An Approach Paper for District and State Wide Scale Up

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

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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.

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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.

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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.

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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) HRP High risk pregnancy IMR Infant mortality rate IPHS Indian public health standards LHV Lady health visitor MCH Maternal and child health MDG Millennium development goals MDHP Model district health project MMR Maternal mortality ratio MNH Maternal and New-born health MO Medical officer MoHFW Ministry of Health and family welfare NHM National Health Mission NRHM National rural health mission NUHM National Urban health mission PHC Primary health centre PIP Programme implementation plan RCH-II Reproductive and child health – phase II RI Routine immunisation RMNCH+A Reproductive, Maternal, New-born, Child health and Adolescent health. SC Sub-centre SDH Sub district hospital TFR Total fertility rate. UHC Universal health coverage.

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Chapter-1

National Health Mission and Millennium Development Goals 4 & 5 2

Reducing maternal and child mortality are among the most important goals of the National health mission (NHM), earlier known as National Rural Health Mission (NRHM), which was launched in the year 2005.2

Vision of NHM “Attainment of Universal Access to Equitable, Affordable and Quality health care services, accountable and responsive to people’s needs, with effective inter-sectorial convergent action to address the wider social determinants of health”.

Huge and strategic investments are being made by Government of India to achieve these goals. At various global platforms, India has reaffirmed its commitment to make every effort towards achieving the Millennium Development Goals 4 and 5.

The NHM essentially focuses on strengthening the primary health care across the country. Emphasis would be on strengthening health facilities and services up to the district level in urban and rural areas.

The Twelfth Plan document states that expenditures on primary health care should account for at least 70% of the health care expenditure. Tertiary care and regulatory functions should be a part of the other Central Sector and/or Centrally Sponsored scheme, namely, Human Resources & Medical Education.

The endeavour would be to ensure achievement of the indicators relevant to Maternal and child health as below... Figure-1 In order to reduce household out-of-pocket expenditure on total health care expenditure the NHM acts as a major instrument of Reduce MMR to Reduce IMR to financing and support to the states to strengthen public health 1/1000 live births 25/1000 live births systems and health care delivery.

Prevention and This financing to the state is based on the state’s Programme reduction of Reduce TFR to 2.1 anaemia in women Implementation Plan (PIP). Within the broad national parameters and aged 15–49 years priorities, States would have the flexibility to plan and implement state specific action plans. The state PIP would spell out the key strategies, activities undertaken, budgetary requirements and key health outputs and outcomes.

All schemes and programmes that constituted RCH-II would be absorbed into the NHM. The NHM provides an opportunity to build on past work and renew the emphasis on strategies for Improving maternal and child health through a continuum of care and the life cycle approach. The inextricable linkages between adolescent health, family planning, maternal health and Child survival have been recognized.

There is additional focus on adolescence as a distinct ‘life stage’ and the strategy is to increase knowledge and access to reproductive health services and information for adolescents and to address nutritional anaemia. Another dimension of the continuum of care which will receive attention is the linking of Community and facility- based care and strengthening referrals between various levels of health care system to create a continuous care pathway.

All these aspects are embodied in the ‘Strategic Approach to Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCH+A) in India’.

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Chapter -2 Model Health Systems in a District 1,3

The health delivery system in the country is structured at three tiers as Primary, Secondary and Tertiary care levels. The District hospital is at the top of the hierarchy and the sub centre is foremost post of service delivery. IN general the different levels of health care are directed towards promotive, preventive, curative and rehabilitation services.

2.1 Sub Centre:

In the public sector, a Health Sub-centre is the most peripheral District Hospital and first point of contact between the primary health care system and the community. Sub district Hospital A Sub-centre provides interface with the community at the grass- Community Health root level, providing all the primary health care services. The Centres purpose of the Health Sub-centre is largely preventive and promotive, but it also provides a basic level of curative care. As Primary health centres per population norms, there is one Sub-centre established for every 5000 population in plain areas and for every 3000 Sub centres population in hilly/tribal/desert areas. Figure-2.1

The Indian Public Health Standards (IPHS) are prescribed to provide basic primary health care services to the community and achieve and maintain an acceptable standard of quality of care. However, the outcomes of health indicators do not match with services that are said to be provided. Therefore it is desirable that manpower as envisaged under IPHS is provided to ensure delivery of full range of services. Categorization of the Sub centres in type A & type B has taken into consideration various factors namely

- catchment area, - health seeking behaviour, - case load, - Location of other facilities like PHC/CHC/FRU/Hospitals in the vicinity of the Sub-centre.

States are required to categorize their Sub-centres into two types as per the guidelines given below and provide services and infrastructure accordingly.

Type A: The facilities for conducting delivery will not be available at these sub-centres and patients may usually be referred to nearby centres providing delivery facilities.

Fig-2.2 These Sub-centres provide all other recommended services and focus on outreach services, prevalent diseases, tuberculosis, Sub leprosy, Non-communicable diseases, nutrition, water, sanitation and Center epidemics

Type B: They provide all recommended services including facilities for Type A Type B conducting deliveries at the Sub-centre itself. This Sub-centre will act as Maternal and Child Health (MCH) centre with basic facilities for

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conducting deliveries and New-born Care

Table-2.1

Type of Sub centre Sub centre A Sub centre B (MCH centre) Staff Essential Desirable Essential Desirable ANM / HW(F) 1 1 2 HW (M) 1 1 Staff Nurse (or ANM if SN is not available) 1 Cleaner 1(part time) 1(full time)

2.2 Primary Health Centres:

PHCs are the cornerstone of rural health services- a first port of call to a qualified doctor of the public sector in rural areas for the sick and those who directly report or referred from Sub-Centres for curative, preventive and promotive health care. It acts as a referral unit for 6 Sub-Centres and refers out cases to Community Health Centres (CHCs-30 bedded hospital) and higher order public hospitals at sub-district and district hospitals. It has 4-6 indoor beds for patients.

The 6th Five year Plan (1983-88) proposed reorganization of PHCs on the basis of one PHC for every 30,000 rural populations in the plains and one PHC for every 20,000 population in hilly, tribal and desert areas for more effective coverage. PHCs should become functional for round the clock with provision of 24 × 7 nursing facilities.

PHC Fig -2.3 Select PHCs, especially in large blocks where the CHC is over one hour of journey time away, may be upgraded to provide 24 hour emergency hospital care for a number of conditions by increasing the number of Medical Officers; Type A Type B preferably such PHCs should have the same IPHS norms as for a PHC with delivery PHC with delivery CHC. load of less than 20 load of 20 or more deliveries in a month deliveries in a month A PHC acts as a referral unit for 6 Sub-Centres and refer out cases to Community Health Centres (CHCs-30 bedded hospital) and higher order public hospitals at sub-district and district hospitals. It has 4-6 indoor beds for patients needing admission for a short duration.

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Table -2.2 Man power: 1 Staff (PHC) Type A Type B Essential desirable Essential desirable 1 Medical officer - MBBS 1 1 1 (Female) 2 Medical officer -AYUSH 1 1 3 Accountant cum DEO 1 1 4 Pharmacist 1 1 5 Pharmacist - Ayush 1 1 6 ANM (Staff Nurse) 3 1 4 1 7 HW (F) 1 1 8 Health assistant (M) 1 1 9 Health assistant (F) / LHV 1 1 10 Health Educator 1 1 11 Lab. Technician 1 1 12 Cold chain and vaccine logistic assistant 1 1 13 Group -D 2 2 14 Sanitary worker cum watchman 1 1 1 15 Total 13 5 14 7

Minimum OPD attendance is expected to be 40 patients per doctor per day. Fig-2.4 2.3 Community Health Centres:

The secondary level of health care essentially includes Community Health Centres (CHCs), constituting the First Referral CHC Units (FRUs) and the Sub-district and District Hospitals.

The CHCs were designed to provide referral health care for cases Non FRU FRU from the Primary Health Centres level and for cases in need of specialist care approaching the centre directly. 4 PHCs are Level -2 Level -3 included under each CHC thus catering to approximately 80,000 populations in tribal/hilly/desert areas and 1, 20,000 populations for plain areas. CHC is a 30-bedded hospital providing specialist care in Medicine, Obstetrics and Gynaecology, Surgery, Paediatrics, Dental and AYUSH. The recommended HR is detailed in the IPHS standards.

2.4 Sub-district (Sub-divisional) hospitals:

Sub-district (Sub-divisional) hospitals are below the district and above the block level (CHC) hospitals and act as First Referral Units for the Tehsil/Taluk/block population in which they are geographically located. Specialist services are provided through these Sub district hospitals and they receive referred cases from neighbouring CHCs, PHCs and SCs. They have an important role to play as First Referral Units in providing emergency obstetrics care and neonatal care and help in bringing down the Maternal Mortality and Infant Mortality. They form an important link between SC, PHC and CHC on one end and District Hospitals on other end. It also saves the travel time for the cases needing emergency care and reduces the workload of the district hospital. In some of the states, each district is subdivided in to two or three sub divisions.

A subdivision hospital caters to about 5-6 lakhs people. In bigger districts the Sub-district hospitals fills the gap between the block level hospitals and the district hospitals. There are about 1200 such hospitals in the country

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with a varying strength of number of beds ranging from 31 to 100 beds or more. Fig-2.5

Based on the assumptions of the annual rate of admission as 1 per 50 populations and average length of stay in a hospital as 5 days, the number of beds required for a Sub-district having a population of 5 lakhs will be around 100-150 beds. Depending on the number of IP beds the SDH has been classified. SDH 2.5 District Hospitals

District Health System is the fundamental basis for Category -I Category II implementing various health policies, delivery of Sub-district Sub-district healthcare and management of health services for defined hospitals norms for hospitals norms for 31-50 beds. 51-100 beds. geographic area. District hospital is an essential component of the district health system and functions as a secondary level of health care which provides curative, preventive and promotive healthcare services to the people in the district.

Every district is expected to have a district hospital linked with the public hospitals/health centres down below the district such as Sub-district/Sub-divisional hospitals, Community Health Centres, Primary Health Centres and Sub-centres.

The district hospitals cater to the people living in urban (district headquarters town and adjoining areas) and the rural people in the district. District hospital system is required to work not only as a curative centre but at the same time should be able to build interface with the institutions external to it including those controlled by non-government and private voluntary health organizations. Inter-sectorial Coordination

The ideal distribution of the different types of facilities based on the population norms discussed in the sections above would be as the figure below considering a hypothetical example of a district with a population of 30 lakhs.

Additionally as per the Maternal and New-born 3 health tool kit (MNH tool kit) published by the MoHFW, GoI three different levels of facilities are mentioned as per the functional status and the ‘signal functions’ performed by these institutions.

CEmOC (Comprehensive emergency obstetric District Hospital - 1 care) centre equates to the Level -3 (L3) facility, whereas Sub District Hospital (AH, MCH) - 6 BEmOC (Basic emergency obstetric care) centre Community Health Centers - 25 are equates to the Level -2 facility.

Primary Health Centers - 200 Fig -2.61

Community Health Centers - 600

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Fig-2.7

•All sub-centres and some PHCs which have not yet reached the next level of 24x7 PHC: where deliveries are conducted by a skilled-birth attendant (SBA). An NBCC must be established in all such facilities Level -1

•All 24x7 facilities (PHC/Non-FRU CHC/others) providing BEmOC services; conducting deliveries and managing of medical complications (not requiring surgery or blood transfusion) and have either a NBCC or NBSU. Level-2

• (Comprehensive Level-FRU): All FRU-CHC/SDH/DH/area hospitals/ referral hospitals/tertiary hospitals where complications are managed including C-section and blood transfusion. An FRU shall be equipped also with a Level-3 New-born Stabilization Unit (NBSU) at CHC/SDH/others or Special New-born Care Unit (SNCU) at DH and above.

The summary of the above is given in the Table -2.3 below,

Type of Institution Population catered Level Type of services Sub-centre 5000 L-1 Basic Primary health centre (Non 24x7) 30000 L-1 Basic Primary Health centre (24x7) 30000 L-2 BEmOC Community health centre – Non FRU 1,20,000 L-2 BEmOC Community health centre – FRU 1,20,000 L-3 CEmOC Sub district Hospital / Area hospital 500,000 L-3 CEmOC District Hospital District Population L-3 CEmOC

2.6 Rationale of Deliveries at Various types of facilities: 3

As per the MNH tool kit the number of expected deliveries per annum are Basic 10% to the tune of 2.3% in a given population. Out of the expected deliveries 50% are expected to be conducted at CEmOC centres, 40% at BEmOC CEmO C 50% centres and the remaining 10% at the basic facilities. Approximately 20% BEmO of the 50% deliveries conducted at CEmOC centres are believed to need C 40% surgical intervention including C-Section.

A hypothetical example is given in the Table -2.4 below,

30% deliveries Of the Remaining 70% District Expected 30% deliveries 50% of deliveries 40% of deliveries 10% of Population Deliveries per are expected at including C-Sec including assisted deliveries at annum @2.3% Private Sector at CEmOC deliveries at basic level centres BEmOC centres centres 30,00,000 69000 20700 24150* 19320 4830 *20% of the 50% would need surgical intervention i.e. 4830

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The man power and resources, equipment’s needed for each level of the facility has been enumerated in detail in the Indian Public health standards and the minimum requirement for a facility to be functional has been enumerated in the Maternal and New born health tool kit. Chapter -3 Approach & Methodology:

The approach and methodology to defining the problem statement and generating evidences to making appropriate recommendations are discussed in this chapter.

The first step towards defining a problem was to analyse the data of various indicators. The source of data was also important. The data from HMIS was analysed initially for the sixteen indicators captured in the block monitoring reports. Discrepancies were noted when HMIS data was compared to the data form primary source for various indicators. As such it was decided that the data from HMIS was not to be considered for the analysis.

Secondly the ‘indicator’ for analysis was to be selected; since the data from HMIS was not taken we had the option of getting the data from the office of DM&HOs of Medak and Mahbubnagar.

We deliberated that it would be better to select one indicator which would be sensitive to the utilisation of services in the public health sector and less prone to data mishandling which are in contrast to the highly unreliable data of service utilisation or provision for example the figures on out-patient and in patient.

The problem statement to be able to make recommendations was to have the below characteristics,

1. Should address the service utilisation parameter. 2. Should reflect the infrastructure, equipment and other logistics issues. 3. Should define the human resource gaps and requirements in terms of quantity and quality. 4. Should be able to identify the policy to practice gaps in the health and other intersectional partners.

In view of the limited time we decided to do a primary analysis based on one important indicator – the ‘delivery load’ of the facility.

The data was requested from the DM&HOs office at Medak and Mahbubnagar. This data for the FY 2014-15 is represented in Annexure-1 and annexure-2.

The next step of the activity was to collect data from the field as such sampling was done to select the facilities which also had geographical representation.

We decided to grade the facilities as level -1, level-2 and level-3 3. Two facilities from each cluster were taken into sampling one each on the extreme end of the spectrum based on the ‘delivery loads’ for each of the facilities. All L-3 facilities were mandatorily selected. At Mahbubnagar we clubbed two clusters (CHNC) as one unit and two facilities at each end of the spectrum were selected based on the delivery load criteria. The sampled facilities are mentioned in the Annexure -3 and Annexure -4.

The CGC team were in the field visiting the facilities for two weeks, using the Gap analysis – checklist as a tool for data collection.

Earlier the team had considered various other data collection tools including the,

- Supportive supervision checklist by MoHFW - The supervisory checklist used by the states of Telangana and Andhra.

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We felt that the Gap analysis checklist would be an ideal tool considering the short time frame and had the added advantage of being approved by the MoHFW and field tested widely across the country during the gap analysis exercise.

The tool addressed all the components of health care delivery system,

1. Infrastructure 2. Human Resource 3. Training 4. Equipment 5. Other / Lab services 6. Quality parameters of service delivery. 7. Service delivery data over two quarters. 8. Supervisory visits

The team felt that in order to bring about reforms or to suggest changes in the way frontline health workers operate in the field a detailed qualitative data was needed. As such a questionnaire for ASHA s and ANMs each were developed. ASHAs and ANMs were interviewed during the field survey. The data is presented in the subsequent sections.

The data on the delivery load obtained from the DM&HOs was analysed initially to draw broad conclusions mentioned at the end of chapters 4 & 5. The data from the field was analysed to assess the constraints from points 1-8 as enumerated above and the data from the interviews was also assessed. The findings were listed appropriate recommendations drafted based on,

- Field observations - Feedback from the frontline health workers - National guidelines.

The team also makes recommendations for innovations and private public mix in the subsequent chapters. Based on the working papers of the CGC recommendations are also made for the integration of Nutritional supplements in the health sector.

The brief outline is given in the figure below. (Fig -3.1)

Defining the Deciding on the Survey problem survey tool

Preliminary data Sampling of the Data Analysis from the districts facilities.

Deciding on the ANM and ASHA Presenting the indicator questionnaire recommendations

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Chapter -4 Health Systems in Medak 4

To assess the utilisation of services we have considered the ‘delivery load’ for each facility. The data was obtained from the office of DM&HO Medak for the current financial year for the months April to November 2014. (Annexure -3)

The delivery load figures at the institution has been considered to assess the utilisation of services as

- It is a very sensitive indicator for utilisation of services. - Probably minimally amicable to data mishandling in comparison to other indicators. - All future planning is to be done on this parameter.

4.1 Analysis of the Delivery Load: 3

As discussed in page 13 on the rationale of delivery load analysis 50% of the expected deliveries are conducted at CEmOC centres and the remaining break up of 40%,10% of the expected deliveries at BEmOC and basic facilities respectively the analysis of the delivery load data received from the DM&HO Medak is done as follows,

- Total population of the district = 3031877 lakhs - Expected deliveries = 2.3 % of 3031877 = 69733 / annum (approximately). Fig -4.1 - 30% of the deliveries are at Private establishments. 3 - Of the remaining 70% There are two broad assessments, o 50% of all deliveries to be conducted at PHCs (24x7 & non 24x7) remaining, PHCs, FRUs, o 50% at FRUs including the DH, SDH, CHC, AH’s. 50% 50% (The deliveries at SC’s being minimal)

Proportion of beds in Govt.to total beds in the district is 26% 4 4.2 Discussion

a) Hence as against the approximate estimated deliveries of 1320 in all the primary health centre catchment area of the district, the number of deliveries conducted at the public health facilities are 434 (33%) in an average month. b) Expected deliveries in the entire district = 2.3 % of the district population 3031877 = 69733 / annum (approximately) = 5811/month. 3 c) Rural population = 2587404 (85%), hence the expected deliveries in rural population = 59510 / annum. (4959/m) d) If the entire rural delivery load is considered then the current performance is 1968 deliveries as against 3471 (70% of 4959) deliveries in the rural area (57%) and 1968 as against the estimated 4068 (70% of 5811) deliveries in the entire district (48%) per month. e) The total PHC s required to serve the rural population is = 2587404 / 30000 = 86 PHCs 1 f) Existing PHCs = 65; Hence the short fall in PHC s = 86-65 = 21 PHCs. g) 24x7 PHCs - 16/37 are conducting > 10 Del /m (43%) 3 h) Non 24x7 PHCs - 13/28 are conducting >3 Del /m (46%)3 i) There is clustering of services at the district and sub district hospitals. j) There are significant inter CHNC differences.

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4.3 Survey Results

Medak N=48 L1 Range L2 Range L3 Range AVG AVG AVG Infrastructure 38% 8-75% 44% 28-72% 48% 14-64% HR 88% Training Equipment 54% 10-85% 69% 38-92% 83% 62-100% Lab Equipment 70% 20-100% 83% 60-100% 91% 80-100% OT Equipment 65% 27-100% Essential drugs 66% 30-90% 57% 50-62% 68% 44-88% Essential Supplies 53% 33-86% 65% 43-86% 67% 43-88% Lab Services 42% 10-50% 54% 33-83% 71% 60-86% BB / BSU 78% 33-100% Service delivery in post natal wards 89% 67-100% Skill set 65% 58-67% 33% Record maintenance 34% 6-61% 43% 23-69% 38% 14-68% JSSK - Pick n Drop 37% 0-67% 61% 33-100% 39% 33-67% IEC Material 49% 0-90% 52% 0-93% 52% 10-90% Other-support services 21% 0-43% 46% 14-86% 46% 25-63%

The data analysis across the sixteen thematic areas under which the data from the survey was analysed shows that there are significant short comings across all the thematic areas. The proportions which are less than 50% mean proportion as opposed to fully operational are highlighted in red for easy navigation. These are the areas which demand attention in terms of completeness and ensuring quality.

The range of the mean proportion is mentioned in the next column. The range shows wide variation to the extent that in certain instances E.g.: infrastructure, equipment the range difference is higher than the mean itself.

This corroborates the findings on the analysis of the service delivery mentioned earlier in the chapter which pointed towards the clustering of service delivery towards the centres higher than the primary level and agrees well with the significant inter-CHNC variations within the district. Such wide range points towards inequality across the different facilities within the same thematic parameter suggesting that certain centres are better off and certain centres having gross inadequacies.

The further listing of the sub-line items is annexed as annexure-7. The plan for the short comings need to be effectively addressed in the PIP in a systematic and staggered approach and thoroughly monitored thereafter.

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24x7 PHCs - 16/37 are conducting > 10 del /m (Fig -4.2) 51

18 16 13 15 14 15 16 14 14 10 13 11 11 11 7 8 7 10 8 8 7 9 8 8 5 5 7 4 4 6

0 2 3 2 2 2

PULKAL

KANGTI

KALHER

PULLUR

TEKMAL

REGODE

NYALKAL

RAIKODE

THEEGUL

MULUGU

MANOOR

TOOPRAN

SIRGAPUR

JINNARAM

RC PURAM RC

NARSINGHI

KONDAPUR

YELDURTHY

MUNIPALLY

ATHMAKUR

AHMEDIPUR

KARASGUTTI

RANGAMPET

MALCHELMA THIMMAPUR

KOWDIPALLY

HATHNOORA

PAPANNAPET

BHOOMPALLY

CHINNAKODUR

JHARASANGAM

GUMMADIDALA

D.DHARMARAM

DOULTHABAD-G

KUKUNOORPALLY

RHC PATANCHERU RHC SHANKARAMPET-A CHNC CHNC CHNC CHNC CHNC CHNC CHNC CHNC CHNC CHNC KOHEER PATANCHERU GAJWEL DUBBAK JOGIPET SADASIVPET NARSAPUR SIDDIPET RAMAYAMPET NARAYANKHED

Non 24x7 PHCs - 13/28 are conducting >3 del /m (Fig -4.3) 10

6 5 5 5 4 4 4 4 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1

0 0 0

KANDI

DIGWAL

RAIPOLE

TALELMA

BHANOOR

NIZAMPET

MIRZAPUR

MIRDODDI

ALLADURG

THOGUTTA

SARDHANA

CHEGUNTA

KONDAPAK

SHIVAMPET

INDUPRIYAL

REDDYPALLY

KANUKUNTA

KULCHARAM

JAGADEVPUR

GADIPEDDAPUR

IBRAHMINAGAR

DOULTHABAD-H

PODICHANPALLY

CHINTALCHERVU

MOGUDEMPALLY

NARAYANRAOPET

SINGANNAGUDEM SHANKARAMPET-R CHNC CHNC CHNC CHNC DUBBAK CHNC CHNC CHNC CHNC CHNC CHNC KOHEER PATANCHERU GAJWEL JOGIPET SADASIVPET NARSAPUR SIDDIPET RAMAYAMPET NARAYANKHED

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to District Performance PHC s and FRUs –Cluster Wise Fig -4.6 437 Total 33% 116% 305 306 Upgrade PHC Narayankhed 72% 66% CHC Ramayampet 30% 81% DistrictSiddipet Performance9% PHC s and FRUs217% – Cluster Wise 147 AH 94 Narsapur 26% 21% 74 59 MCH 30 36 30 Sadashivpet 57% 583% 8 5 0 2 1 DH Jogipet 30% 42% Dubbak 41% 0% Gajwel 15% 22% Patancheru 28% 61% Koheer 39% 220%

Total performance Vs. Expected Fig -4.7

Total 75% 2639 Narayankhed 69% Ramayampet 55% 1968 Siddipet 113% Narsapur 24% Sadashivpet 320% Jogipet 36% Dubbak 21% Gajwel 18% Patancheru 44% Total del at all levels 70% Expected at the Koheer 130% Govt.

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4.4 The Human resource for the primary health care level is depicted in the table below,

Sanitary Total PHC MO(2) SN(4) Lab.Tec(1) Phar(1) DEO(1) Ideal % worker (1) Present Atmakur 2 2 1 1 0 2 10 8 80% Chinnakodor 1 2 1 1 0 2 10 7 70% D.Dharmaram 1 2 1 0 0 1 10 5 50% Jinnaram 2 2 1 1 0 1 10 7 70% Kangti 1 3 1 1 0 2 10 8 80% Kaudipally 2 3 1 1 0 2 10 9 90% Raikod 1 3 1 0 0 1 10 6 60% Regod 1 2 1 1 0 1 10 6 60% Theegul 1 2 0 1 0 1 10 5 50% Thimmapur 1 3 1 1 0 1 10 7 70% Alladurg 1 1 1 0 0 0 10 3 30% Digwal 1 1 1 1 0 1 10 5 50% Kandi 1 1 0 1 0 0 10 3 30% Kanakunta 1 1 0 0 0 0 10 2 20% Mirdoddi 1 2 1 1 0 1 10 6 60% Narayanraopetha 1 1 1 1 0 1 10 5 50% Nizampetha 1 1 0 0 0 0 10 2 20% Podchenpally 1 1 1 1 0 0 10 4 40% Shivampet 1 1 0 1 0 1 10 4 40% Singangudam 1 2 0 1 0 0 10 4 40% Present 23 36 14 15 0 18 Ideal 40 80 20 20 20 20 Average 53% Prop 58% 45% 70% 75% 0% 90%

The ideal number of HR against each cadre is depicted in the brackets as per the IPHS staffing recommendations1. On the whole the HR present is 53% at the primary health centres (among the sampled).

Training is dealt in a separate chapter which is based on the findings from,

1. Survey to assess the knowledge, confidence and competencies of the ANMs. 2. Inferences from the onsite training program conducted at Mahbubnagar for the ANMs and SNs.

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Chapter -5

Health Systems in Mahbubnagar 5

To assess the utilisation of each facility we have taken the ‘delivery load’ for each facility. The data was obtained from the office of DM&HO Mahbubnagar for the current financial year for the months April to October 2014. (Annexure -4) Proportion of beds in Govt.to total 45% beds in the district

5.1 Analysis of the Delivery Load

As explained in Chapter -3 the analysis of the delivery load in the district of Mahbubnagar is done on the same lines, (Annexure -6) 3

- Total population of the district = 4042191 lakhs - Expected deliveries = 2.3 % of 4042191 = 92970 / annum (approximately). - There are two broad assessments done. 50% of all deliveries to be conducted at PHCs (24x7 & non 24x7) remaining 50% at FRUs including the DH, SDH, CHC, AH’s. (The deliveries at SC’s are minimal)

5.2 Discussion

a) Hence as against the approximate estimated deliveries of 3770 in all the existing primary health centre catchment area of the district, the number of deliveries conducted at the public health facilities are 1616 (48%) in a month. b) Expected deliveries in the entire district = 2.3 % of the district population 4042191 = 92970 / annum (7747 / month) –approximately 3 c) 70% of the 7747 is 5422 / month is the delivery load to be conducted at Govt. facilities across all the govt. facilities in the district. d) Rural population = 3637971 (90%), hence the expected deliveries in rural population = 83673 / annum, 6972/m which at the rate of 70% is 4880 / month to be conducted at govt. facilities. e) If the entire rural delivery load is considered then the current performance is 1616 deliveries as against 4880/ month deliveries in the rural area (33%) and 1616 as against the estimated 5422/month deliveries in the entire district. (29% ) f) The total PHC s required to serve the rural population is 3637971 / 30000 = 121 PHCs g) Existing PHCs = 84; Hence the short fall in PHC s 121-84 =37 PHCs. 1 h) 24x7 PHCs - 18/62 are conducting > 10 Del /m (29%) 3 i) Non 24x7 PHCs - 7/21 are conducting >3 Del /m (33%) 3 j) Clustering of services towards higher centres. k) Significant inter CHNC differences within the district.

The challenges to the service delivery are discussed in the subsequent chapters based on the results of the survey of facilities selected by random sampling the list of facilities selected is as per the Annexure-4.

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24x7 PHCs - 18/62 are conducting > 10 del /m Fig-5.1

24 24 25 25 19 18 16 15 15 15 15 12 12 13 13 9 10 10 10 8 9 8 8 9 7 8 6 7 6 6 6 6 5 5 4 5 4 5 4 4 2 3 2 4 2 3 2 3 3 2 3 3

1 2 2 0 2 1 2 1 1 1

Ieeja

Midjil

Narva

Palem

Kodiar

Uppair

Peroor

Kothur

Ghattu

Utkoor

Tadoor

Marikal

Madgul

Pebbair

Rajapur

Kyathur

Maddur

Addakal

Dharoor

Kondurg

Vangoor

Ghanpur

Padra (T) Padra

Maganur

Gopalpet

Hanwada

Veldanda

Manopad

C.C.Kunta

Janampet

Gangapur

Balanagar

Telkapally

Kothlabad

Nandigam

Bijinepally Kothakota

Nawabpet

Gundumal

Chinchode

Dhanwada

Bomraspet

Keshampet

Kadukuntla

Deverkadra

Madanapur

Balmoor (T) Balmoor

Waddepally

Thimmajipet

Siddapur (T) Siddapur

Mannanur(T)

Pentlavelly (T) Pentlavelly

Uppanunthala

Veepangandla

Ambatpally (T) Ambatpally

Raghupathipet

Talakondapally

AngadiRaichur Peddamandadi

Thippadampally

Peddamuddunur Peddakothapally(T) MBNR KOIL SHAD BADE KALW AMA NARA MAK ATHM KOS KOD NAGA PALE ACHA KOLL WANA REVA GADW ALAM

16 Non 24x7 PHCs - 7/21 are conducting >/= 3 del /m Fig -5.2 13

7 5 4 3 2 3 2 1 1 1

0 0 1 0 0 1 0 0 0

Edira

Karne

Itikyal

Pangal

Peddur

Madgul

Burgula

Boppally

Amangal

Apparala

Lingal(T)

Maldakal

Lattupally

Kotakonda

Bhoothpur

Manikonda

Damargidda

Vennacherla

Talakondapally

Kamaluddinpur Vatavarlapally (T) Vatavarlapally MAH KOI AMA NAR MAK NAG PAL ACH WAN REV GAD

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365 Deliveries at CHC /AH/MCH/DH Fig -5.3 Fig-5.4

TOTAL 32% 96% CH-1 Alampur 41% 59% Gadwal District35% Perf PHC s and FRUs –141%Cluster Wise - Fig 28 CH-2 Revally 64% 69% Wanparthy 23% 53% 126 129 CHC Kollapur 21% 39% Achampet 27% 71% 70 AH 80 69 Palem 38% 38% 61 48 Nagarkurnool 11% 90% 29 DH 22 23 15 15 Kodangal 39% 111% 2 13 2 11 Kosgi District Performance52% PHC s and FRUs89% – Cluster Wise Athmakur 14% 30%

Makhtal 31% 131%

KOI

PAL

ALA REV KOL Narayanpet 61% 130%

KOS

ATH

ACH

NAR

GAD

NAG

MAK

WAN

BADE

SHAD KODA

KALW Amangal 38% 38% MBNR AMAN Kalwakuthy 20% 48% Badepally 25% 61% Shadnagar 44% 148% Koilkonda 24% 26%

District Performance Fig 29

Expected Vs. Perf Fig 5.5 TOTAL 48% Alampur 30% 3770 Gadwal 71% Revally 34% Wanparthy 26% Kollapur 20% Achampet 35% Palem 19% Nagarkurnool 45% 1616 Kodangal 55% Kosgi 44% Athmakur 15% Makhtal 66% Narayanpet 65% Amangal 19% Kalwakuthy 24% Badepally 30% Shadnagar 74% Expected Performance Koilkonda 13% Mahbubnagar 195%

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5.3 Survey Results

Mahbubnagar N=33 L1 Range L2 Range L3 Range AVG AVG AVG Infrastructure 31% 8-54% 61% 31-100% 71% 61-74% HR* Training* Equipment 46% 40-60% 64% 38-92% 88% 62-100% Lab Equipment 51% 20-80% 75% 40-100% OT Equipment 55% 27-73% Essential drugs 58% 50-70% 70% 50-75% 61% 56-69% Essential Supplies 32% 0-67% 38% 17-50% 67% 3-100% Lab Services 45% 10-70% 73% 50-80% BB / BSU 83% 67-100% Service delivery in post natal wards 74% 67-100% 78% 56-100% Skill set Record maintenance 60% 39-83% 54% 28-83% 49% 32-77% JSSK - Pick n Drop 33% 0-67% 55% 0-100% 33% 0-67% IEC Material 29% 0-40% 44% 11-78% 55% 30-90% Other-support services 33% 14-57% 59% 50-63%

The further listing of the sub-line items is annexed as annexure-8. The plan for the short comings need to be effectively addressed in the PIP and thoroughly monitored thereafter.

5.4 The Human resource for the primary health care level is depicted in the table below,

Sanitary Total PHC MO(2) SN(4) Lab.Tec(1) Phar(1) DEO(1) Ideal % worker Present AngadiRaichur 1 2 1 1 0 1 10 6 60% Madur 2 3 0 1 0 1 10 7 70% Manikonda 1 1 1 1 0 1 10 5 50%

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Sanitary Total PHC MO(2) SN(4) Lab.Tec(1) Phar(1) DEO(1) Ideal % worker Present Pebbair 2 2 1 1 0 1 10 7 70% Thimmajipetha 2 3 1 1 0 0 10 7 70% Waddepally 1 3 1 1 0 0 10 6 60% Veldanda 1 3 1 1 0 0 10 6 60% Talkondapally 2 2 1 1 0 1 10 7 70% Bijneypally 2 3 1 1 0 1 10 8 80% Bopally 1 1 1 1 0 1 10 5 50% Perur 1 3 1 1 0 0 10 6 60% Pedakotapally 2 3 1 1 0 1 10 8 80% Present 18 29 11 12 0 8 Ideal 24 48 12 12 12 12 Average 65% Prop 75% 60% 92% 100% 0% 67%

The ideal number of HR against each cadre is depicted in the brackets as per the IPHS staffing recommendations1. On the whole the HR present is 65% at the primary health centres (among the sampled).

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Chapter -6

ASHA and Reforms 8b

To assess the present situation among the ASHA pertaining to present incentives that they receive and factors affecting the motivation level in Mahabubnagar & Medak districts one on one interview was conducted (N=36) with the help of questioner in both the Districts.

6.1 Study Sample Profile of ASHA in Both the District

Characteristics of ASHA Mahabubnagar Medak

1.Number of ASHA surveyed 18 18

2.% of ASHA Educated below 10th class 11% 44%

3.% of ASHA Educated up to 10th class 72% 44%

4.% of ASHA Educated above 10th class 16% 11%

5.% of ASHA covering population =< 1000 56% 12%

6.% of ASHA covering population >1000 44% 88%

7.Average number of year of service 8 7

Financial Incentive 0 to 5 days 2 4 1 Improve Health 5 5 to 10 days Facilities 3 18 Social Prestige 10 to 15 days 8 30 Peer Pressure 15 to 20 days

Any other More than a month

Fig6.1-) Response to Motivation to become Fig 6.2) Average Time required to receive Incentive.

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6.2 Discussion:

The summary and findings have been segregated in two main components which are ASHA Incentive/compensation, Training and motivation factor for ASHA………

1. 50% of ASHA said that financial incentive is the main reason that prompted them to become ASHA. 2. ASHA opine that a higher compensation would be a motivating factor for them. 3. Third, the average time required to receive the incentive after submission of the bills/voucher by the ASHA was more than a month (83%). 4. A desire to improve health facilities in their village and social prestige associated with their job were also in the top four reasons to be an ASHA. 5. 72% of ASHA have completed their training out of which 66% felt that the training that was provided to them was not enough to what they actually do in the field. 6. Though refresher training was taken by 47% it was only a one day refresher training whereas it’s desirable to have 2 days refresher training. 7. All the ASHA’s have said that the community is respectful towards them after they have joined as an ASHA in the health system and 94% of the ASHA find it as a motivational factor to work as an ASHA. 8. 86% of the ASHA’s also mentioned that the earning as ASHA has also changed the way there in-laws/husband treat them at home. 9. ASHA were in opinion that acknowledgement, timely receipt of honorarium and appreciation in the form of receiving an award/reward from the district collector for the best performing ASHA would be a huge compliment for their work

Fig-6.3

36 36 36 34 32 28 31 30 30 31 26 24 27 27 18 18 19 18 18 16 13 14 14

36 36 36 30 30 Fig-6.4 24 18 14 13

ASHA Respondents

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Fig-6.5 Flow chart of finance release process for ASHA

6.3 Recommendation: 8b

In the context of our literature review, our study sample, our analysis of the findings, and on the basis of the broad knowledge and experience of the authors, we suggest the following recommendations for the improvement of ASHAs performance in both the districts in the categories of innovation and policy implementation gap that should be filled.

6.3.1 Innovations:

- Induction training should be decentralized to the block level to ensure that all new ASHAs receive training before working in the field. - Develop and provide ASHAs with pictorial job aids for each key health topic that is easily transportable to help ASHAs during their activities. - “ASHA Radio”, an innovation seen in Assam, in the state in order to provide ASHAs with a new and interesting avenue through which they receive on going on-the-job training as well as information about new illnesses and important events - Introduce “ASHA SAMELANAM” to create a platform for cross learning and sharing of experiences earned at field level by ASHA. - To provide District/Taluka authorities with a stage to interact with ASHAs and learn the issues they face at field level and suggested possible solutions as well. The samelanam can be utilized to appraise their work and appreciate/award the well performers. - Providing ASHAs with fix incentive for every month based on certain minimum criteria that should be fulfilled.

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6.3.2 Policy Gaps which need to be addressed: 8b

- Provide a brief, two day refresher training for all ASHAs on a yearly basis providing information pertaining to their roles and responsibilities and guidelines of all national health programs. - During training sessions, include lessons for ASHAs on how to convey complex information in a simplistic manner (in addition to content-based training) - Provide ASHAs with identity cards and uniforms so as to increase their recognition in the community. - Reduce delays in compensation - Consider implementing a regular schedule for paying each ASHA; for example, keep a log of all the activities completed during the month and pay each ASHA at the end of the month on a regular basis. (Strengthen DPHNO office, field level digitisation process can be introduced) - Provide increased opportunity for upward movement for ASHAs, in order to motivate engagement and continued performance. - Consider enrolling an ASHA into a training school to become an ANM after five years of work and successful recommendations. - Provide ASHAs with waiting room facilities at PHCs, CHCs, and Hospitals so that they have a comfortable place to stay when they accompany their patients for institutional delivery.

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Chapter-7

Training - ANM, SN Knowledge, skill assessment and need for training

As part of the survey conducted while drafting the ‘approach paper’ the frontline health workers were assessed on their ability to perform the designated functions. A total of 33 ANMs were sampled across both the districts of Mahbubnagar and Medak. A pretested questionnaire was administered to the ANMs.

Secondly an ‘onsite’ training programme was conducted for the ANMs and staff nurses at Mahbubnagar to assess their knowledge, skill, confidence levels and to assess the training need. The sample size for this activity was a total of 82 participants.

The findings of both the activities are depicted in the graphs and discussed below.

7.1 Discussion: (Refer figures on pages 33, 34 & 35)

1. 42% of ANMs reside in the designated HQ and the same proportions have population based work

distribution.

2. 97% of ANMs have a micro plan for the immunisation activities and 100% of the VHND sessions are

conducted as planned. However only 3% of them maintain a vaccination drop out list.

3. The major reason cited for the children dropping out of the immunisation being that of migration to other

places.*

4. On an average 26% of the ANM and SNs assessed were confident of conducting the skill related activity.

69% were non confident and expressed the need for retraining. 6% expressed total inability to perform

the skill related activity.

5. 87% expressed inability to plot the ‘partograph’ and 79% had poor knowledge levels in general – related

to their activities.

6. Anaemia and previous LSCS were listed as the high risk conditions in pregnancies. 36% identified PIH as a

high risk condition. Significantly a large majority reported ‘referral to PHC/MO’ as the preferred mode of

management of HRP for all conditions except anaemia where the management was limited to

administration of IFA tablets.

7. 12% of ANMs were able to fully identify the 10 predefined high risk conditions.

8. Among the assessed 48% had undergone IMNCI training, 36% SBA training, 39% NSSK training and 15%

immunisation related training.

9. 100% of those interviewed in the onsite training reported the need for training with emphasis on

identifying through the high risk approach.

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Back ground – ANM Immunisation - Practices

Back ground

0 3 6 details of ANMs 18

58 58 no no 97 97 94 100 82 yes yes

42 42

0 3 Residing in the presence of 2nd population availability of availability of availability of vaccination and same village ANM based work Microplan Duelists dropout list VHND sessions distribution planned vs held Needs Assessment for Training (ANM & SN) -Confidence levels Common causes of Drop outs 23

1 5 0 7 10 9 5 10 2 9

61 70 60 61 72 68 67 77 77 73 cannot perform the skill 8 6 39 37 not confident 29 35 27 need training 21 13 15 23 18 3 Confident

Migration Unawareness Traditional beliefs Fear of side effects mainly fever

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Needs Assessment for Training (ANM & SN) – Cont... Knowledge Levels From ANM questionnaire-Line listing

Partograph 94 100 76 70 64 1 55 55 36 30 6 18 6 poor percentage of ANMs who identified the average condition as high risk

87 good

excellent

Proportion of ANMs who identified the HR Conditions as against 10 pre-identified HR-C

Percent of staff trained 21 Knowledge levels 48 18 18 18 36 39 0 15 15 6 poor

average 9 6 6 good 79 3 excellent

20 30 40 50 60 70 80 90

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Total HR cases identified Training Quality 305

0 0 220 33

73 90 no 72 100 100 yes 6 10 13 10 11 7 67 27

Training - doubt The training was as not Training to improve Onsite training will help clarification as expected or fell skills for HRP ? short

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Chapter-8

Nutrition and Sanitation 8c,9

Millennium Development Goal 1 aims to halve the proportion of people suffering from hunger, and indicators include: (a) percentage of children under 5 who are underweight, and (b) proportion of the population below minimum level of dietary energy consumption. India is widely expected to miss the MDG hunger target by a significant margin (Svedberg 2009; Chhabra & Rokx 2004). Indicators of child and maternal under nutrition are particularly dismal. The percentage of children under age three who are underweight has virtually not changed between 1998 1999 and 2005-2006, hovering under 50%. The percentage of women who are underweight decreased only marginally, from 36.2% to 33.0%, during the same period (NFHS-III). More than 75% of the population lives in households with per capita calorie consumption less than the daily minimum requirements1 (Deaton & Dreze 2008).

8.1 Nutritional Status in Mahbubnagar & Medak:

Over half (54%) of all childhood deaths in India are related to malnutrition. Nearly 30% of the global childhood deaths attributed to stunting, severe wasting, and intrauterine growth restriction-low birth weight occur in India—a total of 24.6 million DALYs (Black et al 2008). TABLE 8.1

DLHS-4 DLHS-3 Mahbubnagar (2012-13) (2007-08)

Child feeding practices (%)

Children age 0-5 months exclusively breastfed 62.2 NA

Children age 6-9 months receiving solid/semi-solid food and breast milk 57.1 45.3

Children age 6-35 months exclusively breastfed for at least 6 months 27.3 26.2

Children under 3 years breastfed within one hour of birth 61 40.2

Birth Weight (%) (age below 36 months)

Percentage of Children weighed at birth 87.1 NA

Percentage of Children with low birth weight (out of those who weighted) (< 2.5 kg) 6.5 NA

Anaemia Status by Haemoglobin Level14 (%)

Children (6-59 months) having anaemia 63.7 NA

Children (6-59 months) having severe anaemia 17.8 NA

Source: DLHS-4

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TABLE 8.2

Medak

DLHS-4 DLHS-3 Child feeding practices (%) (2012-13) (2007-08)

Children age 0-5 months exclusively breastfed 70 NA

Children age 6-9 months receiving solid/semi-solid food and breast milk 57.7 42.2

Children age 6-35 months exclusively breastfed for at least 6 months 14.5 27.7

Children under 3 years breastfed within one hour of birth 44.6 46.1

Birth Weight (%) (age below 36 months)

Percentage of Children weighed at birth 89.4 NA

Percentage of Children with low birth weight (out of those who weighted) (< 2.5 kg) 9.4 NA

Anaemia Status by Haemoglobin Level14 (%)

Children (6-59 months) having anaemia 68 NA

Children (6-59 months) having severe anaemia 7.3 NA

TABLE 8.3

DLHS-4 (2012-13) Nutritional status of children below 5 years Andhra Pradesh: TOTAL RURAL URBAN

Children below 5 years wasting (weight for height- below 2 SD) 25.9 26 25.7

Children below 5 years wasting (weight for height- below 3 SD) 15.3 15.8 14.5

Children below 5 years stunting (height for age- below 2 SD) 26.2 26 26.5

Children below 5 years stunting (height for age- below 3 SD) 14.6 15.4 13.4

Children below 5 years underweight (weight for age- below 2 SD) 28.1 30.1 25.2

Children below 5 years underweight (weight for age- below 3 SD) 11.3 12.5 9.4

Anaemia Status by Haemoglobin Level (%)

Children (6-59 months) having anaemia 76.3 78.2 72.2

Children (6-59 months) having severe anaemia 18.4 19.6 15.7

Source DLHS 4

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8.2 Recommendations: 8c

8.2.1 FOCUS AREA: Prioritize Nutrition Outreach

It has been observed in studies that there are a gap in nutrition interventions that particularly require frequent follow-up and support, most notably safe infant feeding. At the same time, home visits are not the pillar of ICDS programming that they are intended to be. (Nirupam ET, al 2011)

8.2.2 Sanction of ANA (Accredited Nutrition Activist) per 1000 population8

The ANA would serve as a joint appointment between ICDS and NRHM, as an intermediary between the AWW and ASHA She will focus on the outreach needs of the AWC and we recommend that this worker focus exclusively on outreach operations. The ANA’s outreach work would focus on a finite list of critical nutrition interventions for: young women, pregnant women, breastfeeding mothers, infants, children under two, children under five, and heads of household. This should be immediately prioritized in difficult to reach and otherwise marginalized areas.

8.2.3 Proposed ANA roles and responsibilities: 8c

Monthly growth monitoring (MUAC, height-weight measurements) for all children less than three years of age. This data is provided to AWC and supervisors for district reporting and AWC micro planning.

Identify cases of malnutrition that require referral for treatment. 8c

Mobilize young mothers and young children to come to the AWC. Follow-up with mothers and children who have not come to the AWC.

Demonstration-education and counselling for mothers on key nutrition messages exclusive breastfeeding, complementary feeding, diversifying diet with locally available foods, household hygiene, hand washing, and seeking care from ASHA/ANM during illness.

Mobilize nutrition programming in the village (e.g. VHND, public meetings). Contribute outreach visit information to VHSC meetings, for planning purposes.

Ensure that ANAs receive targeted training for specific nutrition interventions, with a focus on the 1000 days of opportunity. They should receive annual refreshers.

Proposed incentives could involve: x% of beneficiaries accessing AWC services for an extended period of time, demonstration-education sessions (e.g. diversifying diets with locally available foods, infant feeding practices), or improvement in nutrition indicators within catchment area.

8.2.4 Incentivise and define the role of ASHA in Nutrition related interventions. 8b

Provide ASHA incentive for motivating birth spacing between children, as short birth intervals are associated with higher levels of under nutrition.

Revise ASHA roles and responsibilities to finite list, developed around a field job aid that acknowledges collaboration between all relevant frontline workers (AWW, ASHA, and ANM).

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8.2.5 Develop ICDS workers training in specific to Nutrition 8c

Concretize clear, finite AWW roles and responsibilities. These should include expected outcomes for each activity and how the activity will be monitored. It should also outline concrete expectations for effective collaboration between the ANA, ASHA, ANM, and Nutrition Committee.

Ensure that all AWW receive one day of refresher training every 6 months.

Revise introductory AWW training. Material needs to be refocused towards most important nutrition interventions and programme expectations.

Ensure that all selected AWW receive the full introductory training, including on-the-job training before beginning.

Ensure that significant components of the introductory and refresher trainings are conducted on-the-job and on-going by the AWC supervisor.

8.3 Sanitation: 6

Government health facilities at the level of blocks and below can become more responsive to population needs if funds are devolved to the Panchayati Raj Institutions (Village Council or its equivalent in the Scheduled Areas), and these institutions made responsible for improving public health outcomes in their area. States should formalise the roles and authority of Local Self-Government bodies in securing convergence so that these bodies become stakeholders for sustainable improvements in health standards. The States would be advised to make Village Health, Sanitation and Nutrition Committees as the guiding and operational arms of the Panchayats in advancing the social agenda.

NGOs have an important role in strengthening capacity. An integrated curriculum will be drawn up to facilitate this process. NGOs can play a key role in providing support to VHSNCs and PRIs in capacity building, planning for convergent service delivery and more effective community based monitoring. Recognition and instituting awards for achievers along the lines of Nirmal Gram Puraskar under the Total Sanitation Campaign will be one Way of incentivisation.

To suggest locally (state) relevant recommendations, mandates the need for deeper investigation to include the PRIs as part of the field survey. CGC would be willing to facilitate this activity if the state is interested.

At higher levels (DH and SDH) we advocate that the sanitation and waste management activity be out sourced to a professionally competent firm.

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Chapter-9

Scope of Private Public Partnerships. 6, 7,9,10

9.1 It is widely accepted that the deficiencies in public sector health system can only be overcome by significant reforms. Reform strategies include (i) alternative financing (user-fees, health insurance, community financing, private sector investment); (ii) institutional management (autonomy to hospitals, monitoring and management by local government agencies, contracting); (iii) public sector reforms (civil service reforms, capacity building, productivity improvement); and (iv) collaboration with the private sector (public/private partnerships, joint ventures) (World Bank 1993; Thomason 2002; Abrantes 2003). 7

Partnership with the private sector has emerged as a new avenue of reforms, in part due to resource constraints in the public sector of governments across the world (Mitchell- Weaver and Manning 1992). There is growing realisation that, given their respective strengths and weaknesses, neither the public sector nor the private sector alone can operate in the best interest of the health system. There is also a growing belief that public and private sectors in health can potentially gain from one another (ADBI 2000; Bloom et al. 2000; Agha et al. 2003). 7

Involvement of the private sector is, in part, linked to the wider belief that public sector bureaucracies are inefficient and unresponsive and that market mechanisms will promote efficiency and ensure cost effective, good quality services (WHO 2001). Another perspective on this debate is linked to the notion that the public sector must reorient its dual role of financing and provision of services because of its increasing inability on both fronts (Mitchell 2000). Under partnerships, public and private sectors can play innovative roles in financing and providing health care services. Collaborating with the private sector and fostering a partnership for providing health services to the underserved sections of the population are particularly critical in the Indian context. Due to the deficiencies in the public sector health systems, the poor in India are forced to seek services from the private sector, often borrowing to pay for them. India has one of the world s highest levels of private out-of-pocket financing (87 percent estimated in World Bank 2001). 7

Over the years the private health sector in India has grown remarkably (Baru 1999). At independence the private sector in India had only eight percent of health care facilities (World Bank 2004) but recent estimates indicate that 93% of all hospitals, 64% of beds, 85% of doctors, 80% of outpatients and 57% of inpatients are in the private sector (World Bank 2001). Contrary to commonly held views, private hospitals are relatively less urban-biased than the public hospitals. Given the overwhelming presence of the private sector in health, various state governments in India have been exploring the option of involving the private sector and creating partnerships with it in order to meet the growing health care needs of the population. 7

PPPs offer an opportunity to tap the material, human and managerial resources of the private sector for public good. But experience with PPP has shown that Government’s capacity to negotiate and manage it is not effective. Without effective regulatory mechanisms, fulfilment of contractual obligations suffers from weak oversight and monitoring. It is necessary, as the HLEG has argued, to move away from ad hoc PPPs to well negotiated and managed contracts that are regulated effectively keeping foremost the health of the common man. 6

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Tamil Nadu has issued guidelines to authorise Medical Officers in charge of particular healthcare facilities to enter into MoUs with interested persons to receive contributions for capital or recurrent expenditure in the provision and maintenance of facilities. On available models for self-generation of revenues, the option for cross-subsidy in line with the Aravind eye care system based in Tamil Nadu could also be explored. 6

9.2 In context of the approach paper we recommend that the state can explore PPP in the below mentioned areas, 7, 8,9,10

1. IT enabled planning, decision making and service services which would Information Technology can be

used in at least four different ways to improve health care and systems: 9

1. Support public health decision making for better management of health programmes and health

systems at all levels.

2. Support to service providers for better quality of care and follow up.

3. Streamline of data and other IT enabled systems of training, logistics, finances to name a few

4. Supporting education, and continued learning in medicine and health.

2. Electricity and power back up through renewable energy sources for the critical health centres initially.

3. Annual maintenance / repair contract for various types of equipment.

4. Ensuring water supply (ground water) where ever the running potable water through other sources is not

possible within the stipulated time.

5. Supply of drugs, vaccines and other logistics to the health centres from the district / state stores with a

view towards achieving promptness in the drug stock replacements.

6. Hiring of locally available means of transport at the periphery (ambulance and other means) for the pick-

up and drop services to patients and for the pregnant mother.

7. Hiring of qualified doctors at government facilities on an ad hoc basis or during vacancies where no MO is

available for a prolonged duration. The private doctor can be reimbursed on a case basis. 10

8. At higher levels (DH and SDH) we advocate that the sanitation and waste management activity be out

sourced to a professionally competent firm.

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Chapter-10

District Specific and state wide Recommendations 6, 8, 9, 10

10.1 District Recommendations:

10.1.1During our collaborative situational assessment of the Medak and Mahbubnagar districts we have identified a number of key delivery challenges that will be targeted in a streamlined strategy. It is interesting to note that despite being two districts with different geographical layouts, challenges, leadership and business dynamics we find that the assessment across various broad thematic areas is fraught with a comparable low performance. Table 10.1 summarises these findings. Mahbubnagar appears to be marginally better than Medak district at level-3 facilities except in the areas of a) essential drugs & supplies b) service delivery in post natal wards and c) pick and drop facilities. However since the scenarios in both the districts appear to be similar the approach to betterment has been addressed as a single unit.

Our action plan asserts that poor utilisation rate of services in the periphery of the district are being driven by long travel times to reach services, underutilization of community and village-level health services, and insufficient home- based outreach. This is furthered complicated by inadequate human resource capacity at the facility level, deficient infrastructure, equipment, essential supplies and the quality of services rendered.

10.1.2 In this paper we aim to discuss the Action Plan (AP) 10 developed based on the findings from both the districts of Medak and Mahbubnagar. It presents a package of strategies that maximize available funds to target system strengthening, particularly bolstering health facilities to ensure local access to 24*7 care and safe delivery, building stronger community-based support and care management, and creating stronger emergency referral networks. The strategies outlined are expected to be high-yield if aggressively pursued in operational planning and funding.

Implementation planning will also require progressive thinking around key challenges—like systems accountability, particularly at facility level—and innovative ways to address these issues in the Model District.

The strategy for enhancing the demand at the periphery can be divided into three broad categories. (Immediate, 4.Long term Mid-term and Long term) The key to implement any priority strategy is to have an effective plan which is the DHAP (District health action plan) Districts are deliberately 3.Mid-term chosen as the planning unit because they represent the Priority most aggregate sub-state units of governance in India, and are responsible for planning, budgeting, and 2.Immediate management across all sectors .for scaling up innovations Priority and quality improvements in infrastructure, data management, governance, financing, supply chain management, and frontline health worker capacity. 1.DHAP (Plan) The immediate strategy is to focus on areas which can be rectified almost on an immediate basis and do not require

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Table 10.1

Medak Mahbubnagar Difference* Thematic Area L1 L2 L3 L1 L2 L3 L1 L2 L3 Average (availability) Mbnr - Mdk Infrastructure 38% 44% 48% 31% 61% 71% -7% 17% 23% Equipment 54% 69% 83% 46% 64% 88% -8% -5% 5% Essential drugs 66% 57% 68% 58% 70% 61% -8% 13% -7% Essential Supplies 53% 65% 67% 32% 38% 67% -21% -27% 0% Lab Services 42% 54% 71% 45% 73% -42% -9% 2% Service delivery in post natal wards 89% 74% 78% 0% 74% -11% Record maintenance 34% 43% 38% 60% 54% 49% 26% 11% 11% Pick n Drop 37% 61% 39% 33% 55% 33% -4% -6% -6% IEC Material 49% 52% 52% 29% 44% 55% -20% -8% 3% Other-support services 21% 46% 46% 33% 59% -21% -13% 13%

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Immediate - Rationalization DHAP Step-1: Identify the PHCs functioning optimally based 1. District level pre DHAP on the utilisation parameters and time to care concept. workshop. Mid-term and long term Step-2: Such identified facilities need to be assessed for 2. Training for DHAP to the gaps in infrastructure, HR and equipment. district authorities who are All midterm and long term approaches entrusted with the PIP Step-3: Identify another set of 24x7 facilities which have activity. the potential for improvement e.g. in terms of the population catered and based on time to care concept. should be focused on strengthening the

Step-4: This step will weed out all the poor performing 3. To be used as a tool for 24x7 facilities and those having no potential for 1. Infrastructure monitoring. improvement. Such facilities may be downgraded to function as non 24x7 facilities. 2. Equipment 3. Essential Supplies & Drugs Step-5: Assess the infrastructure, HR and equipment at 4. Recruitments the poorly functioning facilities. ASHA: 5. Trainings – continued Step-6: Relocate all the excess infrastructure, HR and 6. Transport and referral mechanism 1. Diversifying and incentivizing equipment to the 24x7 facilities. 7. Innovations key home-based activities Step-7: The equipment / infrastructure needed to be The detailed 3 year plan has been illustrated 2. Shore up existing ASHA workforce arranged on an immediate basis from any funds at the Govt in the chapter 3. Ensure adequate supervision and disposal. management. Innovations: 4. Fixed minimum incentive. Step-8: HR – no vacancies to be allowed. Where needed qualified doctors from the private sectors may be hired on a case basis and remuneration paid accordingly. 1. IT enabled data handling and data driven This model is being followed by certain central public decision making process. sectors E.g. HAL. 2. Private public partnerships for referral transport, ISO standards,

Based on the training assessment done simultaneously all untrained undergo training.

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1. Infrastructural requirements and quality controls 10 The infrastructure strategy aims to improve the availability and utilization of preventative care at primary level facilities, A) Strengthening sub-centres (SC) and Primary Health Centres (PHC) 10

These major strategic infrastructural components will include: a. Increase availability of 24*7 services, particularly delivery, at primary level. b. Rationalize and upgrade all other PHCs to provide preventative care and basic primary/referral care during daily hours (7 hours a day, 6 days a week). Regular and full-time hours are critical for optimizing the primary healthcare system. First, this can be achieved by ensuring the availability of doctors, reducing ANM duties so that she is only focused on facility-based care; an upgraded ASHA system can be largely responsible for home visit and community-based programming. Second, these facilities require support from more comprehensive referral transport systems. c. Ensure consistent and adequate supplies and medicines at primary level by an informed push or pull system that can account for fluctuations in demand (e.g. seasonal, utilization rates). d. SC must be adequately staffed by ANM and security/cleaning personnel, and quarters provided in the difficult-to-reach areas. Given the challenges for retaining staff at some isolated posts, we have recommended ‘hardship allowance’ addition to the base salary for designated health workers at specific high-focus SCs and PHCs. Job stationing should also account for a health worker’s locality and local requirements (e.g. if female RHPs are requested in some Muslim communities).

2. Increasing capacity for community-based care management10 As the cornerstone of NRHM, the Accredited Social Health Activist (ASHA) has a direct impact on how well services are decentralized to the village level, and how well communities mobilize for care. Our action plan proposes a number of strategies we believe will further streamline ASHA activities for greater public health impact, and provide stronger support in the field. These strategic components include: a) Diversifying and incentivizing key home-based activities for ASHA that are critical care but currently not included in the formal scope of work (e.g. new-born visits, sick child care, key gaps in administrative work). In order to streamline ASHA responsibilities and focus skill sets, Trainings and refresher courses are required to refocus tasks and skill sets, and address challenges from the field. Easy-to-use job aids should be developed as the cornerstone of trainings and in-the- field training and continued mentorship. b) Ensuring that an incentive structure for ASHA is motivating and provides some level of economic security. To this end, we have recommended top-ups for key activities (e.g. course of antenatal care, birth accompaniment, immunizations). Our action plan costing exercise estimated a monthly incentive package of approximately 3000INR per ASHA; according to qualitative reports, ASHA in the district currently earn about 1500INR a month. c) Shore up existing ASHA workforce by: (a) conducting a performance assessment on ASHA hired since 2006 and release those who are no longer working or performing; (b) recruiting, selecting, and training ASHA to fill existing gaps in the population ratio (1:1000) (c) provide immediate basic training to existing ASHAs who are working in the field without having any days of training in order to maximise productivity and minimise potential harm until new training programme is developed. d) Ensure adequate supervision and management for ASHA by recruiting and selecting additional ASHA Supervisors (to maintain a 1:10 ratio) and ASHA managers in each block, who will work with the District Community Mobilizer to manage supervisors, a regular performance review, training calendars, and supplies.

3. 24*7 and timely referral transport services10 Referral transport services are currently provided through GVK EMRI 108 services and facility- based ambulances.

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First, while 108 ambulances are the most efficient and safe way for transport from the home to the health institution, the time of pick-up can range from 45 minutes at a minimum to over 1.5 hours. Additional 108 ambulances are required for adequate coverage. Second, PHC ambulances, which are largely intended to be available for facility-to-facility referral, are either minimally available or non-functional. Third, ambulances are unable to reach populations in the, hilly, forested, and otherwise difficult to reach areas especially in the district of Mahbubnagar which has a large forest cover and poor transport facilities. These areas are severely limited to health system access, often resulting in deaths at home or during late transport. Emergency transport vehicles will be critical in ensuring women in labour and children with emergencies have access to healthcare, therefore reducing maternal and child death.

Given these challenges, our action plan outlines the following capital and management investments in order to improve the referral transport coverage, timeliness, and efficiency, and particularly for delivering institutions: a) Ensure a centralized management system that can coordinate all incoming referral transport requests and ensure driver dispatch. This centralized management system should specify between facility- home transport and facility-facility transport, and between emergency and non- emergency24 transport. Utilization will require a significant information, education, and communication campaign to ensure public awareness about emergency numbers, availability, and expectations for service.

4. Streamline training priorities 10 Human resources for health, both administrative and technical, are only as effective as they are trained to be. In order for the health system to perform efficiently and at its best, each tier within the system, from administrative employees, to senior and junior technical staff, to community workers, must be regularly trained and oriented towards the key health goals within the district. Trainings span the spectrum of motivation, management, and skills in order to equip the workforce with the drive and ability to enhance the health system. These components include: a) Ensure human resources and infrastructural support for a full-time training structure; as the administrative structure stands, district officials and medical officers are responsible for organizing training calendars, managing logistics, and service as master trainers. The district is considerably behind on its training goals. We have proposed a full-time district- level and block-level technical training managers to ensure rapid progress on training calendars and field-level mentorship. We have also proposed additional training space for the district, which comparatively little space, by method of outsourcing hostel space (for immediate need) and repairs to other government buildings that could be used as training facilities. b) Motivational training for all district administrative and technical staff, highlighting maternal and child health goals set by the district, expectations for performance, and rewards to highlight outstanding performance. This will include a new joint training for ANM, ASHA, and AWW focusing on roles for Village Health and Nutrition Day (VHND). c) Immediately provide a streamlined training for skilled birth attendance and Navjat Shishu Suraksha Karyakram (NSSK) for ANM and GNM required at 24*7 delivery facilities. d) Immediately provide all sub-centre ANM with refresher training on quality antenatal care, including reporting and referral systems, and diagnostic requirements that have been highlighted as gaps (e.g. haemoglobin and blood pressure testing). e) Immediately provide specialist trainings for medical officers placed in PHC, CHC/FRU, and the district hospital, as allocated, for short courses31 in: (a) paediatric and neonatal management, (b) anaesthesia, and (c) gynaecology, safe abortion, and IUCD insertion. f) Immediately provide IMNCI training to designated ASHA, AWW, and ANM as district referral strategies will require.

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Our action plan strategy reinforces that training needs can only be met if the appropriate structure is in place, and this will require immediate manpower and infrastructural allocations. A full-time training structure can more effectively drive a training calendar forward for identified training gaps, and better coordinate master trainers and trainees so that health workers are not unnecessarily overburdened with training time.

5. Targeting nutrition programming10,8c

As an exercise in integrated health services, the districts must implement an equally aggressive approach to nutrition programming for young women and children. While the formal nutrition programming—ICDS, or the Integrated Child Development Scheme—falls under the Ministry of Women and Child Development (WCD), NRHM envisions a rural health system that is deeply integrated with local nutrition programming.35 AWC are well-placed to provide nutrition interventions at the community level, but they are not systematically delivered or targeted. Given the tremendous impact of malnutrition in India, the Model District must pursue innovative nutrition programming pilots. Our action plan for nutrition focuses on streamlining operations to better target malnourished children, build out protocols for referral and management at the community level, reinforce home-base nutrition action, and improve monitoring and support of anganwadi workers (AWW). Specific components include: a) Immediate reinforcements to anganwadi centre (AWC) monitoring. First, this requires Recruitment of AWW supervisors. Second, this requires streamlined record keeping at the centre; we have recommended piloting an AWC registrar that focuses on only the most critical and actionable data points; we have learned that AWC report over 100 data points and only four are analysed centrally. b) Improving the targeting of AWC services through: (a) consistent methods of growth monitoring, including a baseline and regular follow-up at the home by the ASHA or an additional nutrition outreach worker, (b) rapid reporting methods (e.g. by mobile phone) of key indicators to facilitate on-the- job support and quick action (c) protocols for managing and referring children who are moderately and severely malnourished, and for collaboration between the ANM, AWW, and ASHA on these children. c) Maximizing operations in the districts AWC, and in the immediacy, releasing AWW with poor attendance and performance, and addressing breakdowns in the supplementary nutrition supply chain. d) Including provisions for universal iron-folate supplementation for women of reproductive age (15- 49), for distribution and tracking by ASHA during household visits and VHND.

6. Increasing capacity for active, data-driven management 10,9

Health planning and management is currently severely limited at the district level due to the lack of real- time data use. Integrated health service provision and utilization is a dynamic process that requires important data to be immediately collected, analysed comparatively (e.g. across time, place, and intervention), and collaborative, corrective actions. Currently data is largely underutilized, and when it is reviewed, it is only in its absolute figure from a given month (e.g. number of institutional deliveries last month in the district), which does not allow for a more dynamic analysis (e.g. proportion of reported deliveries in X block that were in an institution, and viewed over time, and compared to other blocks). While significant efforts to create more comprehensive and timely data systems41 should be applauded, our action plan emphasizes the need for streamlined management tools and support staff at the district level to ensure more informed planning and monitoring. The key strategic components of an active management strategy include:

a) Building a district- and block-level management portal that tracks key indicators by block, and displays data dynamically (e.g. across district, over time) and visually. This portal can draw from existing HMIS data collection, so it does not add burden to staff, and can also be validated by other data sources (e.g. impact surveys, MCTS, national surveying).

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b) Streamlining job profiles at district and block-level NRHM units to maximize performance. We have recommended adding positions in areas of critical need (e.g. technical training coordinators, support administrative staff), and envisioning other roles (e.g. the largely male multi-purpose workers that are stationed at facilities and largely doing malaria outreach, but could be tasked and trained for family and male-specific outreach in family planning and seeking health services). c) Targeting logistical hold-ups for scheme disbursement in the district.

As a closing point in our strategic plan discussion, we want to emphasize that in addition to the technical staff and health infrastructure, the administrative and operational teams and infrastructure are crucial for providing the overall health system the support it needs in order to provide quality health service delivery. Operational teams at district and block levels must be fully equipped – both in terms of personnel and equipment – to handle the management of a workforce of hundreds of people and the oversight of infrastructure quality of hundreds of health institutions in the district. Well trained and well equipped administrative and operational teams form the fulcrum that maintains the balance of the health system; emphasis on these will allow the health system to smoothly provide quality care for mothers and children in the district.

10.2 State wide Recommendations 6, 8, 10, 9

1. Strategic Planning & Needs Assessment 10 2. Upgrading and Building Physical Infrastructure 3. Human Resources for Health

For the three points listed above the strategy and action plan discussed in the section on the district level recommendations may be replicated in the remaining districts of the state. In order to achieve this necessary policy decisions and a case for enhanced spending needs to be made.

4. Information and Communications Technology: 9 the weakest link in the whole chain of events is the ‘data management’ for all the aspects relevant to the delivery of health care. A comprehensive, dynamic, real time data management would require significant investments in terms of hardware, software, maintenance and support technical services to cater to round the clock trouble shooting and guiding the staff on correct usage. The broad idea is to have all programme related data entry from the ground level (bottom up approach) e.g. by empowering the ANMs with the RCH register application on an android platform in a hand held device. This data can be uploaded to the cloud server for viewing, review, and forecasting, records and report generation. Such data is not only real time but will also help in mapping the district about the services and resources available or converse. It can be used for planning, control, ensure transparency, training, logistics, and repair mechanism. The details have been discussed in the chapter on innovations. 5. Nutrition: 8c In order to effectively address the issues related to nutrition and as discussed in the chapter on Nutrion we propose the formation of council the details are as below,

a) The Chief Minister of Telangana to Chair an Inter-ministerial Council on the Challenges of Nutrition in Telangana. This Council should include State Ministers of Health, Women and Child Welfare, Water & Sanitation, Finance, Agriculture, Rural Development and Panchayati Raj. b) This will be along the lines of a similar Council set-up by the Central Government in 2010 on the recommendation of an NRHM Evaluation Report by Bajpai/Sachs 201011. It was recommended that the Government of India constitute a Prime Minister’s National Council on India’s Nutrition Challenges for policy direction; review and effective coordination between Ministries all of who have a sectorial responsibility for dealing with the challenges of nutrition.

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c) The Council was established and its first meeting was held on November 24, 2010. Bajpai/Sachs also recommended that Indian States should set-up under CMs leadership similar councils for dealing with the challenges of nutrition in their States. Under the Nutrition Head, the second recommendation should be the idea of an Accredited Nutrition Activist (ANA), similar to the ASHA, but as an outreach worker with a focus on identifying severely malnourished children and to bring them to the attention of concerned authorities for immediate action concerned authorities for immediate action

6. Community Health Workers: 8b Our field survey has demonstrated that majority of ASHAs have joined for the financial incentive, however they feel that the way the community and family treats them has changed in a positive sense when functioning as an ASHA. The ASHAs feel that they are being over worked and not reimbursed on time. Further discussions have highlighted the fact that a significant proportion of ASHAs get the financial reimbursement by > 1 month. The bottle neck has been depicted in the chapter on ASHA; here we recommend the system of digitisation at the field which can be accessed by the finance person. Alternately till such system is established the DPHNO office at the district level may be empowered by the process of out sourcing for the digitisation process. This activity can also be done by the PHC level supervisors by local out sourcing. These recommendations are in addition to those made in the district level section.

7. Innovations:

a) ISO Standards: One way of improving the quality of services is to have a dynamic system which encourages the inter-facility competition. This not only enhances the performance of the health facilities by encouraging them to meet the standards but also instil the confidence among the people thus enhancing the demand. Those facilities which have achieved the standards may be appreciated and the staff may be considered for other benefits as statutorily relevant.

b) Accredited positions: 8b To enhance community participation in two specific but significant areas is to have two field volunteers or accredited positions in the areas of nutrition and encouraging male participation in family planning services and non-communicable diseases. a. ANA: Accredited nutrition activist – this has been discussed in detail in the chapter on nutrition. b. ASHOK: This would be a male health activist equivalent to that of ASHA serving the similar population. The main objectives for ASHOK would be to encourage male participation in family planning and in encouraging the male community to lead a more healthy life and advocate on the ill effects of alcoholism, tobacco consumption etc. The detailed ToR can be worked out.

c) Evaluations: Internal evaluations would serve as a means of evaluating the various health programs being implemented in the district. This would in lines with the common review mission of NRHM, only that it would be a state driven activity. On an average two districts per quarter may be evaluated. The evaluation team would be heterogeneous comprising of an external district level officer, state officials, development partners etc. The team would evaluate at least 35% of the clusters selected by random sampling. The district and FRU level facilities would be a mandatory addition. This exercise would serve as a fact finding mission and would advise the district and state level authorities on the further course of action the district needs to take based on the findings. This activity would also keep the health workers on their toes. Additional the district needs to submit an action taken report to the state which could be used as a barometer of progress made as per the commitments. The various guidelines, formats, finances and protocol needs to be worked out.

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d) Trainings: - Constitute a team of Master trainers from among the peer for different cadres of staff and immediate induction training for all new recruits. - Plan for sub district level continued refresher trainings from among the peer group ideally during the monthly meeting. - Lessons may be drawn from the ‘onsite coaching’ of staff nurses and ANMs at Mahbubnagar.

e) In context of the approach paper we recommend that the state can explore PPP in the below mentioned areas, 7,6,9,10

1) IT enabled planning, decision making and service services which would Information Technology can be used in at least four different ways to improve health care and systems: a. Support public health decision making for better management of health programmes and health systems at all levels. b. Support to service providers for better quality of care and follow up. c. Streamline of data and other IT enabled systems of training, logistics, finances to name a few d. Supporting education, and continued learning in medicine and health.

2) Electricity and power back up through renewable energy sources for the critical health centres initially. 3) Annual maintenance / repair contract for various types of equipment. 4) Ensuring water supply (ground water) where ever the running potable water through other sources is not possible within the stipulated time. 5) Supply of drugs, vaccines and other logistics to the health centres from the district / state stores with a view towards achieving promptness in the drug stock replacements. 6) Hiring of locally available means of transport at the periphery (ambulance and other means) for the pick-up and drop services to patients and for the pregnant mother. 7) Hiring of qualified doctors at government facilities on an ad hoc basis or during vacancies where no MO is available for a prolonged duration. The private doctor can be reimbursed on a case basis. 8) At higher levels (DH and SDH) we advocate that the sanitation and waste management activity be out sourced to a professionally competent firm.

f) All the above activities need a significant amount of spending on health care for which the DHAP and advocacy at the national level as tool is strongly recommended.

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10.3 Approach Plan: (Prototype) 6

Depicted in the figure below are the essential components for a fully functional system in general, central to it being the motivation as a constant factor. Motivation is required at all levels starting from the political and administrative commitments to the front line health worker. Motivation is also needed by the end user of the facilities which is gained by enhancing confidence in the system.

The approach plan addresses the 16 thematic areas in a broad perspective, clubbing some of the overlapping areas as a single Money unit of planning.

Essentially the approach plan recommends,

Monitori Motivation Men ng - Systematic planning and increased spending on health care. - Prioritisation of interventions to be taken up on an immediate basis.

Material

Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration *1-immediate priority, 2-midterm priority Year 1 2 3

Quarter 1 2 3 4 1 2 3 4 1 2 3 4 Quarters 1 36 Prioritisation criteria Sub- ANM Quarters 1 36 50% of SCs with high potential for improvement SN quarters to be centre accorded priority-1 followed by MO and other Qtrs Infrastructure Strengthening 25% of SCs with medium potential L-2 PHCs should be 25% of SCs with medium potential and accorded priority-1 as additional new SCs this is expected to PHC-L1 MO Qtr 2 36 50% of PHCs with high potential for decongest the improvement overloaded L-3 facilities SN Qtr 1 36 25% of PHCs with medium potential and also addresses the

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Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration equity related constraint and minimise the OPE for the end user of services. Other Qtr 3 36 25% of PHCs with medium potential and additional new SCs PHC-L2 MO Qtr 2 36 50% of PHCs with high potential for improvement SN Qtr 1 36 50% with medium and low potential including new Other Qtr 3 36

CHC-L2 MO Qtr 2 36 50% of CHCs with high potential for improvement SN Qtr 1 36 50% with medium and low potential including new Other Qtr 3 36

L-3 MO Qtr 2 36 50% of L-3s with high potential for improvement

SN Qtr 1 36 25% of L-3s with medium potential

Other Qtr 3 36 25% of L-3s with medium potential and additional new Const. Repairs / Renovations All Toilets M/F 1 12 L2-PHC to be prioritised levels for all the interventions. 24*7 water 1 6 The range for M/F toilets is 0-30% power backup 1 6 The range for power back up is 10-50% Wards M/F 1 3 Most of the health facilities function in the govt bldg

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Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration Toilet in LR 1 6 New buildings may be considered as per the population norms Labor room 1 9

Comp / Sug 1 3 box NBCC 1 3

NBSU 1 3

SNCU 1 3

SC SC Bldg 1 36 50-60% of SCs are functioning in Govt. Bldgs. All General 1 9 Prioritise L-3 and L-2 levels facilities for all kinds of equipment Laboratory 1 6 L-1 and SCs can be supplied the field Equipment equipment as a priority OT 1 9 Including equipment for

ANC, PNC & INC. Blood bank 1 12

Repair / All All equip 1 3 Critical for all Maintenance levels equipment to have a mechanism of seamless service Equipment delivery All Vital 1 3 V,E,D analysis may be levels used - considering the Essential Drugs consumption trend & Medical Essential 1 6 and potential for supplies demand, a staggered

approach may be used.

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Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration Desirable 1 12

Logistics, supply All 1 9 The automated real and demand levels time system may be forecast clubbed with the Automated electronic recording mechanism - and reporting system. real time

All To be planned within levels Induction 1 6 ANMs , SNs and MOs one month of recruitment Decentralised cyclical Re-training approach Assessment of Front line health workers training needs to be 1 3 Training needs assessed on a priority # Identification Peer, well qualified trainers among ANMs and of district and 1 3 SNs to be identified sub-district Training level trainers To be aligned with the Sub-district monthly meeting training 1 3 calendar. Post training

calendar results can be used for continuous assessment. SPHO can be the nodal Initiation of person. Dist and state sub-dist. 1 3 representatives can be

Trainings a part of the quality control. Training Electronic and real time system may be Private public 1 6 management considered partnerships can be

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Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration information explored. system To achieve 100% filled SC ANM 1 12 Recruitment of ANM 1st and 2nd positions. PHC - SN 2 6 Recruitment L1 Current 58-75% of MO's MO 2 6 MO's from low potential PHCs may be relocated are filled Current 45-60% of SNs PHC-L2 SN 1 6 are filled MO 1 6

Human Lab tech. 1 6

Resource Pharmacist 1 6

CHC-L2 Specialist 2 6

MO 2 6

SN 2 6

ANM 2 6

L3 Specialist 1 3

MO 1 3

SN 1 3

All Pick n Drop PPP can be explored. levels Partnerships to be H2F 1 6 explored on a priority Innovative and prompt Referral System on spot reimbursement F2F 1 6 of OPE will enhance demand. PRI can be empowered F2H 1 6 to purchase vehicles.

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Level ACTIVITY of Sub activity Plan* Plan Plan - Breakup Sub-plan Remarks Facility start duration To be able to forecast Real time 2 6 the delivery dates for system pick up n drop. IEC FM radio, text All messages through Interactive 2 12 levels phones, call messages etc.

Monitoring & All Real time 2 18 Supervision levels system

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Chapter-11

Innovations 9,10

In this section on innovations we discuss two scenarios which are potential game changers in the data handling and the way it is used for planning and monitoring.

11.1 Big Data Analytics: Strengthen the HMIS 9

One of the major problems in planning is the lack of reliable data from the field to enable planners to have a realistic plan of action and to request for finances adequately from the central government. Planning is essential to any organisation and the basis for which is to ensure reliable and validated data.

The current trends point towards the ambiguity of available data and this is fortified from the evidences from the field as documented in the block monitoring and other supervisory reports.

Table – 12 – Example of Data differences

Since its inception of the ambitious HMIS by the GoI in 2005 with the sole purpose of digitization of the data it suffers from the lack of validation and data check. This enables the peripheral data providers with the chances of providing with the systematic erroneous entries which has been tailored to meet the targets of the various indicators as per the level of expected achievement.

Additionally the data captured by HMIS is not real time which again adds to the customization of data as per the need as such the reporting facility in specific and the larger district in general is not projected in bad light.

The outcome of this poor quality of data is the unrealistic health action plans which do not reflect the field realities. Hence the vicious cycle of poor planning and ineffective service delivery continues to plague the country’s MIS.

So what can states do to break this vicious cycle? Is the question asked by many? The answer to this is to make the data less prone to systematic erroneous entries so as to eliminate the chances of customisation of data.

It is common knowledge that the real time data meets the above requirement. Hence the available

Real time data mandates the need for a robust electronic and internet dependent surveillance system to be in place. This concept is explained in the figure below.

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Current Process: Fig-11.1

4 The filled in excel sheet is uploaded 3 into the HMIS The collated data is portal. filled in by the DEO at the block / 2 Collated data is cluster level once in reviewed at the PHC a month into a excel and block level. 1 Gets collated at the template. SC,PHC,CHC, levels once in a month. Field data is filled into the registers - adhoc or periodic Review is basis. limited to the activity. DEO is generally overloaded as he has to cater to many facilities Field data – Is not data entry. validated periodically.

The entire Process takes at least one month post the date of completed activity.

As a result the data available is not only non-real time but also unreliable. This is depicted in the figure on Current process.

In the model which we recommend we propose to eliminate the steps from 1 to 4 as a paper based approach and introduce a system of real time data entry. The real time data entry will also over a period of time eliminate the need of not only the paper related logistics and costs but also improve the overall work efficiency by reducing the time spent currently on preparation of reports. Various studies have indicated that one of the main hurdles for effective quality work is the process of record maintenance and subsequent report preparation which can consume up to 60% of the work hours of the front line health workers.

In this approach we describe how the current system of HMIS can be strengthened without disturbing the basic working of the HMIS.

The electronic recording and reporting system has the potential to,

1. Minimise the time involved in record keeping and report preparation. 2. Minimise the errors in transcription which are inherent due to the multiple entries across various record and reports. 3. Minimise wrong or erroneous reporting both with and without intention. 4. GPS tracking ensures accountability for the field visits. 5. Finally but most importantly allows the programme managers and if need be the beneficiaries to have access to the records on a real time basis. (Managers portal) 6. Additionally this electronic R&R has the potential to assist the planners in analysing and presenting genuine data for health related and other development plans. 7. The electronic R&R can also assist the health functionaries in preparing for the anticipated events and the weekly plan (ANM portal).

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11.2 Proposed Flow of Activities: 9, 10

1. ANM interacts with the beneficiary and notes down the necessary details. 2. The data is digitised on the spot using the application on the hand held device which will be customised to capture the data as per the RCH register. 3. The data gets uploaded into the central server on a real time basis. Internet would not be a problem as most of the districts are in plain areas with good phone connectivity. The GPS coordinates also get recorded which can be used for GIS mapping of the beneficiaries and ensuring that the data is generated from the field.

The Proposed system is depicted in the figure below, Fig 11.2

Programme manager 4

5 1 6

DEO 9 7 10

HMIS portal 4. The data from the central server can be accessed by the program managers through a dedicated portal of the state health department which is linked to the server. The GPRS coordinates can also be noted for mapping.

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5. The state health portal can also be used for data analytics at a touch of a button across periods, indicators or facilities. 6. The state health portal through the district / block login can generate the filled excel sheet as required by the HMIS which can be then uploaded into the HMIS portal by the data entry operator. These filled in reports can also be generated by different level of logins for review and or validation. 7. The auto filled in excel sheet data is manually uploaded by the DEO on the HMIS portal. 8. The HMIS data can be used by the programme managers for various programme related activities including planning and review. 9. A portal for the beneficiary can be created to verify their details, benefits, finance disbursements and IEC for active participation. This way the beneficiary can be in touch with their rights. 10. The data from the server can also be used for drugs and other logistics by the concerned department to have a seamless supply chain.

The possibilities are limitless. This system aims to provide a way of strengthening the data flow and its authenticity to the maximum possible.

In the following section we provide two case studies from the district of Mahbubnagar,

11.3 Online Data Entry in MCTS by ANM using Tab’s at sub centre level: An initiative in PHC Angadiraichur & PHC Daulatabad, Mahabubnagar

11.3.1 Background:

With the increasing focus on Mother and child tracking using online portal regular and timely data entry regarding the details of mother and child is an important aspect. But data entry is not being done on regular basis and 100% data entry is also not achieved due to several reasons including non-availability of data entry operator at PHC level, limited internet accessibility, consistent power cuts etc. Similar problems were faced by the staff of PHC Angadiraichur & PHC Daulatabad in kodangal cluster of Mahabubnagar district where an initiative was taken to provide portable TAB’s to ANM worker in the entire sub centre (1 for a sub centre) exclusively for MCTS data entry.

The initiative was taken by Medical office Dr.Ranjit Kumar (PHC Angadiraichur) presently perusing his PG in Osmania University, with an idea to make the ANM independent and efficient in data entry pertaining to MCTS. The initiative was implemented in 16 sub centres (7 in PHC Angadiraichur, 9 in PHC Daulatabad) in the April 2013 where training for handling the TAB’s and procedure for data entry was given over a period of 2 days by the medical officer Dr.Ranjit Kumar himself.

The TAB’s were purchased using the un-tied fund of Sub Centre & sim card and monthly recharge is been provided from the cluster level. Monthly a recharge of Rs.155 is done in all the TAB’s which gives 1GB 2G data for one month.

11.3.2 Rational:

 MCTS data entry is done at cluster level in Kodangal cluster office (which is a system followed in most of the cluster in the district) and the distance between cluster and PHC is 13 & 24 km for PHC Angadiraichur & PHC Daulatabad respectively. ANM has to travel all the way from the SC to cluster office only for MCTS data entry for which there is no provision of refund of the expense which occur during the travel for the same.  The cluster office has only one data entry operator who has to do data entry for the entire sub centre (27 in total) of kodangal cluster. Along with this data entry they have to perform their regular job such as

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preparing monthly report, preparing copies of ASHA incentive etc, so it’s certain that regular data entry would be a problem.  During the summer season there are major power cut in the day time in kodangal cluster further hampering the data entry. The only time for data entry in such situation is in the evening or in the night which again raises the issue of security of the ANM and the availability of transport back to their SC from the cluster office.  If the data entry is done in a private internet cafe they are charged about Rs.5 per entry or Rs.10 per hour for which money is paid from the ANM’s pocket or from the SC untied funds.  During the power cut the private net café’s charge double or triple of their regular charge’s as they use a power backup (power invertor).

11.3.3 Current Situation:

The initiative was started in April 2013 in 16 sub centre but at present working in 12 (5 in PHC Angadiraichur & 7 in PHC Daulatabad) sub centre and being used regularly. The TAB’s are always with the ANM and they carry it along with them to their session site and cluster office during monthly meeting. Data entry is done on or after immunization session/ ANC Day from there session site/SC or from their home.

Pictures Showing ANM of Chinna Nandigam performing data entry

The recharge for internet package is done from the cluster level on monthly basis. With 2G data connection it takes at an average 10 minutes for one data entry in village and 5 minutes at cluster level which is due to the uneven network in villages.

At present any expense incurred for small repairs & damaged charger is handled by Medical officer PHC Angadiraichur, Dr.K.Pradeep Kumar who is also in charge of PHC Daulatabad.

11.3.4 Pros of the intervention

 Data entry has been streamlined and is done on regular basis.  Providing TAB has cut down the time of travelling and the cost incurred in data entry at cluster office.  ANM feel independent of any data operator be it at cluster office or in any private internet café for their data entry in MCTS.  The community perspective towards ANM has changed, as entering details regarding the beneficiaries in MCTS with the use of TAB gives a sense of importance to the beneficiaries and they also receive an instant message from MCTS regarding their details which adds on to the factor that the entry is real and done for their monitoring.

11.3.5 Cons of the intervention

 The main problem faced by the ANM is the speed of data entry which is due to 2G network.  A tab of bigger size would enhance the data entry speed as present TAB is bit smaller

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Pictures showing portable TAB’s that can be carried easily by ANM.

11.4 SUPPLY CHAIN MANAGEMENT LOGISTIMO A CONCEPT NOTE

As part of an on-going technical assistance activity, the Model District Health Project assessed the status of the essential dugs and commodities that are required as per the 5 *5 Matrix of RMNCHA in the year 2014. The objective of the activity was to “take-stock “of the availability of these items as well as identify the reasons for gaps in the availability of these items if any.

11.4.1 Findings

 The overall availability of essential drugs and commodities was 40% in Mahabubanagar and 55% in Medak, based on the sample assessed. These proportions highlight the urgent need to assess the gaps that exist within the existing framework for procurement and supply. Mahabubanagar, a High Priority District is considered one of the backward districts in Telangana. It is one of the largest districts is the state and has always fared poorly on socio-economic indicators. On the other hand, Medak has been a good performing district. The leadership of the District Health Administration has been pro-active and spearheaded and innovation to improve the supply chain management of drugs.  In Mahabubanagar, the availability of all RMNCH+A categories except General was under 35%  In Medak, the only categories to cross the 50% mark are: Maternal, Neonatal, And Adolescent.  Generally the higher level facilities at the district and block were more likely to be stocked with the essential items. However, in Medak the sub-center level in the villages had more number of required items as compared to the sub-district level.

 In both Mahabubanagar and Medak, the Area Hospitals and Community Health Centers have a lower availability as compared to the Primary Health Centres. The District Hospitals have a higher availability as the Central Drug Store is located in the same premises and stock outs can be managed in a timelier manner. The procurement cycle runs from July to June. There is no formal or any scientific system; it is based on utilization rates for the preceding year and current stocks and availability. In most cases, the allocations were done based on projections of population norms. An additional 10% is added to

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account for the increased disease burden. Distribution of drugs is not necessarily as per the facility’s requirement but based on a top-down dispending of drugs. Although stock-outs are experienced at SC level, some centers do receive the D&C from ITDA (Integrated Tribal Development Authority).  In Mahabubanagar, only around one-third of the required drugs were available. Tab Methyldopa, Tab and Inj. Labetalol were not present in any of the facilities. Vaccines were available only at the higher level facilities, due to better cold storage facilities. On analysis of individual D & C, it was noted that overall 16% of the items were present in none or only 5% of the facilities. These included tubal rings, IUCD 375, Tab Mifepristone, Tab Methyldopa, Tab and Inj. Labetalol, Injection TT, Tab Zinc Sulphate (10 and 20 mg) and RTI/STI Kits. On the other hand Pregnancy Testing Kits, Iron Folic Acid tablets, Injection TT, ORS packets, Metronidazole, Amoxicillin, paracetamol and were most commonly found at majority of facilities (>75%).

 In Medak, although the availability of each category was better compared to Mahbubanagar, Reproductive Health and Child Health were below 50%. Tubal rings, IUCD 375, Tab Mifepristone were available at none of the facilities while Zinc sulphate dispersible tablets were available at barely 30% of the facilities. Almost 35% of the items were available in more than 75% of the facilities, many of these being present in all facilities. These included condoms, pregnancy testing kits, Injection TT, ORS packets, Iron Folic Acid Tablets, Paracetamol, Amoxicillin and Metronidazole.

11.4.2 INTERVENTION PROPOSED: LOGISTIMO 5

Objectives of Logistimo

 Real-time visibility of stocks, demand and transactions (e.g. consumption, receipts, waste) at all facilities; enable upstream and inter-echelon replenishment, reallocation and procurement decisions.  Monitor user activity: transactions, processing time & physical movement to ensure appropriate management behaviour.  Logistical agility via enhanced coordination between DHO, supervisors, pharmacists, transporters and other health workers; improve responsiveness, efficiency, accountability.  Data-driven decision support opportunistically extended to all participants through workﬂow alerts across notiﬁcation channels. Maximize coverage, ensure reliable availability, improve responsiveness, minimize waste, lower unnecessary costs and enhance workforce experience.

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Functional overview

 Inventory Management  Order Management  Batch & Expiry Management w/ Barcode scan  Demand Forecasting  Inventory Optimization  Notiﬁcation Switchboard & Streaming Feeds  Workforce Monitoring & Encouragement  Geo-tracking & Location-Based Services  Transport Routing, Scheduling & Monitoring  Network Discovery and Registration  Credit Management and Mobile Money  Telemetry, e.g. Cold Chain Temp Monitoring  Photographs & Social Tools  Multidimensional Analytics & Dashboards

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Chapter-12

Concluding Remarks 6, 9,8,10

The findings from the survey and data analysis are not surprising and the recommendations discussed in the relevant discussions are not entirely new or undocumented as a general concept. However what has been documented and recommended may be considered as specific or tailor made to the sampled districts and the state of Telangana. Some concepts when relevant to other parts of the country these findings and recommendations may add value to the efforts towards achieving UHC.

As discussed the key ingredient to all systems is the ‘motivation’ and ‘will’ to bring about a significant and sustainable change. There is no better place than to start with a strong political and administrative commitment.

The wide range of recommendations discussed are strategic, specific and potential game changers. The above discussion proposes ways in which to improve or modify existing strategies in a widely discussed area of health systems strengthening all over the world.

No single strategy employed in the country has been indisputably successful in enhancing the efficiency and significant strides are necessary to strengthen the strategies in place. 10

At its core, the issue stems from the inherent lack of elementary infrastructure, equipment and facilities which compound the unattractiveness of working and living in rural areas for the health staff and doctors.

The Interim recommendations have the potential to enhance the efficiency of the system almost on an immediate basis, while the long term and medium term strategies need to be implemented in a systematic manner to achieve universal health coverage.

Trainings both induction and continued needs emphasis. A system of peer learning at the sub district level on a continuous basis has been advocated. As a first step, educating and empowering the ANM and nursing cadre to provide primary and basic care is necessary to reduce the burden on higher level facilities and ensure that only the complicated or severe cases are referred.

Motivation by means of acknowledgements, appreciations and growth aspects for the frontline health workers including ASHAs is mandatory to enhance the service delivery and utilisation in terms of quality and numbers.8b

The way data is reported and handled is pivotal in the sense that all planning, monitoring, logistics and control when digitised will strengthen the system and enhance its efficiency. 9

Over the years the private health sector in India has grown remarkably. Given the overwhelming presence of the private sector in health, various state governments in India have been exploring the option of involving the private sector and creating partnerships with it in order to meet the growing health care needs of the population. 6

PPPs 6,7 offer an opportunity to tap the material, human and managerial resources of the private sector for public good. But experience with PPP has shown that Government’s capacity to negotiate and manage it is not effective. Without effective regulatory mechanisms, fulfilment of contractual obligations suffers from weak oversight and monitoring. It is necessary, as the HLEG has argued, to move away from ad hoc PPPs to

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well negotiated and managed contracts that are regulated effectively keeping foremost the health of the common man.

Under the recently drafted Companies Bill, the Government has proposed that companies should earmark 2 per cent of their average profits of the preceding three years for Corporate Social Responsibility (CSR) activities. We advocate the tapping of resources and strongly involve the PPP as a tool and means to achieve universal health coverage. 6

According to our research experience the ‘contracting -in’ method, or incentivizing private providers to provide services on a daily or case-by-case basis, was relatively unfavourable because a) the incentive was often not enough and b) their choice to engage in the arrangement is sporadic and at their convenience rather than as per the facility or patients’ needs. This is despite the fact that most states have provided districts with clear provisions for contracting in private providers. The provision of vouchers for patients to use in the private setting s potential method in which a PPP can work, given that there such a high rate of utilization of private facilities currently. 10

The nutrition, sanitation and involvement of PRIs in these two aspects is challenging. Further investigation is needed to ascertain the factors inhibiting the PRI to take an active and responsible role in determining the health of its people.

We conclude by recommending that all the long-term and interim recommendations mandate higher spending by the states on health care provision. Districts and states need to be aware and empowered about the hurdles in achieving universal health care. The District Health Action Plans s need to be used as an effective tool for projecting the requirements and making an effective case for mobilisation of funds from the central, state governments and the private sector. The 12th plan offers tremendous scope for financial resources. What is needed is the ability to spend the allotted budget in the right spirit so that more can be advocated for.

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References:

1. Indian public health standards – Guidelines for the Sub-centre , Primary health centre, Community health centre, Sub district hospital and the District Hospital – DGHS, MoHFW, GoI – 2012.

2. Frame work for implementation of National Health Mission 2012- 2017, GoI.

3. Maternal and New – born health tool kit. Maternal Health Division, MoHFW, GoI – Nov 2013

4. District health action plan, Medak. 2014-15

5. District health action plan, Mahbubnagar. 2014-15

6. The 12th Five year plan- Planning commission – GoI – (Chapter 20)

7. Public/Private Partnership in Health Care Services in India* Dr. A Venkat Raman and Prof. James Warner Björkman.

8. Working paper series – Columbia global centres – South Asia, Mumbai. a) MODEL DISTRICTS AS A ROADMAP FOR PUBLIC HEALTH SCALE‐UP IN INDIA Nirupam Bajpai, Megan Towle, and Jyothi Vynatheya Working Paper No. 4 July 2011.

b) IMPROVING THE PERFORMANCE OF ACCREDITED SOCIAL HEALTH ACTIVISTS IN INDIA Nirupam Bajpai and Ravindra H. Dholakia Working Paper No. 1 May 2011.

c) IMPROVING THE INTEGRATION OF HEALTH AND NUTRITION SECTORS IN INDIA Nirupam Bajpai and Ravindra H. Dholakia Working Paper No. 2 May 2011

9. mHealth to accelerate data to policy decisions: A case study from rural India - Dr. Kanav Kahol, Dr.Chetan C Purad, Dr Ashfaq Ahmed Bhat, Ms Unni Silkoset, Dr. Yashpal Sharma - Affordable Health Technologies Division, Public Health Foundation of India. 2014

10. MODEL DISTRICTS AS A ROADMAP FOR PUBLIC HEALTH SCALE-UP IN INDIA Strategic planning experience from Assam - Nirupam Bajpai, Ranvir Dhillon, Megan Towle, and Jyothi Vynatheya Working Paper No. 6 January 2012.

11. Improving Access and Efficiency in Public health services. Mid-term evaluation of India’s National Rural Health Mission – Nirupam Bajpai, Jeffrey D.Sachs, Ravindra H.Dholakia. Sage publishers 2010

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