An Approach Paper for District and State-Wide Scaling up of Public Health in Telangana Case Studies of Medak and Mahbubnagar Districts February 2015 Dr.Chetan C Purad, Dr.vikram Reddy, Dr.Sindoora Adulapuram, Rajesh Kumar Dandi Report Prepared Under the Overall Guidance of Dr. Nirupam Bajpai, Project Director, Model Districts Health Project & Senior Development Advisor, Earth Institute, Columbia University Model Districts Health Project, Earth Institute, Columbia University. Columbia Global Centers | South Asia The Earth Institute, Columbia University. Page Contents Acknowledgements 2 Introduction 3 Executive Summary 4 Abbreviations 5 Chapter-1: National Health Mission and MDGs 6 Chapter-2: Model Health System in a district 7 Chapter-3: Approach and Methodology 12 Chapter-4: Health Systems in Medak 14 Chapter-5: Health Systems in Mahbubnagar 19 Chapter-6: ASHA and Reforms 24 Chapter-7: ANM, SN Knowledge, skill assessment and need for training 28 Chapter-8: Nutrition and Sanitation 32 Chapter-9: Scope of Private public partnership 36 Chapter -10: Action plans for Medak, Mahbubnagar & state wide 38 recommendations Chapter-11: Innovations 53 Chapter-12: Concluding Remarks 61 References 63 1 page The Earth Institute, Columbia University. Acknowledgements: This book is dedicated to all those front line health workers who endeavour day in and out towards bettering the lives of mothers, children and all those seeking health care services and acknowledge that countless lives have been saved by their unselfish efforts. They are truly the unsung heroes of this crusade against illness and all those factors which threaten the lives of young and old alike on a daily basis. The authors would like to thank and acknowledge Sri.Suresh Chanda, The Principal Secretary Health, Medical and FW, Govt. of Telangana, for being pivotal and a driving force not only to this project but his commitment to the goal of achieving universal health access to the people of Telangana. We are extremely thankful to The Director of Public health and Family welfare, Govt. of Telangana, The Commissioner, Vaidhya vidhana parishat, Govt. of Telangana, The Chief planning officer, NHM, Telangana, District Medical &Health Officers of Medak and Mahbubnagar for their vision, encouragement and continued support towards conceiving and drafting the approach paper for an efficient health system. Finally we pledge our support and services to the people of Mahbubnagar and Medak for whom seeking health services is an uphill task and probably the last of the priorities in the kaleidoscope of numerous constraints clouding their very existence. We are very grateful to the Ikea Foundation for their generous support to the Model Districts Project in Telangana and without their generous support this approach paper could not have been undertaken. 2 page The Earth Institute, Columbia University. Introduction The Model Districts project is a joint initiative between the Earth Institute, Columbia University, and the Ministry of Health & Family Welfare, Government of India. Its goal is to demonstrate which health and nutrition interventions are required to narrow policy‐ practice gaps in the NRHM in five regionally representative districts across India. The project’s strategy is to target interventions and additional public health spending at the intersection of the six building blocks of health systems strengthening (infrastructure, data management, governance, financing, supply chain management, and frontline health worker capacity) and five areas along the continuum of care for mothers and children (antenatal care, safe delivery, immediate postnatal care, early childhood development and nutrition, and routine and sick child care). The Model Districts scale‐up model is supported by a robust baseline and monitoring and evaluation plan, pilot interventions at the block level, growth and expansion to the district level based on learning exchanges within and across districts, and finally national level scale‐up through policy adaptation and replication. In consultation with the MoH&FW, GoI the Earth Institute selected two districts each from three states – Jharkhand, Rajasthan and Telangana. The six Model Districts will serve as regional pilots for scaling up innovations and quality improvements in the six health system building blocks: infrastructure, data management, governance, financing, supply chain management, and frontline health worker capacity. By targeting active management and improved delivery processes within these six areas of the system, the project aims to enhance the quality of, and access to, health services delivery for the continuum of maternal and child health care, including antenatal care, safe delivery, immediate postnatal care, early childhood development and nutrition, and routine and sick child care. With this strategy, the Model Districts will seek to create ‘centres of excellence’ which address existing challenges in designing, managing, and implementing scaled‐up health systems, particularly in large rural areas and with a focus on maternal and child health and nutrition. On the request of the Govt. of Telangana the Columbia Global Centres – south Asia, has done a bottle analysis of the prevailing health systems in the two project districts of Medak and Mahbubnagar to assess the various parameters which need to be strengthened and where innovations and improvisations can be suggested so as to create an ‘Efficient health care delivery system’ not only as a model to the state of Telangana but with the broader perspective of using the study as a learning exercise of mutual benefit to both the partners and to any other relevant health agencies who wish to benefit from this model. 3 page The Earth Institute, Columbia University. Executive Summary The pooling of services and the trend of service seeking behaviour towards the centres higher than that of the primary care level is a well-documented fact. The reasons for this shifting of demand towards the district and sub district hospitals is due to the lack of availability of general duty and specialist services, due to both a shortage of doctors in appropriate locations and poor infrastructure or management practices, is a pervasive concern throughout rural India. Many strategies have been employed to address this issue both in India and elsewhere, including a) attempting to increase the number of health facilities and human resources, b) providing incentives to enhance community participation with a view to enhance demand, c) redesigning the infrastructure and nomenclature , d) engaging in public/private partnerships, e) rational distribution of medical officers and other staff, f) efforts to make more realistic and achievable PIPs, g) creating new cadres of health professionals, and h) using information communication technologies to fill the gap. Primary research in this case study attempts to examine the contributing factors to the low availability and utilisation of services at the peripheral health institutions within the local context of the two surveyed districts and from state -and nation- wide insights. Data indicates that the key causal factors are- poor utilisation of the DHAP as an efficient tool for planning and control, insufficient number of sanctioned positions, absence of infrastructure, logistics, equipment and so on at the peripheral health institutions, lack of training and confidence, oversight and control. Another contributing factor is the non-effective utilisation of community volunteers (ASHA) who are often used as replacement workers by the front line health workers rather than community activists. The financial incentives also tend to get delayed due to a) understaffing at the district level and or apathy. The problem is multifaceted, spanning human resource and governance issues. During primary research, through qualitative discussions, the viability and benefit of potential mitigating strategies were explored. Based on assimilation of findings from literature and primary research, a set recommendations are put forth in this paper for consideration as strategies to shift the demand curve towards primary care level and improve the efficiency of health services. While a long term plan is recommended to be implemented in a systematic manner to achieve the universal health coverage, an interim plan is also suggested to make best use of the available resources and infrastructure. Strong recommendations are made towards IT enabled interventions for data handling and pragmatic planning, forecasting and improving the overall governance. Significant weightage has been accorded to explore the private public partnerships on a more sustainable mode. These strategies are discussed in detail in the paper. 4 page The Earth Institute, Columbia University. Abbreviations: CGC Columbia Global centres AH Area hospital ANA Accredited nutrition activist. ANM Auxiliary nurse and mid-wife APVVP Andhra Pradesh vaidhya vidhana parishat ASHA Accredited social help activist. AWC Anganwadi centre AWW Anganwadi worker AYUSH Ayurveda, Unani, Siddha, Homeopathy BB/BSU Blood bank / blood storage unit BEmOC Basic emergency obstetric care CEmOC Comprehensive emergency obstetric care CH Civil hospital CHC Community health centre CHNC Community health and nutrition cluster DEO Data entry operator DH District hospital DHAP District health action plan DM&HO District medical and health officer DP Delivery point FRU First referral unit GA Gap Analysis GoI Govt. of India GoT Govt. of Telangana HRC High risk condition (in pregnancy)