STATUS
Essential Facilities required at FRUs Status of FRU
Cesarean Section Blood Transfusion New Born Care
Available Available Available Fully Functional
Available Available Not- Available Partially Functional
Available Not-Available Available Partially Functional
Available Not-Available Not-Available Partially- Functional
Not- Available Available Available Partially Functional
Not- Available Not-Available Available Partially Functional
Not-Available Available Not- Available Partially Functional
Not- Available Not- Available Not- Available Non- Functional
Based on the above criteria, all the 163 FRUs in Gujarat were analyzed to determine their
current status as shown below.
TABLE 4.2 COMPLETE LISTS OF FRUs, TYPES, SERVICE AVAILABILITY
AND STATUS
Sr. No.
FRU Name
FRU Type
Cesarean Section
Available
Blood Transfusi
on Available
New Born Care
available
Status
1 Dhandhuka CHC Yes Yes Yes FF
2 Dholka CHC Yes Yes Yes FF
3 Sanand CHC Yes Yes Yes FF
4 Viramgam CHC Yes Yes Yes FF
5 Bavla CHC Yes Yes Yes FF
6 Singarva CHC NO Yes Yes PF
7 Sola DH Yes Yes Yes FF
8 Balasinor CHC NO Yes Yes PF
9 Dakor CHC Yes Yes Yes PF
10 Matar CHC Yes Yes Yes FF
11 Nadiad DH Yes Yes Yes FF
12 Kheda SDH Yes Yes Yes FF
13 Khambhat CHC Yes Yes Yes FF
14 Petlad DH Yes Yes Yes FF
15 Tarapur CHC Yes Yes Yes FF
16 Umreth CHC NO Yes Yes PF
17 Anklav CHC NO Yes Yes PF
18 Sarsa CHC Yes Yes Yes FF
19 Sojitra CHC NO Yes Yes PF
~ 58 ~
20 Chotila CHC NO Yes Yes PF
21 Dhrangadhra SDH Yes Yes Yes FF
22 Patdi CHC NO Yes Yes PF
23 Surendranagar DH Yes Yes Yes FF
24 Limbdi SDH NO Yes Yes PF
25 Sayla GIA Yes Yes Yes FF
26 Kalol MCs NO Yes Yes PF
27 Gandhinagar DH Yes Yes Yes FF
28 Mansa CHC Yes Yes Yes FF
29 Dahegam CHC Yes Yes Yes FF
30 Charada CHC NO Yes Yes PF
31 Kadi CHC Yes Yes Yes FF
32 Unjha SDH Yes Yes Yes FF
33 Mahesana DH Yes Yes Yes FF
34 Visnagar SDH NO Yes Yes PF
35 Vadnagar SDH NO Yes Yes PF
36 Vijapur CHC NO Yes Yes PF
37 Sarvajanik Hospital GIA Yes Yes Yes FF
~ 59 ~
& Maternity Home, Gojaria, Mehsana
38 Patan DH Yes Yes Yes FF
39 Radhanpur CHC Yes Yes Yes FF
40 Siddpur SDH Yes Yes Yes FF
41 Deesa SDH Yes Yes Yes FF
42 Deodar CHC Yes Yes Yes FF
43 Thara CHC Yes Yes Yes FF
44 Tharad CHC Yes Yes Yes FF
45 Palanpur DH Yes Yes Yes FF
46 Dhanera CHC Yes Yes Yes FF
47 Mehmadpur CHC NO Yes Yes PF
48 Bhansali Trust Gandhi - Lincoln
Hospital,
Radhanpur
GIA
Yes
Yes
Yes
FF
49 Shihori CHC NO Yes Yes PF
50 Bhiloda SDH NO Yes Yes PF
~ 60 ~
51 Idar CHC Yes Yes Yes FF
52 Khedbrahma SDH Yes Yes Yes FF
53 Himatnagar DH Yes Yes Yes FF
54 Malpur CHC Yes Yes Yes FF
55 Shamlaji GIA Yes Yes Yes FF
56 Talod CHC NO Yes Yes PF
57 Prantij CHC Yes Yes Yes FF
58 Ganbhoi CHC NO Yes Yes PF
59 Rasiklal Shah Sarvjanik Hospital,
Modasa
GIA
Yes
Yes
Yes
FF
60 Chhota Udaipur CHC Yes Yes Yes FF
61 Dabhoi CHC Yes Yes Yes FF
62 Padra CHC Yes Yes Yes FF
63 Jabugam CHC Yes Yes Yes FF
64 Vadodara DH Yes Yes Yes FF
65 Kwant CHC Yes Yes Yes FF
66 Savli CHC Yes Yes Yes FF
~ 61 ~
67 Motafofadiya GIA Yes Yes Yes FF
68 Jambusar CHC Yes Yes Yes FF
69 SR - Jhagadia GIA Yes Yes Yes FF
70 Bharuch DH Yes Yes Yes FF
71 Vagra CHC Yes Yes Yes FF
72 Dediapada CHC NO Yes Yes PF
73 Rajpipla DH Yes Yes Yes FF
74 Tilakwada CHC NO Yes Yes PF
75 Sagbara CHC Yes Yes Yes FF
76 Dahod DH Yes Yes Yes FF
77 Zalod CHC NO Yes Yes PF
78 Limkheda CHC Yes Yes Yes FF
79 Devgadhbaria SDH Yes Yes Yes FF
80 Halol CHC Yes Yes Yes FF
81 Santrampur SDH Yes Yes Yes FF
82 Godhra DH Yes Yes Yes FF
83 Shehera CHC NO Yes Yes PF
84 Gogamba CHC Yes Yes Yes FF
~ 62 ~
85 Malav* GIA NO Yes Yes PF
86 Bardoli CHC Yes Yes Yes FF
87 Mandvi CHC Yes Yes Yes FF
88 Mangrol CHC NO Yes Yes PF
89 Olpad CHC Yes Yes Yes FF
90 Klaranj MCs NO Yes Yes PF
91 Althan MCs Yes Yes Yes FF
92 Sanjivani Hospital Ta. - Palsana
GIA
Yes
Yes
Yes
FF
93 Sardar Smarak Hospital Bardoli
GIA
Yes
Yes
Yes
FF
94 Zankhov CHC NO Yes Yes PF
95 Songhad CHC Yes Yes Yes FF
96 Uchchhal CHC NO Yes Yes PF
97 Vyara DH Yes Yes Yes FF
98 Janak Smarak Trust Hospital ,Tapi
GIA
Yes
Yes
Yes
FF
99 Chikhli CHC Yes Yes Yes FF
~ 63 ~
100 Navsari DH Yes Yes Yes FF
101 Vansda SDH Yes Yes Yes FF
102 Gandevi CHC Yes Yes Yes FF
103 Gram Seva Trust, Kharel, Navsari
GIA
Yes
Yes
Yes
FF
104 Bhilad CHC Yes Yes Yes FF
105 Dharampur SDH Yes Yes Yes FF
106 Valsad DH Yes Yes Yes FF
107 Shrimad Rajchandra Hospital Dharmapur
GIA
Yes
Yes
Yes
FF
108 Nana Pondha CHC NO Yes Yes PF
109 Kastuba Hospital Valsad
GIA
NO
Yes
Yes
FF
110 Kaprada CHC NO Yes Yes PF
111 Ahwa DH Yes Yes Yes FF
112 Gadhada CHC NO Yes Yes PF
113 Gariadhar CHC NO Yes Yes PF
114 Palitana SDH Yes Yes Yes FF
~ 64 ~
115 Botad CHC Yes Yes Yes FF
116 Sihor CHC Yes Yes Yes FF
117 Talaja CHC NO Yes Yes PF
118 T.M.Vadodaria Hospital, Botad
GIA
Yes
Yes
Yes
FF
119 Mahuva Municipal Hos.
MCs
Yes
Yes
Yes
FF
120 Babra CHC NO Yes Yes PF
121 Dhari CHC Yes Yes Yes FF
122 Lathi SDH Yes Yes Yes FF
123 Rajula CHC Yes Yes Yes FF
124 Amreli DH Yes Yes Yes FF
125 Khambha CHC NO Yes Yes PF
126 Savar Kundla SDH Yes Yes Yes FF
127 Radhika Hospital, Amreli
GIA
NO
Yes
Yes
FF
128 Keshod CHC NO Yes Yes PF
129 Manavadar CHC NO Yes Yes PF
~ 65 ~
130 Junagadh DH Yes Yes Yes FF
131 Una CHC Yes Yes Yes FF
132 Veraval SDH Yes Yes Yes FF
133 Talala* CHC NO Yes Yes PF
134 Mangroad CHC NO Yes Yes PF
135 Madiahatina CHC NO Yes Yes PF
136 R.N.Vala Trust Hospital,Kodinar
GIA
Yes
Yes
Yes
FF
137 Porbander DH Yes Yes Yes FF
138 Dhoraji SDH Yes Yes Yes FF
139 Gondal SDH NO Yes Yes PF
140 Jasdan CHC NO Yes Yes PF
141 Jetpur SDH Yes Yes Yes FF
142 Morbi SDH Yes Yes Yes FF
143 PK Rajkot DH Yes Yes Yes FF
144 Vinchhiya CHC NO Yes Yes PF
145 Paddhari CHC NO Yes Yes PF
146 Upleta SDH Yes Yes Yes FF
~ 66 ~
147 Dhrol CHC NO Yes Yes PF
148 Dwarka CHC NO Yes Yes PF
149 Jamjodhpur CHC NO Yes Yes PF
150 Khambhalia DH Yes Yes Yes FF
151 Bhanvad CHC NO Yes Yes PF
152 Lalpur CHC NO Yes Yes PF
153 Kalavad CHC NO Yes Yes PF
154 Anjar CHC Yes Yes Yes FF
155 Bhachau CHC Yes Yes Yes FF
156 Mandvi SDH Yes Yes Yes FF
157 Mundra CHC Yes Yes Yes FF
158 Nakhatrana CHC Yes Yes Yes FF
159 Bhuj DH Yes Yes Yes FF
160 Gandhidham SDH Yes Yes Yes FF
161 Rapar CHC NO Yes Yes PF
162 Naliya CHC NO Yes Yes PF
163 Khavda CHC NO Yes Yes PF
FF= Fully Functional, PF = Partially Fnctional.
~ 67 ~
~ 68 ~
The above table gives a complete list of all 163 FRUs in state along its type, status of the
main services and their performances.
FIGURE 4.2 GRAPHICAL SUMMARY OF FRU STATUS
A graphical summary of the status of all FRUs in Gujarat state is shown below shows that
there are still only 67% FRUs that are Fully Functional and the remaining 33% are
Partially Functional FRUs. One of the biggest achievements made by the state is that
there are no FRUs that are completely non- functional in the state.
~ 68 ~
TABLE 4.3 REGION WISE DISCRIPTION OF FRU’S FUNCTION ALITY
FRUs Details for 2012-13 Sr. No.
Regional Office
Name of District
No of designated FRUs
No of Operationlise
FRUs
No of Fully Functional FRUs
No. of FRUs Conducting C-Section
No of Partial Functional FRUs
Non-Functional FRUs
1
Ahmedabad
Ahmedabad 7 7 6 6 1 0 2 Kheda 5 5 3 3 2 0 3 Anand 7 7 4 4 3 0 4 Surendranagar 6 6 3 3 3 0
Sub Total :- 25 25 16 16 9 0 5
Gandhinagar
Gandhinagar 5 5 3 3 2 0 6 Sabarkantha 10 10 7 7 3 0 7 Banaskantha 9 9 7 7 2 0 8 Mehsana 7 7 4 4 3 0 9 Patan 3 3 3 3 0 0
Sub Total :- 34 34 24 24 10 0 10
Vadodara
Vadodara 8 8 8 8 0 0 11 Dahod 4 4 3 3 1 0 12 Panchmahal 6 6 4 4 2 0 13 Bharuch 4 4 4 4 0 0 14 Narmada 4 4 2 2 2 0
Sub Total :- 26 26 21 21 5 0 15
Surat
Surat 9 9 6 6 3 0 16 Navsari 5 5 5 5 0 0 17 Valsad 7 7 5 5 2 0 18 Tapi 4 4 3 3 1 0 19 Dang 1 1 1 1 0 0
Sub Total :- 26 26 20 20 6 0 20
Bhavnagar Bhavnagar 8 8 5 5 3 0
21 Amreli 8 8 6 6 2 0 22 Junagadh 9 9 4 4 5 0
Sub Total :- 25 25 15 15 10 0 23
Rajkot
Rajkot 9 9 5 5 4 0 24 Jamnagar 7 7 1 1 6 0 25 Kachchh 10 10 7 7 3 0 26 Porbandar 1 1 1 1 0 0
Sub Total :- 27 27 14 14 13 0
A region wise detailed list of the FRUs showing their Status , in terms of the number of
the FRUs operationalized, the number of Fully Functional , How many FRUs are
performing C-section deliveries and the number of partially Functional and non-
functional FRUs is as shown above.
~ 70 ~
FIGURE 4.3 DISTRIBUTIONS OF FRUs ACCORDING TO THE T YPES
From the above table we can arrive at the distribution of FRUs as per the types as shown
in the figure above. It can be observed that majority of the FRU centers are of CHC type
comprising of 57% of the total FRUs, District hospitals, Sub-district hospitals occupy 15
% of the share each and remaining 13 % is shared among the Grant - in- aid hospitals and
Municipal corporation hospitals.
A geographical distribution of the FRUs in Gujarat based on their types is represented
below; The Map shows hat districts like Anand and surat are having a higher number of
FRUs compared to other districts. Rajkot district has only 03 CHCs functioning as FRUs
where as there are more number of sub district hospitals which are FRUs, Rajkot district
has 05 sub district hospital working as FRUs in addition to 02 District Hospitals . Certain
districts like Sabarkantha, Valsad and Surat have Grant-in aid hospitals working as FRUs,
all of the above three 3 districts have 02 GIA hospitals as FRUs. Dang district has only
~ 71 ~
one FRU which is a District Hospital, similarly, Patan District has only 3 FRU centers as
these districts have comparatively smaller population than the other districts. Majority of
the FRU centers are located at southern and eastern region of Gujarat to match with the
density of the rural population in Gujarat. As per the norms it is sufficient if there is 1 one
FRU (Providing all services designated for an FRU) for 5 lakh population which should
be supported by 5 BEmOC centres (1 per 1 lakh population). Average population per
FRU in Gujarat is 3, 70,452 (ranges from 1, 47,595 to 10, 29,743). Hence the number of
FRUs designated is more than sufficient for the state.
FIGURE 4.4 GEOGRAPHICAL DISTRIBUTIONS OF FRUs IN GU JARAT
~ 72 ~
4.3 Functional and Weak Delivery Points
Maternal health can be improved to a large extent if provision for safe delivery with
emergency care is available for all women; on these lines it is essential to provide both
normal deliveries and c-section deliveries facility to all women. One of the major purpose
of setting up FRUs and operationalize them was to provide safe delivery services. From
the above data it is evident that Blood transfusion and New Born care facilities are
available at all 163 centers whereas the Cesarean section services are available at 121
centers only but only 110 FRU centers are fully functional at present.
It was essential to carry out an analysis of these centers based on the number of deliveries
performed to get the actual picture and more over this would serve as a basis to know if
these centers were actually providing the necessary services for which they w ere set up.
In order to evaluate the way the FRUs are performing in trems of the number of
deliveries conducted on an average per month, the following criteria was set for different
type of Centers based on the load or the number of population of patient s a particular
center would serve along with the level of the location of the center. For Example a
District Hospital is located at the District level and would be serving a larger population
in comparison to the sub- district or the community health center which is located at the
taluka or village level.
TABLE 4. 4 CRITERIA FOR SETTING FRU AS FUNCTIONAL D ELIVERY
POINT
Type of FRU center Number of deliveries on
an Average per month
Status of FRU Center
CHC >/= 20 Functional Delivery Point
< 20 Weak Delivery Point
District Hospitals >/= 50 Functional Delivery Point
< 50 Weak Delivery Point
Other FRUs >/= 20 Functional Delivery Point
< 20 Weak Delivery Point
~ 73 ~
When determining the FRUs as FDP or WDP, the total number of deliveries performed
i.e. both normal and caesarean deliveries were taken into consideration. , since CHC is
smaller center having a bed occupancy of 20-30 beds , the average number of deliveries
per month for setting it as a FDP was 20 , however the district hospital has a larger inflow
of patients as it servers 5-6 villages and the bed occupancy is over 100 beds.
An analysis of the FRUs in terms of the FDP shows that all that out of 163 FRUs, there
are 124 centers which are functional delivery points and 19 centers and WDP. This
implies that 76% of the FRU in state are functional delivery points. A break up of these
Functional delivery points in terms of FRU type reveals that 16 centers out of 24 at the
District Hospitals level , 76 out of 93 at Community Health Center leve l and 32 out of 46
centers at the other FRU level are functional delivery points and the remaining one are
weak delivery points.
When an analysis of cesarean section delivery performed in a year at these FRU was
done , it was found that all FRU at District Hospital Level were performing Cesarean
section delivery, But the story was different for FRUs of CHC type, although the number
of FDPs were high at CHC, but the number of centers performing cesarean section
delivery was much lower only 45 centers at CHC level were performing C-section
delivery which meant that only about 48% of CHC were performing cesarean section
delivery. However the Other FRU centers showed much better performance in terms of
conducting Cesarean section where in 38 centers out of 46 were performing cesarean
section deliveries showing that 82% of the centers were showing a good performance. 05
centers at the Sub –district hospital level were not performing cesarean section deliveries
apart from the 08 centers which were weak delivery points. Grant- in-aid hospitals were
better compared to CHC and SDH centers as there was only one center which was not
performing cesarean section delivery.
All in all a total of 53 centers out of 163 centers were not performing cesarean section
deliveries in the the state.
~ 74 ~
The table shown below gives the deatils of the list of FRU centers with their
functionality details in terms of FDP, WDP and C-section performance.
TABLE 4.5 DETAILS OF DELIVERY POINTS
State Health care facilities
as CHCs, SDHs, DHs, GIA-Hs & MC-Hs working as per FRUs
functionalities
Sr.No.
Name of type
Delivery
Points
Functional
Delivery
Points
Weak
Delivery
Points
Delivery
Points; not
Performing
C-Section
1
CHC-FRUs 93 76 17 45
2
SDH-FRUs
25
17
8
5
3
DH-FRUs
24
16
8
0
4
Grant in Aid
Hospital- FRUs
17
12
5
1
5
Municipal
Corporation Hospital-
FRUs
4
3
1
2
State total FRUs 163
124
39
53
FIGURE 4.5 FDP
FIGURE
~ 75 ~
DP & WDP DATA OF FRUs BASED ON THEI
4.6 FRU TYPES WITH DELIVERY STAT US
IR TYPES
US
~ 76 ~
As seen earlier , the major reason for an FRU to remain partially function is that cesarean
section deliveries are not being performed at certain centers , while there are few centers
which are performing below the target set for average deliveries per month , there are
other centers which either underperforming or not performing cesarean section deliveries
at all.
4.4 Health Region wise Study of FRUs
As mentioned earlier Gujarat state is divided in six health regions for administration, a
study of FRUs region wise was conducted to understand the gaps in their functionality.
Ahmedabad Region: This region comprises of 4 districts, Ahmedabad, Anand, Kheda
and Surendranagar. All in all, there are 25 FRUs located in this region. Out of these 25
FRUs, 17 are of CHC types, 04 FRUs are District Hospitals, there are 03 sub-district
hospitals type FRUs and 01 Grant- in aid type FRUs. All the FRUs have been
operationalized in this region. However not all of them are functioning as completely
functional. 24 FRUs out of the 25 operationalized FRU centers are Fully Functional
which means that only 96% of FRUs in Ahmedabad region have all three critical
facilities required to be Fully functional FRUs. There is only one FRU that is Partially
Functional and an equal number of FRU though being operationalized is not performing
C-section delivery. In terms of percentage, we can determine that 1% of FRUs are not
performing cesarean section operations.
Most of these FRUs are in urban region and are comprising of all the necessary resources
and infrastructure, but still 01 center i.e. 1% of FRU is not functioning to provide the
required emergency services. One of the good things in Ahmedabad region is that there
are no completely non- functional FRUs as all centers are capable of providing at least
one of the three critical health services along with emergency Care for all particularly for
the maternal, new borns and other regular patients.
The Map of the Ahmedabad region shows the distribution of 25 FRUs in this region, their
types and their status.
~ 77 ~
FIGURE 4.7 AHMEDABAD REGION GRAPH SHOWING TYPES OF FRUs AND ITS STATUS
In terms of the delivery points, out of the 25 FRU centers, only one FRU center located at
Surendranagar district which is a District hospital is a weak delivery point wherein this
center is not performing 50 or more deliveries per month and the remaining 24 centers
comprising of 03 SDH, 17 CHC and 01 GIA centers are all functional delivery points.
The next figure depicts the Delivery points in Ahmedabad Region
~ 78 ~
FIGURE 4.8 AHMEDABAD REGION’S FRU- DELIVERY POINT S TATUS
Gandhinagar region:
Gandhinagar region comprises of the 05 districts which includes Gandhinagar, Mehsana,
Patan, Banaskantha and Sabarkanta districts. This region has the highest number of FRUs
compared to any other health region of Gujarat. There are 34 FRU centers that are
operationalised in this region out which only 24 centers are fully functional with
availability of three critical facilities, there are 10 FRU centers which are partially
functional and equal numbers of centers are not performing the adequate number of
Cesarean section delivery. In terms of Functional delivery points, only 12 centers out of
34 are functional delivery points where in there are performing the set target number of
deliveries according to their type which means that only 35% of the FRU centers are
functional delivery points and the remaining 65% of the centers are weak delivery points
which is the highest number of weak delivery centers compared to any other region. The
Sabarakanta distinct has the highest number of FRUs comprising of 11 FRU centers and
~ 79 ~
5 out these 11 centers are weak delivery points. Only 6 CHC centers out of 17 centers are
functional delivery points, implying that more than 65% of CHC types FRUs are Weak
delivery points.
FIGURE 4.9 MAP OF GANDHINAGAR SHOWING FRU DISTRIBUT ION
ALONG WITH THEIR STATUS
The only type of center which does not have any weak delivery point is the municipal
corporation centers.
~ 80 ~
FIGURE 4.10 GANDHINAGAR REGION’S FRU DELIVERY POINT
Vadodara Region:
Vadodara region comprises of 05 districts, Panchmahal, Vadodara, Dahod, Bharuch and
Narmada. This region has 26 FRU centers, comprising of 16 CHC centers, 05 District
Hospitals- FRU centres, Sub-district Hospitals-CHC centers, and 03 Grant- in –aid
Hospitals- FRU centers. Vadodara region has the highest percent of fully functional
FRUs, 21 centers out of 26 centre s are fully functional centers implying 80% of the
FRUs were having all critical facilities available in this region. An analysis of the
delivery points in this region shows that Vadodara region has a better percentage of
functional delivery points with 20 out of 26 centers are functional delivery points and
~ 81 ~
only 06 centers are weak delivery point showing that a good 76% of the centers are
functional delivery points. Out of the 16 CHCs in Vadodara, 15 centers are Functional
delivery points and only one CHC-FRU in this region is a weak delivery point. 04 CHC
centers which are FRUS are not performing cesarean section deliveries. All in the entire
Vadodara region has shown better performance in comparison to the other regions during
the year 2011-12. The map below shows the details of the FRU types and their
functionality in terms of functional and weak delivery points.
FIGURE 4.11 MAP OF VADODARA REGION SHOWING FRU LOCA TION
AND THEIR STATUS
~ 82 ~
FIGURE 4.12 VADODARA REGION’S FRU DELIVERY POINT ST ATUS
Surat Region:
Surat region comprises of 05 districts – Surat, Tapi, Navsari, Dang and Valsad. This
region has 26 FRU centers, comprising of 12 CHC centers, 04 District Hospitals, 02 Sub-
district hospitals, 06 Grant- aid- Hospitals and 02 Municipal corporation hospitals. 20 of
the FRU centers are fully functional, and 06 centers are partially functional, which means
that 76 % of the FRU centers in Surat region are fully functional. 06 out of these 26
centers are not performing any cesarean section deliveries. Only 09 out of 12 CHC
centers are functional delivery points and 03 centers are weak delivery points.
~ 83 ~
FIGURE 4.13 MAP OF SURAT REGION SHOWING LOCATION OF FRUs
Figure below shows the FRU status in Vadodara region with their classification
according to their types and in terms of their delivery performance status.
~ 84 ~
FIGURE 4.14 FUNCTIONAL AND WEAK DELIVERY POINTS IN SURAT
REGION
Bhavnagar Region:
Bhavnagar Region comprises of only 03 but large districts- Junagadh, Amreli and
Bhavnagar. This region has 25 FRU centers among these 15 centers are of CHC type, 02
centers are district hospitals, 04 sub-districts centers, 03 grant-in –aid hospitals and 01
municipal corporation hospitals centers. In Bhavnagar region only 15 centers out of 25
are fully functional and 10 centers are partially functional showing that only 60% of the
centers are fully functional, around 40% of the centers are not performing cesarean
section deliveries. All of the 15 CHC centers are functional delivery points. There are no
weak delivery points in CHC, District Hospitals and Municipal corporation Hospitals
~ 85 ~
type of FRU centers in this region. Out of 25 centers, only 02 centers are weak delivery
points and 23 centers are functional delivery points thus showing that 92% of the centers
are functional delivery points which are the highest number of deliveries points compared
to any other region in Gujarat.
FIGURE 4.15 FRUs LOCATION IN BHAVNAGAR REGION
~ 86 ~
FIGURE 4.16 FRU DELIVERY POINTS STATUS IN BHAVANAGA R REGION
Rajkot Region:
The Rajkot region comprises of 04 districts, Kutch the largest district of Gujarat falls
under this region along with Jamnagar, Rajkot and Porbander. This region has the second
highest number of FRUs in the state. There are a total of 27 FRU centers among which 16
are CHC centers, 04 District Hospitals and 07 Sub-District Hospitals. There are no Grant-
in-aid centers and no municipal corporation hospitals designated as FRUs in this region.
Out of the 27 FRU centers, only 14 centers are fully functional, 13 centers are partial
functional and an equal number of centers are not performing cesarean section operation
~ 87 ~
this implies that only 51% of the FRU centers are fully functional in this region however
the number of functional delivery points is having a better percentage with 24 out of 27
centers are functional delivery points with a good percentage of 88% of FDPs in this
region.
FIGURE 4.17 FRUS LOCATION IN RAJKOT REGION
~ 88 ~
FIGURE 4.18 DELIVERY POINTS STATUS IN RAJKOT REGION
A region wise breakup of the Functional delivery points shows that almost all FRUs in
Ahmedabad region are Functional delivery points except for one center. Gandhinagar
region showed the poorest performance, only 12 centers out of 34 FRUs were Functional
delivery points and 22 centers were weak delivery points. Bhavnagar was the only other
region other than Ahmedabad which has most number of Functional Delivery Points.
TABLE 4.6 REGIONWISE DETAILS OF FDP AND WDP
Region
Total no. of FRUs /
Delivery Points
Functional
Delivery Points
Weak Delivery
Points
Ahmedabad 25 24 1
~ 89 ~
Gandhinagar 34 12 22
Vadodara
26
20 06
Surat
26
21 05
Bhavnagar
25
23 02
Rajkot
27
24 03
As shown below, the graphical presentation of the functional Delivery points
FIGURE 4.19 ALL REGIONS’ FUNCTIONAL DELIVERY POINT S
FIGURE 4. 20 ALL REGIONS’ DELIVERY POINTS ACCRODING TO TYPES
~ 90 ~
~ 91 ~
FIGURE 4.21 DELIVERY POINTS NOT PERFORMING C- SECTI ON
4.5 Evaluation of EMOC specialists’ availability at FRUs
One of the Critical concerns in ensuring CEmOC and providing Cesarean section at
FRUs was shortage of specialists. The specialists needed for EmOC are:
• A gynecologist specialist ,
• An anesthetists
• A pediatric specialist
The current positioning of these specialists in Gujarat state shows that there are only 109
gynecologists available in the state and for 163 FRUs, only 98 of them are posted at
FRUs and 11 gynecologists are posted at non-FRU centers. Thus there is a shortage of
atleast 65 gynecologists at FRUs. Although all of the 78 available anesthetists are posted
at FRUs and none are posted at non-FRU centers, yet there is a shortage of 85
anesthetists at FRUs. There is shortage in the availability of the pediatricians at FRUs.
~ 92 ~
State has a total of 62 pediatricians out of which only 58 are available at FRUs and 04 of
them are posted at non- FRU centers thus there is a shortage of more than 61% of
pediatricians at the FRUs. The table below shows the availability and positioning of these
staff at the FRUs.
TABLE 4.7 SPECIALISTS STAFF POSITIONING
Specialists Positioning at First Refer ral units & Non- FRUs
Objectives Obs. & Gynecologists
Anesthetists
Pediatricians
Position in state Regular/ NRHM
Contractual Regular/ NRHM
Contractual Regular/ NRHM
Contractual Posted at FRUs 98 78 58 Posted at Non- FRUs
11
0
4
Total 109 78 62
In order to fill the gaps of Gynecologists and Anesthetists manpower, trainings were
provided to the existing medical officers at these centers by the Government of India.
Assistance was taken from FOGSI and Jhpiego for this training program, Medical
officers were trained for 16 weeks on comprehensive emergency medical care ( CEmOC)
and for 18 weeks on Life saving anesthetic skills. Theses trained docotors are called as
CEmOC specialist and LSAS Specialist respectively.
A detailed study of the CEmOC and LSAS trainings provided to medical officers shows
that since 2005, there have been 11 batches of training conducted so far for both CEmOC
and LSA skills and a total of 77 CEmOC and 104 LSAS doctors have been trained during
this period. Despite having adequate number of trained CEmOC specialists, only 41 of
them are posted at FRU centers indicating that almost 53% of trained CEmOC are posted
at FRUs. On the other hand, out of the 104 trained LSAS specialists, 66 are posted at
FRUs. In other words about 63% of these specialists are posted at FRUs. Some of these
trained staff are not available at FRUs due to miscellaneous reasons such as either some
of them have opted of other trainings or higher studies, some of them have either resigned
~ 93 ~
or demised. A major reason for the shortage of staff is the un-organized posting of
CEmOC and LSAS trained staff at non-FRU centers.
FIGURE 4.22 AVAILABILITY OF CEmOC TRAINED SPECIALIS TS AT FRUs
The Figure above show that 31 out of 77 CEmOC specialists are posted at non- FRUs
centers and similarly 22 out of 104 LSAS staff are posted at centers which are not
designated as FRUs, and their services are not utilized for providing emergency obstetric
care at FRUs. Out of the 77 trained CEmOC, only 36 are working at FRUs implying the
availability of only 47% of the trained staff at FRUs and 40% of these trained specialist s
are still working at non-FRU centers where their services are not fully utilized. About
13% of the trained specialists are not available at FRUs due to miscellaneous reasons as
shown in the graph above. 06 candidates who have resigned from the posted aft er being
trained is a loss to the FRU and to the government and such cases need to be avoided
~ 94 ~
similarly there are candidates who have taken a long term leave is not serving the purpose
of being trained on CEmOC facility.
Figure 4.6 shows the details of the LSAS trained medical officers and their positioning, it
can be seen that there have been 96 medical officers trained on LSAS, however only 51
of these are posted at FRUs and about 30 trained specialists are working at non- FRU
centers, implying that only 49 % of the LSAS trained specialists are available at FRUs
and 29% are working at non FRU centers. About 7% of the medical officers trained on
this skill did not pass out the training. Candidates who have resigned or taken a long term
leave are 06 medical officers and their services are not utilized at FRUs despite being
trained on LSAS skills. Hence the miscellaneous reasons for not having the trained
officers posted at FRU comprises of 22% which can be avoided.
FIGURE 4.23 AVAILABILITY OF LSAS TRAINED SPECIALIST S AT FRUs
~ 95 ~
It is evident from the above information that the shortage of specialist manpower can be
dealt to a large extent by having the CEmOC and LSAS trained specialist posted at only
FRU centers within state. In order to perform a successful C-section delivery, a team of
both Gynaecologist and Anaesthetist is necessary.
Analysis shows that there are 51 FRU centers which lack the availability of either
gynaecologists or a CEmOC trained specialists. Similarly 64 FRUs lack an anaesthetist or
a LSAS trained specialists. There are 32 centers like Rajpipla, Tharad and others which
do not have the availability of any of the four specialists mentioned above. This indicates
that about 19% of the FRU centers are not fully functional due lack of all specialists and
about 31 % of centers are not fully functional due to lack of only CEmOC specialists and
39% of the centers are having shortage of LSAS / anaesthetists.
TABLE 4.8 EmOC SPECIALISTS AVAILABILITYA AT FRUs
FRU Centers having all 4 Specialists
FRUs Having Only Gynecologists/
CEmOC
FRUs Having Only Anesthetics / LSAS
FRUs Not having any of
the 4 specialists.
110 112 99 32
4.6 Status of Blood Transfusion facility at FRUs.
The Gujarat Sate Council for Blood TRansfusion (GSCBT) was established by
Government of Gujarat for ensuring safe blood safety standards were maintained in the
state. In Gujarat, the availability of blood is ensured through a network of 143 functional
blood banks. Out of these, 80 are in the public and charitable sectors and are supported by
NACO. This includes 1 Model Blood Bank, 12 Blood Component Separation Units, 12
Blood Banks which are Major and 55 Blood banks at district level. As per the SRS report
for 2011, the maternal mortality rate of Gujarat is 160, the major cause of maternal death
in Gujarat was also found to be bleeding/hemorrhage during delivery. Availability of
blood transfusion facility is another mandatory requirement for a FRU to be fully
~ 96 ~
functional and provide comprehensive emergency medical and obstetric care. Hence an
analysis of the blood transfusion services is carried out for Gujarat State. The table 4.9
provides the check list for analyzing the status of the Blood storage units at all FRUs in
Gujarat state.
Table 4.9 Checklist for determining the Status of Blood Storage Units in
Gujarat state.
Center License
Status
Status of
Construction
at PIU level
Equipment Status
( Procurement/ Installation)
Lice
nse
Issu
ed(Y
es/N
o)
Ren
ewal
Pen
ding
Com
plet
ed(
yes
/no)
Und
er p
rogr
ess(
Yes
/No)
Not
Sta
rted
( ye
s/N
O)
Pen
ding
at
CM
SO
(
Yes
/No)
Pen
ding
at
G
SC
BT
( Y
es
/No)
Pro
cure
men
t C
ompl
eted
&
inst
alle
d at
cen
ter(
Yes
/No)
Pro
cure
men
t
com
plet
ed
But
not
Ins
talle
d( Y
es/ N
o)
Dhandhuka Yes No Yes No No No No Yes No
Dholka No No Yes No No No No Yes No
Sanand No No Yes No No Yes No No No
Viramgam Yes No Yes No No No No Yes No
Bavla No No Yes No Yes No No No No
Singarva No No No No Yes Yes No No No
Balasinor No No No No Yes No Yes No No
Dakor Yes No Yes No No No No Yes No
Dharmaj Yes No yes No No No No Yes No
Tarapur No No Yes No No Yes No No No
Chotila Yes No Yes No No No No Yes No
Patdi No No No Yes No Yes No No No
Mansa Yes No Yes No No No No Yes No
Dahegam No No Yes No No Yes No No No
Kadi No No No No Yes no Yes No No
Vijpur No No Yes No No Yes No No No
Radhanpur No No Yes No No No Yes No No
Siddpur Yes No Yes No No No No Yes No
Deodar Yes No Yes No No No No Yes No
Thara Yes No Yes No No No No Yes No
~ 97 ~
Tharad Yes No Yes No No No No Yes No
Dhanera Yes No No No Yes No No Yes No
Idar Yes No No No Yes No No Yes No
Khedbrahma No No No No Yes No No Yes No
Malpur No No No No Yes Yes No No No
Prantij No No No No Yes Yes No No No
Chhota
Udaipur
Yes No Yes No No No No Yes No
Dhaboi Yes No Yes No No No No Yes No
Padra No No No No Yes Yes No No No
Jabugam Yes No Yes No No No No Yes No
Kwant No No No No Yes Yes No No No
Savli No No No No Yes Yes Yes No No
Jambusar Yes No Yes No No No No Yes No
Dedipada No No Yes No No No No Yes No
~ 98 ~
Rajpipla Yes No Yes No No No No Yes No
Tilakwada No No No No Yes Yes No No No
Sagbara Yes No Yes No No No No Yes No
Zalod Yes No Yes No No No No Yes No
Limkheda No No No No Yes Yes No No No
Halol Yes No Yes No No No No Yes No
Gogamba No No No No Yes Yes No No No
Bardoli Yes No Yes No No No No Yes No
Mandvi Yes No Yes No No No No Yes No
Mangrol Yes No Yes No No No No Yes No
Olpad No No Yes No No No No Yes No
Uchhcal No No No No Yes Yes NO No No
Zankhov No No No No Yes Yes No No No
Vyara No No Yes No No No Yes No No
~ 99 ~
Chikli No No Yes No No No No Yes No
Vansda Yes No Yes No No No No Yes No
Gandevi No No Yes No No No No Yes No
Bhilad Yes No Yes No No No No Yes No
Dharampur Yes No Yes No No No No Yes No
NanaPonda No No No No Yes Yes No No No
Kaprada No No No No Yes Yes No No No
Gadhada Yes No Yes No No No No Yes No
Palitana Yes No Yes No No No No Yes No
Botad No No No No Yes No Yes No No
Talaja No No No No Yes Yes No No No
Dhari Yes No Yes No No No No Yes No
Rajula No No No LP LP Yes No NO No
Khambha No No No No Yes Yes No No NO
~ 100 ~
Keshod NO Yes Yes No No No No Yes No
Manavadar No yes Yes No No No No Yes No
Mangroad No Yes Yes No No No No Yes No
Paddhari No No No No yes Yes No No No
Dhoraji No No Yes No No No No No Yes
Dhrol Yes No Yes No No No No Yes No
Dwarka Yes No Yes No No No No Yes NO
Bhanvad No No No No Yes Yes No No No
Lalpur Yes No Yes No No No No Yes No
Anjar No Yes Yes No No No No yes No
Bhachau No No No No Yes No No Yes No
Mundra Yes No Yes No No No No Yes No
Nakhatrana Yes No Yes No No NO NO Yes No
Rapar No No yes No No Yes No No No
~ 101 ~
~ 102 ~
Khavda No No No No Yes Yes No No No
Mandvi No No Yes No No No No yes No
Total 39 03 60 06 43 51 07 50 01
As per the analysis carried out for the state’s Blood banks and Blood storage units and
secondary data obtained from Rural Health department (RH), Project Implementation
Unit (PIU) and GSCBT, It was found that since the last 7 years (i.e. since the year 2005-
06 till the year 2011-12), 109 centers have designated to have the Blood storage units. An
amount of Rs. 10 Lakhs per unit was given for each unit set up, out of this Rs. 6 Lakhs
are to be utilized for Infrastructure set up by PIU at each unit (Air conditioning, Backup
Generator set, Renovation/construction for the BSU) and Rs. 4 Lakhs to be utilized by
GSCBT for the procurement of essential Blood storage unit’s equipments.
TABLE 4.10 DATA OF BLOOD SUPPLY CENTERS IN GUJARAT
Status of blood banks and Blood Storage Units in Gujarat
Number of Blood Banks in state
142
Number of Blood Storage Units in state
109
State Total ( Blood Banks and Blood Storage Units)
251
The study of the blood banks in Gujarat state shows that Blood banks are distributed
among various sectors in the state , out of 142 blood banks, 49 (38% ) are available with
private blood banks. Government established blood banks are only 32 (22%) out of 142
blood banks. 31 blood banks belongs to various trust and about 14 blood banks are
~ 103 ~
established by the Indian red cross society. 12 blood banks were established by NGOs .
04 blood banks fall under the municipal corporation sectors.
The Government established blood banks are distributed among Government Medical
colleges, Government District Hospital, Government Sub-district Hospital and
Government- Grant-in-aid hospitals. 07 Blood banks are set up at Government medical
colleges, 15 banks are set up at district hospitals, 02 blood banks are set up at Sub-district
hospitals and 08 blood banks are set up at grant-in-aid hospitals.
. FIGURE 4.24 BLOOD BANK DISTRIBUTIONS IN GUJARAT
The study of the blood banks form First Referral Units perspective shows that only 17 out
of 142 or 12% of the blood banks are associated with FRUs.
~ 104 ~
Only the Blood banks associated with District Hospitals and Sub- district hospitals can be
utilized by the FRUs. There are 19 nos. or 13% blood banks which are under Government
sectors and are not associated with FRUs, a large portion of these Blood banks fall under
the Indian Red Cross Society, Grant-in-aid and private sectors, about 79% or 112 blood
banks are in this category, about 3% of the blood banks in the state fall under municipal
corporations. Although these blood banks are not directly set up for providing Blood
supply for FRUs, they can still be associated with referral units to overcome the shortage
of blood supply in the state. Other Government blood banks like the ones associated with
medical colleges and Grant-in-aid hospitals do not form a part of the FRUs.
FIGURE 4.25 FRU- BLOOD BANKS DETAILS
A region-wise distribution of the blood banks shows that there 38 blood banks in the
Ahmedabad region, although there are 34 FRUs in Gandhinagar but there are only 27
blood banks.
~ 105 ~
TABLE 4.11 DISTRIBUTIONS OF BLOOD BANKS IN HEALTH R EGIONS
Bhavnagar region has 25 FRUs as against only 14 blood banks in this region. This clearly
shows that the number of blood banks is insufficient to match the number of FRUs in the
state.
FIGURE 4.26 REGIONWISE SHARE OF BLOOD BANKS
In remote areas where limited blood requirement does not justify establishing blood
banks, Govt. of Gujarat supports the establishment of storage centres. Analysis of blood
~ 106 ~
storage units in Gujarat shows out of the 163 FRUs, 143 centers are projected to have
Blood transfusion facility either in the form of Blood Banks, or blood storage units or
assured tie-ups with nearby blood banks. However a detailed study shows that out of 142
Blood banks in the state, only 16 blood banks is associated with FRUs indicating that out
of the total number of Blood banks, 11% are allocated to first referral units. Majority
numbers of blood banks are private and trust centers comprising of 78% of total blood
banks available in Gujarat.
Blood bank facilities are available only to FRU centers which are of district hospital type
as these are bigger centers serving larger patients in comparison to other Community
centers. At Sub district hospitals and Community Health Center level, Blood Storage
Centers provide the necessary blood transfusion services.
State has 109 Blood Storage units but not all are functional at present. 31 out of 109
Blood Storage Centers (BSC) are not functional. Out of the remaining 78 BSC which are
connected to FRUs, not all are holding the license from FDCA for safe blood supply.
Authorized safe blood for transfusion can be obtained only from 35 licensed blood
storage units which are associated with FRUs for EmOC services.
Certain Units such as the Blood Storage units located at Junagadh and Bhuj districts need
FDCA license renewal to be done and thereafter they can serve FRUs for Blood
Transfusion services.
After a detailed analysis of the blood storage units and the information collected from the
checklist, it was found that only 35 centers out of 109 centers are having complete Food
and Drugs Control Administration (FDCA) license implying that only 36% of the BSU
are authorized to store blood units, there are 03 centers that need renewal of FDCA
license for functioning as BSU.
Unless a blood storage unit is having complete FDCA license, it is not considered to be
fit to store/ supply blood units. A total of 28% i.e. 31 number of the centers are not
functioning because of various reasons such as construction work pending for setting up
~ 107 ~
of BSU, pending procurement of equipments for blood storage units, installation of
equipments pending at blood storage units etc. unt il these issues are fixed , a blood
storage unit cannot apply for a license. Hence the infrastructure set up requires to be paid
more attention in making the blood storage units functional.
A detailed breakup of the status of all Blood storage units in the state is as shown in the
table 4.10, which shows the various steps at which the work for setting up a blood storage
unit is pending.
FIGURE 4.27 STATUS OF BLOOD STORAGE UNITS IN GUARAT
As seen the the table below which shows a detailed picture of year wise grant released,
for each health care facilities (104 CHCs, 03 SDHs and 02 DHs). It is observed that since
the year 2005-06 till the year 2011-12, 109 FRU centers were designated to have BSU
out which only 78 were designated to FRU centers and the remaining 31 BSU were
~ 108 ~
designated to non FRU centers. However out of there 78 designated centers, only 39
centers have FDCA license for BSU. It is also observed that in the initial two years i.e.
2005-06 & 2006-07 a total of 11 BSU units were designated and all of these were
designated to FRU centers out of which 07 were for CHCs, 03 were for Sub-district
hospitals and 01 was for District Hospitals, a good point was that all of these BSU are
having FDCA license. However it is observed that since past four years i.e. from 2008-12
, there have been 66 BSU designated however not all are for FRUs, only 40 are meant to
be set up at FRUs and 06 centers have obtained FDCA license in the past four years. It
can be observerd from the table below that a majority of the BSU are non- functional due
to work pending at PIU level (infrastructure) and at CMSO level.
TABLE 4.12 BLOOD STORAGE UNITS DATA
~ 109 ~
4.7 Facility Based New Born care availability status.
New born care is available at all health centers at Primary level, secondary and tertiary
level of health care. In Gujarat state, new born care corner is available at all PHC centers.
In addition to the new born care corner neo natal stabilizing units are available at CHC
level and Special new born care units are available at district hospital level these two
types of facility are necessary for sick newborns who require emergency treatment which
can avert the neonatal transience in the state.
Analysis of Facility based new born care shows that the essential requirements for
providing new born care at FRUs are:
TABLE 4.13 ESSENTIAL REQUIREMENTS FOR NEW BORN CARE AT FRUs
Sr. no.
Requirements
Description
1
Specialists
Pediatrician
2.
Trained MO
EmNB trained specialists
1 month Newborn Care trained MO
4 months Newborn Care trained MO
IMNCI trained MO
F-IMNCI trained MO
GoI's Newborn Care-16 Days Training
3.
Staff Nurses trained in
F-IMNCI
IMNCI
NSSK
~ 110 ~
4.
Logistics
Radiant Warmer
Phototherapy unit
Newborn resuscitation kit
Ultrasonography machine
Newborn weighing machine
Feotal Doppler
Analysis of the above mentioned essential requirements shows that new born care area
with a radiant warmer is available in all FRU centers according to its type, hence
logistics is not an issue in case of new born care at FRUs.
There are 113 FRU centers where there is a shortage of Pediatrician specialist. To
overcome this shortage , Gujarat state has started providing emergency new born care
trainings to medical officers and have them posted at FRUs .There are only 2 CHC type
FRU centers – CHC Anjar and CHC Khavda which do not have any specialists for new
born care . These are also among the centers which do not have any of the 4 EmOC
specialists to perform Cesarean section delivery although the necessary equipments and
infrastructure are in place. Availability of staff nurses is also good at all FRU centers
expect for a GIA hospital located at Valsad.
Hence it is evident that facility based new born care is available in adequate amount at all
FRU centers. This has resulted in bringing down the infant mortality rate in Gujarat.
~ 111 ~