Quality Assurance Project in Public Health
Report on
Quality Improvement in Primary Health Center By Applying
in DAHOD and SABARKANTHA District
Project Submitted to Integrated Population Development Project State Project Management Support Unit Gandhinagar
Submitted By 1 Center for Action Research and Developmental Studies
(A Unit of Vardaan Foundation)
Prepared by Dr. Harshit Sinha
September-December 2002
This is a workshop report supported by MoHFW, GOG, Gandhinagar and UNFPA regional office, Gandhinagar under IPD V project in Gujarat State. The report was developed by Vardan Foundation in collaborating efforts of Centre for Action Research and Developmental Studies – CARDS (A sub Unit of Vardaan foundation)
Disclaimer
The innovations made under the current project is solely belongs to the organization. Hence no part of findings and results of this project may be referred or reproduced (or disclose or reprinted or utilized in any form) other than the funding agencies (GOG) and other supporting agencies (UNFPA). The data inferences and opinion expressed in the report are not the opinion of funding agencies or any central or state authorities of India.
CARDS served as Vardaan Foundation Publications and editorial coordinator. Restricted copies are available from:
The Publication Division: Vardaan Foundation, Baroda, Gujarat, India www.varfound.org [email protected]
First Draft 15th December 2002 Final Report 31st December 2002
Author: Dr. Harshit Sinha
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An Appeal, those who believe in Quality work
) Every Beginning is hard – German proverb ) Quality is simple, people are complicated –Forsha ) Quality is not a sprint; it is a long distance event - Haunt ) A beginning is the most importan t part of the work – Plato. ) A good Beginning makes a good ending – English Proverb ) Plans are one things, action is another. – Murgatroyd and Morgan ) It takes a long time to bring excellen ce to maturity – Publilius Syrus ) If you think you can or you think can ’t, you’re probably right – H. Ford
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Index
Topics Page
Preface iii Acknowledgement iv List of Figures v List of Tables vi List of Annexes vii Abbreviations viii Executive Summary ix
Introduction 1 Background 1 Brief Introduction of Project Area 2 Designing Quality Assurance Project 6 Barriers in Designing Quality Assurance Project 8 Core Objectives of Quality Assurance Project 8 Pilot Strategy to Implement Quality Assurance Project 9 Task Planned 9 Task Accomplished 10 A: Designing Tool 10 B: Designing Training Manual 11 C: Designing Training Activities 11 D: Imparting Training to Service Providers 13 E: Introducing Rewarding System 20 F: Formation of Quality Circle Committee 21 G: Follow up Meeting 25 Data Description 26 Observations and Findings 27 1. Analysis of KAP Schedule 28 2. SWOT Analysis of PHCs 29 3. Description of 4ME 32 4: Human Behaviour 38 5: Feed Back 40 Discussion and Recommendations 42 Epilogue 47 Future Strategies 48 References 55 Annexes 58
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Preface
Today public health system requires substantial and careful reconsideration of the human resource management that includes training, supervision, accountability, performance appraisal, and reward/appreciation for the commendable work performance for any health programme operating in public health institutions.
The need for preparing the quality assurance project arises out to implement ICPD agenda for decentralized planning, community participation at grassroot level, and quality centered services.
Under the joint collaboration with UNFPA assisted IPD project with Government of Gujarat, Vardaan Foundation has designed Quality Assurance in Public Health and implemented in pilot phase in Dahod and Sabarkantha district. This is the first time in India when the component of “Quality” is systematically reviewed, designed and implemented by professionals.
I hope that reader will benefit from pilot experience by taking up the challenges that lie ahead in improving efficiency in health services, changing the perceptions and behaviours of providers, patients, and public; reorientating the role of government; and regulating safety, efficacy, and, of course, QUALITY.*
Dr. Harshit Sinha M.Sc; DCPA; Ph.D, Hon. Director, CARDS (Vardaan Foundation) Baroda. Email: [email protected]
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Acknowledgements
My sincere thanks to all health officers and staff members who had giving time, efforts and sharing the thought to introduce and execute the concept of Quality in public health.
My sincere thanks to the following members who had giving me an opportunity as well their useful suggestion for implementing the Quality Assurance project.
UNFPA Regional Office : Mr. Arvind Pulikar, Regional Coordinator State Health Department : Mr. S.K. Nanda, Health Secretariat : Dr. K.N. Patel, Director Family Welfare : Dr. J.G. Gajjar, Assist Director Family Welfare
State IPD Support Unit : Dr. S.R. Patel, SPO, IPD Project : Ms Jyotsana Shah, PO, IPD Project : Kamalaben Srimali, PO, IPD Project
Dahod District : Mr. H.S. Mehta IAS, DDO : Dr. D.M. Patel, CDHO : Dr. S.B. Shah, ADHO
Dahod IPD Project Team : Mr. J.P Parmar PO, IPD Project : Balwant Rathod, Computer Operator : Mr. Bhatia, Accountant
Sabarkantha District : Mr. R.R. Chauhan IAS, DDO : Dr. R.K. Nagada, CDHO. : Dr. K.S. Patel, ADHO
Sabarkantha IPD Team : Mrs. Haseenaben Mansoori, PO, IPD project : Mr. Himanshu Bhartia, Computer Operator : Mr. Ketan, Accountant.
I wish the same support and cooperation for the future.
Harshit Sinha M.Sc; Ph.D; DCPA
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List of Figures Page
Figure 1: Map of Dahod district 03
Figure 2: Map of Sabarkantha district. 05
Figure 3: Model for Developing Quality Assurance Project 07
Figure 4: Four tier structure of quality circle in Public Health 21
Figure 5: Scope of the quality circle in public health system. 22
Figure 6: Comparative Analysis of Pre and Post Test for Medical officer 29 For Dahod district
Figure 7: Comparative Analysis of Pre and Post Test for Medical officer 29 For Sabarkantha district
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List of Tables Page
Table 1: Important Demographic Variables of Dahod District 03
Table 2: Public Health set up in Dahod District 04
Table 3: Important Demographic Variables of Sabarkantha District 04
Table 4: Public Health set up in Sabarkantha District 05
Table 5: Status of Participants undergone QA project training in 15 Dahod district.
Table 6: Status Participants undergone QA project training in 19 Sabarkantha district.
Table 7: Summary of type of Information Schedule filled in the district 26
Table 8: Type of Respondent in the district 28
Table 9 Comparative analysis and classification of responses for pre test. 28
Table 10 Summarized information of SWOT analysis for PHCs 30
Table 11: Reported vacant post in the PHCs in comparison to national norms. 32
Table 12: Training status reported by the PHC medical officers 33
Table 13: Status of Construction with type of PHCs in both the district. 34
Table 14: Details of basic Amenities present in the constructed building 34 of the PHCs
Table 15: The description of the units present in the PHCs. 35
Table 16: PHC requiring Repair and Furniture (in percentage) 36
Table 17: Average responses on the availability of items in different units 37 of the PHC (in %).
Table 18: Average responses of the participant for human parameters 39 in both districts.
Table 19: Reaction of the participants for the current subject. 41
Table 20: Expectation of participants in the matter of Quality of 41 Care through Quality Circle (N=150).
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List of Annexures Page
Annexure 1: List of Participants from Dahod District. 58
Annexure 2: List of Participants from Sabarkantha District. 61
Annexure 3: List of Participants of Quality Circle Committee at PHC level from 62 Sabarkantha District.
Annexure 4: List of Participants of Quality Circle Committee at PHC level from 64 Dahod District.
Annexure 5: Minutes of District level Quality Circle Meeting at Dahod District. 65
Annexure 6: Minutes of District level Quality Circle Meeting at 68 Sabarkantha District.
Annexure 7: Detail analysis of the Pre KAP information for 71 Dahod and Sarbarkantha district.
Annexure 8: Detail analysis of the Pre and Post KAP information among 73 among medical Officers for Dahod and Sarbarkantha district.
Annexure 9: Detail analysis of SWOT analysis for Dahod and 74 Sabarkantha district.
Annexure 10: Details of the construction and repair work done Dahod and 78 Sabarkantha district.
Annexure 11: Details of construction and the type of PHCs in Dahod and 80 Sabarkantha district.
Annexure 12: Details of availability of each item for different services unit 86 in the PHCs of Dahod and Sabarkantha district.
Annexure 13: Details of the content analysis for human behaviour information 90 Schedule for Dahod and Sabarkantha district.
Annexure 14: Team Members of Vardaan Foundation, Baroda 97
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AABREVATIONS
ADHO : Additional District Health Officer ANC : Antenatal Care ANM : Auxiliary Nurse Midwives AV : Audio Visual BIECO : Block Information Education Communication Officer CHC : Community Health Center CDHO : Chief District Health Officer DDO : District Development Officer EOS : Emergency Obstetric Services FRU : First Referral Unit FHW : Female Health Worker GOG : Government of Gujarat HRD : Human Resource Development HQ : Head Quarter IMR : Infant Mortality Rate IEC : Information Education and Communication ICPD : International Conference on Population and Development IPD : Integrated Population and Development KAP : Knowledge, Awareness, Perceptions MHW : Male Health Worker MCH : Maternal and Child Health MO : Medical officer MMR : Maternal Mortality Rate MTP : Medical Termination of Pregnancy MPW : Multi Purpose Health Worker NGO : Non Government Organization OT : Operation Theater PHC : Primary Health Center QAP : Quality Assurance Project. QC : Quality Circle QCC : Quality Circle Committee RH : Reproductive Health RCH : Reproductive and Child Health RTI : Reproductive Tract Infection SC : Sub Center SPO : State Programme Officer STD : Sexually Transmitted Disease SWOT : Strength, Weakness, Option, Threat UIP : Universal Immunization Programme TQM : Total Quality Management UNFPA : United Nation Population Fund WHO : World Health Organization
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Executive Summary
After ICPD conference, quality is regarded as the core issue for improving the client services and ensures its safe and time bound delivery. It also highlights to improve the service infrastructure with the quality standards developed under country/state specific accreditation system. To ensure such challenges a good beginning has been made in Dahod and Sabarkantha district by introducing the concept of quality of care with the most popular Japanese philosophy of “Quality Circle”. This concept was widely accepted by the participants as they do not realize it as an additional burden and adopted it as routine activities. Looking IPD project agenda, the demand of both internal and external customers, the following recommendations are made:
1. Recognition of Structure and Process: A four tier quality structure system is developed so that all quality matters could get justice right from grassroot level to State level policy and programme managers. It is recommended to make the structure statuary at all level. 2. Developing Quality Assurance Standards: To introduce Quality Assurance and Accreditation for Public Health Care services in Gujarat, it becomes essential to develop standards focus on the clients, systems, process, measurement and team work. 3. Improving and Strengthening Service Facilities: Quality work in Public health could be attained if service infrastructure is improved in relation to repair and maintenance, manpower, training and supervision with follow up activities. To attain the said objectives of IPD project, it is recommended that QA project should be started in those PHC where service infrastructure is better, especially looking Operation Theater, Labour and delivery, Laboratories and Pharmacy. 4. Imparting Modular Training: Too many topics covered in short duration of time neither found helpful in up bringing their skills nor their acumen. Modular training is the best possible solution to cover each topic with hand on training, and also describing the role and responsibilities. 5. Integrating NGOs for Quality: Grassroot level - community participation is the major issue discussed at ICPD conference. NGOs working at the grassroot level could very useful in preparing strategy, outreaching the PHC services and making the success of community based interventions. 6. Integrating RCH Service Package: Under CP 5, the community based project activities were separately conducted discarding the local PHCs. It is recommended all strategy should be designed (as per the RCH service packages designated for our country) and operated under joint collaboration of PHCs and regional NGOs. 7. Strengthening Planning of Health worker: The concept of planning is very poor among the service providers and hence the set targets are not achieved
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and if at all achieved, it is either partly reported or some time wrongly reported. It is advised to develop a regular system that help planning for their routine work 8. Strengthening Referral System: During current time, major weakness in public health is related with referral services. The present system needs an efficient system that keeps track of the referred patients and the services imparted to them, provided that all service infrastructure at FRU is fully equipped. 9. Developing Follow up Procedure: In public health most of the programme looses grip because of the poor follow-up activity. Integrating Quality, it is advised to introduce monitoring committees at all level of system. 10. Monitoring Financial Implication: For effective implementation of the health programmes, it is important for the programme managers to know how much does it cost to provide health services under any health programme under different hierarchy of health care system of any project. It is recommended to develop a system that tells us the cost effectiveness of the services being provided through rural public health institutions. 11. Integrating Quality Data through GIS: A lot of health activities are happening after spending a huge amount. However timely information on achievements and failures are lately reported or sometime never reported or are wrongly interrupted. Without such obstacle, the policy or the programme managers can now have direct access to such information. This could be done by developing computer based management information system that gives on line information of the parameters with geo reference data. It will help for proper monitoring of programme as well check the performance of individual services providers.
This is just a beginning; however there is lot of scope to introduce and improve quality in public health services for the long term gain.
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-: Introduction :-
In Cairo conference (1994), a historic conceptual shift had taken place that had provided an international forum to view population programs with a broader concern for sexual and reproductive health. Apart from women empowerment, addressing life cycle approach and adolescent needs, the main emphasis was on decentralized client oriented planning, community participation at grassroot level and quality centered services. Thus the focus of health programs has now shifted from narrow demographically driven agency-oriented programs to individuals-needs-driven, clients-centered, broad reproductive health program. Earlier the impact of family planning programs has been measured mainly in terms of their contribution to increase contraceptive prevalence and to decrease fertility. These indicators are inadequate for measuring the impact of quality in reproductive health services from the perspective of the client, which are urgently needed.
Hence providing quality services to execute the reproductive health components is a challenging job, especially in rural health institution. The problems such as inadequate staff, lack of accountability and related problem hinders the efficient execution of the components. This suggests that, quality of the services in the public sector is poor and that it offers very limited range of services. In order to view reproductive health in a holistic perspective with client-centered approach through total quality management care, an attempt is being made by Vardaan Foundation to introduce and pilot test Quality Assurance Project at Primary Health Care centers of Dahod and Sabarkantha district.
-: Background :-
Today’s quality movement in public health remained in infancy stage because of lack of proper government licensing and accreditation system, internal or external audits and inspections to maintain standards, and the most neglected - the rewarding system. Even the ICPD did not provide all the solutions in the matter of quality of care, but it certainly pointed programme managers in a different direction – a direction that gave more emphasize to meeting client needs and being more responsive to community perspective. The paradigm shift that had occurred after ICPD clearly articulate the demands to recognize needs beyond contraception and emphasized the importance of addressing a comprehensive basket of reproductive health interventions.
Today many countries reported the availability of various elements of reproductive health care, and many had taken steps to integrate some components of reproductive health into the primary health-care system. Yet, progress in implementing comprehensive, integrated services has been limited. Some countries were more advanced in moving from policy adjustments to actual implementation of the reproductive health approach, while others were just setting out to undertake
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changes in service delivery. The initial steps taken by countries that were advancing in this area included translating reproductive health policies into operational guidelines by designing an approach to reproductive health services reflective of the ICPD commitment, analyzing the human and institutional constraints, and preparing for monitoring progress.
Looking the objectives of the ICPD programme, two key strategic aspects of moving towards a reproductive health approach are the integration of existing services and the broadening the constellation of available services. Managerial concerns in implementing these strategies include institutional set-up, training and supervision. Further the main objectives of the ICPD Programme of Action are to improve the quality of services, defined as the way clients are treated by the service- delivery system. The definition focuses on the process of service delivery, including communication and information sharing; criteria for minimal standards for procedures and examinations; and whether clients receive the service appropriate to their needs. Since the ICPD conference much of the debate has centered on the feasibility of improving the standard of quality of care, because it is seen as too costly. However, many studies reveal that improvements in the quality of service provision can be made at a reasonable cost and that without such improvements, initial and continuing utilization of services may suffer.
Thus five years back the Government of Gujarat with the joint efforts of UNFPA assisted Integrated Population Development project had taken initiated to introduce the component of “quality of care” in public health institutions of five backward districts (Dahod, Kutch, Surendranagar, Sabarkantha and Banaskantha) of Gujarat state. Taking lead from this, VARDAAN Foundation, Baroda (an NGO) had become partner organization with UNFPA in collaboration of Government of Gujarat (GOG) to vanguard and promote the development programme and creating consciousness among the policy makers for the desired objectives.
- : Brief introduction of the Project Area : -
In the pilot phase the Govt. of Gujarat has selected two district viz., Dahod and Sabarkantha district. The brief description of each district is as follows:
District Dahod: The Dahod district is one of the new tribal districts formed after the bifurcation from the Panchmahal district in 1999. The total (2001) census population of the district is 1635374, which is 3.23 percent of total population of Gujarat. The percentage decadal population growth rate has shown a decline trend from 1981-91 (+34.60) to 1991-01 (+28.35). However there is an increase in the sex ratio from 1991 (976) to 2001 (985). The problem lies in the literacy rate, which are lowest 27 comparative to other district of Gujarat. The district profile shows some what better situation - comparative to state level with different demographic indicators as shown below table 1:
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Table 1: Important Demographic Variables of Dahod District Variables/Indicators Gujarat Dahod Population (in million) 41.3 1.6 Population Density 258 449 Crude Birth Rate 25.3 25.9 Crude death Rate 8.01 8.1 Sex Ratio 934 985 Total Fertility rate 2.72 3.64 Infant Mortality rate 63.01 64 Maternal Mortality rate 3.89 4.1 Percentage of birth order 3+ and above 40.9 36.92 Male Literacy rate 73.12 59.45 Female Literacy rate 48.64 31.7 Deliveries conducted by trained health personnel* 53.5 48.15 Number of Institutional deliveries* 46.3 25.12 Percentage of married girls below 18 years 27 47.09 Unmet need for Family Planning 8.5 22.14 Source: Report of RCH society, Dahod District (September, 2002). : * NFHS Report for India 1998-99
The Dahod district is further sub divided into 7 different blocks as shown in figure 1.
Figure 1: Map of Dahod district
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The district has about 72.06% of tribal population of which the highest tribal population is in Garbada taluka and the lowest is found in taluka Devgadh Baria. Overall the district has fair health infrastructure as shown in table 2:
Table 2: Public Health set up in Dahod District Type of Health facilities Actual Number District hospital 1 Medical colleges 0 Community Health Center 11 Primary Health Center 52 Urban Family Welfare Center 2 Urban Health post 1 Sub centers 332 District IEC bureau 1 Trained Dais 853 Source: Report of RCH society, Dahod District (Sept, 2002).
Looking the demographic indicators, there is a acute necessary to improve and empower women status and also the health infrastructure for the smooth implementation of quality aspects in the RCH programme in the district.
District Sabarkantha: The Sabarkantha district is situated on the north of Gujarat and is flanked by Rajasthan on its east. A large area of the district is hilly, and nearly 1258.25 sqkm of area is covered under forest. The district has population of 20, 83,416 of which 51% are males and remaining 49% are female (Census 2001). The comparative district demographic indicators is shown table 3:
Table 3: Important Demographic Variables of Sabarkantha District Variables/Indicators Gujarat Sabarkantha Population (in million) 41.3 2.0 Population Density 258 282 Crude Birth Rate 25.3 27.5 Crude Death Rate 8.01 8.4 Sex Ratio 934 948 Total Fertility rate 2.72 3.0 Infant Mortality rate 63.01 63 Maternal Mortality rate 3.89 2.8 % of birth order 3+ and above 40.9 21 Male Literacy rate 73.1 63.1 Female Literacy rate 48.64 34.0 Deliveries conducted by trained health personnel* 53.5 64.2 Number of Institutional deliveries* 46.3 61.2 Percentage of married girls below 18 years 27 4 Unmet need for Family Planning 8.5 13 Source: Report of RCH society, Sabarkantha (Sept). : * NFHS Report for India 1998-99
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The percentage decadal population growth rate has shown an increasing trend from 1981-91 (+17.23) to 1991-01 (+18.30). However there is a decrease in the sex ratio from 1991 (965) to 2001 (948). The Sabarkantha district is further sub divided into thirteen different blocks as indicated in figure 2.
Figure 2: Map of Sabarkantha district.
Table 4: Public Health set up in Sabarkantha District
Type of Health facilities Actual Number District hospital 1 Community Health Center 16 Primary Health Center 61 Urban Family Welfare Center 1 Govt Dispensary 8 Referral Hospital 4 Sub Centers 413 Anganwadi workers 1825
Looking the demographic indicators, there is acute necessary for the improvement and empowerment of women status. Further it is advisable to upgrade the infrastructure especially in tribal areas of the district. Looking the delivery status Emergency Obstetric Services are weak and needs to be strengthening for imparting quality services.
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- : Designing Quality Assurance Project: -
Designing quality assurance project is a challenge in itself as many hidden as well as concrete problem of public health makes the project unsuitable. The idea of putting the “quality of care” in public health of our country many experts believes and considered as impossible task. There are several centrifugal and centripetal forces that restrict such innovation in a vertical health care system of our country. For many years World Health Organization (WHO) has been promoting the concept of primary health care which place the individual and the family at the very core of health care delivery. However simultaneously a new concept for quality of health care provision also developed with the work of several quality experts (Donabedian, Deming, Juran, Batalden etc) that was chosen to represent all common approaches (QA; TQM,CQI etc) to have a concentrated efforts for developing and improving the delivery of health services. Looking earlier efforts, the current quality assurance project was framed by introducing popular Japanese philosophy of “Quality Circle1”.
Dr. Harshit Sinha referred numerous management philosophies and found four dimensional philosophy of quality circle suitable for public health system. Here four dimension means problem identification, problem selection, problem analysis and solution to the problem. This is integrated with new definition of customers that classifies the customer as internal (service providers) and external customer (client or beneficiaries). To know their demand in public health, he explores their needs by developing a formula based on four ‘M’ and one ‘E’ and termed it as 4ME formula. The 4ME stand for manpower, material, method, measurement and the environment associated with them. In order to integrate the concept of quality of care and make it as a mandatory process, he developed a four tier quality structure by forming quality circle committee, right from the grassroot level to state level policy makers. He developed ten steps for solving problems identified at the village, PHC and district level. For achieving the quality result he introduces the human factor by developing two formulas as K-LIMB and L-TIT. Here K-LIMB stands for knowledge, leadership, imagination, motivation and behaviour while L-TIT stands for leadership, team, individual and task. All the stated human qualities are very essential for all individual in providing the quality services in teamwork. Taking account of the said elements he intend to introduce quality assurance system, to develop standards, focused on the clients, system, process, measurement and team work. This would be developed with the joint efforts under UNFPA assisted IPD project, health officials from state government, and other public health experts. The entire model is pictorially represented in figure 3.
1 Quality circle is small voluntary group of people from the same work area who meet together on a regular basis of the purpose of identifying, selecting, analyzing and solving quality, productivity, cost reduction, safety, customers services and other work related problems in their work area, leading to the improvement in their work effectiveness and enrichment of their work life.
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Figure 3: Model for Developing Quality Assurance Project
Customer Planning and Orientations Human Factors (Internal & External) For Quality (K-LIMB & L-TIT) (Using Philosophy of Quality Circle)
Setting and Communicating Standards In Quality for Accreditation (Client, system, process, measurement and team work)
Formation of Quality Circle Committee (At State; District; PHC and Village level)
Implement four dimension of Quality Circle (Problem: identification; selection, analysis and solution)
Use 4ME Use Follow Ten Formula Measurable Tools Steps of (PARETO Chart…) Flow Chart
Continuous Process
Performance Evaluation (Quality Control, Quality Surveillance, Quality Audit)
Performance Rewarding (As per the set Quality Standards)
For details refer QC Manual Developed by Dr. Harshit Sinha
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- : Barriers in Designing the QAP : -
Putting such new philosophy and changing the individual behaviour (both for the services providers and clients) cannot being accomplished overnight, but gradually done step- by step, requiring untiring efforts on the part of policy makers, programme managers and also on services providers. Before designing the QAP for PHC level, the following major issues acted as barriers:
The managerial capacity of the services providers considered to be an important factors bearing the degree of success of any health programme;
The increasing burden due to several on going health programmes at the grassroot level;
Poor service infrastructure, vacant post and the short supplies of materials leads to collapse of the PHC services at the grassroot level;
Weak or poor contact between service providers and clients leads the majority of population (80%) for the private treatment;
Lack of commitment and accountability system results in de-motivation of the service providers
And above all absence of congenial atmosphere of interaction due to the regional or local chemistry of the politics, social and other hierarchical interference.
Assessing and improving quality of health care was until recently, a low priority for both policy makers and technical agencies in developing countries like India. The idea of triggering up the concept of ‘quality in health’ gained momentum only after ICPD conference in 1994 as explained earlier. Owing to the agenda of the ICPD conference and taking account of the mission objectives of United Nations Population Fund, Vardaan Foundation the quality assurance project was developed with the following core objectives.
- : Core Objectives of Quality Assurance Project : -
Looking the vertical health care system of our country the objectives defined for QAP under reproductive and child health programme of our country are as follows:
Develop a feasible mandatory process for introducing quality that could easily support the structural integration of reproductive health (RH) services in the matter that includes core issues of RH for effective referral systems, training and supervision.
Designing standards of services provision for maximizing the use of existing resources to provide quality services and conducting continuing evaluation;
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Increase investments in training not only to provide technical skills but also to safe guard their interest, prepare them to communicate clearly with empathy and with respect for human rights, gender equality and dignity, and to provide dignified care;
Improve regulatory frameworks and their application to ensure to deliver high- quality care, and,
Design an effective monitoring system to ensure the optimum utilization of public health services from the community residing at the grassroot level.
- : Pilot Strategy to implement Quality Assurance Project : -
In the pilot phase of quality assurance project it was planned to materialize the first aforesaid objective i.e., to develop a feasible mandatory process for quality that could easily support the structural integration of reproductive health services that includes effective referral systems, training and supervision. The training and supervision will basically confined more on quality issues under district reproductive health programme. The lessons learnt from the pilot testing would be useful in developing larger projects to address quality of care issue in future and may feed into the UNFPA assisted IPD project in collaboration with the Government of Gujarat to other three IPD district and later in the entire State of Gujarat.
- : Task Planned under Pilot Strategy for QA Project : -
The specific task planned of current strategies is as follows:
1. To identify their knowledge, awareness, and practice or perception (KAP) in the matter quality and also about reproductive and child health programme of our country;
2. To orient the medical officer, among selected PHC staff and NGO volunteers for “quality of care” by introducing the most popular Japanese concept of “Quality Circle”;
3. To identify their professional needs for improving quality at institutional level (PHC and SC) for manpower, material, method, measurement and environment in which the problem exist;
4. To recognize and reward under the existing set up for the outstanding performance, so as to inculcate and encourage the motivation factors to generate fair competition among the service providers.
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5. To identify their professional and personal needs for the betterment of service conditions in order to create congenial and healthy competitive working environment.
6. To develop a “quality circle committee” at district, and PHC level to address the quality issue matter or problems so as to make regular mandatory process
7. To generate the quality database for regular monitoring and supervision of quality work.
- : Task Accomplished under Pilot Strategy for QA Project: -
A. Designing Tool: One of the key issues for implementing the pilot strategy is to develop different material and tools for the planned tasks for the pilot strategy under quality assurance project. In order to understand their technical caliber, personal and professional needs the following type of information data collecting schedule were prepared:
a. Knowledge, Awareness and Practice (KAP) information schedule (Pre and Post):
b. PHC Schedule comprising to take the information on the following: i. Performa to SWOT analysis of their institutions ii. Description of the existing and required manpower iii. Description of the existing and required infrastructure iv. Description of the training undergone v. Description of the existing and required materials and medicines
c. SC Schedule comprising to take the information on the following: i. Performa to SWOT analysis of their institutions ii. Description of the existing and required manpower iii. Description of the existing and required infrastructure iv. Description of the training undergone v. Description of the existing and required materials and medicines
d. Information schedule for medical officer.
e. Village level health information schedule
f. Information schedule for Human Behaviour
g. Feedback Form
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The KAP information schedule was basically designed to know there knowledge, attitude and perception or practice regarding reproductive and child health programme. It also helps to identify the training need of the service providers. In order to provide quality services, it is very essential to know or to have database of each public health institution regarding their existing manpower, material, method (training undergone), and existing infrastructure at different level. Further looking the broad objectives of IPD project, it was also decided to develop village level health information system by introducing village information schedule. Human factors are an important element for sustaining quality services. Thus a separate information schedule was designed to know their individual needs so as to ease their work and make the working environment safe with congenial atmosphere. The last Performa was designed to know their reaction about the concept of quality and quality circle and also to explore the future needs in the matter of providing quality of care services under RCH programme.
B. Designing Training Manual: So far the services providers have largely undergone technical training and to introduce the concept of quality with the managerial aspect is a challenging task at two fronts. First - Taking account of their workload, which type of management philosophy would be best fitted in? – so that the quality programme should not look like an additional burden and easily integrated in their regular routine work. Referring Nemours project reports on quality assurance in library and internet search, it was decided to introduce the most popular Japanese management concept of Quality Circle. The second challenge was to make the study material simple so that it is easily adopted by all (district health officials, medical officers, PHC staff and NGO volunteers) at different level of health care delivery system. Thus it was decided to prepare manual in two languages. The English version is for programme managers (Plate A) at district and PHC level (medical officers), while with little modification in defining roles and responsibility for the PHC staff (Plate B) and NGO volunteers (Plate C), it was translated into local Gujarati language. These manuals were given at free of cost to all service providers at district, PHC sub center and at village level to NGO volunteers.
C. Designing Training Activities: In order to make the orientation training session interesting, it was decided to have two way training programme so that the participants could come out from the monotonous training attitude which they had undergone in past. Further to make the participants busy, several theoretical concepts were put forward with examples and ask them to do manual exercise - so as to inculcate reasoning power for the subject matter. To remove wrong notions, doubts, criticism against introducing the new concept of quality of care - special emphasis were given to question – answers session. Overall a congenial atmosphere was created to make the training session interactive and meaningful for the entire day.
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Why Quality Circle in PH? Brief Description of the Manual
The philosophy of quality circle The English manual (Plate A) is was introduced in 1942 in Japan giving divided into six chapters. Chapter one much impetus to the lower most introduces the concept of quality and workers serving in the industry. This quality circle in public health. Chapter two concept was well established in describes the main characteristics of the industries. After the ICPD Cairo quality circle and clarifies the concept in conference in 1994, the reproductive depth. Chapter three shows the probable and sexual health was looked with structures, roles and responsibilities of the broader aspect giving much emphasis quality circle committee in a vertical health on decentralized client oriented care system. planning, community participation at grassroot level and quality centered Chapter four explains the process services. of organizing and implementing quality Though there is a wide gap in circles in public health institutions. Chapter the origin of these philosophy, but one five describes the tools to be used in common thing - the” bottom up quality circles for identifying and rating the approach” makes both the philosophy problems, and chapter six explains the suitable to each other. The other human factors involved in making the features that make the philosophy of concept of quality circle viable in public quality circle more appropriate are: health institutions. This is followed by the - It is truly participatory annex containing a Proforma for organizing - It is group activity quality circle meetings and suggested - It involves task performers exercises to be executed in the meeting. - It is only management support - It is voluntary. With their different role, the same is - It is the most easiest method of also translated in Gujarati for PHC staff problem solving (Plate B) and NGO voluntiers (Plate C).
Plate A Plate C
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D. Imparting Training to Service providers: As per the schedule planning it was decided to impart orientation training to medical officer; PHC staff and NGO volunteers. The detail description of the training is explained for each district: a. District DAHOD: On 22 October the medical officer from selected PHCs were invited to attend the workshop. The list of the participants is indicated in annex 1. The workshop was presided by programme officer Mr. J.P. Parmar (Plate 1) and was inaugurated by the Chief district health officer Dr. D. M. Patel (Plate 2). Mr. Parmar in the beginning of the workshop explained the importance of quality from
Plate 1 Plate 2 Plate 3
the perspectives of clients in health care delivery system and recalled the ICPD agenda to impart client centered quality of service. He requested Dr. D.M. Patel to express his view on the subject matter. Dr. Patel explaining the importance bottom up approach in the RCH. Meanwhile State Programme officer of IPD project Dr. S. R. Patel joined the session. On the behalf of the district Dr. D.M. Patel (Plate 4) and Dr. Harshit Sinha (Plate 5) from Vardaan Foundation greeted Dr. S.R. Patel. In continuation Dr. D. M. Patel further said that the bottom up approach is still under infancy stage and is not properly implemented in the district. He stress that the quality improvement is now primary need and should be integrated in our routine work. He further emphasized on quality planning and community participation at the grassroot level to achieve the set goals of the health programme. Proper planning automatically attracts the people for the services imparted through PHC or from SC.
Plate 4 Plate 5 Plate6
Later Dr. S.R. Patel (Plate 6) made realized the participants about the quality aspects of the private health services to which people are attracted. He further raised the issues of quality planning that addresses the need of current RCH program. He pointed out the issues related with the availability of manpower,
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material; technical competence and interpersonal communication in providing quality services. Lastly he concluded the session stressing the need of series of workshop to address all such issues which has importance in providing the quality of health services to community residing at the grassroot level. Dr. Harshit Sinha begins his session by pointing out that one should not take it as additional programme but should integrate it as routine activity. He further emphasized that quality orientation training is different and is meant to systematize and ease the work. He started his session by narrating story of four persons and
Plate 7 later introduces the concept of “quality” in general and also for public health. He explained the most popular Japanese management philosophy of “quality circle” and made aware about the new concept of “customer”.
While doing so, the district development officer Mr. H.S. Mehta arrived in the workshop. He regretted for not attending the workshop
Plate 8 from the beginning as simultaneously several other meetings were also scheduled on the same day. Dr Harshit Sinha greeted him (Plate 8) and requested to make official release of the manual developed by him (Plate 9).
Mr. Mehta expressed his views by saying Quality as new concept in public health and a
Plate 9 good beginning for Dahod district. He shared his experience saying that so far the public health community had only worked for quantity, but with the introduction of reproductive health, the perspective of service providers should be more on quality side for the incoming client at their respective PHCs. One should realize the need of current time and take up this issue as a challenge for its smooth execution. Plate 10
He further emphasized on the growing competition and expectation of the people for quality of life. He draw attention of the participants towards the life style and the quality aspect in the working style as a prime demand of the people of today.. He appreciated the efforts made by Vardaan Foundation for introducing Quality Assurance project in Public Health and requested the participants to regularize such concept as a routine activity.
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After the departure of Mr. Mehta, Dr. Sinha continued his session by assessing the needs of the participants as a internal customer (Plate 11) for manpower, material, method, measurement and the environment in which it is needed. He further made aware the participants about their roles, rules and regulation for organizing quality Plate 11 circle meeting with the recently designed four tier quality assurance systems applied to public health. The participants were also made aware about the measurable tools for quality work and the human factors involved while imparting the quality services to the clients and among themselves.
On 23rd October 2002, the 2nd batches of the participants (Plate 12) were made aware about the subject matter as explained above. On the third Plate 12 day, under the chairmanship of CDHO, group of NGO voluntiers working in Dahod district were also introduced to the subject matter and explained their possible role in sustaining quality services in public health institutions and generating demand from the community. In the continuing efforts, on 20th – 21st November 2002, six selected PHC staff (that includes, two additional PHC on demand) taken was introduced to the subject of “quality” at Limidi PHC (Plate 13) and Limkheda CHC (Plate Plate 13 14) incorporating three PHC staff in each place. The training session also included the similar topics, however their role in sustaining the quality services at PHC and Sub center were different.
Overall from the total of 180 participants, 78% of the participants have undergone the orientation training for QA project in Dahod district. The details are indicated in table 5. Plate 14
Table 5: Status of participants undergone QA project training in Dahod district. Type of Participants Total Number* Participated Absent Medical officers 52 43 09 PHC staff 88 77 11 NGO 40 20 20 Total 180 140 40 * Does not includes the other participants from state, district and other individuals
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b. District SABARKANTHA: The Beginning of the quality assurance project was done by imparting orientation training first at the PHC level. The training was conducted in seven selected PHC (that includes, two additional PHC on demand) from 28th October to 1st November 2002. The meeting was organized at five different PHCs viz., Demai; Kheroj (Plate 15); Attarsumbha; Kadiyadra (Plate 16) and Ramgadhi. The ADHO remained present at Kadiyadra and Attarsumbha PHC. The participants were given orientation on quality and explain their role in sustaining quality services in their respective PHC and sub-centre. As an internal customer, their needs related to man power and material were also assessed for their respective sub centers. The details of participants participated in training is indicated in annex2
Plate 15 Plate 16 Plate 17
As scheduled on 12th November 2002, the first batch of medical officer form the selected PHCs of Sabarkantha gathered at the venue for the training and orientation programme under QA project. The IPD State Programme officers Dr. S.R. Patel and District Development officer Mr. R.R Chauhan were special invitee to the Plate 18 workshop. The chief district health officer Dr. R.K. Nagada, along with his team - ADHO Dr. K.S Patel, RCH officer Dr. S.S. Chauhan remained present in the workshop.
The workshop was presided over by district programme officer Mrs. Haseen Mansuri (Plate 17). On the behalf of the Vardaan Foundation, Dr. Plate 19 Harshit Sinha along with his team members greeted DDO (Plate 18), SPO (Plate 19), CDHO (Plate 20), ADHO and district RCH officer.
The programme officer Mrs. Haseena Mansoori explained the objectives of the workshop and requested DDO Mr. R.R. Chauhan to official open the session by inaugurating the workshop. Plate 20
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Plate 22 Plate 23 Plate 21 The workshop was inaugurated by DDO (Plate 21). On the first day, workshop session was started by ADHO Dr. K.S Patel (Plate 22) explained the importance of quality in the RCH programme and assured the participants that such techniques not only improve the health services but will change the behaviour of an individual. The District RCH Officer Dr. S.S Chauhan (Plate 23) explained the quality as the center point in implementing the RCH programme. He raised the issue for the low acceptance of people as majority (80%) opts for the private treatment. He high lighted the difference between the approach of public and private health institutions.
Plate 24 Plate 25 Plate 26 Plate 27
Dr. S.R. Patel (Plate 24) highlighted the pitfalls in public health service that resulted in poor acceptance of the people. He further pointed out that public health services are poor in the matter of quality and suggested to explore the expectation of people for the issues related with quality services for reproductive and child health programme. He requested the participants to replicate the same as taught in the workshop and have patience - as initially it seems to be a difficult task but will have long term benefits which not only sustain the desired quality of the services but will also ease the working process.
Dr. R.K. Nagada (Plate 25) stressed that people do talk lot to improve the quality, but express his concern over not staying at the Head Quarter (HQ). He quoted the example of the people who had served earlier in the backward area used to live in the HQ not only complete their assigned work but also enjoys respects of the people. He further stressed that what ever being taught in the workshop should be taken as challenge to replicate in their respective PHCs and sub centers.
Mr. R.R. Chauhan (Plate 26) said that quality improvement in public health is first of its kind and should be taken seriously as now the medical services are also under consumer Protection Act and hence one has to exercise quality issues in their routine task. He highlighted that standards of pharmacy and other clinical procedure
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are well defined. However there is urgent need to develop standard of Quality for public health services. He officially realized the English version of the manual for Sabarkantha district.
Dr. Harshit Sinha (Plate 27) narrated his previous experience of introducing quality in public health through Indian Institute of Management, Ahmedabad and acknowledges the work of pilot project of RCH in Sanand taluka under the leadership of Dr. D.V. Mavalankar. He pointed out that so far people have barrowed theoretical management concept from the industries and replicated the same in health sector with making any modification are required. This the first time, when the entire quality assurance project was practically designed and applied at the grassroot level of public health system - by introducing the most popular Japanese philosophy of Quality Circle. He further assured the participants that such frequent quality orientation training will reduce the burden and systematize their work in their routine schedule. He also emphasized that the current QA project is utter need of state government not as our individual organization.
Taking lead from this, Dr. K.S Patel emphasized to form quality circle committee at the district level. Mr. RR. Chauhan showed keen interest and request to form the QCC committee at district level by adopting the probable structure as explained in the training manual. Further Dr. K.S. Patel announced that such structure have already being formed in seven PHCs and request Dr. R.D. Gosawmi of Kadiyadra PHC and Dr. K.N. Gosawmi of Dhemai PHC to share their experience. Both the doctor seems to be very enthusiastic and suggest that that quality could only be achieved if demand related to man power, material, infrastructure are met for their PHC and SC located in the villages.
Plate 28 Plate 29 Plate 30
Dr. Harshit Sinha continued his session (Plate 28) on the various aspects of quality and took their point of view as a internal customer in the matter of manpower, material, method, measurement and the environment in which it occurs.. The second day i.e., on 13th November 2002, Mr. S.K. Verma, a senior trustee member of Vardaan Foundation inaugurated the workshop (Plate 29) for the second batch of the medical officer. Dr. Sinha again made the participants aware about the quality assurance project with the similar type of sessions as narrated previous day (Plate 30).
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The third day of the workshop was meant for NGO voluntaries coming from different parts of Sabarkantha district. The deputy director of family welfare Dr. J.K. Gajjar inaugurated the workshop (Plate 31) and officially realized of the Gujarati version of the manual for NGO (Plate 32). He appreciated the efforts made by Dr. Harshit Sinha for developing the new concept of quality and designing its study material for public health (Plate 33).
Plate 31 Plate 32 Plate 33
He explained the importance of quality in public health and stressed that one should think public health in terms of community and also explore health-seeking behaviour of the community for public health. He further said that there is a great gap - existing in between the service providers and clients or beneficiaries. One must explore the reasons for this existing gap in between the two. Since 80% of the people take private costly treatment, he stressed to know - why people want costly treatment? Why people regret to come to the public health institutions? He reminds the landmark decision taken in 1994 at ICPD conference for the quality and thereafter pointed out that service provider should be made first quality conscious. He pointed out that NGO could play a major role in making the community quality conscious and then generating demand for the quality services. He suggested having repetitive training and orientation programme to know the health seeking behaviour of the people and hope that Vardaan Foundation could contribute to it largely with new quality innovations. Dr Sinha later continued his session and concluded the workshop by explaining different role for NGO under Quality Assurance Project.
Overall from the total of 198 participants, 78% of the participants have undergone the orientation training for QA project in Sabarkantha district. The details are indicated in table 6.
Table 6: Status participants undergone QA project training in Sabarkantha district. Type of Participants Total Number Participated Absent Medical officers/BIECO 62 50 12 PHC staff 92 80 12 NGO 44 26 18 Total 198 156 42 * Does not includes the other participants from state, district and other individuals
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E. Introducing Rewarding System: One of the important factors that have been largely neglected is the appreciation for the work done by the sincere employees in any public institution. Taking account of public health, it becomes very sensitive issues, because there are large numbers of sincere workers (including medical officer) whose work are not being rewarded or ever recognized neither by the administration nor by the media. Vardaan Foundation on experiment basis took a bold and innovative step to recognize the services of sincere workers in public health.
Plate 34 Plate 35
Dr. J.L. Mina of Limdi PHC of Zalod taluka in Dahod district was awarded for upgrading the PHC services by generating local resource through community participation. On the behalf of the Vardaan Foundation Dr. D.M. Patel (CDHO) presented the award during medical officers meeting on 5th December 2002 in Zila Panchayat office of Dahod. Mrs Deepikben Patil IPD staff nurse from Ramgadhi PHC of Megraj taluka was awarded for conducting the highest number of deliveries in the entire Sabarkantha district. On the behalf of Vardaan Foundation, Dr. R.K. Nagadha along with the senior trustee member of Vardaan Foundation Mr. S.K. Verma presented award on 13th November 2002 in medical officer Quality Assurance Workshop at Sabarkantha district.
The idea behind introducing the award is to draw attention of policy makers for developing and introducing accreditation system in public health. The current initiative was an exercise that had generated positive result. A sense of competition was inculcated among the services providers. As a result the District Development Officer of Sabarkantha had also announced a similar award to Mrs Deepikaben Patil. He further said that similar type of awarded will also be imparted for of each category of services providers (MO, BIECO, MHW, FHW etc) in Sabarkantha district.
The district officials had appreciated the efforts made by the Vardaan Foundation and requested to take initiative in developing the accreditation system in public health services under QA project for the state of Gujarat. Dr. Harshit Sinha on the behalf of Vardaan Foundation, efforts are on in developing the standard of Quality control, quality audit and quality surveillance.
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F. Formation of Quality Circle Committee: Owing to several limitations in the public health system of our country, applying the concept of quality circle is a challenging task. One should appreciate the efforts made the service providers for working under odd circumstances. This made the philosophy of quality circle more suitable and viable. The bottom up approach is the common element in the reproductive health programme of our country (after the ICPD conference of 1994) and the philosophy of quality circle (which originated in 1962). In the last 40 years to quality circle concept has been introduced in as many as 130 countries.
Many Indian public sector organizations have also been experimenting with quality circles for quite some time and a large number of them have achieved success in its application. Application of quality circles in public health is new and ever demanding. In industries this concept has been widely accepted and has produced positive results. In the health sector it is a new approach and its application has been so far restricted to some private sector hospitals. Looking the administrative setup of public health in the country, four tiers the structure of quality circle was defined in the public health system as shown in figure 4.
Figure 4: Four tier structure of quality circle in Public Health
QCC
QCC At State Level Steering QCC Committee At District Level at DHO QCC At PHC/CHC Hospital Level At Village Or Community Level
GENUINE DEMAND FOR IMPROVING QUALITY
The above diagram shows that demand is at all level and is passed to the upper level of QCC in hierarchy. Such type of structure helps to integrate the ground realities to the top level management and also for keeping regular supervision for quality issues matters. The scope of quality circle at four levels of the public health system is much broader in the long term. This is because; it covers the concerned issues from the grassroot level to top level management: policy makers. The system proposes to generate demand for health services for the village community by involving community level workers through voluntary organizations. On the other side, service providers in the institutions strengthen and sustain the health service to meet the demand of the community. The district
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health administration monitors the achievement through pre-defined indicators of any health programme in the district and reports the status of various health programmes to state level administration. The achievements made at the state level will result in achieving the set goals of national health programmes. Quality circles help to achieve the national targets of any health programme as indicated in figure 5.
Figure 5: Scope of the quality circle in public health system.
NATIONAL HEALTH PROGRAMME
Achieving set targets of State Level Health Programme
Achieving set targets of District Level Health Programme
Strengthening and PHC level Sustaining Health Services
Generating Demand for
Health Services Village Level
COMMUNITY IN VILLAGE
The aforesaid process could be feasible, if at all four levels quality circle committees are formed and are officially recognized under the quality assurance project. However, one should not forget that the structure described in the quality circle committee at all four levels should be made mandatory and should also define the role and responsibilities at each level. Further, addition of members and assigning designations should be done through mutual consensus of all members selected in the quality circle committee.
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Following the four tier quality assurance system, quality circle committee was successfully formed in seven PHCs of Sabarkantha district. Under the chairmanship of PHC medical officer Dr. K.K. Gosowami from Demai PHC (Plate 36); Dr. B.S. Neenama from Ramgadhi (Plate 37); Dr. R.D. Gosowmi from Kadeyadra (Plate 38); Dr. A.K.Jatav from Kheroj (Plate 39); Dr. Sanjay Naik from Attarsundha (Plate 40); Dr. S.K. Chauhan from Kodiyawada (Plate 41); and Dr, R.B. Patel from Sarsava PHC (Plate 32) the quality circle committee was formed as desired under QA project.
Plate 36 Plate 37 Plate 38
Plate 39 Plate 40 Plate 41
The formation of QCC at PHC level was an effective step for inculcating the concept of quality consciousness among the service providers. The details of each member in QCC at PHC level of Sabarkantha district is provided in annex 3. The foundation of district level QCC was laid down on 12th November 2002 - first day of orientation training workshop at Sabarkantha. Dr K.S. Patel, under the guidance of CDHO and DDO announced the probable structure of district level QCC committee in Sabarkantha district. The first district level QCC was organized (Plate 43) on 26/12/02 in which all PHC level QCC were registered (Plate 44).
Plate 42 Plate 43 Plate 44
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Similarly PHC level QCC was also formed in Dahod district. Under the chairmanship of Dr. J.L. Mina (Plate 45) from Limdi PHC; Dr. S.K. Azad from Boradi (Plate 46); Dr. M.P. Sharma from Gangardi PHC (Plate 47); Dr. L.K. Arya from Bandibar (Plate 48); Dr. P.D. Fanasiya from Dabhava (Plate 49) and Dr. G.L Bariya from Dungar PHC (Plate 50) formed the QCC at their respective PHCs. The details of each member in QCC at PHC level of Dahod district is provided in annex 4.
Plate 45 Plate 46 Plate 47
Plate 48 Plate 49 Plate 50
The district level quality circle committee was formed on 5/12/2002 under the guidance of Dr. D.M. Patel. He gave justice by incorporating different department from the Dahod district offices. All the PHC level QCC were officially registered and a new beginning in Dahod district was started in the matter of quality work for public health department.
Plate 51 Plate 52 Plate 53
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G. Follow-up Meeting for Future Strategy: Follow up is the essential factor in maintaining the quality service sustainable in public health institution. During orientation training, Dr Harshit Sinha (Plate 54) pointed out that three main weakness of programme management. The first is poor planning followed by lack of supervision and follow procedure.
Owing to these short comings - from the very beginning Vardaan Foundation had planned to
do regular “follow up activity” under Quality Assurance Project.
th On 5 December 02, while forming district level QCC committee for Dahod, the CDHO Dr. D.M. Patel (Plate 55) decided to review the current Plate 54 activity and plan for future course of action under quality assurance project. Due to election duty, majority of QCC member could not attended the meeting. However CDHO decided
to continue the meeting. Majority of discussion was related with the criteria for selecting the PHCs, CHCs, and NGOs and to explore the future strategies for integrating under QA
project. The other details of the meeting are narrated in annex 5. Plate 55
Later during the same month the CDHO Dr. R.K. Nagada (Plate 56) planned follow up meeting on 26th December 02. Dr Nagada was in the favour to select PHC from backward area
and distribute the community awareness work equally among the resident NGOs under QA project. One of the a enthusiastic medical officer Dr. R.D. Gosowami (Plate 57) suggested for
wider coverage of RCH services through RCH
camps approach by integrating local NGOs. The Plate 56 other details of the meeting and its decisions are narrated in annex 6.
Overall the follow-up meeting was very fruitful in deciding the future course of action under QA
project for both districts. However still it was felt that the agenda and issues related to quality is at infancy stage and hope with growing experience, it will mature.
Plate 57
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- : Data Description : -
The end result observed during the orientation training imparted at the district and PHC level are analyzed by direct observation as well by specially designed information schedule for different issues pertaining to quality under QA project. The description of the type of questionnaires prepared and filled in both the district is indicated in table 7.
Table 7: Summary of type of Information Schedule filled in the district Type of Information Schedule Dahod Sabarkantha Total 1. Pre test information schedule 133 151 284 2. Post test information schedule 50 64 114 3. SWOT Analysis information schedule 43 50 93 4. PHC information schedule 43 50 93 5. Sub Center Information schedule 23* 35** 58 6. Medical officer information schedule Nil 2*** 02 7. Village Health Information schedule Nil 18**** 18 8. Human Behaviour Information schedule 127 136 263 9. Feedback forms 76 106 182 * Out of total 32 sub center; ** Out of total 42 sub center; *** Out of total 13 PHC selected; **** 128 total villages in 42 sub centers.
In pilot phase of QA project about nine type of information schedule was developed. Among these some are activity based information schedule while others are specifically designed to develop quality data using geographical information system for monitoring in future.
The information schedule on pre test was of medical officer, health workers, and NGO volunteers. However due to lack of time and also the lack of interest of participants (Health workers and NGO volunteers), the post test were confined to only for medical officers. The SWOT analysis was restricted for PHCs and hence the number of doctors undertaking had filled the SWOT information schedule. Similarly in the PHC information schedule was filled by medical officers attending orientation training. Out of total 74 sub centers from both the district, 78% of the sub center information scheduled were filled and was submitted late and thus discarded from the analysis. Similar is the case with information schedule belonging to medical officer and of village level and thus discarded from the analysis. The information schedule for human behaviour was restricted among medical officer and health workers only. However the feedback information schedule was filled from medical officer, Health workers and NGO volunteers.
The direct observation made during orientation training and the data collected from these information schedules are narrated below.
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- : Observations and Findings : -
During orientation training, direct observations were made by discussing various issues on quality as well acknowledged the idea, opinion, suggestion and criticism done by the participants. Below here we list the major issues raised by the participants.
Concern Issues:
1. The interaction among the participants, depict their keen interest because such training not only help to gain technical matters but also teaches the management aspect in public health.
2. Most of the participants appreciated the idea of introducing quality through quality circle in public health. However some participants were not sure about its success in the absence of proper infrastructure and manpower.
3. Since the topic is new does not fall as a routine activity, it would be difficult to start without support from district as well as external agency like Vardaan Foundation. Many suggested repeated training to inculcate confidence for the smooth beginning.
4. The four tier hierarchy for introducing the concept of quality through quality circle in public health was liked by the participants as now one can hope quality concern issues and task could be channalized in proper way.
5. An effort to introduce rewarding system was appreciated by the district level authority and suggests following the same for each category of the employees in Public Health.
6. The young medical officers were more enthusiastic than the experienced ones. Even the grassroot level health workers demanded to have frequent training session as it would help them to systematize work with proper planning.
7. The NGO volunteers were very enthusiastic but were found confused about their role. They agreed that quality in public health is possible through GO and NGO collaboration in generating demand from the community, provided that the grassroot level activities are funded by the government.
The detail analysis of the data collected through different types of information schedule is narrated as follows.
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-: Analysis of KAP Schedule :-
1. Pre Test: During the orientation and training workshop, the first task was to judge the level of the knowledge, awareness, perception/practice (KAP) among the participants for reproductive health programme. A special Performa was designed that include question pertaining to quality of care and about RCH programme. Pre-test was conducted among three different types of respondent as shown in table 8.
Table 8: Type of Respondent in the district Respondent/Dist. Dahod Sabarkantha Total Medical officer 50 64 114 Health worker 65 68 133 NGO 18 19 37 Total 133 151 284
All the responses were compared with the standard definition mentioned in different literature and then it was classified under three categories as fully correct; partly correct and wrong answers. The KAP analysis for pre test is indicated in table 9.
Table 9 Comparative analysis and classification of responses for pre test. Types of DAHOD SABARKANTHA Questions asked during Pre-Test (In % from N=133) (In % from N=151) Under KAP schedule WA PC FC Mi WA PC FC Mi Definition of Reproductive Health 66 23 4 7 60 15 11 15 Components of RCH Package of our country 27 32 5 35 34 23 6 38 Formulae to calculate unmet need 81 3 0 16 74 5 0 21 Definition of Quality of Care in Public Health 53 23 1 23 62 20 0 19 Definition of Gender in Public Health 29 38 2 32 28 35 1 36 Essential components of QA Programme 74 0 0 26 69 0 0 31 Definition of Customer and TQM 18 44 12 13 17 46 1 35 Three main elements stressed in ICPD 36 11 2 52 51 5 0 44 Average of overall percentage 48 22 4 25 49 22 5 30 Note: WA-Wrong Answer; PC-Partial Correct; FC-Fully Correct and Mi-Missing
From the table it is clear that performance of respondent is very poor. Looking the low figures of average responses for the fully correct answers in Dahod (4%) and Sabrakantha (5%) the performance of the participants is very poor. This is also much evident looking the average figure of the wrong answers in Dahod (48%) and Sabarkantha (49%) district. It seems that the average responses of the participants for the partial knowledge of the subject matter (22%) in both the districts are almost same. The overall percentage of missing responses lies in between 25% to 30% shows that the knowledge regarding quality and reproductive health is not up to the mark. The detail analysis for Pre test of KAP schedule for the each question among different types of respondent in both the districts is summarized in annex 7.
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2. Post Test: The post test was thoroughly filled by medical officers only. Participants belonging to other category (Health Worker and NGO Volunteers) have returned the blank schedule because of lack of time. Hence they were discarded from the analysis. Figure 6 and 7 shows the comparative analysis of the average responses given by medical officer in Dahod and Sabarkantha district.
Figure 6 The comparative picture for the average 60 Pre Post responses for both the district have similar 50 pattern. The responses may vary by proportion,
40 but overall the status of responses of the
30 participants in both the districts remains same. (in %) (in 20 The average response of wrong answers
10 during post test had dropped down while there 0 was an increase in the responses of partially Wrong Partially Right Fully Correct Missing Answers right answers and also in the right response. In Status of Answers Dahod district there was a sharp decrease in
Figure 7 the pattern of missing responses compared to 60 Pre Post Sabarkantha district.
50 The description of each question during 40 pre and post test for knowledge, awareness and 30
(in %) perception is described in annex 8. Overall it 20 seems that the orientati on training for Quality 10 of Care through Japanese philosophy of 0 Wrong Partially Right Fully Correct Missing “Quality Circle” found to be effective among Answers medical officers and dist rict health authorities Status of Answers of Dahod and Sabarkantha district.
From the detailed analysis it was found that participants are weak in the issues related to gender, calculation of unmet need for both limiting and spacing family planning methods and application of quality in public health. Such short coming could be resolved with issue based training under different types of modules.
-: SWOT Analysis of PHCs :-
In the field of strategic management, it is essential to know the strength, weakness, threat and option associated with that organization. To provide quality of services that can sustain in public health institutions, it becomes essential to strengthen the service infrastructure of PHC and sub centers at grassroot level. By doing SWOT analysis - it is important to demonstrate the fact that within the constraints of the PHC system, it is possible to introduce new services and new orientation to help move from the FP focus to broader quality oriented RCH services.
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After explaining the motto and the concept for doing SWOT analysis, the participants were asked to elaborate the same of their allotted PHCs. The following results were observed as indicated in table 10.
Table 10 Summarized information of SWOT analysis for PHCs Sr SWOT Analysis Dahod Sabrakantha No Strengths of the PHCs (N=43) in % (N=50) in% Total Missing 1 3 S1 Related with PHC infrastructure 37 47 S2 Behaviour of the Service Providers 22 27 S3 Community Participation 3 9 S4 Institutional Activities 37 14 Total Percentage 100 100 Weakness of the PHCs Total Missing 1 7 W1 Related with PHC infrastructure 36 52 W2 Behaviour of Service providers 32 16 W3 Institutional Activities 18 8 W4 Administrative & Coordination problems 14 17 Total Percentage 100 100 Threats to the PHCs Total Missing 1 12 T1 Directly to the Institution 28 38 T2 Related to Administration 60 29 T3 Related to Service Providers 10 12 T4 Related to Community 2 9 Total Percentage 100 100 Available Option for the PHCs Total Missing 1 12 O1 For monitoring and Supervision 29 24 O2 For upgrading PH Institutions 25 23 O3 Policy issue matters 16 10 Total Percentage 100 100
The above table gives information under broad category for each variable of SWOT analysis.
A. Strengths: The major strength (S) pointed out by the participants in Dahod (37%) and Sabarkantha (47%) district is related with their institutions that includes central location and well established service infrastructure. Behaviour of the service providers is another major strength in the PHCs as 22% of the respondents belonging to district Dahod and 27% from Sabarkantha district have agreed to this. With their effective leadership - better coordination at PHC helps to provide good service to the community. Almost 37% of participants from Dahod and 14% from Sabarkantha reported of having regular OPD services, MCH clinics, sterilization, deliveries and UIP sessions. The community participants was the least compared to percentage other strengths as reported for the PHCs. The details of PHC strengths for both the district are indicated in annex 9a.
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B. Weaknesses: The major weakness reported was related with the poor infrastructure in the public health institution. About 36% of the participants from Dahod and 52% from Sabarkantha reported having poor service infrastructure, followed by vacant post considered as the most prominent weakness of the PHCs. Behaviour of the service providers was another major issues as weakness in the PHCs. Poor leadership qualities, lack of coordination and commitments and poor communication skills are some of the major weakness of the service providers. This had effected the services of the PHCs as 18% of the participants from Dahod and 8% from Sabarkantha district reported absence of deliveries and sterilization, irregular OPD and field work. Further administrative and coordination problem within themselves and with the community and also with their immediate controlling officers was another issues highlighted as weakness in the PHCs. Poor supervision, irregular payment of salary, and poor cooperation from the district authority are some of the major problem of administration in the PHCs. The details of PHC weaknesses for both the district are indicated in annex 9b.
C. Threats: The major threats identified to PHCs are related with administration and governance of the PHCs. About 60% of the participants from Dahod and 29% from Sabarkantha district pointed out that too many health programme, frequent session of meeting, political interference enormous paper work and poor supplies disturb the routine functioning of the PHCs. Another threat which is directly related with the service of the PHCs is on going high and sophisticated private practice in the PHC area. This is followed by absence of proper infrastructure, remote location of the PHCs, and theft leads to poor utilization of the PHC services. About 10% of participants from Dahod and 12% from Sabarkantha district reported attitude of the service providers is also a major threat in the PHCs functioning. Reaching and convincing the community for the public health services is also one of the major threat reported from both the district. The details of associated threats in PHCs for both the district are indicated in annex 9c.
D. Options: Looking the weaknesses and threats associated with the PHCs, the participants largely put forward their option related to improvement in monitoring and evaluation system of the PHCs. About 29% of the participants from Dahod and 24% from Sabarkantha were very curious to introduce accreditation system followed by regular monitoring of the PHC system by external agencies and frequent supervision from the district. Besides, 25% of participants from Dahod and 23% from Sabarkantha were unanimously in the favour to upgrade the service infrastructure of the PHCs with well defined strategy for the community participation. Other options put forward were related with the policy issue matter that needs to be addressed to either district or state level health administration. The details of such options in PHCs for both the district are indicated in annex 9d.
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- : Description of 4ME : -
To provide quality services through PHC system, it becomes essential to explore the need of the service providers as internal customers of any organization. The need could be very well expressed by a formulae defined as four ‘M’ and one ‘E’ jointly named as 4ME. The participants were asked to fill the information schedule that address the needs related to manpower, material, methods, measurement and the environment in which it is need most. The details of requirement in the PHCs of Dahod and Sabarkantha district are as follows:
A. Man Power: Manpower is the basic force required to impart and sustain health services at the PHC level. If the required numbers of service providers are not present, the health services will effected in two ways. Either the services would be closed down or there will be acute pressure on service providers for providing the additional burden of desired level of health services. Looking the national norms, the following type of vacant post found vacant at the end of December 2002 indicated in table 11:
Table 11: Reported vacant post in the PHCs in comparison to national norms. Type of vacant post as per Dahod (N=43) Sabarkantha (N=50) the national norms % of PHC reported % of PHC reported Medical Officer ------BIECO 51.2 38.8 Male Supervisors 69.8 29.8 Male Health Worker 53.5 72.3 Female Supervisors 27.9 36.2 Female Health worker 48.8 51.1 Lab Technician 53.5 36.2 Pharmacy 58.1 34.0 Clerk 44.2 42.6 Ayah 55.8 31.9 Peon 32.6 34.0 Driver 41.9 29.8
In Dahod district, the post of male supervisor (69%) while in Sabarkantha, the post of male health worker (72%0 are vacant. More than 50% of the post of BIECO, male health worker, laboratory technicians, pharmacist and ayas are reported vacant in Dahod district, while in Sabarkantha it was reported with only female health worker. These posts are considered to be the pillars of the PHC for making services available and sustainable for the community. From the above table, it is clear that the posts in the PHCs are not filled as per the national norm. The non availability of the basic team at PHC will definitely affects the quality of services imparted through it.
B. Method: Here method is basically refers to the different type clinical or non – clinical trainings undergone by the medical officers. Looking the Primary health care system and the RCH programme, the participants were asked to list the
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training undergone by them. The training status of medical officers of both the district is indicated in table 12.
Table 12: Training status reported by the PHC medical officers Type of vacant post as per Dahod (N=43) Sabarkantha (N=50) the national norms % of cases % of cases reported reported No Training/Missing 11.9 12.0 15 days RCH Training at Padra 61.9 82.0 IUD/Cu T 14.3 6.0 Non Scalp Vasectomy 2.4 4.0 Vasectomy 11.9 6.0 Tubectomy 9.5 4.0 Laparoscopy 0.0 0.0 MR. Syringe 4.8 0.0 Normal Delivery 23.8 20.0 RTI/STD/AIDS 61.9 54.0 Emergency Obstetric Services 9.5 8.0 Gender sensitivity 11.9 0.0 Adolescent Health 7.1 0.0 Quality of Care 9.5 2.0 Interpersonal communication skills 9.5 0.0 Counselling skills 2.4 0.0 Managerial responsibility for PHC 7.1 0.0 Epidemiological Surveillance under RCH program 0.0 0.0 Nutrition in RCH Program 16.7 2.0 Disinfection and infection control in RCH program 7.1 0.0 Concept and Component in RCH 2.4 8.0 Calculation of unmet need 23.8 20.0
Majority of medical doctors from both the district have undergone training of 15 days for RCH and of treating RTI/STD. Looking the individual figures of various other type of training, it is concluded that immediate attention is needed to have modular training (Each topic at a time) covering all the themes associated with RCH programme.
C. Environment: Working environment play an essential role for the smooth functioning of an institution. Here attempt was made to know under what type of environment the service providers are working. Status of the construction is an important bearing in providing healthy environment for working.
Table 13: Status of Construction with type of PHCs in both the district. Status of Type of PHC in Dahod district Status Construction Old Upgrade New Total No building/hired 1 - 7 8 Yes 11 1 18 30 Under cont./New - - 5 5 Dahod Total 12 1 30 43 Status of Type of PHC in Sabarkantha district Status
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Construction Old Upgrade New Total No building/hired - - 6 6 Yes 16 8 12 36 Under cont./New 2 2 4 8 Sabarkantha Total 18 10 22 50
In Dahod district, 19% of the PHC reported having no building of its own or has hired old or new building in panchayat office of the village. While in Sabarkantha it is around 12%. About 70% of the PHC are duly constructed in both the district. About 12% of the PHC in Dahod and 16% in Sabarkantha are under the process of construction. Overall it seems that the construction status in both the district is reasonably well.
The total constructed building (hired or its own) in both the district is around 82, of which 38 belongs to Dahod and 44 to Sabarkantha district. The PHCs with building in both the district is 82. The details of the basic amenities present in these PHCs having constructed structure is indicated in table 14.
Table 14 Details of basic Amenities present in the constructed building of the PHCs Amenities Status Dahod Sabarkantha Total in % Boundary wall Yes 13 13 26 32 No 19 24 43 52 Yes but no Gate 06 04 10 12 Missing 0 03 03 04 Total 38 44 82 100 Water Supply No Supply 05 08 13 16 Adequate 21 20 41 50 In adequate 10 13 23 28 Missing 02 03 05 06 Total 38 44 82 100 Electricity No Electricity 04 01 05 06 Regular 26 37 63 77 Irregular 06 03 09 11 Missing 02 03 05 06 Total 38 44 82 100 Drainage Do not exist 07 07 14 17 Septic tank 27 26 53 65 Panchayat line 02 08 10 12 Missing 02 03 05 06 Total 38 44 82 100 From total of 82 building of PHCs, 52% of the PHC building has no boundary wall and 12% has boundary wall with out gate. As regards water supply, 28% of the PHCs have inadequate supply while 16% of PHCs is running without water supply. The remaining 50% has adequate supply of water. Further 77% of the PHCs have regular electric supply. However a small percentage of the PHCs have no electric supply (6%) or and has irregular supply (11%).
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The sewerage and drainage lines were restricted to 12% of the PHCs. However majority of the PHCs (65%) are connected to septic tank, while the facility is absent in 17% of the PHCs. To provide the quality services in the community, it becomes essential to provide such minimum amenities so that the image of the PHC could be upgraded in providing sustainable services to the resident community.
For providing quality services it is expected that the PHC must have all the units as specified in the national norms. The table below gives the details of different unit existing for the constructed PHC only.
Table 15: The description of the units present in the PHCs. Dahod N=43 (%) Sabarkantha N=50 (%) Type of unit / room in the PHC Yes No Missing Yes No Missing Existence of Medical officer 79 5 16 88 0 12 Existence of Indoor ward 65 19 16 56 32 12 Existence of inject/vaccine room 49 35 16 58 30 12 Existence of OT room 16 65 16 24 64 12 Existence of Labour and delivery 47 37 16 52 36 12 Existence of Pharmacy 63 21 16 78 10 12 Existence of Store room 72 12 16 66 22 12 Existence of office 65 19 16 68 20 12 Missing of Toilet 63 21 16 56 32 12 Note: In Dahod 5 PHCs are not constructed and information in 2 PHC is missing : In Sabarkantha 6 PHCs are not constructed counted as missing.
From the above table it is quite evident that there is acute shortage of Operation Theater and labour and delivery room. Both of these units bear an important role as majority of the objective of RCH programmes are to be attained by conducting institutional deliveries, sterilizations that will directly effecting IMR and MMR. Under CP 5 programme the UNFPA has provided provision of construction repair of Operation Theater (OT) and labour room (LR). Annex 10 gives the details of the construction and repair work done in the both the district. However, it is not clear what kind of standard followed in the matter of construction design and type of plan for OT and LR for providing quality services? Usually the design of the rural health institutions is as per the national guidelines based on the World Health Organization recommendation.
D. Material: It is frequently reported that materials and supplies are always in shortage. Even if they are supplied, they are not in use and later get deteriorated. In the PHCs the first essential items are furniture and repair. The demand for basic items like furniture and repair were asked separately and the results are indicated in table 16.
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Table 16: PHC requiring Repair and Furniture (in percentage) Dahod Sabarkanth Dahod Sabarkantha Furniture (N = 38) a (N = 44) Repair (N = 38) (N = 44) Not Adequate 81 94 Yes 56 68 Not Required 11 2 No 35 28 Missing 9 4 Missing 9 4 Total % 100 100 100 100
Figures from the above table indicate that there is an acute shortage of the furniture in both the district. UNFPA during CP 5 program had supplied furniture in both the district. However it is not clearly from the records whether the furniture supplied is as per the functional needs of each unit in the PHCs or are supplied for general use?
Taking account of the number for constructed PHCs only, it was found that 56% of the PHCs in Dahod and 68% in Sabarkantha need urgent repairing. The repair are confined with the doors, windows, floor, ceiling etc and the cost estimated ranges from minimum of Rs.1000 to maximum of Rs. 25,000. The details of construction and the type of PHCs in both districts are indicated in annex 11.
After the Alma-Ata international conference on Primary Health Care in 1978, the standard recommendation by World Health Organization, the items of materials and supplies are classified according to different units of the PHCs. The respondents were asked to fill requirement of materials and supplies according to the different service units. Table 17 gives the details of average availability of the materials and supplies in both the district.
Annex 12 gives the details of availability of each item for different services unit. Here descriptions of these items are summarized and discussed for both the districts. In the OPD consulting room the average availability of the items which are in working conditions is around 60% and 30% items are not available. About 10% of the items are available but are not in working conditions. The most neglected item is of curtain for privacy, followed by thermometer, torch, tongue specula and washbasin with water and soap which are considered to be the essential for OPD room.
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Table 17 Average responses on the availability of items in different units of the PHC (in %) Sr Types of Service Unit in PHC DAHOD (N=33) SABARKANTHA (N=39) No AW ANW NA AW ANW NA 1 For Medical officer / OPD room 59 13 28 63 8 29 2 For Dressing and injection room 48 17 35 63 17 20 3 Gynecological Examination room 59 13 28 66 6 29 4 Labour Room 37 9 54 50 6 45 5 Vaccine Storage equipments 68 5 27 86 2 12 6 Laboratory (Instruments) 46 4 50 60 4 36 7 Operation Theater 17 8 74 22 5 73 8 Autoclaving and boiling instruments 64 4 32 59 10 31 9 Counseling/Health Education room 45 4 51 44 3 53 10 IEC Equipment 7 7 87 13 6 81 11 Indoor ward 61 6 33 49 11 40 AW – Available and in working condition; ANW - Available but not in working condition; NA –Not at all available.
In dressing and injection rooms the availability of items in working condition range from 48% to 63% and about 17% of available items are not in use. While about 20% to 35% of items were found absent. There is shortage of instrument like holding forceps, and solutions like spirit, betadine, Iodine, hydrogen paraoxide and washing facilities.
In gynecological examination room about 30% of the items are absent. Curtain for privacy was again one of the most neglected items, followed by viginal speculum, uterine sound, volsellum / tenaculum etc. The most common instruments like Foetoscope and height measuring inch mark on wall was found absent Laboratory services are reported very weak as some of the most essential items reported totally absent. Centrifuge, VDRL test set, TC BC RBC set and chemical and regent had restricted many important laboratory tests to be conducted under RCH programme.
In labour room, about 50% of the items reported not available in the PHCs of the both the district. It includes the most essential items like cord forceps, Cord Scissor etc. Similar situation also exist in operation theater, where 73% of the items in the both the districts found absent. Item wise description is listed in annex 12. To some extent, the autoclaving and boiling instrument, vaccine storage equipments and items related to indoor wards are largely present among the different PHCs of the both the districts.
One of the astonishing fact emerges that the 50% of the PHCs does not have IEC unit and IEC equipments are absent among 80% of the PHCs. This suggests that IEC activities through PHC are very poor and could be the main reason for the weak or poor contact of health worker with the community. As a result people don’t come to the PHCs or are not aware of the available services in the PHCs.
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Though efforts are on for the repair and construction of Operation Theater and labour room, it is equally important to see that they are well equipped.
E. Measurement: When we talk about accountability. Measurement plays an important role. Performance evaluation of individuals usually is based on number of variables. Since each individual or participants is allotted PHCs, the MMR, IMR, vaccination rate, family planning operation etc are some of the important variables that helps to judge the performance of an individual. Unfortunately, the required data of the two PHCs were not up to the mark and hence this discarded from the analysis. Such short comings also points out to develop a GIS based monitoring system that keeps track of such records and gives on line information for verity of information pertaining to coverage and performance evaluation.
- : Human Behaviour : -
Human behaviour is one of the key variables to impart quality services to the client. However it a very difficult task to introduce human factor in the pre defined hierarchy system, because the priority is more towards system rather maintaining human relation. So far in public health system of our country, not much attention has been paid to the human attitude from the cliental perspective. Here we mean both the internal customer or the service providers and the external customer or patients or beneficiaries. This is the first attempts were service providers were given preference to know their attitude and the working mentality of their profession. Such analysis help in changing human behaviour so as to provide quality services to the resident community at the grassroot level.
A special Proforma was prepared to know their strength, weakness of their working attitude. The summarized details of the analysis are indicated in table 18. The major strength lies in working attitude, as average 35% of the participants admitted to do conduct their professional work regularly and in time at their respective PHCs. Further on an average 15% of the participants admitted individual positive attitude that helps to conduct their duties smoothly. Good leadership, cool temperament, resolving problems etc are some of the major individual strength to conduct their professional duties. Weakness is very sensitive issue and majority of individuals don’t want to disclose individual weakness publicly. Hence we represented combined result rather doing district wise or type of employees. Even though, about 31% of the participants do not want to share their weaknesses, while on an average 6% showed individual and 3% showed professional related weaknesses. One of the astonishing thing came out is that a small proportion of participants (2%) pointed out weaknesses in the hierarchical vertical system as their associated weaknesses. The major weaknesses were related with not doing field work and other is related with human temperament that gets excited (either positively or negatively) due to heavy work load.
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Table 18: Average responses of the participant for human parameters in both districts. Human attitude Variables Average (N=263) In % Strength Wrong answers* 2 1 In profession 91 35 Individual Attitude 40 15 Weakness Wrong answers/Missing/Not Applicable* 82 31 In profession 7 3 Individual Attitude 15 6 Against Hierarchy System 5 2 Expertise Wrong answers/Missing* 73 28 Professional Expertise 13 5 Individual caliber 8 3 Activities Wrong answers/Missing* 37 14 Unable to do Management of the PHC 13 5 Technical Programme skills 12 5 Individual Needs 1 0 Avoid doing Wrong answers/Missing* 109 41 Activities About their assigned work 8 3 Individual dislikes 13 5 Expectations Wrong answers/Missing* 13 5 Individual needs 36 14 Financial needs 9 4 Programme specific needs 8 3 Change in Wrong answers/Missing 75 29 Profession Yes 161 61 No 27 10 Set back Wrong answers/Missing* 136 52 Related to PHC 6 2 Human interference 8 3 Individual experience 2 1 Note: * in actual numbers and percentage while for others, average are represented.
As related to expertise work, 28% of the participants were unable to report their either individual or professional expertise suggest that they are just working for the sake of their livelihood or in formalities. On an average about 5% of the participants showed professional expertise and a very small proportion (3%) showed individual caliber to conduct professional duties. Professionally, conducting their routine work in the PHC and generating demand or creating demand in the community are the most frequent expertise reported by the participants.
About 14% participants did not report the activities which they are unable to do in their profession. On an average, 5% of the participants admitted their inefficiency in the management of the PHCs while similar average number (5%) reported their inefficiency in the technical skills of the health programme. Upgrading the PHC facilities and 100% achievement for the set target of health programmes are two major unachievable tasks as reported by the participants.
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Individual working in any system or organization gives an idea about their attitude toward their allotted duties. People always report, what they do but hide what they don’t do? This was the reason that about 41% of the respondent did not disclose about the activities which they usually avoid in their profession. Further average 3% of the participants were frank to disclose the type of activities they dislike and avoid. In technical matters, any thing which is against their medical ethics is avoided. Participants (5%) were more interested to narrate their individual dislikes in the profession. Overall the participants dislikes - is more towards positive side as they don’t want to do any wrong activities which against their profession.
Expectation plays a crucial role to mobilize efficiency in the working system. This is the first time that the participants were asked about their expectation from the profession. Average participants expectation were more on towards their individual needs (14%) followed by financial needs (5%) and programme specific needs (3%).
Change is the essential element either in personal or professional needs. Human behaviour always explore for change for betterment of life. In profession, change is considered to be an effective tool that creates enthusiasm if simultaneously individual personal needs are fulfilled. About 60% of the participants agreed that profession had changed their life while 10% don’t agree and 30 were unable to answer. Upgrading skills and changing behaviour of individuals and meet the demand of the people expectation for public health services are some of the major changes occurred in the life of the participants. Too many new programmes without supervision, old policies, dictatorship etc are some of the major reasons reported by the participants that restricted any change in their life.
In order to gain the confidence of an individual, it is essential to give respect to the sentiments of an individual related to his failure or success. A similar attempt was made over here, however could not succeed as 50% of the participants were unable to describe their set back in their profession. Average 2% of participant describes setback related with PHC and its programme, while other described the human interference as major cause of setback in their professional life. About small proportion of participants narrates individual experiences as a setback in their profession. Extensive variable content analysis of human behaviour on the different aspects is described in annex 13.
- : Feed Back : -
At the end of the workshop, participants were asked to give their reaction by filling up feedback forms. The results of the feedback incorporate the reaction of the district officials, medical officers, health workers and NGO volunteers. A total 182 participants had filled the feedback form and the result is narrated in table 19. Overall the training seems to successful as 52% of the participants found the subject matter to be very effective and 32% gave their opinion as an only effective training. The results of the feedback forms were found to be good enough to trigger the subject matter the
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quality in the Public health. However a lot has to be done more because the concept is new and people are accustomed to the old procedure of working.
Table 19: Reaction of the participants for the current subject. Total (N=182) in % Feedback Questions V.Eff Effect Sat N.Sat Story of Four Persons 38 50 11 0 The Quality and Quality Circle 40 40 20 0 Dos and Don'ts in Quality Circle 23 50 26 1 Structure and Scope of Quality Circle 57 24 19 0 Process of Organizing QC 46 36 16 3 Measuring Tools in Quality Circle 23 48 28 2 Human factor in Quality Circle 55 33 11 1 Course Material of Quality Circle 49 30 21 1 Overall grading for Quality and Quality Circle in PH 52 32 16 0
On asking what are their future expectation in the matter of quality of care through quality circle the following results were observed as indicated in table 20.
Table 20: Expectation of participants in the matter of Quality of care through Quality Circle (N=150). Sr Expectation in the matter of Quality and Quality Circle in PH In % 1 Will have quality work and efficiency will improve a lot 37 2 Better problem solving techniques and understand difficulties of service providers 19 3 Will bring drastic change in working performance in public health 4 4 Repeated training in personality development and problem solving techniques 6 5 First to resolves problems at the grassroot level for proper infrastructure 11 6 Customer expectation is very high and thus should have quality work 5 7 Such system should be implemented with external agency only 3 8 Should not start where shortage of service infrastructure including manpower 2 9 The PH system must be introduced with accreditation system 2 10 To achieve the set target of RCH package 2
Majority of the participants expectations (66%) were very enthusiastic for improving the work; increasing the efficiency of an individual; better problem solving techniques, easily meet customer expectation and demanded for repetitive training. Other associated expectations were related with improving service infrastructure, implementing accreditation system and also to achieve set target of the RCH programme. This suggests that they are very anxious to implement quality circle approach at their respective PHCs. From the total of 115 medical officers, 90% of the participants agreed to implement the quality assurance project at their PHCs, and remaining 10% put forward their personal reasons in not doing so. The main reasons put forward for implementing QA project are related with improvement and upgrading the service infrastructure, improving skills of an individual, increase the coverage, better reorganization and rewarding system for the fruitful work and better integration with the community and NGOs residing at the grassroot level.
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- : Discussions and Recommendations : -
The pilot experience could be considered as beginning to introduce the concept of ‘quality’ in public health. The success or failures are given least importance because the major objective was to institutionalize the concept of quality of care as a priority activity in reproductive health programme with a mandatory concrete structure that is governed through public health system of the state Government. Overall the pilot project seems to be a learning experience to initiate the project to cover other districts under UNFPA assisted IPD project. The following recommendations were put forward under various topics associated to improve and introduce quality assurance project.
1. Recognition of Structure and Process: As discussed earlier the two major problem encountered is related with the integration and making the concept of quality as a mandatory process in public health. Looking these pitfalls a four tier quality assurance structure was designed with the help of a popular management philosophy of ‘quality circle’. The formation of quality circle was successfully done at district and PHC level. In continuing efforts, it is proposed to form a quality circle committee at the state level. This will act as a statutory body that will help to address all matters related to quality issues and take appropriate decision for it smooth execution and designing the future strategy.
2. Developing Quality Assurance System: With the beginning of nineties, the QA system has developed tools and methods based on quality management principals used in industry and applied them in the context of developing country health systems. Once the state level quality committee becomes statutory body, it is recommended to develop quality assurance standards focused on the clients, system, and process (including rewarding system after performance evaluation), measurement and team work. The specialized skills training needs much more systematization and a good quality steps suggest to an optimal proficiency certification system yet to be first developed, pilot tested and than implemented all over the state. Such efforts for hospital were done in Andhra Pradesh with the assistance of World Bank.
3. Improving and Strengthening Service Facilities: One of the up coming issues under QA project is to satisfy the internal customers (service providers) needs and than demand for quality work. The result of the SWOT analysis and looking demand for service infrastructure of each PHC, it is advisable to select few PHCs under quality assurance project which has minimum level of physical infrastructure, desirable strength of health workers, with all requisite of materials and supplies.
Appreciating the ongoing efforts made by UNFPA assisted IPD project for construction and repair of labour and Operation Theater in PHCs, it is suggested to adopt standard guidelines as recommended by World Health Organization
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(Kleczkowski et al 1985) for construction of such service unit in the PHC. Such type of construction helps to give quality services, maintain flow of health services and reduce the waiting hour of the clients.
The efforts made by UNFPA assisted IPD project for furniture supply is appreciable again. However the inference drawn from our analysis shows that more than 50% of the labour room and Operation Theater is with out essential items. Thus for future course of action, we suggest that apart from construction repair, and furniture, budget provision should also be made for materials and supplies looking different functional units (for list, refer annex 12). It is advisable that Operation Theater, labour and delivery room, laboratory and pharmacy should be given first priority, to ensure the safe delivery of emergency obstetric service (EOS) to the resident community. A lot has to be done for upgrading the skills and developing technical material for the PHC workers.
4. Imparting Modular Training: The result of pre and post KAP test of the participants was poor. This suggests that 15 days at stretch training does not produce the fruitful results to the expected level. The are many reasons for the poor performance of the participants which are listed below:
a. We appreciate the notable work done by the Padra training center but our analysis shows that only a small portion (10 – 20%) of the topics has been covered under RCH programme for medical officer. Hence in future there is a great need to speed up the training not only of medical officer but also for health workers and lab technicians. Training capacity also needs to be enhanced – quantitatively and qualitatively, with more and better quality material defining stepwise role in public health.
b. There is substantial quantity of material produced by Government agencies in terms of modules for training of various categories of staff. These modules are useful and comprehensive, but are very voluminous and needs substantial quality improvement in reduction in size to make them more useful for PHC level workers.
c. The total duration of most training are short (1-2 weeks) and these trainings try to cover many topics – from old MCH, FP program and new components of reproductive health. This also includes hand on training that further restrict the theory session (2-4 hours). The hands-on part of the training is planned but time available is limited and its implementation is practicably not viable. Hence it is recommended that training should be imparted in modules covering one topic at a time giving equal justice to both theory and practical (hand on training).
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d. Since quality is now center point in RCH programme it is recommend including training human resource and personality development in the regular training curriculum.
e. Post training evaluation mechanism is not yet developed and needs urgent priority to develop in future. The supervisor and the trainers should monitor the performance of the staff after training. The trainers should also visit a sample of their trainees in the field to assess their performance.
f. The training activity needs concurrent monitoring. It is recommended to set up a state level computer based interactive system that will periodically monitor training and provide direction to the efforts. Proper integration of MIS at district and state level needs to be develop a separate GIS based information system for monitoring of the training and to measure performance of the staff that are trained.
5. Integrating NGOs for Quality: The four tier quality structure was developed to ensure that the grassroot level realities reach to the top level management or policy makers. This is done by developing quality circle committee (QCC) from village level to state level. We recommend the following for the integrating NGOs under QA project:
a) As discussed earlier that QCC has already being formed and started functioning at district and PHC level, it is recommended to select NGOs for making QCC at village level (refer figure 4).
b) The selection of NGOs in the district should fix the area of operation and associate it with the PHCs located in there specified areas.
c) Looking the result of the pre-test among the volunteers coming from different NGOs, it is recommended to impart training to the NGOs regarding RCH programme that includes the recent concept emerging in RCH and also about the public health system of our country. They should also made familiarized with the concept of programme management that will enhance their capacity for executing programme effectively.
d) The community demand generating programme such as adolescent health, folk dances, school health programme, Mahila Swastha Sang and other disease preventive programme should be assigned to local NGOs in collaboration with PHCs.
6. Integrating RCH Service Package with PHC: In order to attain objective of the RCH programme, it advised to integrate all type of projects with the PHC as a routine activities. For e.g.: PHC conduct routine activities of MCH clinic and UIP session. Thus it is advisable to integrate, adolescent camp, school health,
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nutritional programme, sex education, etc with PHCs and joint collaboration of the selected NGOs associate to the PHCs.
One has to work out on defining the role and specific strategy of health workers in the matter to gender, and adolescent health in public health. However the pregnancy related complication, preventing and treating STI/RTIs, etc could be best integrated in the PHCs by organizing RCH camp in the beginning and later make it as a regular activity of the PHCs.
7. Strengthening Planning for Health Workers: Quality is the central component in RCH programme so as grassroot level planning of health worker. During the course of discussion, majority of the participants pointed out planning a major weakness to cope up all ongoing health programmes. Looking their point of view, it is recommended to introduce a daily dairy system that ensure prior planning of the activities to be conducted and would be very helpful in assessing the performance of individual health worker.
8. Strengthening Referral Services: Referral services are one of the important components of RCH program. It is recommended to integrate CHC and district hospital under QA project. Apart from service infrastructure, there is an urgent to develop a system which ensures the referral services are genuinely imparted to the referred patient and become easy for follow up. Looking previous experience of pilot project on RCH in Sanand taluka in Ahmedabad district, it is recommended to introduce system of referral slip that will ensure the delivery of the service to the referred patients as well, help in keeping track of the referred patient during follow-up.
9. Developing Follow up Procedure: To ensure for the quality work at PHC, CHC and district hospital, it is advisable to conduct regular follow-up meeting. Such follow up meeting will help to keep track of the quality work being done and decide the future strategy for continuing the quality efforts in public health services. Such follow up meeting should be made mandatory to communicate every decision to the state level QCC. This should also be made mandatory to state level quality circle committee so that the end results are communicated to the policy makers. Our experience regarding follow up procedure was found very effective in Dahod and Sabarkantha district. (For details refer annex 5 and 6)
10. Monitoring Financial Implications: The implementation of health sector programmes requires considerable amount of resources and therefore an analysis of resources required establishing infrastructure and implement programmes becomes imperative. For effective implementation of the health programmes, it is important for the programme managers to know how much does it cost to provide health services under any health programme under different hierarchy of health care system of any project. These programmes not only require investments in long-term capital but substantial recurring expenditures to implement various
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programme components. It is obvious that analysis of sources and uses of financial resources in efficient way assumes critical importance. It has always been endeavour of policy makers to design effective structures that ensure efficient and effective use of resources.
Thus it is recommended to develop an effective financial monitoring system which ensure the effective utilization of resources and make prediction about the on going programmes are cost effective or not. This will make the policy makers conscious of the cost of services and also make the providers and clients more responsible about the services.
11. Integrating Quality Data through GIS: One of the most important questions arising in public health today concerns the type of instrument that can be used to devise quick, reliable and scientifically valid methods of rapid assessment, to assist health research and in the planning, monitoring and evaluation of health programmes. New techniques must enable public authorities to gain insights into the consequences of decisions relating to investment in public health and make it possible to review current situation in which new interventions for development are proposed. However, recent advances in geographical information system (GIS1) mapping technologies and increased awareness have created new opportunities for public health administrators to enhance their planning, analysis and monitoring capabilities.
For a policy/programme manager, it becomes too clumsy and difficult to remember the regional figures. The GIS could handle the said limitations in conventional methods with a simple microcomputer-mapping package solely for presentation and taking related decisions for the programme. Besides, GIS has user friendliness environment that is most important for the decision-maker that generally has little knowledge of computer. Since the process of collecting data pertaining to training, PHCs, SCs and village level health information has already started, it is recommended to build separate GIS information monitoring system for five IPD district. This will help for know the current status of the following:
Training, Man Power, Infrastructure details, Their demand for material, supplies, and also for repair and maintenances. Performance of an individual, Performance of the area (SC; PHC; CHC; taluka and district level.
This would be one time investment for term gain in the aforesaid matters.
1 GIS are often described as an organized collection of computer hardware, software, geographical data and personnel designed to efficiently capture, store, update, manipulate, analyze and display all forms of geographically referenced information.
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- : Epilogue : -
After ICPD conference, quality is regarded as the core issue for improving the cliental services and ensures its safe and time bound delivery. It also highlights to improve the service infrastructure with the quality standards developed under country/state specific accreditation system. To ensure such challenges a good beginning has been made in Dahod and Sabarkantha district by introducing the concept of quality of care with the most popular Japanese philosophy of “Quality Circle”. This concept was widely accepted by the participants, as they do not realize it as an additional burden and adopted it as routine activities.
As an internal customer the demand put forward to improve the service infrastructure and provide the sufficient manpower is genuine looking the concept of quality of care. The UNFPA assisted IPD project has already taken the initiatives by supplying the furniture, and providing provision for repair and construction specially to labour room and operation theater. However a lot more has to be done to up bring the skills of the services providers and to initiate at the earliest for emergency obstetric services for the community.
To address such issues, a four-tier quality structure was developed to ensure - that the ground realities (village level) related to quality of care are genuinely represented to the highest state level health authorities to a swift action. Further, there have been substantial efforts to improve training under the RCH program. There is lot of scope for quality improvement by integrating it with topics of human resource and development. Above all the daunting requirement is of concurrent monitoring of the activities in the matter of coverage of services and performance evaluation of service providers through computerized information system linked with Geographical information system.
Vardaan Foundation under joint collaboration with UNFPA assisted IPD project and officials of Government of Gujarat, will continue efforts for strengthening the quality assurance project through continuous monitoring, providing quality training, preparing effective strategy, developing study and training material and above all addressing all issues concerned under UNFPA assisted IPD programme. Overall looking the positive result of the Quality Assurance pilot project one can say a “beginning of quality care services in public health”. However a lot has to be done in developing the quality assurance system for standards focus on the clients, systems, process, measurement and teamwork.
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FUTURE STRATEGIES
Owing to the pilot experience in Dahod and Sabarkantha, there is urgent need for the following strategy:
1. Sensitization the concept of “quality of care” through the philosophy of quality circle and formation of quality circle committee in the remaining three IPD district: Banaskantha; Surendranagar and Kutch. This will help in implementing the project strategy uniformly in all five districts.
2. Developing Standards for Quality Assurance System is the most utmost necessity under quality assurance project. The entire standards for the different aspects in public health would be developed by Vardaan Foundation but validated by health officials of Government of Gujarat and experts appointed by UNFPA. The development activities would be confined by doing internet search, literature survey of similar types of manual developed by other countries. Studying the subject matter, Vardaan Foundation will develop different quality standards and put forward for its approval through the state level quality circle committee that would be the statuary body to look after all matters related to quality under QA project.
3. For implementing the four tier structure developed under quality assurance system, it becomes essential to up grade the skills of PHC level health workers and local NGOs, so that the desired objectives of the QA project under UNFPA assisted IPD project could be achieved. According to our analysis, the PHC staff and NGO are found weak at many fronts that includes, planning, monitoring, calculating the desired target etc. Hence capacity building of health workers and NGO volunteers is essential strategy.
4. Since lot of data would be collected for on various aspects of quality, it is desirable to develop a computer based management system linked with geographical information system. This will help the programme and policy makers at many front (monitoring and evaluation, service coverage, calculating and comparing different epidemiological rates etc)
) Since large volume database has to be developed and processed, Vardaan Foundation Team (annex 14) humbly request for a sophisticated computer system with printer, scanner and other necessary computer peripherals and software. The expected cost of the entire system is around one lakh as a separate budget. This is would be effective for the long term activities under QA project during CP 6 for UNFPA assisted IPD project.
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Activity 1: Sensitizing the concept of Quality in public health.
Project strategy: Orientation training through Workshop : Formation of the Quality Circle Committee at District level. : Formation of Quality Circle Committee at PHC level : Follow up meeting.
Target Group: Medical officer, PHC staff and NGO volunteers.
Project area: Kutch, Banaskantha and Surendranagar district.
Expected number: 600 participants (includes some additional participants) among three district. The break of participants for each district is as follow: 1. At district level: PHC medical officers and district health officials = 100 2. At PHC level: For six PHCs in each district = 100
Proposed Budget: This being prepared owing to the previous experience in Dahod and Sabarkantha district. The total Budget for three districts is Rs. 7.5 lakhs. The expense of one district is Rs. 2.5 lakhs whose details are as follows:
Budget Items No At the rate of Rs. Total Amount (Rs.) Major orientation workshop for 2 30,000/workshop 60,000.00 DHO and PHC MOs Major orientation workshop for 2 18,000/workshop 36,000.00 NGO representatives Minor orientation workshop for 5 7,000/workshop 35,000.00 PHC staff Printing Manual, Poster etc 59,000.00 Traveling Expenses 35,000.00 Contingency Expenses 25,000.00 Total Expense for one district 2,50,000.00 Total Expense for three district 7,50,000.00
Time Duration: Four Months probably from Jan to April 2003
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Activity 2: Developing Standards of Quality Assurance System.
Project strategy: 1. Review of the manual present. (Internet and library search)
: 2. Developing Quality standards manuals focused on Sub center; PHC; CHC and district hospitals. Looking Client perspective Process (all sort of clinical process) Subject based: Quality manual for o Family Planning o Counselling o Gender o Emergency Obstetric Services o RTI/STI o Adolescent Health Quality Accreditation System o Standard of Quality control o Standard of Quality Surveillances o Standard of Quality Audit
: 3. Two days State level workshop. Formation of Quality Circle Committee at state level. Getting Approval of the designed manual from State level Quality Circle Committee.
: 4 Printing and distribution of Manuals in Five IPD district.
: 5. A two days workshop for each IPD district for DHO and MO.
Target Group: State level Health officials, CDHOs, ADHOs, RCH officers, IPD programme officer of five district, external public health experts national and state level, State and national level UNFPA representative .
State level Workshop for Developing Quality Assurance System: Place: Probably in Ahmedabad. Venue: Any reputed hotel Number of State level Workshop: Two days workshop probably two workshops
District level orientation Workshop for Quality Assurance System: Place: Probably in district head quarter. Venue: Any good hotel Number of district level Workshop: Two days workshop probably five workshops
Expected number: For State level Workshop: Around 40 For District level Workshop: Around 80 (80 from each district)
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Proposed Budget: This being prepared owing to the previous experience in Dahod and Sabarkantha district. The total Budget for three districts is Rs. 7.5 lakhs. The expense of one district is Rs. 2.5 lakhs whose details are as follows: Budget Items Total Amount (Rs.) 1. Review of the manual present. (Internet and library search) 1,00,000.00 2. Developing Quality standards manuals focused 5,50,000.00 3. Two days State level Two workshops. 3,50,000.00 4. Printing and distribution of Manuals in Five IPD district 5,00,000.00 5. A two days Five workshop for each IPD district. 5,00,000.00 Total Expenses for developing Quality Assurance System 20,00,000.00 Note: 1. Purchase of books, internet charges, Xerox, postal etc for gathering information on Quality Manuals. 2. Honorarium to the Team of Vardaan Foundation and expert consultancy fee. 3. Boarding lodging and Traveling expenses (Air fair); Honorarium, workshop kit bag and other material 4. Approximately 1000 copies of each of the 10 type of manual would be printed in English only. 5. Boarding lodging and Traveling expenses; Honorarium, workshop kit bag and other material
Time Duration: Six Months probably from Jan to June 2003
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Activity 3: Capacity Building of PHC staff.
Project strategy: Orientation training for attaining the objectives of QA project. : Training how to do planning. : Training for Strengthening Referral Services. : Reporting Information System : Training for calculating unmet needs. : Strengthening birth and death registration. : Outreaching the RCH service through RCH camp. : Developing success story for Quality innovations
Target Group: Selected PHC under quality assurance project.
Project area: All five IPD districts
Expected Number: 750 participants among five districts. It is expected that each PHC would have minimum 15 staff. Thus in one district about 150 PHC level health workers would be trained.
Number of Workshop: 50 minor workshops for five IPD districts. Each workshop would be conducted for two days. Thus in one district about 20 days would be spent for 10 PHCs.
Proposed Budget: This being prepared owing to the previous experience in Dahod and Sabarkantha district. The total Budget for three districts is Rs. 7.5 lakhs. The expense of one workshop is Rs. 15,000 whose details are as follows:
Budget Items At the rate Total Amount of Rs. (Rs.) Workshop Material* 13, 000 13,000.00 Lunch, Tea and Coffee for two days 5000 5,000.00 Boarding, Lodging, traveling of team for two days 6000 6,000.00 Total Expense 24,000.00 Total Expense of ten workshops in one district 2,40,000.00 Total Expense of fifty workshops in five district 12,00,000.00 * Printing of daily dairy, referral books, Poster, and QA manuals in Gujarati. Time Duration: In one year from Jan to Dec 2003.
Time Duration: One year from Jan to December 2003
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Activity 4: Capacity Building of NGO volunteers.
Project strategy: Orientation training for attaining the objectives of QA project. : Training how to do planning. : Training for Strengthening Referral Services. : Strengthening birth and death registration
Target Group: Selected NGOs under quality assurance project.
Project area: All five IPD districts
Expected Number: 250 participants among five districts. It is expected that each NGO would have minimum 10 staff. Thus in one district about 100 NGO volunteers would be trained.
Number of Workshop: 50 minor workshops for five IPD districts. Each workshop would be conducted for two days. Thus in one district about 20 days would be spent for 10 NGOs.
Proposed Budget: This being prepared owing to the previous experience in Dahod and Sabarkantha district. The total Budget for three districts is Rs. 7.5 lakhs. The expense of one workshop is Rs. 15,000 whose details are as follows:
Budget Items At the rate Total Amount of Rs. (Rs.) Workshop Material* 9000 9,000.00 Lunch, Tea and Coffee for two days 5000 5,000.00 Boarding, Lodging, traveling of team for two days 6000 6,000.00 Total Expense 20,000.00 Total Expense of ten workshops in one district 2,00,000.00 Total Expense of fifty workshops in five district 10,00,000.00 * Printing of daily dairy, referral books, and QA manuals printed in Gujarati.
Time Duration: In one year from Jan to Dec 2003.
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Activity 5: Geographical Information System. The project also emphasis to strengthen, surveillance, monitoring and management of on going RCH Programme in five IPD district of Gujarat.
Project strategy:
STEP 1: To Acquire Appropriate Hardware: STEP 2: To Acquire Appropriate Software: STEP 3: Digitizing Geo data of 5 IPD districts. STEP 4: Creating Socio-Economic with epidemiological database STEP 5: Integrating and Desktop Programming in GIS System: STEP 6: Implementing and Training of GIS System: . Project area: All five IPD districts
Target Group: Health ministry of Government of Gujarat, IPD project team and UNFPA team of Gujarat.
Task Accomplished: We have already started creating database of health information right from village level, SC and PHC level. Apart from this we are also creating database for training. This is being accomplished in two districts
Proposed Budget: Sr. PROJECT ITEMS AMOUNT in Rs. 1. Two Assembled Computers with high configuration* 2,00,000.00 2. License Software ARCVIEW (two Copies) 2,00,000.00 3. Acquiring/developing digitizing geographical data of 5 district 5,00,000.00 4. Creating RCH database (Clinical, Social, epidemiological. etc) 4,00,000.00 5. Customization, Interface Designing and Training* 2,00,000.00 Total Expense of the Project 15,00,000.00 *Officials of Govt. of Gujarat; UNFPA and IPD project Team.
Time Duration: Two years From Jan 2003 to December 2004
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References:
Anrudh Jain, Judith Bruce, and Barbara Mensch (1992) COMMENTARY: Setting Standards of Quality in Family Planning Programs. Studies in Family Planning, Vol. 23 (6),Pp. 392-395.
Andhra Pradesh (1995) First Referral Health System Project, World Bank funded to Govt. of Andhra Pradesh.
A Five-Year Review of Progress towards the Implementation of the Programme of Action of the International Conference on Population and Development. A background paper prepared by the United Nations Population Fund (UNFPA) for The Hague Forum The Hague, Netherlands 8-12 February 1999.
Bruce, J. (1990), Fundamental element of quality care: A simple framework. Studies in Family Planning 21(2); 61-91, Mar/Apr.
Bruce, Judith and Anudh Jain (1991), Improving the quality of care through operation research, In Operation Research Helping family Planning Programs Work Better. Eds Myrna Seidman and Marjorie Horn, New York, John Wiley & Sons.
Baldrige National Quality Program (2002) Health Care Criteria for Performance Excellence, Gaithersburg.
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Donabedan, A. (1980), The definition of quality: A Conceptual Frame exploration. In Exploration in quality assessment and monitoring: the definition of quality and approaches to its assessment. Vol. 1. Ann Arbor, Michigan, Health Administration Press. 1980 p: 3-28.
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Kleczkowski, B.M (1985), Approaches to Planning and Design of Health Care Facilities in developing countries. Vol. 5 WHO Publication No. 91.
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Lori DiPrete Brown et al., “Quality Assurance of Health Care in Developing Countries” Quality Assurance Methodology Refinement Series (Bethesda, MD: Quality Assurance Project, 2000).
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Management Effectiveness Programme (1999): A Journey to Improve Quality for Health, WHO/EMR/EML/99.2
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Quality of Care, Manual (1995), Dept. of Health and Family Welfare, Govt. of Himanchal Pradesh.
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Udpa, S.R. (1992) Quality Circle: Progress through Participation, New Delhi, Tata McGraw-Hill Publishing Company Limited.
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Vesaira, Leela and Pravin Vesaria (1999) Quality of family planning services in Gujarat State, India: An exploratory analysis, in Managing quality of care in Population programmes Ed. Anrudh K. Jain, New York: Kumarian Press, Pp. 113- 138.
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Annex 1a: List of PHCs Medical Officers participated in the workshop at Dahod. Sr.No Name of MO Name of PHC Name of Taluka 1 Dr. A. M. Shukla Dhadhela Limkheda 2 Dr. M.P. Shrama Gangardi Gobada 3 Dr. S. K. Singh Saneja Jahlod 4 Dr. P.C. Doshi Bhatirad Dahod 5 Dr. L.K. Arya Bandibar Limkheda 6 Dr. R. M Roza Jambua Garbada 7 Dr. R.R. Banodiya Timrada Dahod 8 Dr. S.S. Joshi Chhaperbad Limkheda 9 Dr. C.H. Bamani Jeswad Garbada 10 Dr. M.B. Choudary Bhathwada D.Bariria 11 Dr. B.P Parmar Ved Dhanpur 12 Dr. M.N. Alam Rachhva Dahnpur 13 Dr. M. Kapoor Mandur Dhanpur 14 Dr. D.N. Patel Borwani Dahod 15 Dr. Hans Raj Dhaddiya Afaver Fatepura 16 Dr. Arvind Varshey Kathla Dahod 17 Dr. V.M. Mishra Auasuari Dhanpur 18 Dr. Sangeeta Prasad Nin-Khapari Limkheda 19 Dr. Vijay Labana Abhlod Garbada 20 Dr. S.K. Azad Boradi-Khord Dahod 21 Dr. R.K. Srivastava Nagirala Dahod 22 Dr. J.P. Agarwal Garadu Zalod 23 Dr. S.V. Kotasa Khoroda Dahod 24 Dr. Arun Kumar Dudhiya Limkheda 25 Dr. Amit K. Shihora Handi Limkheda 26 Dr. G.L. Bariya Dungar Fatepura 27 Dr. R.D. Chaudhary Gultar Jhalod 28 Dr. S.R. Baria Mahudi Jhalod 29 Dr. Ramesh P. Kadia Antela D. Baria 30 Dr. J.L. Meena Limidi Jhalod 31 Dr.B.M Patel Balaiya Fatepura 32 Dr. Sanjay Kumar Mirakhodi Jhalod 33 Dr. K.R. Handa Chalaliya Jhalod 34 Dr. Ajay Kumar Bilwani Jhalod 35 Dr. Ashok V. Parmar Vansiya Jhalod 36 Dr. Chandua Pawani Kawadal Jhalod 37 Dr.Anirudh Tiwari Gamada Jhalod 38 Dr. Manohar Lal Regawada D. Bariya 39 Dr. P.D. Fanasia Dabhava D. Bariya 40 Dr. B.R. Sinha Lilva thakor Jhalod 41 Dr. Shirish K. Tiwari Kuva Baria D. Bariya 42 Dr. Vinit Vikram Madhava Fatepura 43 Dr. Madan Tripati Sevariya D. Bariya Note: Excluding participants from District and State.
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Annex 1b: List of NGOs volunteers participated in the workshop Sr.No Name of Volunteers Name of the Name of Taluka Organization 1 Mr. B.B. Baria NYK Godhra 2 M. N.B. Baria NYK Godhra 3 Ms. Sreetama Gupta FES Dahod 4 Mr. Rajendra Jaiswal PF Jhalod 5 Mr. S.S. Munja DISHA Dahod 6 Mr. Paresh Rathod LS Limkheda 7 Mr. K. B. Chavada AP Jaswada 8 Mr. S.S. Shastri AKH Dahod 9 Mr. R.B. Domar GRRK Santrampur 10 Mr. K.F. Damor GRRK Santramput 11 Mr. S.M. Rathod SST Jekot 12 Mr. R.B. Chavada AP Jeswada 13 Mr. R. Vasaiya GAVP Dahod 14 Mr. M.M. Bhargav GAVP Dahod 15 Mr. J.K. Damor NT Shegul 16 Mr. R.B. Solanki AS Jaswada 17 K.R. Rathod SF Jaswada 18 P.R. Rathod SF Jaswada 19 Mr. R.K. Buriya GLG Dahod 20 MR. V.V. Kayar AV Dahod
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Annex 1a: List of PHCs MO participated in the workshop at Sabarkantha Sr.No Name of MO Name of PHC Name of Taluka 1 Dr. R.V. Tarika Davad Idar 2 Dr. B. B. Patel Mudeti Idar 3 Dr. J.H. Parmar Jaswantgadha Idar 4 Dr. J.K. Gor Kadiyadra Idar 5 Dr. M.J. Patel Vedhli Idar 6 Dr. S.B. Charan Navarevas Idar 7 Dr. H.M. Chauhan Mobile J.Gadha Idar 8 Dr. R.D. Goaswami Kadiyadra Idar 9 Dr. N.R. Damor Chitroda Idar 10 Dr. S.M Chauhan Kidiyawada Vijaynagar 11 Dr. H.K. Kharada Kishangadha Bhiloda 12 Dr. Hema Muniya Bhiloda 13 Dr. A.K.Chaudary Chorimala Bhiloda 14 Dr. Gopal Janshid Lusadriya Bhiloda 15 Dr. S.S. Agarwal Torada Bhiloda 16 Dr. S.H. Bamariaya Vankenar Bhiloda 17 Dr. K.N. Goasai Demai Bayad 18 Dr. V.M. Trivedi Gabat Bayad 19 Dr. I.R. Patel Chodiay Bayad 20 Dr. D.C. Parmar Ambaliyara Bayad 21 Dr. M.A. Memon Mobile Torada Bhiloda 22 Dr. Kaushik Zala Bamana Bhiloda 23 Dr. Rajesh PAtel Sarsava Vijaynagar 24 Dr. C.L. Ghiya Jamchitraliya Bhiloda 25 Dr. S.A Bhavayia Antarsumbha Vijaynagar 26 Dr. Chandramani Kumar Pogalu Prantij 27 Dr. R.S. Dohre Majara Prantij 28 Dr. D.N. Modi Antroli Talod 29 Dr. J.M. Shah Virmal Himantnagar 30 Dr. R.R. Patel Chandarani Himantnagar 31 Dr. V.J. Mayoi Punsari Himantnagar 32 Dr. L.B. Yadav Kherol Talod 33 Dr. S.H. Dedhrahat Ilol Himantnagar 34 Dr. P.K.Malak Desasri Himantnagar 35 Dr. R.K. Yadav Jamoli Himantnagar 36 Dr. M.A. Suthar Jkodiya Himantnagar 37 Dr. S.T. Shah Lambadiya Khedbrahma 38 Dr. D.V. Naik Jitpur Malpur 39 Dr. J.M. Pandor Shangol Megraj 40 Dr. Y.K. Polari Derol Khedbrahma 41 Dr. R.L. Zapaukar Limbhoi Modasa 42 Dr. N.L. Thakor Aksund 43 Dr. Ila PAtel Isai Vijaynagar 44 Dr. Satish K. Vyas Aniod Jhalod 45 Dr. N.S. Kothari Vadgaham 46 Dr. A.K. Nayak Moyad Prantij 47 Dr. J.N. Shah Shinawad 48 Dr. S. A. Rawal Lusadiya 49 A.K. Patel Modasa Modasa 50 Dr. R.C. Veghla Sardie 51 Dr. A. Prasad Delwada 52 Dr. A.K. Jetav Kheroj Khedbrahma 53 Dr. B.A Reddy Posina Khedbrahma 54 Dr. Vinod Prasad Dhunhiya Megraj 55 Dr. H.F. Damor Chadhichand Khedbrahma Note: Excluding participants from District and State.
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Annex 2b: List of NGOs volunteers participated in the workshop Sr.No Name of Volunteers Name of the Name of Taluka Organization 1 Mr. U. Desai SGVS Prantij 2 Mr. U. Parmar SGVS Prantij 3 Mr. K.B. Patel MGLSS Megraj 4 Mr. S. B. Chavada ST Himantnagar 5 Mr. J.P. Patel RT Himantnagar 6 Mr. B.B Patel SVP Idar 7 Mr. A.B. Patel SVP Idar 8 Ms. Rupali Khan MSS Himantnagar 9 Ms. L.J. Ninoma MSK Himantnagar 10 AT Himantnagar 11 Mr. Manoj Rajan GVST Idar 12 Mr. Prashant Parmar GVST Idar 13 Mr. K.V. Mehta NYK Himantnagar 14 Mr. Mr. D.V. Zala NYK Himantnagar 15 Mr. R.H. Parmar Sogand Modasa 16 Ms. P.H. Bhat Himantnagar 17 Ms. S. Mehta SS Himantnagar 18 Ms. K.H. Parmar Vedeli 19 Mr. S.H. Patel GMT Bayad 20 Ms. L.B. Patel Himantnagar 21 Ms. Kokila S. Patel ANERDE Himantnagar 22 Mr. Ketan Prajapati ARPAN Himantnagar 23 Mr. Apurva Dave ARPAN Himantnagar 24 Mr. Himanshu Saxena ARPAN Himantnagar 25 Mrs. Gulnar N. Pathan SMGST Vadeli
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Annex 3: Name and Designation of Quality Circle Committee in Sabarkantha district. Name of the PHC Name of the QCC members Designation in QCC DEMAI PHC 1. Dr. K.N. Gosai Chairman 2. Shri. C.M Patel Secretary 3. Shri V.M. Joshi Member 4. Smt. S.C. Parmar Member 5. Shri G.C. Goasai Member 6. Smt. M.A. Beg Member 7. Shri P.K. Prajapati Member 8. Smt. J.M. Parmar Member 9. Mithiben Parmar (Peon) Member 10. Hiteshbhai (NGO) Member 11. R.J. Suthaar Member RAMGADHI PHC 1. Dr. B.S. Neenma Chairman 2. Dr. K.T. Vyas Secretary 3. Smt. D.V. Patil Member 4. H.N. Vora Member 5. R.R. Vasawa Member 6. A.K. Mirza Member 7. Smt. J.M. Paggi Member 8. Smt. M.K. Gore Member 9. Smt. S.J. Damore Member 10. Smt. S.R. Parmar Member 11. Smt. J.J. Damor Member 12. Mr. Arutbhai (Peon) Member !3. Mr. A.C.Banghi (Peon) Member KADIYADRA PHC 1. Dr. R.D. Gosawami Chairman 2. Shri V.A. Patel Secretary 3. Shri .B.J. Patel Member 4. Smt. S.R. Ansari Member 5. Smt. K.R. Sugar Member 6. Ku. L.M. Kadiya Member 7. Smt. P.R. Patel Member 8. Smt. M.D. Solanki Member 9. Smt. A.B. Patel Member 10. Mr. Harsunabhai (Peon) Member 11. Vacant Member KHEROJ PHC 1. Dr. A.K. Jatav Chairman 2. Shri B.K. Patel Secretary 3. Shri. R.M. Patel Member 4. Shri R.A. Joshi Member 5. Smt. M.V. Rathod Member 6. Shri N.V. Tara Member 7. Smt. K.B. Patel Member 8. S.P. Paggi Member 9. Smt. B.N. Rajput Member 10. Smt. D.Y. Trivedi Member 11. Smt. S.L. Parmar Member 12. Mansoor R. Gurav Member
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Continue Annex 3: Name of the PHC Name of the QCC members Designation in QCC ATTARSUMBHA 1. Dr. Sanjay S. Naik Chairman 2. Shri M.N. Parmar Secretary 3. Smt. G.S. Panchal Member 4. Smt. G.S. Gosami Member 5. Smt. V.V. Jariya Member 6. Smt. V.N. Bhadar Member 7. Ku. B.N. Gamti Member 8. Smt S.M. Mitala Member KODIYAWADA 1. Dr. S.K. Chauhan Chairman 2. Shri. V.S. Pandya Secretary 3. Smt. J.H. Gogara Member 4. Shri. M.K. Solanki Member 5. Shri. M.K. Parmar Member 6. Smt. D.K. Varsat Member 7. T.P. Papavasni Member 8. Smt. J.V. Chauhan Member 9. Smt. S.N. Patel Member 10. Shri DalaBhai Patel (Peon) Member 11. Vacant for Gram Panchyat Member 12. For NGO Member SARSAWA 1. Dr. R.B. Patel Chairman 2. Shri S.G. Hudula Secretary 3. Smt. L.V. Khatat Member 4. Shri L.S. Makwana Member 5. Smt. S.G. Asariya Member 6. Smt. S.K. Parmar Member 7 Smt. S.T. Khardi Member
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Annex 4: Name and Designation of Quality Circle Committee in Dahod district. Name of the PHC Name of the QCC members Designation in QCC LIMIDI PHC 1. Dr. J.L. Mina Chairman 2. A.L. Patel Secretary 3. Smt. S.L .Mundawala Member 4. Mr. T.S. Analiya Member 5. Smt. V.K.Vora Member 6. Mr. Y.C. Chauhan Member 7. Mr. S.K. Handa Member 8. Mr. S. G. Damor Member 9. Smt. S.H. Nimarhari Member 10. Mr. T. K. Makawana Member 11. Pritesh Panchal Member 12. Smt. N.B Patel Member 13. Munna B. Jain Member DUNGAR PHC 1. Dr. G.L .Baria Chairman 2. Shri D.R. Dindor Secretary 3. Shri R.M.Kharedi Member 4. Shri M.A. Baria Member 5. Shri P.K. Patel Member 6. Shri S.K. Babhar Member 7. Smt J.B. Tarasia Member 8. Shri. S.K. Tarasiay Member 9. Smt. S.K. Patidaar Member 10. Shri S.C. Pagi Member 11. M.S. PAtel Member BANDIBAR PHC 1. Dr. L.K. Arya Chairman 2. Shri. K.D. Vankar Secretary 3. Smt. S.R. Solanki Member 4. Smt. R.R. Bandre Member 5. Smt. S.A. Patel Member 6. Smt. J.J. Patel Member 7. Smt. U.S. Chauhan Member 8. Shri. P.A.Patel Member 9. Shri. R.N. Chauhan (Peon) Member 10. Shri R.G. Garosai (NGO) Member 11. Shri R. Bastalia (Gram) Member DABHAVA PHC 1. Dr. P.D. Fanasiya Chairman 2. Mr. V.D. Ruthava Secretary 3. Mr. C.S. Baria Member 4. Mr. S.S. Kazi Member 5. Mr. D.D. Patel Member 6. Mr. M.V. Varia Member 7. Mr. A.V. Parmar Member 8. Mrs. Maltiben Trivedi Member 9. MRs. Shantaben Ashokbhai Member 10. Mrs. Januben Naik (NGO) Member 11. Mr. Kalubhai Harijan (Village) Member
NOTE: The QCC list of PHC Boradi and Gangardi was not available.
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Annex 5: Minutes of District level Quality Circle Committee for Dahod. ______Minutes of the First Meeting of Quality Circle Committee in Dahod under Quality Assurance Project for Public Health for UNFPA assisted IPD Project
Date: 5th December, 2002 Time: 11.00 – 12.00 pm Venue: CDHO room, Zila Panchayat Office, Dahod.
The following persons attended the meeting:
1. Dr. D.M. Patel, CDHO. 2. Mr. J. P. Parmar IPD Programme officer 3. Executive Engineer, PWD, Dahod 4. District Education officer, Dahod 5. Smt. R.B. Kadakiya PHN, Jilla Panchayat, Dahod 6. Mr. Balwant Rathod, computer programmer. 7. Dr. Harshit Sinha Facilitator, Director – Vardaan Foundation, Baroda.
The Agenda of the meeting was as follows:
1. Formation of the District level Quality Circle Committee (QCC) under CDHO guidance. 2. Briefing the concept for the formation of Quality Circle Committee. 3. Setting criteria for selection of PHCs under Quality Assurance Project in Public Health in Dahod district. 4. Setting criteria for selection of NGOs under Quality Assurance Project in Public Health in Dahod district. 5. Setting criteria for selection of CHCs and civil hospital under Quality Assurance Project in Public Health in Dahod district. 6. Presentation of the medical officer regarding their experience at QCC meeting in their respective PHCs. 7. On the behalf of the Vardaan Foundation, Baroda Award presentation to Dr. J.L. Mina. 8. Joint decision for future strategy.
The CDHO Dr. D.M. Patel started meeting and greeted all the members present in the meeting. He narrated the reason for calling up this meeting and later asked Dr. Harshit Sinha (Director, Vardaan Foundation, Baroda) to briefly discuss the importance of forming the Quality Circle Committee at district level. Dr. Sinha discussed the importance of forming the Quality Circle Committee at district level under the defined structure of the project. He emphasized that district level Quality Circle Committee will act as catalyst agent between the State authority and rural/urban public health institutions. He also said that in the coming period of time similar type of QCC will also be formed at State level for resolving quality issues matters.
Taking lead from this Dr. D.M. Patel announced the category of the members to be included in quality circle committee, which are as follows:
Dr. D.M Patel CDHO invited member 1. Dr. S.B. Shah ADHO Chairman of QCC for Dahod district 2. Dr. K.S. Patel District RCH Officer, Joint Secretary of QCC for Dahod district 3. Shri. J.P Parmar, IPD Project Officer, member of QCC for Dahod district
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4. ICDS Programme officer, member of QCC for Dahod district. 5. Dr. S.K. Devdha, Epidemic control officer, member of QCC for Dahod district. 6. Dr. Smt. D.B. Rathod, District TB officer, member of QCC for Dahod district. 7. NGO Volunteers, member of QCC for Dahod district. 8. Mr. RCH officer, , member of QCC for Dahod district. 9. Executive Engineer, PWD: Building Construction – Zilla Panchayat, member of QCC for Dahod district. 10. District Primary Education officer, Zilla Panchayat, member of QCC for Dahod district. 11. Social Welfare officer, (Panchayat), member of QCC for Dahod district. 12. District Agriculture officer, (Panchayat) member of QCC for Dahod district.
Further Dr. Sinha raised the issue for setting the criteria for future selection of the PHC under Quality Assurance (QA) Project in Dahod District. Dr. D.M. Patel suggested that PHCs with bearable structure and minimum supportive staff should be considered. Later it was unanimously decided to implement his suggestion under QA project during CP6. Since the six PHCs (Bandibar – Limkheda taluka; Limdi - Zalod taluka; Dungar – Fatepura taluka; Dabhava – Davgadh Baria taluka and Gangardi – Garbada taluka) have been already selected under QA project for CP5, it was decided to include six more PHCs for the coming year 2003 under CP6.
Dr. Sinha raised the issue for generating demand for the PHCs services through NGOs as explained during training session with medical officer and NGO volunteers. Since the participation of the NGOs was not as per the expectation, he raised the issue as to which type of NGO should be included under QA project? Mr. Parmar suggested that NGOs working in the villages of PHC areas should be give preference. Later it was unanimously decided to select NGOs working in the villages of selected 12 PHCs (as mentioned above).
Mr. Parmar pointed out the problem of low attendance in STIs/RTIs clinic. Dr Sinha suggested a solution of organizing the RCH camps. He further suggested to include NGOs in such activity so that the community level demand could easily be generated.
Effective referral system is an important issue under reproductive health programme. Taking lead from this Dr. Sinha raised the issue of selecting CHCs and Civil hospital under QA project for the coming CP6. Dr. D.M. Patel and others agreed that CHC as a first referral unit must be strengthened. However how to include civil hospital has yet to be clarified with higher authorities. Looking the need for an effective referral system, it was unanimously decided to include CHC under QA project during 2003 under CP6 of IPD.
Due to unavoidable circumstance none of the invited medical officer (accept one of Limidi PHC) attended the QCC meeting. The scheduled meeting for medical officer was already planned on the same day and hence most of them busy in their routine reporting work. Thus opinion of the medical officer could not be included in the QCC meeting. Dr. J.L. Mina later joined in the mid of the meeting. He expressed his positive opinion regarding the training of Quality Circle at their PHC and request to continue the same in future in all other aspects of the reproductive health programme.
Motivation - an important human factor in the improvement of quality of public health services, Vardaan Foundation, decided to award Dr. J.L.Mina for his outstanding work in
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community participation to upgrade and popularize the PHC services in the community. Since medical officer did not turn up in the QCC meeting, it was decided to present the award today, through CDHO in the scheduled meeting of medical officer.
Dr. D.M. Patel explained the importance of the award among medical officer and suggested that every body should work with the similar enthusiasm as Dr. J.L. Mina did in Limdi PHC. Dr. Sinha also explained the significance of the motivation in working culture and how it could be made effective in public health institution with such awards. He also expressed that in future an accreditation system in public health would be developed and PHCs would be brought under them. Dr. Mina expressed his thanks and high lighted the team work done in their PHCs for achieving such reward. Explaining the said incident of his mother, emotion rolled out from his eyes. He further said that this incident had motivated and later he pledged to work for the poor people with the same enthusiasm in the rural remote areas.
Further in the meeting, Dr. Sinha had asked Mr. Balwant Rathod to distribute the forms to the selected PHC medical officer who had formed quality circle committee at PHC level. He requested Dr. D.M. Patel to acknowledge the QCC of PHCs and official registered at the district QCC meeting.
Lastly every body agreed to make district Dahod a model district under UNFPA assisted IPD project for Quality Assurance in Public Health.
Copy to: All QCC committee members. : Mr. H.S. Mehta, IAS, DDO, District Dahod. : Dr. K.N. Patel, Director Family Welfare, Gandhinagar. : Mr. Arvind Pulikar, Regional Coordinator, UNFPA, Gandhinagar. : Dr. S. R. Patel, SPO; IPD-State Project Management Support Unit, Gandhinagar : Dr. Harshit Sinha, Director of Vardaan Foundation, Baroda.
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Annex 6: Minutes of District level Quality Circle Committee for Sabarkantha ______Minutes of the First Meeting of Quality Circle Committee in Himantnagar under Quality Assurance Project for Public Health for UNFPA assisted IPD Project
Date: 26th December, 2002 Time: 2.00 pm to 3.30 pm Venue: CDHO room, Zila Panchayat Office, Himantnagar.
The following persons attended the meeting:
1. Dr. R. K. Nagada, CDHO, Sabarkantha Distirct. 2. Dr. Sanjay Kumar Chauhan, PHC Kotiyawada, Taluka Vijaynagar. 3. Dr. R.B. Patel, PHC Sarsawa, Taluka Vijaynagar. 4. Dr. Anil Kumar Jatav, PHC Khorej, Taluka Khedbrahma. 5. Dr. R.D. Goswami, PHC Kadiyadra, Taluka Idar 6. Ms. Kokilaben Patel, representative from ANRADE Foundation. 7. Ms. Purviben Chauhan from representative ARPAN 8. Mrs. Hasniben Mansoori, IPD Project Officer, Himantnagar. 9. Dr. Harshit Sinha Facilitator, Director - Vardaan Foundation, Baroda.
The Agenda of the meeting was as follows:
1. Formation of District level Quality Circle Committee under CDHO guidance.
2. Selection of PHCs under Quality Assurance Project in CP 6 programme.
3. Defining criteria for selecting NGOs in the Sabarkantha district.
4. Defining criteria inclusion of civil hospital and CHCs of Sabarkantha district under Quality Assurance Project in CP 6 Programme.
5. Presentation of medical officer regarding their experience at QCC meeting at PHCs level in Sabarkantha district.
6. Review of the work done for STI/RTI clinic.
7. Joint decision for future strategy.
The CDHO Dr. R.K Nagada in the presence of Dr. Harshit Sinha, representative of NGOs started meeting by announcing the types of member to be involved in the quality circle committee meeting for Sabarkantha district. Since it was FP camp day and simultaneously leprosy training was also in progress, the two medical officers did not attend the meeting. However, in spite of the busy schedule, the other four medical officers joined the meeting after fifteen minutes. The district level QCC structure as defined by Dr. R.K. Nagada is as follows:
1. CDHO, Chairman of QCC, District Sabarkantha. 2. ADHO, Secretary of QCC, District Sabarkantha. 3. RCH officer, member of QCC, District Sabarkantha. 4. District Immunization Officer, member of QCC, District Sabarkantha. 5. Epidemic MO, member of QCC, District Sabarkantha. 6. District Malaria Officer, member of QCC, District Sabarkantha. 7. Executive Engineer, PWD, member of QCC, District Sabarkantha.
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8. District Education officer, member of QCC, District Sabarkantha. 9. District ICDS officer, member of QCC, District Sabarkantha. 10. Representative of ANRADE Foundation (NGO), member of QCC, District Sabarkantha. 11. Representative of ARPAN (NGO), member of QCC, District Sabarkantha.
Later Dr. Nagada along with the other members asked Dr. Harshit Sinha Dr. Harshit Sinha (Director, Vardaan Foundation, Baroda) to briefly discuss the importance of forming the Quality Circle Committee at district level. Dr. Sinha briefly elaborated the significance of forming the Quality Circle Committee at district level. He further said that district level Quality Circle Committee will act as catalyst agent between the State authority and rural/urban public health institutions. Further he also said that, in the coming period of time similar type of QCC will also be formed at State level for resolving quality issues matters. Dr. Sinha had asked the medical officer present in the QCC meeting to fill the forms who had formed quality circle committee at PHC level. He requested Dr. R.K. Nagada to acknowledge the QCC of PHCs and official registered at the district QCC meeting.
Further Dr. Sinha raised the issue for setting the criteria for future selection of the PHC under Quality Assurance (QA) Project in Dahod District. Dr. R.K. Nagada suggested that PHCs requiring the utmost demand of structure, manpower and other things should be considered. He suggested that apart from seven selected PHCs (Kheroj, Ramgadhi, Dhamei, Attarsumbha, Sarsava, Kodiyawada and Kadiyadra have been already selected under QA project for CP5, it was decided to include five more PHCs for the coming year 2003 under CP6. The PHCs are Kishangad, Vakaner, Mejaraj, Satarda, and Shrinagar.
Dr. Sinha raised the issue for generating demand for the PHCs services through NGOs as explained during training session with medical officer and NGO volunteers. Since the participation of the NGOs was up to the mark, even though he raised the issue as to which type of NGO should be included under QA project? This is because Ms. Kokilaben Patel (ANARDE Foundation) had pointed out that still many of the NGOs are not yet clear about their role QA project. She also raised the issue about funding in doing the quality work at the grassroot level. The project officer Mrs. Haseenaben Mansoori suggested that NGOs working in health sector should be given priority. Later Dr. Sinha suggested that selected NGOs should be assigned areas of the district in collaboration of selected PHC.
Later, it was unanimously decided to assign Idar, Himantnagar and Prantij talukas to ANRADE Foundation and Khedbrahma, Vijaynagar and Bhiloda to NGO “ARPAN”. Regarding the other taluka, selection of NGO and assigning the talukas would be made by Dr. Nagada with joint efforts of IPD programme officer, Mrs. Haseenaben Mansoori.
Effective referral system is an important issue under reproductive health programme. Taking lead from this Dr. Sinha raised the issue of selecting CHCs and Civil hospital under QA project for the coming CP6. Dr. R. K. Nagada said that civil hospital and CHC does not come under him and hence suggested Dr. Sinha to contact civil surgeon and Regional Deputy Director. Dr. Mafatbhai Patel.
The invited medical officers showed their great interest in the Quality Assurance Project but were unable to do any type of quality work in their respective PHCs because of the on going programme in their PHC. Medical officer of the Kotiyadra and Sarsava PHC
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said that quality could only come when material and man powers are with them. They informed that the process of acquiring land for construction of the PHC is over and for construction, tender process is about to be materialized.
Dr. Gosowami of Kadiyadra PHCs raised the issue of treating the STIs and RTIs at the PHCs. Since the number of the incoming patients was less, Dr. Sinha suggested revise the strategy by organizing the RCH camps. Every body agreed to this suggestion. It was also suggested that NGOs could play a major role in generating demand from the RCH services. I was decided that All selected PHCs under QA project should organize at least one RCH camp in a month.
Lastly along with Dr. Nagada every body agreed to make district Sabarkantha a model district under UNFPA assisted IPD project for Quality Assurance in Public Health. They all suggested doing RCH camps, Adolescent Mela, renovation and new construction of the PHCs, Sex education and IEC for water and sanitation programme.
Copy to: All QCC committee members. : Mr. R. R. Chauhan, IAS, DDO, District Sabarkantha. : Dr. K.N. Patel, Director Family Welfare, Gandhinagar. : Mr. Arvind Pulikar, Regional Coordinator, UNFPA, Gandhinagar. : Dr. S. R. Patel, SPO; IPD-State Project Management Support Unit, Gandhinagar : Dr. Harshit Sinha, Director of Vardaan Foundation, Baroda.
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Annex 7a: KAP analysis for Dahod district. List of Question asked for KAP Responses in Actual numbers Sr Number and Type of Respondents Pre Test KAP Post Test KAP No WA PC FC Mi WA PC FC Mi Q1 Definition of Reproductive Health Medical Officer (N=50) 35 13 1 1 31 11 4 4 Health Worker (N=65) 41 17 2 5 4 1 060 NGO Volunteers (N=18) 12 1 2 3 NA NA NANA Total (N=133) 88 31 5 9 35 12 464 Q2 Components of RCH Package of our country Medical Officer (N=50) 8 33 7 2 11 29 6 4 Health Worker (N=65) 21 8 0 36 3 1 061 NGO Volunteers (N=18) 7 2 0 9 NA NA NANA Total (N=133) 36 43 7 47 14 30 665 Q3 Formulae to calculate unmet need Medical Officer (N=50) 38 2 0 10 40 1 0 9 Health Worker (N=65) 57 1 0 7 5 0 060 NGO Volunteers (N=18) 13 1 0 4 NA NA NANA Total (N=133) 108 4 0 21 45 1 069 Q4 Definition of Quality of Care in Public Health Medical Officer (N=50) 36 10 0 4 21 18 5 6 Health Worker (N=65) 27 15 1 22 4 1 060 NGO Volunteers (N=18) 8 6 0 4 NA NA NANA Total (N=133) 71 31 1 30 25 19 566 Q5 Definition of Gender in Public Health Medical Officer (N=50) 21 19 2 8 8 29 4 9 Health Worker (N=65) 10 24 0 31 2 1 062 NGO Volunteers (N=18) 7 7 0 4 NA NA NANA Total (N=133) 38 50 2 43 10 30 471 Q6 Essential components of QA Programme Medical Officer (N=50) 48 0 0 2 40 1 1 7 Health Worker (N=65) 37 0 0 28 2 0 063 NGO Volunteers (N=18) 14 0 0 4 NA NA NANA Total (N=133) 99 0 0 34 42 1 170 Q7 Definition of Customer and TQM Medical Officer (N=50) 16 22 0 12 5 21 13 11 Health Worker (N=65) 6 24 34 1 2 2 03 NGO Volunteers (N=18) 2 12 0 4 NA NA NANA Total (N=133) 24 58 34 17 7 23 1314 Q8 Three main elements stressed in ICPD Medical Officer (N=50) 27 5 2 16 17 18 3 12 Health Worker (N=65) 19 4 0 42 2 0 063 NGO Volunteers (N=18) 2 5 0 11 NA NA NANA Total (N=133) 48 14 2 69 19 18 375 Note: WA-Wrong Answer; PC-Partial Correct; FC-Fully Correct and Mi-Missing NA: Not Attempted ; Figures represented are actual numbers
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Annex 7b: KAP analysis for Sabarkantha district. List of Question asked for KAP Responses in Actual numbers Sr Number and Type of Respondents Pre Test KAP Post Test KAP No WA PC FC Mi WA PC FC Mi Q1 Definition of Reproductive Health Medical Officer (N=64) 42 8 11 3 43 7 8 6 Health Worker (N=68) 40 11 5 12 NA NA NANA NGO Volunteers (N=19) 8 4 0 7 NA NA NANA Total (N=151) 90 23 16 22 43 7 86 Q2 Components of RCH Package of our country Medical Officer (N=64) 16 33 9 6 11 30 18 5 Health Worker (N=68) 30 0 0 38 NA NA NANA NGO Volunteers (N=19) 5 1 0 13 NA NA NANA Total (N=151) 51 34 9 57 11 30 185 Q3 Formulae to calculate unmet need Medical Officer (N=64) 44 8 0 12 47 6 0 11 Health Worker (N=68) 56 0 0 12 NA NA NANA NGO Volunteers (N=19) 11 0 0 8 NA NA NANA Total (N=151) 111 8 0 32 47 6 011 Q4 Definition of Quality of Care in Public Health Medical Officer (N=64) 47 11 0 6 16 32 10 6 Health Worker (N=68) 39 14 0 15 NA NA NANA NGO Volunteers (N=19) 7 5 0 7 NA NA NANA Total (N=151) 93 30 0 28 16 32 106 Q5 Definition of Gender in Public Health Medical Officer (N=64) 26 24 1 13 24 20 5 15 Health Worker (N=68) 14 22 0 32 NA NA NANA NGO Volunteers (N=19) 3 7 0 9 NA NA NANA Total (N=151) 43 53 1 54 24 20 515 Q6 Essential components of QA Programme Medical Officer (N=64) 54 0 0 10 56 0 0 8 Health Worker (N=68) 39 0 0 29 NA NA NANA NGO Volunteers (N=19) 11 0 0 8 NA NA NANA Total (N=151) 104 0 0 47 56 0 08 Q7 Definition of Customer and TQM Medical Officer (N=64) 14 35 2 13 5 35 19 5 Health Worker (N=68) 10 25 0 33 NA NA NANA NGO Volunteers (N=19) 2 10 0 7 NA NA NANA Total (N=151) 26 70 2 53 5 35 195 Q8 Three main elements stressed in ICPD Medical Officer (N=64) 42 7 0 15 37 9 6 12 Health Worker (N=68) 27 0 0 41 NA NA NANA NGO Volunteers (N=19) 8 0 0 11 NA NA NANA Total (N=151) 77 7 0 67 37 9 612 Note: WA-Wrong Answer; PC-Partial Correct; FC-Fully Correct and Mi-Missing NA: Not Attempted ; Figures represented are actual numbers
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Annex 8: Responses given by medical officers for pre and post test for KAP Sr. Dahod District (N=50) Pre Test KAP Post Test KAP No. Questions of KAP Schedule WA PC FC Mi WA PC FC Mi Q1 Definition of Reproductive Health 70 26 2 2 62 22 8 8 Q2 Components of RCH Package of our country 16 66 14 4 22 58 12 8 Q3 Formulae to calculate unmet need 76 4 0 20 80 2 0 18 Q4 Definition of Quality of Care in Public Health 72 20 0 8 42 36 10 12 Q5 Definition of Gender in Public Health 42 38 4 16 16 58 8 18 Q6 Essential components of QA Programme 96 0 0 4 80 2 2 14 Q7 Definition of Customer and TQM 32 44 0 24 10 42 26 22 Q8 Three main elements stressed in ICPD 54 10 4 32 34 36 6 24 Average 57 26 3 14 43 32 916 Sabarkantha (N=64) Pre Test KAP Post Test KAP Sr. Questions of KAP Schedule WA PC FC Mi WA PC FC Mi No. Definition of Reproductive Health 66 13 17 5 67 11 13 9 Q1 Components of RCH Package of our country 25 52 14 9 17 47 28 8 Q2 Formulae to calculate unmet need 69 13 0 19 73 9 0 17 Q3 Definition of Quality of Care in Public Health 73 17 0 9 25 50 16 9 Q4 Definition of Gender in Public Health 41 38 2 20 38 31 8 23 Q5 Essential components of QA Programme 84 0 0 16 88 0 0 13 Q6 Definition of Customer and TQM 22 55 3 20 8 55 30 8 Q7 Three main elements stressed in ICPD 66 11 0 23 58 14 9 19 Q8 Average 56 25 4 15 47 27 13 13 Note: Figures represented are in percentage from N.
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Annex 9a: Strengths associated with the PHCs. Sr SWOT Analysis Dahod Sabrakantha No Type of Strengths of the PHCs (N=43) in % (N=50) in% A Total Missing 1 3 B Related with PHC infrastructure 1 Centrally located and easily accessible 18 23 2 Well established infrastructure 9 10 3 Well trained staff 8 15 4 Neat and Clean PHC 2 0 Total Percentage 37 47 C Behaviour of the Service Providers 1 Stay at the head quarter 0 2 2 High commitment of Staff 7 18 3 Better coordination and team spirit among staff. 7 1 4 Effective leadership of medical officer 8 7 Total Percentage 22 27 D Community Participation 1 Enormous local support 1 3 2 Better community linkage and network 1 6 Total Percentage 3 9 E Institutional Activities 1 Regular OPD 21 5 2 Regular Sterilization Camp are conducted 6 2 3 Regular Deliveries are conducted 6 4 4 Regular MCH clinics and UIP session 5 4 Total Percentage 37 14 Grand Total of Percentages (A+B+C+D+E) 100 100
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Annex 9b: Weaknesses associated with the PHCs. Sr SWOT Analysis Dahod Sabrakantha No Type of Weaknesses of the PHCs (N=43) in % (N=50) in% A Missing 1 7 B Related with PHC infrastructure 1 Vacant staff position 16 13 2 Inadequate or poor service infrastructure 20 39 Total Percentage 36 52 C Behaviour of the Service Providers 1 Poor Leadership of the Medical Officer 1 2 2 Field staff are not staying at the sub center 6 2 3 No or poor commitment of staff 22 6 4 Lack of Communication skills 2 3 5 Poor communication skills 1 3 Total Percentage 32 16 D Institutional Activities 1 No Delivery 7 3 2 No Sterilization 7 4 3 No or irregular field work 4 1 Total Percentage 18 8 E Administrative and Coordination Problem 1 Villages are scattered 5 3 2 Irregular payments of bills and salary 2 2 3 Poor/No Supervision 3 8 4 Poverty & migration leads to poor utilization of the PHC 2 1 5 No or poor cooperation from the district 2 3 Total Percentage 14 17 Grand Total of Percentages (A+B+C+D+E) 100 100
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Annex 9c: Threats associated with the PHCs. Sr SWOT Analysis Dahod Sabrakantha No Type of Threats of the PHCs (N=43) in % (N=50) in% A Missing 1 12 B Directly to the Institution 1 Remote location with no approach road 8 7 2 Private practice is very high and sophisticated 3 12 3 People don't know and people don't come to PHC 7 6 4 Weak or poor image of the PHC services 6 2 5 Theft 1 1 6 No Building 3 9 Total Percentage 28 38 C Related to Administration District cooperation is poor in the matter of HRD & 1 Supplies 3 1 2 Paper workload is enormous 15 9 3 Frequent meeting disturbs the routine programme 14 6 4 Local political interference 10 8 5 Too many health programmes increased the workload 17 5 Total Percentage 60 29 D Related to Service Providers 1 Weak/Poor contact of health worker with community 5 4 2 Difficult to monitor the PHC system 3 4 3 Post are filled in formalities without proper infrastructure 1 2 4 Vacant post 1 3 5 Total Percentage 10 12 E Related to Community 1 People are uneducated/believes in quacks/illiterate 1 8 2 Backward areas 1 1 Total Percentage 2 9 Grand Total of Percentages (A+B+C+D+E) 100 100
76 Vardaan Foundation, Baroda
Annex 9d Options to improve the PHC Services. Sr SWOT Analysis Dahod Sabrakantha No Type of Options of the PHCs (N=43) in % (N=50) in% A Missing 1 12 B For Training 1 Needs proper training and orientation on planning side 21 21 2 Task specific specialized hand on training 2 2 3 Leadership and sanitization training and their follow up 6 7 Total Percentage 29 31 C For Monitoring and Supervision 1 Cross checking by occasional visits of DHO 6 5 2 Needs external monitoring and evaluation system 5 6 3 Introduction of Accreditation system 5 6 4 Assessing performance of service providers 12 7 Total Percentage 29 24 D For Upgrading Service Institutions 1 Linkage of PHC services with external community program 6 14 2 Proper infrastructure with manpower & also supply of drug 13 5 3 Safe (Fortification) house establishment of PHC campus 6 4 Total Percentage 25 23 E Policy Issue matter 1 Make compulsory stay at the head quarter 5 3 2 Make responsible to staff for any ill health in their area 3 1 No interference in working at PHC from DHO, local 3 politicians 3 2 4 Make regular payment of TA/DA/Salary/Diesel bill etc. 5 4 Total Percentage 16 10 Grand Total of Percentages (A+B+C+D+E) 100 100
77 Vardaan Foundation, Baroda
Annex 10a Status of the construction of the PHC. Name of the Construction Status of the PHC as on 31/1/03 Total of sub district Hired/Not build Constructed Under Construction Sub district Dahod 2 5 - 7 Garbada - 3 1 4 Zalod - 11 1 12 Fatepura - 2 2 4 Limkheda 1 4 1 6 Dhanpur 3 1 - 4 Dev Baria 2 4 - 6 Dahod Total 8 (19) 30 (70) 5 (11) 43 (100) Bayad - 3 - 3 Bhiloda 2 6 - 8 Megraj - 3 - 3 Idar - 4 1 5 Khedbhrama - 4 1 5 Malpur - - 1 1 Modasa - 4 1 5 Vijaynagar 1 2 1 4 Prantij - 1 2 3 Himantnagar 3 2 1 6 Talod - 4 - 4 Dhansuriya - 2 - 2 Vadeli - 1 - 1 Sabar. Total 6 (12) 36 (72) 8 (16) 50 (100) Grand Total 14 (15) 66 (71) 13 (14) 93 (100) Note: Figures in bracket are horizontal percentage from the total.
78 Vardaan Foundation, Baroda
Annex 10b Status of type of the PHC. Name of the Status of type of PHCs as on 31/12/2002 Total of sub district Old Upgraded New Sub district Dahod 2 1 4 7 Garbada 1 - 3 4 Zalod 4 - 8 12 Fatepura - - 4 4 Limkheda 2 - 4 6 Dhanpur 2 - 2 4 Dev Baria 1 - 5 6 Dahod Total 12 (28) 1 (2) 30 (70) 43 (100) Bayad 2 0 1 3 Bhiloda 1 2 5 8 Megraj 1 1 1 3 Idar 3 2 - 5 Khedbhrama 4 - 1 5 Malpur - 1 - 1 Modasa 2 1 2 5 Vijaynagar 1 3 4 Prantij 2 1 3 Himantnagar 1 5 6 Talod 1 1 2 4 Dhansuriya 1 1 2 Vadeli 1 1 Sabar. Total 18 (36) 10 (20) 22 (44) 50 (100) Grand Total 30 (32) 11 (12) 52 (56) 93 (100) Note: Figures in bracket are horizontal percentage from the total.
79 Vardaan Foundation, Baroda
Annex 11a: Details of construction of PHC for Dahod District. Details of the Dahod District No building or Building Under Total Name of Taluka Name of PHC Hired Building Constructed Construction Dist/Tal Dahod Borvani 1 1 Bhativada 1 1 Bordi 1 1 Timarda 1 1 Kathala 1 1 Kharoda 1 1 Nagarda 1 1 Total 2 5 7 Garbada Jesvada 1 1 Abhalod 1 1 Gangardi 1 1 Jambua 1 1 Total 3 1 4 Zalod Sanjeli 1 1 Vansiya 1 1 Kadval 1 1 Garadu 1 1 Mahudi 1 1 Chakaliya 1 1 Gamdi 1 1 Gultara 1 1 Mirakhedi 1 1 Bilvani 1 1 Limdi 1 1 Lilvathakor 1 1 Total 11 1 12 Fetepura Dungar 1 1 Balaiya 1 1 Alwa 1 1 Madhva 1 1 Total 2 2 4 Limkheda Handi 1 1 Chhaparvad 1 1 Bandibar 1 1 Dudhiya 1 1 Dhadhela 1 1 Ninma Khakaria 1 1 Total 1 4 1 6 Dhanpur Mandor 1 1 Agasvani 1 1 Ved 1 1 Rachhava 1 1 Total 3 1 4 Dev Baria Antela 1 1 Sevaniya 2 2 Bhathvara 1 1 Degavada 1 1 Kuvbena 1 1 Total 2 4 6
80 Vardaan Foundation, Baroda
Annex 11b: Details of Type of PHC for Dahod District. Name of Taluka Name of PHC Old Upgrade New Total Dahod Borvani 1 1 Bhativada 1 1 Bordi 1 1 Timarda 1 1 Kathala 1 1 Kharoda 1 1 Nagarda 1 1 Total 2 1 4 7 Garbada Jesvada 1 1 Abhalod 1 1 Gangardi 1 1 Jambua 1 1 Total 1 3 4 Zalod Sanjeli 1 1 Vansiya 1 1 Kadval 1 1 Garadu 1 1 Mahudi 1 1 Chakaliya 1 1 Gamdi 1 1 Gultara 1 1 Mirakhedi 1 1 Bilvani 1 1 Limdi 1 1 Lilvathakor 1 1 Total 4 8 12 Fetepura Dungar 1 1 Balaiya 1 1 Alwa 1 1 Madhva 1 1 Total 4 4 Limkheda Handi 1 1 Chhaparvad 1 1 Bandibar 1 1 Dudhiya 1 1 Dhadhela 1 1 Ninma Khakaria 1 1 Total 2 4 6 Dhanpur Mandor 1 1 Agasvani 1 1 Ved 1 1 Rachhava 1 1 Total 2 2 4 Dev Baria Antela 1 1 Sevaniya 1 1 2 Bhathvara 1 1 Degavada 1 1 Kuvbena 1 1 Total 1 5 6
81 Vardaan Foundation, Baroda
Annex 11c: Details of construction of PHC for Sabarkantha District. Details of Sabarkantha District No building or Building Under Total Name of Taluka Name of PHC Hired building Constructed Construction Dist/Tal Bayad Ambaliyara 1 1 Gabat 1 1 Demai 1 1 Total 3 3 Bhiloda Vakaner 1 1 Muniya 1 1 Baman 1 1 Torada 1 1 Lusadiya 1 1 Khisangadha 1 1 Jabchittra 1 1 Chorimala 1 1 Total 2 6 8 Megraj Pateldundha 1 1 Isari 1 1 Shangal 1 1 Total 3 3 Idar Deved 1 1 Jaswantgadha 1 1 Navevasa 1 1 Kadiyadra 1 1 Mudeh 1 1 Total 4 1 5 Khedbhrama Posina 1 1 Unchidhnal 1 1 Derol 1 1 Lambadiya 1 1 Delwada 1 1 Total 4 1 5 Malpur Jitpur 1 1 Total 1 1 Modasa Modasa 1 1 Shiyawada 1 1 Totoi 1 1 Sardoi 1 1 Limbhoi 1 1 Total 4 1 5 Vijaynagar Atarsumbha 1 1 Chitoda 1 1 Kodiyawada 1 1 Sarsava 1 1 Total 1 2 1 4 Prantij Moyoda 1 1 Poguloo 1 1 Manjara 1 1 Total 1 2 3 Himantnagar Chandrani 1 1
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Hindol 1 1 Virvada 1 1 Jamada 1 1 Ilola 1 1 Desasum 1 1 Total 3 2 1 6 Talod Punsari 1 1 Chitroli 1 1 Kheroi 1 1 Aniod 1 1 Total 4 4 Dhansuria Akrund 1 1 Vadgham 1 1 Total 2 2 Vadeli Vadeli 1 1 Total 1 1
83 Vardaan Foundation, Baroda
Annex 11d: Details of Type of PHC for Sabarkantha District. Name of Taluka Name of PHCs Old Upgrade New Total Bayad Ambaliyara 1 1 Gabat 1 1 Demai 1 1 Total 2 1 3 Bhiloda Vakaner 1 1 Muniya 1 1 Baman 1 1 Torada 1 1 Lusadiya 1 1 Khisangadha 1 1 Jabchittra 1 1 Chorimala 1 1 Total 1 2 5 8 Megraj Pateldundha 1 1 Isari 1 1 Shangal 1 1 Total 1 1 1 3 Idar Deved 1 1 Jaswantgadha 1 1 Navevasa 1 1 Kadiyadra 1 1 Mudeh 1 1 Total 3 2 5 Khedbhrama Posina 1 1 Unchidhnal 1 1 Derol 1 1 Lambadiya 1 1 Delwada 1 1 Total 4 1 5 Malpur Jitpur 1 1 Total 1 1 Modasa Modasa 1 1 Shiyawada 1 1 Totoi 1 1 Sardoi 1 1 Limbhoi 1 1 Total 2 1 2 5 Vijaynagar Atarsumbha 1 1 Chitoda 1 1 Kodiyawada 1 1 Sarsava 1 1 Total 1 3 4 Prantij Moyoda 1 1 Poguloo 1 1 Manjara 1 1 Total 2 1 3 Himantnagar Chandrani 1 1 Hindol 1 1
84 Vardaan Foundation, Baroda
Virvada 1 1 Jamada 1 1 Ilola 1 1 Desasum 1 1 Total 1 5 6 Talod Punsari 1 1 Chitroli 1 1 Kheroi 1 1 Aniod 1 1 Total 1 1 2 4 Dhansuria Akrund 1 1 Vadgham 1 1 Total 1 1 2 Vadeli Vadeli 1 1 Total 1 1
85 Vardaan Foundation, Baroda
Annex 12: Details of availability of each item for different services Unit in the PHCs of Dahod and Sabarkantha district.
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For OPD/Doctor room AW ANW NA AW ANW NA 1 Examination table 79 3 18 74 10 15 2 Doctors table and chair 79 6 15 64 15 21 3 Curtain for privacy 21 6 73 28 8 64 4 Examination tray 85 6 9 87 8 5 5 BP instruments 85 6 9 87 5 8 6 Stethoscope 76 9 15 90 3 8 7 Torch 30 9 61 49 6 45 8 Thermometer 18 4 78 54 8 38 9 Tongue spatula 27 71 2 36 20 44 10 Adult weighing machine 85 5 10 85 10 5 11 Infant weighing machine 73 22 5 62 3 36 12 Wash basin with soap and water 49 6 46 44 3 54 Average response for the items 59 13 28 63 8 29
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For dressing & Injection room AW ANW NA AW ANW NA 1 Wash basin, soap and water 33 9 58 28 8 64 2 Sterilizer 73 9 18 80 8 13 3 Dressing instruments 52 9 39 72 15 13 4 Dressing drum 67 6 27 80 5 15 5 Syringes and needles 52 12 36 74 8 18 6 Cotton, gauge and bandages 88 6 6 92 5 3 7 Emergency medicine tray 42 9 49 64 5 31 8 Oxygen Cylinder 12 18 70 33 18 49 9 Instrument holding forceps 52 12 36 67 8 26 10 Sprit 67 18 15 69 23 8 11 Betadin 30 33 36 59 28 13 12 Iodine 49 24 27 54 33 13 13 Savalon 27 30 42 62 33 5 14 Hydrogen Paraoxide 30 27 42 51 26 23 15 Rubber Gloves 46 27 27 59 31 10 Average response for the items 48 17 35 63 17 20
86 Vardaan Foundation, Baroda
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Gynec examination room AW ANW NA AW ANW NA 1 Adult weighing machine 88 9 3 82 5 13 2 Infant weighing machine 76 21 3 69 28 3 3 Height measuring wall marking 36 3 61 36 3 62 4 Measure tape 39 58 3 64 5 31 5 Gloves 70 27 3 82 5 13 6 Viginal speculum 42 9 49 74 5 21 7 Uterine sound 49 6 45 62 3 36 8 Volsellum/tenaculum 39 6 55 64 5 31 9 Bowls with savalon and cotton balls 58 6 36 69 3 28 10 Torch 36 6 58 41 3 56 11 Instrument tray with lid 61 36 3 56 5 39 12 Sterlizer 76 6 18 77 3 21 13 Foetoscope 42 9 49 56 3 41 14 Exam table 64 3 33 64 3 33 15 Writing table and Chair 64 33 3 72 8 21 16 Curtain for Privacy 30 3 67 26 8 67 17 Needle syringes for TT 76 3 21 77 8 15 18 ANC Cards 91 3 6 92 5 3 19 ANC registers 88 3 9 82 0 18 Average response for the items 59 13 28 66 6 29
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Labour Room AW ANW NA AW ANW NA 1 Labour table and Mackintosh 61 6 33 67 5 28 2 Cord forceps 34 12 54 49 8 44 3 Cord scissor 39 9 52 44 8 49 4 Autoclave blade and thread 49 6 45 62 8 31 5 Scissor for epistomy 21 9 70 36 10 54 6 Outlet forceps for delivery 12 6 82 21 3 77 7 Tissue holding forceps 39 3 58 46 8 46 8 Needle and holder 33 3 64 51 15 33 9 Catgut and thread 27 6 67 51 3 46 10 Gloves 55 3 43 74 3 23 11 Antiseptics 61 3 36 74 5 21 12 Hand washing arrangement 46 6 49 44 3 54 13 Enema and Shaving instrument 36 9 55 44 8 49 14 Baby cot and mattress and mackintosh 27 9 64 23 3 74 15 Baby resuscitation equipment 24 9 67 31 10 59 16 Ambubag and Mask 39 3 58 49 10 41 17 Mucusaspirator 39 52 9 36 5 59 18 Oxygen 15 6 79 33 5 62 19 Emergency medicines 30 6 64 51 3 46 20 Oxytocin 39 6 55 69 3 28 21 Syntocinon 24 12 64 59 3 38 22 Needle Syringes 70 6 24 80 21 Average response for the items 37 9 54 50 6 45
87 Vardaan Foundation, Baroda
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Vaccine Storage Equipment AW ANW NA AW ANW NA 1 Ice lined Refrigerator 73 3 24 97 0 3 2 Normal Refrigerator 52 5 44 62 5 33 3 Cold box 82 6 12 97 0 3 4 Thermometer 58 6 36 90 3 8 5 Temperature Record book 67 3 30 85 3 13 6 Voltage Stabilizer 64 3 33 72 3 26 7 Vaccine carrier 85 6 9 97 0 3 Average response for the items 68 5 27 86 2 12
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Laboratory Instruments AW ANW NA AW ANW NA 1 Urine test strip/reagents 46 3 52 54 3 44 2 Haemoglobinometer 73 3 24 92 3 5 3 Microscope 85 1 14 92 3 5 4 slides 79 0 21 85 0 15 5 TC DC RBC set 15 9 76 41 3 56 6 Reagent and Chemical 27 12 61 54 5 41 7 Centrifuge 6 3 91 36 5 59 8 Table chair 52 3 46 56 5 39 9 Light Source 55 3 43 69 5 26 10 Registers 66 3 31 69 10 21 11 VDRL set 3 6 91 15 3 82 Average response for the items 46 4 50 60 4 36
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Operation Theater AW ANW NA AW ANW NA 1 Hydraulic operation table 3 9 88 5 3 92 2 Ordinary operation table 18 9 73 10 5 85 3 OT light 15 12 73 10 0 90 4 Equipment for minor/General surgery 24 9 67 15 8 77 5 Vasectomy 12 6 82 77 8 15 6 Tubectomy 9 9 82 13 3 85 7 MTP 18 9 73 18 0 82 8 Bolyes apparatus for anaesthesia 3 6 91 3 3 95 9 Emergency drugs 30 9 61 41 5 54 10 Oxygen Cylinder and mask 6 9 85 23 13 64 11 Ventilation (fan/window) 52 9 39 33 13 54 12 Clock with second arm 15 3 82 10 0 90 Average response for the items 17 8 74 22 5 73
88 Vardaan Foundation, Baroda
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Autoclaving and boiling Equipments AW ANW NA AW ANW NA 1 Autoclave (elect/stove) 70 6 24 77 10 13 2 Kerosene stove 85 3 12 69 12 19 3 Pan with lid pressure cooker 79 3 18 46 13 41 4 Instrument drums 64 6 30 74 8 18 5 Autoclaving indicators tape 21 3 76 28 5 67 Average response for the items 64 4 32 59 10 31
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Counselling/Health Education Room AW ANW NA AW ANW NA 1 Table and chair 52 6 42 44 3 54 2 Posters, flip charts 61 -- 39 51 10 38 3 Give away materials 36 6 58 44 3 54 4 Models 42 6 53 28 3 69 5 Samples of contraceptives, ORS 64 3 33 74 0 26 6 Screen for privacy 15 3 82 26 0 74 Average response for the items 45 4 51 44 3 53
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For IEC Equipments AW ANW NA AW ANW NA 1 Film projector 3 12 85 3 0 97 2 Loudspeaker 3 15 82 31 15 54 3 Exhibition panels 6 6 88 21 10 69 4 View Master 12 0 88 3 0 97 5 Model Kit bag 9 0 91 8 5 87 Average response for the items 7 7 87 13 6 81
Availability Status of Items in Percentage DAHOD (N=33) SABARKANTHA (N=39) Sr. For Indoor ward AW ANW NA AW ANW NA 1 Total beds 64 6 30 51 10 38 2 Supporting table 33 9 58 41 10 49 3 Pillows 67 6 27 49 13 39 4 Mattress 67 6 27 51 10 38 5 Besheets 73 3 24 54 10 36 Average response for the items 61 6 33 49 11 40
89 Vardaan Foundation, Baroda
Annex 13: Details of the Content Analysis of Human parameters. Q1 List of Good Qualities among the participants (N=263) Total (in %) Working Attitude Wrong Answers 1 1 Regular and timely duty 57 2 Doing IEC for Govt. Health Programme 30 3 Take and make innovation in the health programmes for community 12 4 Behaves properly with patients 40 Average 35 Individual Attitude 1 Good leadership qualities 48 2 Trying best to resolve problem in the matter of planning & monitoring 17 3 Taking opinion of other staff members 14 4 Stay at the HQ. 12 5 Good communication skill 7 6 Excellent Knowledge for both theory and practical of the subject matter. 5 7 Cool Temperament 4 Average 15
Q2 List of Weakness among the Participants (N=263) Total (in %) Wrong Answers 18 Missing 6 Not Applicable 7 Total 31 Working Attitude 31 1 Unable to do physical work (field work) 14 2 Take health programme/ assigned work very lightly 5 3 Do not conduct regular duty 3 4 Lack of knowledge of the subject matter (surgical/delivery/MTP/) 3 5 Largely depended upon others 2 6 Unable to perform delivery 2 7 Avoid home visit 2 8 Poor knowledge because of the non availability of study material. 2 9 Do not stay at the HQ 1 10 Least knowledge of new drugs 0 11 Unable to work as per plan 0 12 Social Reasons creating hindrance in working 0 Average 3 Individual Attitude 1 Loose temperament/Impatient/rude/Euphoria/Obstinate 23 2 Lack of confidence/over confidence/inferiority complex 9 3 Lack of practical knowledge 8 4 Hate doing paper work 6 5 Cannot take out work from the staff members 6 6 Very sensitive to any event. 5 7 Do not stay long duration at the PHC 4 8 Problem with local language 4 9 I only do IEC. 3 10 Want to live in urban place 2 11 Lack of work experience. 2
90 Vardaan Foundation, Baroda
12 Very talkative 2 13 Do not like to here the word “No”. 1 Average 6 Attitude against system 1 Lack of understanding to surrender before politicians 3 2 Don’t want any boss on oneself 3 3 Avoid assigned responsibility 2 4 Failure in maintaining relationship with others. 2 5 Regional feeling 0 Average 2
Q3 List of Expertise among the participants (N=263) Total (in %) Missing 12 Wrong Answeres 16 Total 28 Professional Expertize 28 1 Conduct regular OPD and other routine assigned duties. 36 2 To understand and generate deamand from the community regularly 35 3 Tackle all health programme with better leadership 7 4 Good Time management 5 5 Can do good administration and impart subject knowledge 3 6 Can do Minor surgery 2 7 Helpful to the patient in dealing gynecological problems 1 8 Can initiate good corporation from NGO 1 9 Supervising 1 10 Can do emergency relief services. 1 11 Impart training for the realted topics in the PHC system 0 Average 5 Individual Expertized Qualities 1 Can address public gathering on any health issues 5 2 Better control over staff 5 3 Up grade individual personality 3 4 Taking higher authorities into confidence 1 5 Can work in any atmosphere 0 Average 3
91 Vardaan Foundation, Baroda
Q4 List of Activities - Participants unable to do (N=263) Total (in %) Missing 8 Wrong Answere 6 14 Management of PHC 1 To upgrade the facilities of PH 33 2 Lack of administration and poor coordination among staff 5 3 Timely work and proper sequence manner 3 4 Motivate Patients and staffs 2 5 Support from the higher up 2 6 Misbehavior with the staff / by people 2 7 Reduce paper work load 2 8 Regular monitoring of staff 2 9 Issues concern with vehicle management 1 10 Irregular in coming to the duties 1 11 More contingency grant and administrative power 0 Average 5 Technical Programme Skills 1 100% target achieved 13 2 Management of Emergency Obstetrics Services 8 3 Providing quality of health services (Accreditation system) 8 4 Conduct MTP/Delivery/NSV/TL/Lap/RTIs/STIs 5 5 Exploring community need through IEC 3 6 Unable to give time for Counselling 3 7 Clinical process: Cu insertion/Examination/ Delivery. 1 8 Promote all health services in the village 1 9 Want to conduct MCH services 0 Average 5 Individual Needs 1 Remove quacks doctors from the area 1 2 To further study / Skill developing 1 3 Want to work for women liberation/AIDS 1 4 Want to accomplish computer 1 5 I dream model PHC in the village 0 Many time want to take and act for decision but no permission from higer 6 ups 0 7 Want to educate more and upgrade the economic condition people 0 8 Unable to control pollution 0 9 In spite of health, want to do other associated developmental work 0 10 Want to learn English 0 11 Want to make doctors to come in time 0 Average 0
92 Vardaan Foundation, Baroda
Q5 List of activities participants avoid or don't want to do it (N=263) Total (in %) 1 Missing 25 2 Wrong answers 16 Total 41 About their assigned work 1 MTP/Abortion/PM/ 10 2 In doing Private practice 5 3 Irregularity of the staff members 5 4 Wrong certification 3 5 Informing negative work to higher ups 3 6 Don’t to punish any body financially (No Boss positive approach) 3 7 Refer patient for the treatment 3 8 Wrong information and misguiding patients 2 9 Harassment to the staff members 2 10 Pressure and harassment form the higher ups/ more workload 2 11 Target free approach 1 12 Irregularity in the field visit/ Diagnosis are not written on case paper 1 Average 3 Individual Dislikes 1 Political interference 12 2 Misbehavior 11 3 Corruption and malpractice 10 4 Administrative work 6 5 Avoid increasing number of meeting 5 6 Delay in giving salary by TDO 5 7 Avoid controversy/criticism 4 8 Avoid argument 4 9 Problem solving 3 10 Largely depended upon others 3 11 Avoid red Tapesum 1 12 Non or poor cooperation from the staff members 1 13 No work after office hours/Unnecessary paper work 1 Average 5
93 Vardaan Foundation, Baroda
Q6. Expectation from profession (N=263) Total (in %) Missing 4 Wrong Answers 1 Total 5 Individual Needs 1 To serve the people as social worker 51 2 To become famous doctor 2 3 Will shift to urban area for better education of their children 1 4 To become officer at district and state level 0 Average 14 Financial Needs 1 Increase pay structure as per qualification and promotion 6 2 More money 1 Average 4 Programme specific Needs 1 To impart quality work to the community 26 2 Emergency Obstetric services 5 3 Teamwork a the PHC 5 4 Remove the wrong notion of the community 4 5 Regularities in the duties 3 6 Support from higher up as well as for the grassroot level 2 7 Regular planning and follow-up 2 8 Facility for up gradation of the PHC 2 9 Management training 1 10 Specialization in services/upgrading the skills 1 11 Workload is very heavy 1 12 Computer in each PHC 1 13 Work should be recognized 1 14 Follow medical ethics 0 15 Don’t waste time in attending workshop 0 16 PHC should have security system 0 17 Paper work load should be reduced 0 18 Work responsibility should be divided and held responsible 0 Average 3
94 Vardaan Foundation, Baroda
Q7A Reasons that make Change in their Professions (N=161) Total (in %) Missing 2 1 Upgrade my skills 48 2 People are now more health programme conscious 31 3 Lot of change in my behaviour 31 4 Self confidence and control over anger 8 5 Wrong Answere 4 6 Spiritual gain 4 7 made my behaviour dry (more frustration) 2 Average 19
Q7B Reasons for no change in the Professions (N=27) Total (%) Missing 4 1 So many programme that it is very difficult say anything 30 2 Every boss is boss of every one 15 3 No change in the Govt. policy for assigning responsibilities 15 4 No body can change the current system 11 5 Administrative skills are very poor 7 6 Not getting promotion to the desired scale 7 7 No proper facilities 7 8 Less than one year of experience 4 9 Absence of rewarding system. 4 Average 11
95 Vardaan Foundation, Baroda
Q8 List of Set Back in the Profession among the participants (N=263) Total (in %) Missing 30 Wrong answeres 19 Not Applicable 3 Total 52 Related to PHC 1 Lack of the facilities and other infrastructure in the PHC 6 2 People had lost faith in public health institution 3 3 PHC/SC infrastructure development demand 2 4 In spite of hard work people are not coming to PHC/SC. 2 5 many health programme with no supervision 3 6 Regular and frequent meetings 2 7 Avoid community relationship 1 8 Irregularities in work and lack of dedication 1 9 PHC activities for 24 hours/unnecessary paper work 1 Average 2 Human interference 1 Political interference 6 2 Harassment from the higher ups/Administrative negligence 5 3 Misbehaviors of the seniors 2 4 Health workers don’t respect their medical officer 2 5 Corruption and wrong information and telling lie 2 6 Exploitation of staff members 1 Average 3
Individual experience 1 Unable to get chance to be promoted in spite of hard work 2 2 Avoid wrong procedure and working with ethics and principles 1 3 Summon from the court 1 4 Not getting Tikku commission salary 1 5 Frequent transfers punishment 1 6 Do not get desired pay scale 1 7 Every health profession is a leader 1 8 More freedom 1 9 No more examination 1 10 Since long year of service no self respect 1 11 When any cases relapsed (TL/Malaria/TB ) 1 12 Could not impart the right information to the people 0 13 Any case referred by MO 0 14 Referred patient is not entertained at higher institutions 0 15 My request for transfer was neglected 0 16 Any deaths 0 17 Increase in paper work load 0 Average 1
96 Vardaan Foundation, Baroda
Annex 14: Team of Vardaan Foundation:
Project Director: Dr. Harshit Sinha (Resource Person and Facilitator)
GIS System : Mr. Shahikant Kumar
External Advisor: Dr. D.V. Mavalankar, IIMA : Mr. S.K. Verma, B.M. Mental School, Ahmedabad.
Research Assist: Miss. Beena Rai : Miss. Reena Rai : Mr. Deepak Gohil : Mr. Hardik Shah : Mr. Shailesh Kishori : Mr. Nikhil Drave.
Graphic & Design: Mr. Jayant Katzu : Tarun Sood
Secretarial Assist.: Miss Abhilash Chanana
97 Vardaan Foundation, Baroda
Vardaan Foundation a public trust, formed in 1997 with the motto to serve the people with both action cum research and other developmental activities from wide range of diversified field of operation. A sub unit named: Centre for Action Research and Developmental Studies (CARDS) was also established. The former is devoted to provide the services giving much impetus to behavioural science such as social work, psychology, education, communication etc. and other related science. While latter being the sub unit of it, is devoted for doing operation and action research, development of action plan and project strategy, monitoring and evaluation. The purpose of the Centre is to assist development programme of the region in conducting studies, implementation, management, evaluation, developing strategies and policies. In doing so, the CARDS collaborate with government and non-government research and training institutions or organizations at local, national and international level. For more detail visit us www.varfound.org Email: [email protected]