Safer Pregnancy in Tamil Nadu: from Vision to Reality
Regional Office for South-East Asia WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Safer pregnancy in Tamil Nadu: from vision to reality.
1. Pregnancy Complications - prevention and control. 2. Maternal Health Services - organization and administration. 3. Maternal Mortality. 4. Infant Mortality. 5. Reproductive Health services. 6. Urban Health Services. 7. Blood Banks.
ISBN 978-92-9022-356-6 (NLM classification: WQ 240)
© World Health Organization 2009
All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South- East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: [email protected]).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.
Printed In India Contents
Foreword v Acknowledgements vi Executive Summary vii 1. Profile of Tamil Nadu 1 2. Enabling Environment 6 3. Progress and Challenges: Health Policy and Programmes in Tamil Nadu 14 4. Rhetoric to Reality: Reducing the MMR 17 5. Systems Strengthening 38 6. Community Sensitization on Gender-related Health Issues 47 7. For the Future 50
Additional Information 52–77 1. Referral Transport 52 2. Logistics and the Supply Chain 57 3. Voluntary Blood Donation for Blood Banking 62 4. Continuous Monitoring and Periodic Evaluation 64 5. Urban Health 70 6. Operationalization of First Referral Units and use of GIS Mapping 75
Annexures 78–83 1. Case Studies 78 2. Organogram 83
Abbreviations & Acronyms 84
Foreword
bout six years remain before the target date of 2015 for achieving the UN Millennium Development AGoals. While there has been steady and consistent progress towards most of the targets, progress in improving maternal health lags behind perceptibly. Due to an intricate correlation between maternal and neonatal health, maternal health has implications for the achievement of the MDG 4 target of reducing under-five child mortality, in which neonatal mortality is a critical component.
Due to sociocultural and economic differences, the situation of maternal and neonatal health varies considerably between countries of the South-East Asia Region, as well as within each country. India, the country with the largest population in the Region (over one billion inhabitants) has the highest number of maternal and newborn deaths in the world. It alone contributes over 68% of maternal and 76% of neonatal deaths in the Region. However, there are enormous variations within the country, with some states demonstrating tremendous progress in improving maternal and neonatal health.
The state of Tamil Nadu in South India is an example of such a success story, reflecting how the power of political will, the right blend of effective women-centred interventions tailored to the local sociocultural environment, and a well-established continuum of care based on the strong edifice of efficient health systems can bring about conspicuous improvement in maternal and neonatal health, as well as in the overall well-being of the population. In this monograph the officials of the Health and Family Welfare Department of the Government of Tamil Nadu generously share their experiences, achievements and lessons learnt from their efforts to ensure safer pregnancy and better newborn survival through the successful implementation of the Family Welfare Programme.
This monograph was prepared by the WHO Regional Office for South-East Asia, WHO Country Office, India and the Department of Making Pregnancy Safer of WHO Headquarters in collaboration with the Department of Health and Family Welfare, Government of Tamil Nadu and Government of India. It is intended for a wide range of health authorities and programme managers to learn and adapt successful programme strategies in their settings to accelerate action to improve maternal and neonatal health.
Dr Samlee Plianbangchang Regional Director Acknowledgements
his monograph, Safer Pregnancy in Tamil Nadu: initiatives in resource mapping to provide inputs TFrom Vision to Reality, is the result of a very in the documentation process. He, along with interactive and participatory process involving Dr K. Kasturi, a health economist and specialist a core team of public health specialists in Tamil in health systems development, did the actual Nadu. The inspiration for this monograph came documentation work to organize the monograph. from Dr P. Padmanaban, former Director of Public Both of them deserve deep appreciation for Health and Preventive Medicine, Tamil Nadu, and providing their valuable time and effort, and they currently Advisor (Public Health Administration), are profusely acknowledged. Dr Saradha Suresh, National Health Systems Resource Centre, National Director, Institute of Child Health and Hospital for Rural Health Mission, Ministry of Health and Family Children, Chennai, undertook analysis of verbal Welfare, Government of India, New Delhi. Not only autopsies of maternal deaths and provided inputs his inspiration but also his sharing a rich collection in understanding systemic issues contributing to of technical materials has made this monograph maternal mortality. Her inputs and efforts in the possible. His untiring motivation and inputs are documentation process are highly appreciated. graciously acknowledged. Dr B.R. Desikachari, a Last but not the least, Mr V.K. Subburaj, IAS, senior public health specialist with nearly thirty the Principal Secretary, Department of Health years of standing in reproductive and child health and Family Welfare, Government of Tamil Nadu, and health systems development in Tamil Nadu is warm-heartedly acknowledged for giving in his capacity as DANIDA Advisor and currently permission for the documentation process and Consultant in HIV/AIDS control, took many preparation of the monograph. Acknowledgements Executive Summary
his monograph, Safer Pregnancy in Tamil Nadu: initiatives in resource mapping to provide inputs The vision by 2005 and again in 2006 the maternal TFrom Vision to Reality, is the result of a very in the documentation process. He, along with mortality ratio (MMR) had fallen to 90 per interactive and participatory process involving Dr K. Kasturi, a health economist and specialist Tamil Nadu’s cherished vision is to significantly 100 000 live births, compared with 450 in a core team of public health specialists in Tamil in health systems development, did the actual reduce, if not eliminate, the high toll of maternal 1980; Nadu. The inspiration for this monograph came documentation work to organize the monograph. death and pregnancy wastage. The state’s chosen for every 1000 children born, 37 did not from Dr P. Padmanaban, former Director of Public Both of them deserve deep appreciation for path is to realize this vision as a comprehensive survive to their first birthdays in 2005 and Health and Preventive Medicine, Tamil Nadu, and providing their valuable time and effort, and they public health initiative that responds to women’s 2006 compared with 113 in 1971 and currently Advisor (Public Health Administration), are profusely acknowledged. Dr Saradha Suresh, needs from a rights-based approach. 59 in 1990. In 2005, 26 infants died in the National Health Systems Resource Centre, National Director, Institute of Child Health and Hospital for first month compared with 53 in 1971 and Rural Health Mission, Ministry of Health and Family Children, Chennai, undertook analysis of verbal The achievement 44 in 1990. Welfare, Government of India, New Delhi. Not only autopsies of maternal deaths and provided inputs his inspiration but also his sharing a rich collection in understanding systemic issues contributing to In the last several decades Tamil Nadu has recorded An enabling environment of technical materials has made this monograph maternal mortality. Her inputs and efforts in the impressive achievements in reducing maternal and possible. His untiring motivation and inputs are documentation process are highly appreciated. infant mortality (see Figs. 1 and 2). Key indicators of Social transformation, supported by a committed graciously acknowledged. Dr B.R. Desikachari, a Last but not the least, Mr V.K. Subburaj, IAS, progress are: political system irrespective of the party in power, senior public health specialist with nearly thirty the Principal Secretary, Department of Health years of standing in reproductive and child health and Family Welfare, Government of Tamil Nadu, and health systems development in Tamil Nadu is warm-heartedly acknowledged for giving Fig. 1: Maternal mortality ratio, Tamil Fig. 2: Infant and neonatal mortality in his capacity as DANIDA Advisor and currently permission for the documentation process and Nadu, 1980–2005 rates, Tamil Nadu, 1971–2006 Consultant in HIV/AIDS control, took many preparation of the monograph. 450 450 120 113 IMR 400 NMR 100 350 93
300 80
250 ve births 61 59 60 53 200 51 49 44 44 140 43 41 MMR/100,000 live births 150 120 130 40 36 37 37 110 110 32 INR-NMR/1000 li 30 30 29 100 26 90 20 50
0 0 1980 2000 2001 2002 2003 2005 2004 1971 1980 1990 2000 2001 2002 2003 2004 2005 2006 Year Year along with a paradigm shift in public health Successful implementation of the family welfare policy to emphasize maternal and newborn health, programme has brought down the fertility level are the key factors behind these advances. Overall, (total fertility rate) to 1.7 in 2005 and the crude their impact is reflected in improved literacy; birth rate to 16.2 in 2006. Sustained efforts have in the reduced incidence of early marriage, reduced the unmet demand for family planning. early pregnancy, and frequent pregnancies; This, coupled with provision of safe abortion and in a high level of public awareness of services in public health facilities, has helped family planning and good nutrition. A dynamic address the issue of unwanted pregnancies. public health system has made use of this A fertility transition has occurred, evidenced by a environment to progress towards its goal of making sizeable decrease in fertility among adolescents. pregnancy safer through effective women-centred initiatives. High-quality antenatal care is on the upswing, with higher rates of early registration of pregnancies A 3-fold path and sustained follow-up. Over 96% of mothers had at least three antenatal visits during their last Tamil Nadu’s effort to ensure safer pregnancy pregnancies, according to the National Family and newborn survival pursues a three-pronged Health Survey 3 in 2005–06. The state policy strategy: promoting institutional deliveries, coupled with prevention and termination of unwanted appropriate incentives, has led to 96% of deliveries pregnancies; taking place in institutions by 2006 (see Fig. 3). Even accessible, high-quality antenatal care and among the 4% that were domiciliary deliveries institutional delivery, with routine essential in 2005–06, untrained persons attended only a obstetric care and emergency obstetric first negligible proportion. aid at the primary level; accessible, high-quality emergency The innovative 24×7 model, providing around-the- obstetric care at the first referral level. clock access to essential obstetric and newborn care
Fig. 3: Institutional and domiciliary deliveries, 1993–2006, and attendance at domiciliary deliveries, 2005–06, Tamil Nadu
2005-06 Domiciliary Delivery Attendance
2004-05 Village health Nurse, 2.1 2003-04
2002-03
2001-02
2000-01
1999-00 Year
1998-99 Untrained 1997-98 Dai, 0.3
1996-97
1995-96
1994-95 Domicillary Institutional 1993-94
0 10 20 30 40 50 60 70 80 90 100 Trained Dai, 2 Percentage
viii Safer Pregnancy in Tamil Nadu: From Vision to Reality and emergency obstetric first aid services at the and newborn care services around the clock. primary level, is paying rich dividends. Under this Currently, 62 CEmOC and newborn care centres are model three staff nurses, working on 8-hour shifts, in operation, strategically located throughout the provide skilled attendance throughout the day state, and more are being established. and night at primary health facilities, conducting deliveries, attending to sick newborns, and The CEmOC and newborn care centres are equipped arranging timely referrals. Delivery performance with the requisite equipment and human resources. at the primary health facilities has improved All the personnel have been trained to provide the significantly, while pregnancy complications have emergency obstetric services that these facilities been identified early and referred in time to first offer. An obstetrician and a paediatrician are on referral units for management. This initiative was stay-in duty at these centres around the clock, while piloted successfully under the Reproductive and an anaesthetist is on call duty. The centres also Child Health Programme (RCH) in Phase I and now have the flexibility to hire in private anaesthetists has been scaled up to cover the entire state. if needed. To address the shortage of anaesthetists in government health facilities, a new initiative Shortening the three delays provides short-term training in anaesthesia for MBBS (Bachelor of Medicine and Bachelor of Surgery) Steps taken to address the three delays, which play degree doctors in the public health system. a critical role in maternal deaths, have had a positive impact. The first delay, in seeking appropriate care The CEmOC and newborn care centres have in time, accounted for 40% of maternal deaths in separate obstetric and paediatric casualty services 2004. This delay has been shortened substantially by in addition to general casualty services. Each has ensuring the availability of a skilled birth attendant an operating theatre, a well-equipped laboratory, at the primary level, through the 24×7 model. and a blood bank. Blood banks, periodic blood donation campaigns, and networking of blood Delay in reaching a first-level referral facility in case banks in the state have helped ensure regular of complications, the second delay, accounted availability of blood at the CEmOC and newborn for 37% of maternal deaths. This delay has been care centres. tackled through provision of emergency transport. An initiative piloted in one district provided A baseline survey on the operations of the CEmOC ambulance service through partnership with a and newborn care centres was conducted in non-governmental organization (NGO). The NGO 2004–05, the teething phase of this programme. manages and operates the service, with a vehicle Results were positive: provided by the government, free of cost to poor one third of the beneficiaries belonged to pregnant women and at a nominal fee for others. underprivileged sections of society; The success of this pilot initiative has paved the way 78% of mothers came to the centres for phased replication in 385 Blocks across the entire directly, an indication of widespread state. Selected NGOs receive new vehicles under the community awareness; World Bank-supported Tamil Nadu Health Systems 86% of the mothers could reach the CEmOC Project. and newborn care centres within half an hour; 83% of the women admitted received Provision of timely and comprehensive emergency services within half an hour, and another obstetric and newborn care has effectively tackled 12%, in half an hour to an hour; the third delay, which had accounted for 23% of wrong referrals, resulting in delays in maternal deaths. This care is organized through a reaching the centres, had declined to 18% network of Comprehensive Emergency Obstetric of cases; and Newborn Care centres (CEmOC and newborn 19% of the deliveries were caesarean care centres). These facilities are accessible within an sections, indicating life-saving intervention hour and provide all the crucial emergency obstetric in complicated deliveries.
Executive Summary ix A number of other measures designed to make the Challenges ahead public health system vibrant have helped to improve maternal and newborn survival. Important among While Tamil Nadu’s performance over the years in these are: maternal and newborn health is impressive, the infrastructure strengthening through state faces a variety of challenges on the road upgrades of primary health facilities, ahead: providing communications support and sustaining and even accelerating the flexible funding for regular maintenance momentum gained in the past; and innovative initiatives; overcoming the slow pace, or near a committed and sensitized workforce, with stagnation, in the decline of the MMR and continuous capacity upgrades, as well as the infant mortality rate (IMR) in recent rationalized allocation of human resource years; among public health facilities; focusing attention on neonatal mortality assured availability of essential drugs at the and the high incidence of stillbirths; health facilities through improved logistics; reducing regional disparities in maternal an effective health management and neonatal health indicators; information system; addressing the high incidence of higher empowerment of frontline health care order births in some communities; providers through skills upgrades, extending emergency obstetric care confidence building, and support for services to the entire state; mobility for outreach; community sensitization to gender issues; replicating the innovative initiatives throughout the state; on-going monitoring and review at primary, secondary, and tertiary care levels; placing more emphasis on urban health a focus, albeit limited, on urban health; issues; an adequate budget. assuring continued budgetary support.
About this monograph
This monograph documents the path pursued by Tamil Nadu in making pregnancy safer and the lessons learnt about improved maternal and neonatal health (MNH) outcomes. The Tamil Nadu experience, and the lessons learnt, can serve as useful pointers for designing and implementing similar programmes in other places. Section 2, which follows, profiles the sociodemographic and economic features of the State of Tamil Nadu. Section 3 examines the environment in the state that enabled it to move toward achieving its vision. Section 4 focuses on how the state transformed rhetoric into reality in MNH interventions. Chapter 5 details the strengthening of public health systems in the state that supported improvements in MNH care. The last chapter looks to current challenges and future initiatives. Case scenarios, an organization chart of the Department of Health and Family Welfare, and additional information on special topics follow.
Data limitations The information in this monograph comes from a desk review of relevant literature and the collation and analysis of available data from published and unpublished sources. Key informant interviews and selected site visits contributed insights from the field. The scope of the monograph is, of course, affected by the extent of data available in secondary sources. Varying reference periods for different data sets are unavoidable, since information has been culled from different sources. Care has been taken, however, to present the latest information available.
Safer Pregnancy in Tamil Nadu: From Vision to Reality 1 Profile of Tamil Nadu
amil Nadu is one of the most socially and the adjoining states. Tamil Nadu’s mountain chains Teconomically developed states of India. It is are the western ghats and the eastern ghats, while bounded by the Bay of Bengal on the east, the the river systems includes the Cauvery, running the Indian Ocean on the south, and the Arabian Sea on breadth of the state, as well as the Palar, Pennar, the west. Karnataka, Andhra Pradesh, and Kerala are Vaigai, and Tamiraparani rivers.
Fig. 4: Map of Tamil Nadu
Tiruvallur Chennai
Vellore Kanchipuram
Tiruvannamalai
Dhamapuri
Viluppuram P Salem The Nilgiris Erode Cuddalore Namakkal Peram- baur Ariyalur Nagappattinam Coimbatore Tiruchchirappalli Karur Than- javur Thiruvarur Nagapattinam Dindigul Pudukkottai
Teni Madurai Sivaganga
Virudhunagar Ramanathapuram
Tuticorin
Tirunelveli
Kanniyakumari Administration adolescent females (10–19 years) constitute 18% of the female population, distributed Tamil Nadu is divided into 31 revenue districts, of equally between the 10–14 and 15–19 age which Chennai is entirely urban while the rest are groups; a rural–urban mix (see Fig. 4). The Revenue Districts the older population is growing, with 8.8% are subdivided into 206 taluks, spread over 385 of the total over the age of 65 years; development blocks. In each Revenue District a overall, 73% of the population is literate, District Collector oversees all activities—revenue, with females lagging behind males, 64% development, and law and order. to 82%. The male–female literacy divide is greater in rural Tamil Nadu than in urban Health administration in the state is organized areas—55% for females versus 77% for through 42 Health Unit Districts (HUDs). These are males; usually but not always coterminous with Revenue the workforce participation rate in 2004–5 Districts; a few Revenue Districts span more than was 47.5% overall—35.5% for females and one HUD. Each HUD is under the charge of a Deputy 59.5% for males. The female workforce Director of Health Services (DDHS), while health participation rate is rising; administration at the level of the Revenue District compared with the national average, is the responsibility of a Joint Director of Health a higher proportion of socially Service (JDHS). underprivileged population strata— Scheduled Castes (SCs) and Scheduled Socio-demographic scenario Tribes (STs)—receive state support: 19% versus the national 16%. Census 2001 estimated the state’s population at 62.4 million, up by 11.1% over the 1991 population. Economy
The socio-demographic picture that emerged in Agriculture is the mainstay of nearly half the 2001 is: state’s population, directly in cultivation in their the state is on the path towards population own lands or indirectly through wage labour. The stabilization; vagaries of the monsoons, coupled with loss of 56% of the population inhabit rural Tamil arable land due to urbanization, have adversely Nadu, spread over 17 244 villages; affected the farm sector, shrinking the farmer’s the state is one of the most urbanized in average holding. The increasing marginalization the nation, with 27.5 million city residents and indebtedness of the farmers has given a push (see Additional Information, Part 5, Urban to rural–to–urban migration. While crop husbandry health); figures are down, an encouraging rising trend is population density averages 480 persons seen in allied segments such as dairy, sericulture, per square km, with urban density averaging over seven times the rural floriculture, and horticulture. density; The growth sectors are, however, the industrial and the imbalance in the sex ratio, which had grown over nearly four decades, reversed, service sectors, aided by state policies that create with 987 females for every 1000 males born a conducive environment. In the service sector the in 2001. The sex ratio varies greatly within high-end information technology (IT) and other the state, with half the districts reporting a sub-sectors have witnessed rapid growth. sex ratio favouring females; the child sex ratio (0–6 years) declined, from The incidence of poverty has been declining in 948 females for every 1000 males in 1981 to the state over recent decades. Data from the latest 942 in 2001, due to son-preference in some National Sample Survey (2004) suggest that 22% of communities and consequent sex-selective the state’s population is below the poverty line. In abortions; absolute numbers this amounts to roughly 140 lakh
Safer Pregnancy in Tamil Nadu: From Vision to Reality (14 000 000) persons living in poverty. These figures a sharp decline in the total fertility rate, need to be interpreted with caution, however, in from 3.9 in 1971 to 1.7 in 2006, points view of controversies concerning the estimation of to Tamil Nadu's movement towards this statistic. replacement-level fertility; the crude death rate has declined from Human development 14.4 per 1000 population in 1971 to 7.5 in 2006; Tamil Nadu is one of the most advanced states in the maternal mortality ratio, at 90 per the country in terms of human development, 100 000 live births in 2006, is down by 80% largely due to its history of social reform from 1980; movements and supportive state interventions. the infant mortality rate has fallen The state’s human development index (HDI) stood significantly, from 113 per 1000 live births at 0.657 in 1999, compared with the nation’s 0.571. in 1971 and 59 in 1990 to 37 in 2005 and Over the last two decades, the state has moved up 2006; the ladder on the HDI, from seventh rank among the neonatal mortality rate has declined by states in 1981 to the third position in 1991, which it half in this period. In 1971 the rate was retained in 2001 as well. Variations among districts 53 deaths per 1000. In 1990 the rate was 44. persist, however. By 2005 it had fallen to 26; the percentage of deliveries taking place in The extent of gender equality is greater in Tamil institutions has risen from 67% in 1993–94 Nadu than on average in the country as a whole. to 98% in 2007–08; The gender development index (GDI), based on life expectancy at birth has improved, from key indicators such as per capita income, literacy 58.2 for males and 57.8 years for females rate, combined gross school enrolment ratio, and in 1981–86 to 67.0 and 69.8 years in 2006, life expectancy at birth, is estimated at 0.654 for the putting the state on a par with a number of state. By comparison, the national GDI was 0.553 developed countries. in 1999. As with the HDI, regional variations in GDI exist in the state. Major indicators related to maternal and child health show that the situation in Tamil Nadu is The health scene considerably better than that in India as a whole (see Table 1). Health status Prominent among Tamil Nadu’s other achievements Improvement in the health status of the population in health are: is evident in several key indicators: eradication of guinea worm; the crude birth rate is down from 31.4 per impressive performance in controlling 1000 population in 1971 to 16.2 in 2006; vaccine-preventable diseases;
Table 1: Major demographic and health indicators, Tamil Nadu and all India, 2006 Indicator Tamil Nadu India Birth rate 16.2 23.5 Infant mortality rate 37 57 Under 5 mortality rate 50 94.9 Maternal mortality ratio 90 301 Sex ratio (females per 1000 males) 987 933 Child sex ratio (ages 0–6) 942 927 Life expectancy at birth male 67.0 male 64.1 female 69.8 female 65.4
Profile ofTamil Nadu near-elimination of leprosy; in semi-urban and urban areas. These a consistent effort to tackle tuberculosis organizations run a few clinics or mobile and cataract blindness; units in rural areas as well. special attention to mental health issues and adequate care for the mentally ill; The practice of self-medication and reliance on local prevention of disabilities and rehabilitation chemists and druggists is prevalent. of the disabled. Since data limitations preclude in-depth There are, however, several challenges that face the examination of the contribution of the private and public health system, including: NGO sectors, discussion here is confined to the a slowdown in the decline in infant public health system. mortality in recent times; a disturbingly high incidence of stillbirths Tamil Nadu has a vibrant public health system with a despite the high rate of institutional committed public health cadre. The health facilities deliveries; in the public sector operate at three levels: emerging lifestyle disorders and road traffic Primary—Primary Health Centres (PHCs), accidents; Community Health Centres (CHCs), and insufficient outreach support for the Health Sub-Centres (HSCs); vulnerable strata of society in remote areas; secondary—district headquarters hospitals, the persistence of communicable diseases taluk and non-taluk hospitals and and resurgence of non-communicable dispensaries; diseases. tertiary—teaching hospitals and specialty hospitals. Public health infrastructure The mix at the facility level has undergone The health care needs of the Tamil Nadu population continuous change in the past two decades through are met by: upgrades and expansion (see Table 2). a state-wide infrastructure of health facilities in the public sector; The primary level network of PHCs and HSCs has, hospitals, including corporate hospitals, over the years, offered preventive, curative, and nursing homes, and medical practitioners rehabilitative services, essentially to the rural in the private sector, mostly serving population. Currently, 1421 PHCs are in operation, metropolitan or urban areas; with 8683 HSCs functioning in their command hospitals run by non-government areas. The PHC/HSC grid in the state by and large organizations (NGOs) or trusts, also largely meets the national norm—one PHC for every
Table 2: Mainline public health facilities in Tamil Nadu 1980 1990 1999 2006 Category No. Beds No. Beds No. Beds No. Beds Teaching hospitals 32 14 689 33 16 374 37 18 742 44 21 399 District HQ hospitals 15 4641 22 6609 26 8263 29 8478 Taluk hospitals 117 6156 121 7550 162 10 266 155 10 017 Non-taluk hospitals 108 9095 72 2014 77 2265 80 2268 PHCs and CHCs 392 2298 1386 5208 1399 5334 1421 7191 Health sub centres ND ND ND ND 8682 ND 8683 ND PHCs (Primary health centres); CHCs (Community health centres) ND (not determined) Source: Directorate of Medical Education, Directorate of Medical and Rural Health Services, Directorate of Public Health and Preventive Medicine
Safer Pregnancy in Tamil Nadu: From Vision to Reality Fig. 5: Numbers of positions in public employees state insurance (ESI) hospitals and health system of Tamil Nadu, by dispensaries, leprosy hospitals, and women and category, 2006 children’s hospitals.
Human resources in public health sector Besides these public health facilities, there is a vast network of health care providers in both the private nmw and NGO sectors (formal and informal health care 23657 providers) with facilities dispersed across the state medical but located largely in metropolitan and other urban 11017 areas.
Health human resources para 21058 Sanctioned positions of different skill categories
mas associated with service delivery or with support 28684 services, such as managerial, supervisory, and basic services, in the public health system numbered over 84 000 in 2006. 30 000 population in plains and every 20 000 in hilly and tribal areas, and one HSC for every 5000 These personnel can be broadly grouped into four population in plains and every 3000 in hilly and categories (see Fig. 5): tribal areas. Variations among centres in the size of medical workforce—doctors and specialists, their command areas are not uncommon. such as obstetricians, gynaecologists, paediatricians, and anaesthetists; At the secondary level a variety of hospitals operate, nmw (nursing and midwifery workforce)— with varying levels of infrastructure and support nursing staff and also auxiliary nurse- facilities, and personnel with different skill levels. midwives; The numbers of these facilities and of their personnel have increased over the years. Besides para medical workforce—an amorphous offering curative services, these hospitals serve as group of pharmacists, optometric referral facilities. assistants, lab technicians, etc.; mas (managerial, administrative, and At the tertiary level teaching hospitals, including a support) workforce—a mix of managers, handful of specialty hospitals, are the highest-level such as directors and additional/joint/ medical institutions. deputy directors, as well as support staff in administration, accounts, data–gathering In addition to these facilities there exist auxiliary and analysis, and such ancillary services as facilities, such as TB hospitals, clinics and centres, driving, office maintenance, and security.
Profile ofTamil Nadu 2 Enabling Environment
Three strands as ”Periyar”, had a massive impact on the society through his South Indian Liberal Federation. Also, The force propelling Tamil Nadu's march towards he founded the Self-Respect Movement in 1925 and making every pregnancy safer has been a favourable the Dravidar Kazhagam in Tamil Nadu. sociopolitical climate. Three strands combined to create this climate. These three vital strands are: Periyar's movement was essentially a politico- social reforms; social movement aimed at ensuring equal gender advancement; rights for all sections of the society. It advocated political commitment to women-centred the representation of communities in state policies (see Fig. 6). governance and administration proportionate to their population size. The overall purpose was A commingling of these forces has enabled the betterment of the community. The South Indian public health system to respond with women- Liberal Federation, or Justice Party, promoted this focused policies, programmes, and interventions concept and emphasized intellectual emancipation that have helped significantly improve women’s and a healthy worldview. An egalitarian social order health status. was the goal, to be achieved through abolition of the hierarchical, grade-based, birth-based caste Social transformation structure.
The dawn of the preceding century saw a steady This reformist movement essentially called for: rise in social activism in the state. The movement moving away from harmful superstitions, led by E.V. Ramasamy Naicker, popularly known traditions, customs, and habits; dispelling ignorance; stimulating changes to meet the Fig. 6: Three stands create an enabling requirements of the changing times. environment for making pregnancy safer In the late 1920s the followers of this group—the Self-Respecters—performed marriages without Brahmin priests and without any religious Enabling Environment ceremonies, contrary to the prevailing custom. Instead, respected persons of the locality, mostly
Dravidar Kazhagam is a sociocultural movement that aims at Social Political Women-centred establishing an egalitarian society by eradicating the system Reform Commitment Health Policies of Varna Jathi (casteism) and by creating conditions in which different segments of the population, including women, have equal status, rights, and opportunities in all walks of life. political leaders, presided over such marriages. Dr Muthulakshmi Reddy (1886–1968) was one of There was no legal sanction for such marriages, but India’s most distinguished women of her time. She they were recognized as “self respect marriages”. In was the first woman to be admitted as a medical 1967 the Tamil Nadu government headed by the student at the Madras Medical College. She was also Dravidian party legalized such marriages. the first woman nominated to the Madras Legislative Council, where she was elected Deputy Chairman. Important social offshoots of this movement were: She was founder–president of the Indian Women’s emphasis on equality between the sexes; Association and became the first alderwoman of the encouragement of inter-caste and widow Madras Corporation. marriages; a rise in female age at marriage.
The beneficiaries were particularly people belonging Dr Reddy was thus the prime mover behind to the poorer strata of society. the legislation that abolished the devadasi system in 1929 and played a key role in raising In terms of women’s health, three crucial principles the minimum age of marriage for girls in India. The emphasised by Periyar have immense significance: Dr Muthulakshmi Reddy Maternity Benefit Scheme encourage women not to marry before is an offshoot of her efforts. Through this scheme 22 years of age; the Government of Tamil Nadu provides Rs. 3000 encourage women to avoid having many during pregnancy to every woman below the pregnancies and births too close together; poverty line and another Rs. 3000 in the postpartum promote contraception to liberate women period. The money makes up for lost wages and from frequent childbearing. helps poor women maintain good nutrition, thus avoiding low birth weight of babies. The initial push given by Periyar for raising the age at marriage and promotion of contraception Despite such emphasis on social reforms and the have continued to receive support from successive political support that they received, the pace of political parties in the state. transformation in the status of women has been quite slow. The social milieu and traditional beliefs Gender advancement and misconceptions were the major barriers. Gender inequality, the inadequacy or lack of Tamil Nadu has the pride of a legend in women’s decision-making power, and also strong Dr Muthulakshmi Reddy (1886–1968), who, son–preference in some communities have placed alongside Periyar, first addressed gender concerns women in a relatively disadvantaged position. In and launched advocacy for women’s advancement these circumstances women naturally had limited and gender equality. Dr Reddy fought constantly for ability to make their own reproductive choices. the emancipation and uplifting of women in India. It is only in recent years that women are moving, Facing opposition from many quarters, Dr Reddy albeit slowly, towards realization of their rights. enlisted the support of no less a personage than Awareness-raising in various forums, gender Mahatma Gandhi when she sought to liberate sensitization sessions for men, and facilitation devadasi women from the tyranny of their tradition. of women's self-help groups have imparted Gandhiji made public speeches and wrote in his momentum to women’s advancement. published columns in support of Muthulakshmi’s efforts to raise the status of women in India. Literacy improvement
The advancement of literacy emphasized by social The term devadasi originally described a Hindu religious practice in which girls were "married" and dedicated to a reformers has received a boost from political deity (deva or devi). commitment. That commitment is based on the
Enabling Environment conviction that a child’s development is linked than that for boys at both primary and with social progress. “Education for all” has been upper primary levels. encouraged to ensure harmonious development of a child’s personality in an atmosphere of happiness Nutrition schemes and love and in a spirit of peace, dignity, tolerance, freedom, and equality. Nutrition has always been high on the political agenda in the state. Many nutrition programmes Universal elementary education in the age group for young children and mothers have been of 6 to 14 years has been the primary intent of the implemented in recognition of the fact that social programme sponsored by the Government of India, investment in nutrition will reduce health care costs, known as the Sarva Shiksha Abhiyan. The objectives reduce the burden of non-communicable diseases, of the programme are: improve productivity and economic growth, and by 2007 all children would be completing promote education. five years of primary schooling; by 2010 all children would be completing A school mid-day meals scheme has operated eight years of elementary schooling; since 1956, when it began in 8000 elementary to assure good-quality elementary schools and covered 2 lakhs (200 000) children. education, with emphasis on education for Started initially with voluntary contributions, the life; scheme has been funded subsequently by the to close gender and social gaps at government. In 1961 coverage was extended to the primary stage by 2007 and at the 16 lakhs (1 600 000) children in 30 000 schools. In elementary education level by 2010. 1967 the system was radically modified to operate through Central Kitchens, where food was cooked Tamil Nadu has initiated several welfare measures to and packed in polythene packets. Vehicles deliver help meet these goals, including: these packets to the schools 200 days a year. free supply of text books to all children studying in government and government- The mid-day feeding through the Noon Meal aided schools, including self-financing Programme was expanded significantly in 1982 sections in aided schools and children during the administration of the former Chief studying in recognized but self-financing Minister Dr M.G. Ramachandran, who felt that no institutions adopting the state syllabus; child should go hungry. At first the State focused on free supply of uniforms for Noon Meal the difficult-to-reach rural pre-school age group, 2 to Scheme beneficiaries in Standards I to VIII; 5 years, who cannot be covered in the centres free bus passes to facilitate school access unless brought there by an adult. Subsequently, for students in Standards I to XII. urban pre-schoolers in this age group were also covered through a network of centres. At a later Statistics on school enrolment and retention point stage older school children in rural areas, up to to the success of the state's efforts in education: 15 years of age (i.e. class X), were also brought the net enrolment rate (NER) has increased under the scheme. to 99.3% at the primary level; the NER is 98.3% at the upper primary Despite bureaucratic doubts about funding level; and logistics, personal commitment and dropout rates at primary and upper primary political will contributed to the success of this levels, at 1.9% and 4.1% respectively, in ambitious programme. Successive governments 2006–07 were nearly half of the previous have continued to commit very significant portions year's levels and just 13% of the levels in of the state’s budget to this programme. This 2002; programme, with its strong "food bias", has caught the dropout rates of girls and boys are the imagination of the Government of India, which is similar, with the rate for girls slightly lower now starting to support similar efforts in all states.
Safer Pregnancy in Tamil Nadu: From Vision to Reality While the scheme was initiated as a feeding programme introduced throughout the country by programme, over the years the State has tried the Government of India. to include other services, such as health care, immunization, growth monitoring, pre- and Political commitment, policies, postnatal care, and communication and nutrition and programmes education, along with feeding. This has been done through two main nutrition and child development Tamil Nadu has been fortunate that there has been programmes—the Integrated Child Development adequate realization, on the part of the political Services Scheme (ICDS), started as a small pilot establishment, of the importance of improving project in 1976, and the Tamil Nadu Integrated women's health in general and maternal health Nutrition Project (TINP), which began in 1980. in particular. This realization is reflected in the Both these nutrition schemes were subsequently continuing political commitment and policy support integrated with the Noon Meal Programme for the various health initiatives over the years, infrastructure for pre-schoolers. regardless of which party was in power.
The state government has continued to emphasize Tamil Nadu Public Health Act complementary feeding and at the same time has brought about an integration of all major health Tamil Nadu was the first state in India to enact a law and nutrition interventions for children. In 1994 a relating to public health—the Tamil Nadu Public State Policy on Nutrition was drafted with technical Health Act, 1939. The State enacted the law under support from UNICEF. Tamil Nadu was probably the the stewardship of the then Honourable Minister for first Indian state to have such a policy, following the Health Dr T.S.S. Rajan. The Act was amended in 1941, National Nutrition Policy, 1993. 1944, 1958, and 1970.
Age at marriage The Tamil Nadu Public Health Act, 1939 places health at centre stage in the development of the Social reforms, gender advancement, and nutrition people of Tamil Nadu. It also assures continuing and education reforms have had the positive emphasis on health regardless of the political impact of raising the age at marriage for girls party in power. Section 82 under Chapter VIII of (see Fig. 7) and drawing greater attention to women's the Act deals specifically with maternity and child health status. The emphasis on delayed marriage, welfare. contraception, birth spacing, and regulation of family size was the harbinger of the family planning This Act provides for: formulation of policies for improving the health of the people, especially women and children; Fig. 7: Increasing female age at marriage in Tamil Nadu, 1991–2003 cost–sharing between the Government of Tamil Nadu and local government bodies, at the ratio of 1:2, in urban areas; 22.3 22.5 22.2 cost–sharing between the Government of 22 Tamil Nadu and the Government of India 21.6 21.5 e 21.5 21.1 for better funding of health services in rural 20.9 21 20.7 21.2 Urban areas, in varying proportions depending on All 20.5 20.3 Rural the activities. 20.6
Age at marriag 20 20.1 20.2 19.5 Policy transition 19 1991 1995 1999 2003 Public health policy regarding family planning underwent a paradigm shift beginning in the 1980s.
Enabling Environment Two sets of objectives were set forth for family The child survival and safe welfare programmes and, thus, for their services: motherhood project macro objectives, which are basically demographic, aimed at arresting The child survival and safe motherhood project, population growth and lowering fertility by funded by the World Bank, operated country-wide use of contraceptives; with the overall objectives of: micro objectives focused on families and shifting India’s family welfare programme their welfare. from its nearly exclusive concern with fertility regulation to a focus on MCH; This shift acted as a forerunner for maternal and providing a social safety net during the period child health (MCH) policies. of financial stringency and economic reforms.
India’s Family Welfare Programme (or Family The project was approved on 17 September 1991 Planning Programme, as it was known earlier) was and made effective on 5 March 1992. The credit was launched in the mid-1950s. The programme was closed on 30 September 1996. entrusted to the Ministry of Health, Government of India. It was a low-key programme at this stage and The specific objectives of the project were to: not well funded. increase child survival; promote safe motherhood, including A decade after its inception, the Family Planning establishing first referral units (FRUs) for Programme attracted the attention of the large secondary-level care of mothers and their international donors. In 1966 the arrival of a newborns; UN Advisory Mission precipitated an increase strengthen the delivery of services by in international funding for family planning improving institutional capability. programmes. An important landmark in improving the quality Accepting the advice of the UN Mission, the of health of mothers and children in the state Government of India created separate directorates was the issuance of Government Order (GO) within the central and state ministries and Ms No. 353 Health and Family Welfare Department, departments of health, renaming them as those dated 30 May 1995, with retroactive effect from of Health and Family Planning. The nation’s top 1 June 1994. The crux of this GO is a significant change priority at that time was population control, with in emphasis in the Family Welfare Programme from fertility reduction dominating the health services a target orientation to the target-free approach. The agenda. impact of this GO is examined in Chapter 4.
In 1977 there was widespread dissatisfaction with The operationalization of MCH and FW policy some of the means adopted by the programme. The reforms were taken further through both centrally programme was renamed the Family Welfare (FW) sponsored and externally funded projects in the Programme, bringing within its fold the Mother and public health sector in Tamil Nadu. Child Health (MCH) Programme. The emphasis in the late 1980s through mid-1990s was survival of India population project funded by mothers and children. the World Bank
These changes at the national policy level spurred The India Population Project (IPP V) was approved the Tamil Nadu government to initiate policy on 21 June 1988, and the credit was closed on reforms relating to MCH. The Government of Tamil 31 March 1996. Initially, the project covered India’s Nadu capitalized on the opportunity provided by second and fourth largest urban agglomerates— the nationwide Child Survival and Safe Motherhood Bombay (Maharashtra), Greater Bombay Municipal Project (CSSM). Corporation and Chennai, Chennai Municipal
10 Safer Pregnancy in Tamil Nadu: From Vision to Reality Corporation (Tamil Nadu) and four adjoining smaller was assisting the Government of India to improve municipalities. In 1990 the geographic coverage the performance of its Family Welfare Programme. expanded to include Navi Mumbai Municipal The work aimed at reducing maternal and infant Corporation in Mumbai and all urban areas in Tamil mortality and morbidity and unwanted fertility, Nadu with populations of more than 100 000. thereby eventually contributing to population stabilization. The objectives of IPP V were to: expand family welfare services, with Built on the successes of the Universal Immunization emphasis on MCH, birth spacing, and Programme, the Child Survival and Safe Motherhood increased use of temporary contraceptive Programme, and the Family Welfare Programme, methods; RCH I aimed at providing high-quality care, improve the quality of family welfare empowering the community to demand better services; health services, and substantially improving the strengthen the capacity of Greater performance of the health care delivery system. RCH Mumbai, Chennai City, and Chingleput I covered all aspects of women’s health across their District in Tamil Nadu to plan, manage, and reproductive lifecycle from puberty to menopause. implement family welfare programmes in the urban areas; The broad objectives of the project were to: increase the participation of private improve the health status of women, voluntary organizations (PVOs) and private adolescents, and children; medical practitioners in urban family improve women’s health care-seeking welfare programmes. behaviour; increase the credibility of service providers Danida-supported area development by improving quality of care. project on health in Tamil Nadu In Tamil Nadu RCH I was implemented in two The Danish International Development Agency Districts—Madurai and Theni. The RCH programme (Danida) supported the health and family welfare enabled the State to pilot innovative MCH initiatives programmes in Tamil Nadu for over two decades and helped with scaling these up subsequently, in (1981–2003). The period of coverage paralleled a RCH II, to cover the entire state. phase of substantial development in Tamil Nadu’s health policy framework, with a sharpened focus on National Population Policy, 2000 the delivery of primary health care, particularly to the rural poor. The national government's commitment to voluntary and informed choice and to the consent The Danida project commenced with the coverage of citizens in availing themselves of reproductive of two districts—Salem and South Aroct—but health care services was affirmed in the National eventually supported health and family welfare Population Policy, 2000 (NPP 2000), along with activities in eight Revenue Districts (10 Health Unit continuation of the target-free approach to Districts) along with support to selected statewide providing family planning services. NPP 2000 activities—systems strengthening in human provides the policy framework, for the current resource development, essential drug supplies, and decade, for meeting the reproductive and child the Health Management Information System (HMIS) health needs of the people of India and achieving (see Chapter 5). net replacement-level fertility by 2010. Reproductive and Child Health (RCH) Project, Phase I The policy emphasizes the need for: addressing simultaneously issues of This nationwide World Bank funded project began child survival, maternal health, and in mid-August 1997. Its development objective contraception;
Enabling Environment 11 increasing outreach and coverage of a reduction of Infant Morbidity and Mortality comprehensive package of reproductive (IMR); and child health services by government, reduction of under-5 morbidity and the for-profit sector and the voluntary non- mortality; governmental sector, working in partnership. reduction of the total fertility rate; promotion of adolescent health; Reproductive and Child Health control of RTIs/STIs/cancer. Programme, Phase II RCH II interventions have made a significant The outcomes envisioned in NPP 2000, the contribution to the state's progress towards making Millennium Development Goals (MDG), the Tenth pregnancy safer. These are discussed in the next Plan Document (2002–2007), and the National chapter. Health Policy 2002, as well as the lessons of RCH I, were built into the vision of the RCH II programme, The RCH programme has received the strong which was launched in 2007. support of the Tamil Nadu government, which has provided all the necessary policy initiatives The development objective of RCH II is expansion and resources for implementing the various of the use of essential reproductive and child health interventions under the programme. This support services of adequate quality with a reduction in is reflected in the Health Policy Notes submitted geographic disparities. The salient features of to the Legislative Assembly every year by the RCH II are: Honourable Health Minister of the Government of an integrated vision, addressing family Tamil Nadu (see box). planning, maternal and newborn/child health, adolescent health, and control of National Rural Health Mission (NRHM) reproductive tract and sexually transmitted infections (RTI/STI control); The National Rural Health Mission (NRHM), a comprehensive sectoral approach; launched in 2005 and funded by the Government partnership with private and NGO sectors; of India, aims (1) to make structural changes in institutional strengthening, decentralized the health system that will enable it to effectively planning, and devolution of state ownership; handle increased allocations and (2) to improve a results-based approach, focusing on management and service delivery policies. The outputs and outcomes. goal is to improve the health of the people, especially those living in the villages. The vision RCH II covers the entire state of Tamil Nadu and has is to provide universal access to equitable, the following objectives: affordable, and good-quality health care services, reduction of Maternal Morbidity and accountable to the needs of the people. The NRHM Mortality (MMR); will be in force from 2005 to 2012.
The role of the state legislature
All health initiatives are implemented in the state only after they are presented, along with the budgetary implications, in the state Legislative Assembly each year in the Policy Note by the Honourable Health Minister of the Government of Tamil Nadu. This Policy Note is discussed at the Assembly sessions and duly passed.
Also, the Honourable Finance Minister of the Government of Tamil Nadu incorporates the financial requirements into the state budget and presents it to the state Legislative Assembly every year for approval.
Only after these approvals does the state government issue the necessary Government Orders (GOs) for implementing the various health initiatives.
12 Safer Pregnancy in Tamil Nadu: From Vision to Reality The objectives of NRHM are: Lessons learnt providing universal access to public health services—women’s health, child Tamil Nadu's experience in dealing with women's health, safe drinking water, sanitation health issues in general and maternal and newborn and hygiene, nutrition, and universal health issues in particular has revealed that: an enabling environment will help propel immunization; women-centred initiatives; prevention and control of communicable political consensus, regardless of parties in and non-communicable diseases; power, is essential to fuel such initiatives. population stabilization, addressing gender In the state the Tamil Nadu Public Health and demographic factors; Act, 1939 placed health at centre stage, providing access to integrated and supporting further policy changes; comprehensive primary health care; centrally driven policies and programmes revitalizing local health traditions and in family welfare have had an impact on the mainstreaming the Indian System of state’s priorities, even though health is a Medicine (ISM); state responsibility; promotion of healthy lifestyles. Tamil Nadu utilized the opportunities for policy reforms in MCH and FW provided The NRHM has not only lauded Tamil Nadu's by externally funded and centrally achievements in the health field, in particular in funded programmes and projects. These improving maternal and newborn health, and has programmes and projects provided space even suggested replication of the state's health for pursuing the state’s priorities; interventions in other states in the country. project funding was seen as a means for policy reform to improve service delivery The continuing support of the NRHM and the to mothers and children, as well as for Government of Tamil Nadu give added strength to strengthening institutions; the commitment of the RCH Directorate, whose Tamil Nadu’s FW and MCH policy reforms, Project Director has been renamed Mission Director. particularly the target-free approach to The commitment of the state government with FW and the MCH route to achieving FW support from the NRHM assures that the RCH goals, contributed to the design of the RCH initiatives will continue beyond the programme Project, Phases I and II, and the National period. Population Policy, 2000.
Enabling Environment 13 3 Progress and Challenges: Health Policy and Programmes in Tamil Nadu
he Constitution of India states in its Directive comprehensive Emergency Obstetrics and TPrinciples that: Newborn Care (CEmOC and newborn care) centres handle obstetric emergencies day The enjoyment of the highest attainable standard or night, with obstetricians, gynaecologists, of health is one of the fundamental rights of every anaesthetists, and paediatricians always human being, without distinction of race, religion, available; political belief, economic or social condition. anaesthetists, obstetricians, and paediatricians from the private sector are The government of Tamil Nadu has set its health hired in as needed to fill staffing gaps at goals, including stabilization of population size by CEmOC and newborn care centres; 2010, based on these principles. Most importantly, more doctors from PHCs and secondary- Tamil Nadu’s Health Policy 2003 focuses on greatly level hospitals are being trained in improving access, equity, and quality of care and on anaesthesia skills for emergency obstetric reforming health care financing. care; ambulance services transport emergency Key initiatives obstetrics cases to health facilities. A referral control room in each district Public health facilities and health services have takes emergency calls and coordinates played key roles in improving the health status ambulance services and blood supply; of the population in the state. Initiatives blood banks stay stocked with all blood contributing to these improvements, and groups year-round, thanks to regular particularly to safer pregnancy and childbirth, blood donation drives and lists of are listed below. Other chapters describe these donors willing to contribute blood in an initiatives in more detail. emergency; the birth companionship programme Infrastructure, staffing, and services allows a woman who is delivering to have at facilities a female relative or friend with her at the Primary Health Centres (PHCs) offer local health facility; access to skilled obstetric services and many centres that offer basic emergency referral for complications. Three nurses obstetric and newborn care also conduct on eight-hour shifts assure 24 hour a family health clinics on Mondays, day care. Laboratory equipment and Wednesdays, and Fridays, providing operating theatres have been upgraded laboratory tests for RTIs/STIs and voluntary in these centres. Annual grants support HIV testing and counselling; maintenance of the PHCs and other facilities are continuously monitored and primary-level facilities; periodically evaluated. Outreach The programme will combine special times village Health Committees, established and days for adolescents in public health in the 1990s in all Health Sub-Centres, institutions, counseling, and outreach to participate in planning and implementing school children, college students, and all health programmes. Also, these youth working in industries; committees and the panchayats PHC medical officers will receive training play an important role in multimedia on MVA, tubectomy, obstetric sonography, communication campaigns to improve anesthesia, emergency obstetric and health-seeking behaviour and to change newborn care, breast and cervical cancer health-related practices. Under the detection, colposcopy, and blood bank RCH II programme these Village Health operations; Committees have become Village Health staff nurses and auxiliary nurse-midwives and Water Sanitation Committees, with at PHCs will be trained in basic emergency enlarged scope. A revised norm calls for such obstetric and neonatal care, integrated committees in all villages with populations management of neonatal and childhood over 1500 to bring together community illnesses, adolescent-friendly services, leaders and village officials on board; detection of breast and cervical cancer, and skilled birth attendance; mobile medical units have been established to serve coastal and difficult- efforts to prevent and control gestational to-reach villages. As per schedule, the diabetes will include training for doctors, mobile units offer the entire range of adequate supply of drugs for the PHCs, and reproductive health services, including awareness-raising in the community; antenatal, postnatal, and newborn care a multifaceted programme will seek to and family welfare services, as well as reduce disabilities among newborns. The other health services; efforts will include rubella vaccination for all adolescent girls, screening of high- the PHCs and their field staff conduct risk newborns, training medical and regular outreach services to meet the needs paramedical staff, and organizing referral of various health programmes; clinics in district hospitals; trained “health link volunteers”—one all PHCs will receive computers to help with woman for every 1000 population—in the data entry and transmission; tribal areas serve their communities by each family will receive an electronic “smart providing information on healthy practices cards” that stores their health information. and available health services, identifying A pregnant woman will receive a similar and referring high-risk pregnancies, card, and all maternity benefits will be treating minor ailments, and performing claimed and monitored through the card. various other functions; poor mothers receive six months of Also, several new initiatives are proposed: financial aid for nutritious food during maternity waiting homes would be set up pregnancy and to compensate for lost in remote and tribal areas, so that women wages. could await the onset of labour close to a health care facility, rather than risk lengthy Current plans and proposals for and difficult travel that could prove fatal in scaling up an emergency; To continue progress, diverse initiatives will be RCH Centres of Excellence would be set scaled up: up in several institutions. They would to address adolescent reproductive and serve as the primary training institutes on sexual health issues, adolescent-friendly reproductive health for personnel at all services will be established throughout levels—not just from Tamil Nadu but from the state, scaling up from a pilot project. throughout India.
Progress and Challenges: Health Policy and Programmes in Tamil Nadu 15 Strategic issues between 1971 and 1989, from 113 to 52 per 1000 live births. During the 1990s the rate of decline On the demographic front, the family welfare slowed. By 2006 the IMR in the state was 37. While interventions have contributed to population a perceptible decline in post-neonatal mortality stabilization. Similarly, there has been a steady has been achieved, the neonatal mortality rate has decline in the infant mortality rate and the maternal remained stubbornly high. Rates of early neonatal mortality ratio over the years. During the decade of mortality, in particular, have been practically the 1990s, however, the rates of decline in IMR and stagnant. This rate was 33.8 in 1971 and 32.1 in MMR have slowed. 2002.
On the epidemiological front, most of the infectious Substantial success has been achieved in the diseases that once took a heavy toll of lives and state in improving the quality of ante-natal well-being have been largely contained. New health care and in promoting institutional delivery. conditions have come into prominence, however, Currently, 90% of deliveries are institutional, such as HIV/AIDS, non-communicable diseases, life and 99% are attended by trained personnel. style disorders, mental illness, injuries, and road The MMR was 90 in 2006—a considerable traffic accidents. Overall, therefore, the burden of improvement over earlier levels. The main factor disease in the state has not fallen significantly. behind maternal mortality reduction is the capacity building to ensure readily accessible emergency On the infrastructure front, significant gains have obstetric care round-the-clock throughout the been made, but uneven distribution and under- state. served pockets remain in the state, resulting in inequity. Gender and health
Finally, health care costs in both the public sector It is recognized that women are unequally placed and the private sector have been increasing, in Indian society. Patriarchal structures and value straining the state exchequer and family incomes. systems inhibit women’s access to health facilities and services in various ways. Women and girl Clearly, there is scope for improvements in health children also face nutritional discrimination service delivery in the public sector. Improved within the household, even while carrying an planning and management of health services, with inordinate share of the burden of household work. the goals of improving access, equity, quality, and Adolescent girls are particularly vulnerable. They health care resources, is a major focus of policy. are poorly served by government programmes Despite undoubted advances and achievements in because they fall between programmes dealing demographic, epidemiological, and infrastructural with children and those for mothers. The indicators over time, Tamil Nadu's health system resulting gender discrimination in health care faces such challenges as regional disparities in leads to poorer health outcomes for females. health status, differentials in access to health service The female IMR is higher than the male IMR in the delivery, distributional issues in health resources, state, the incidence of anaemia is greater among and inadequacies in quality of care, planning, and women, especially among adolescent girls, and management. The possibility of public–private so on. partnerships that improve health service delivery also needs to be explored, drawing on the experience The issue of gender discrimination in already gained in the state. health needs to be addressed. Resulting improvements in women’s health today will have Infant and maternal mortality substantial benefits for the health of the next generation, both men and women. (See Community A key focus of policy is maternal and child health. sensitization on gender-related health issues, The state saw a significant decline in the IMR p. 47).
16 Safer Pregnancy in Tamil Nadu: From Vision to Reality 4 Rhetoric to Reality: Reducing the Mmr
The threefold path As mentioned in the previous chapter, the Family Welfare Programme (earlier known as Family Tamil Nadu has adopted a threefold approach to Planning Programme) shifted emphasis from fertility ensuring safer pregnancy and newborn survival: reduction to protection of the health and survival of reduce the likelihood that a woman mothers and children. The target–driven, method– becomes pregnant when she does not specific approach that dominated the scene before wish to; 1995 has since moved towards what is popularly reduce the likelihood that a pregnant known as “the MCH route to family welfare”, with woman experiences a serious complication its target–free approach, choice of contraceptive of pregnancy or childbirth; methods, and planning based on expected level reduce the likelihood of death among of demand as determined by community needs pregnant women who experience assessment. Under this approach the decline of complications. fertility has continued but at a slower rate than the dramatic decline between 1980 and 1990. The core strategy developed to achieve these objectives has three corresponding strands: Through successful implementation of the prevention and termination of unwanted Family Welfare Programme, Tamil Nadu has pregnancies; ushered in a demographic transition toward the promotion of good-quality antenatal care replacement level of fertility. Two key indicators and institutional deliveries—that is, routine chart the impressive achievements over the years essential obstetric care and additional care (see Fig. 8): as needed; the Total Fertility Rate (TFR) has declined promotion of access to good-quality markedly, falling from 3.9 in 1971 to 2.0 in emergency obstetric care at the first referral 2000 and, further, to 1.7 in 2005; level—that is, specialized obstetric care. similarly, the Crude Birth Rate (CBR) is on a downward curve, falling from 31.4 in 1971 Path 1: Prevention and and 19.3 in 2000 to 16.2 in 2006. termination of unwanted pregnancies Unmet need
Fertility reduction Despite the achievements of the Family Welfare Programme and a progressive decline in fertility over Reduction in the likelihood or frequency of a the years, there still exists an unmet need for family woman’s becoming pregnant is an effective way to welfare services. The National Family Health Survey lessen the number of maternal deaths. The Family 2 (NFHS 2) estimated such unmet need at 13.0% Welfare Programme plays a key role here. of married women of reproductive age in Tamil Fig. 8: Declines in total fertility rate and crude birth rate, Tamil Nadu, 1971–2005 Total fertility rate Crude birth rate 3.9 31.4 4 32 3.8 30 3.6 3.4 27.9 3.4 28 3.2 26 3 24 2.8 21.6 2.6 22 2.3 19.3 19.1 2.4 20 18.5 18.3 17.1
ility rate ility 2 2.0 2.0 2.0 1.9 18 16.5 16.2 rt 2.2 1.8
fe 1.7 1.8 16 1.6 14 total 1.4 12 1.2 1 10 0.8 8 0.6 6 0.4 0.2 4 0 2 1971 1980 1990 2000 2001 2002 2003 2004 2005 0 1971 1980 1990 2000 2001 2002 2003 2004 2005 2006 year year
Nadu in 1998–99. By 2005–06 (NFHS 3) unmet need by a formally trained health care provider or an appeared to have declined to 9%. By comparison, informal health care provider. Despite increased use NFHS 3 estimated the unmet need for family welfare of contraception, the demand for abortion persists. services at the national level at 13% in 2005–06. India was one of the first countries in the world Regional disparities persist within the state. In to legalize abortion, promulgating the Medical some areas a relatively large number of women Termination of Pregnancy (MTP) Act in 1971. Tamil giving birth already have two or more children. The Nadu followed suit with a similar act in 1971 and Government of Tamil Nadu took a policy decision the Medical Termination of Pregnancy Rules, 1975, in 2003–04 to emphasise permanent methods of which provide for termination of certain pregnancies contraception in these areas and to emphasize spacing by registered medical practitioners. methods in other areas. The objective is to arrive at levels of demand for contraception throughout the Despite this, unsafe abortions do continue. In these state that will reduce regional disparities. cases women resort to unsafe abortions either due to lack of knowledge or access to safe abortion Termination of unwanted services or for fear of stigmatization if they openly pregnancies: access to safe abortion visit a health facility for this service. services An estimated 150 000 unwanted pregnancies occur Women provide emotional, physical, and economic each year. By comparison, statistics show that about support for their families. The death of a mother 65 000 to 68 000 MTP procedures are performed is one of the most traumatic events that can befall annually (see Fig. 9). Thus, only 43% to 45% of a family. Deaths and severe illness due to unsafe unwanted pregnancies are safely terminated. Most abortion, which women may resort to when pregnancy of the remainder of these unwanted pregnancies is unwanted, need to be prevented at any cost. result in births, but in too many instances women resort to unsafe, clandestine abortion—sometimes Abortion is not unique to Tamil Nadu. It is a universal with dire consequences. Analysis of verbal autopsies phenomenon. Women have always sought to has revealed that lack of access to MTP services terminate pregnancy through abortion, whether explains 6% of maternal deaths in Tamil Nadu.
18 Safer Pregnancy in Tamil Nadu: From Vision to Reality women are encouraged to use MVA Fig. 9: Legal terminations of pregnancy services, if they need them, through in Tamil Nadu, 2002–2007 discussion in outpatient services (antenatal and postnatal outpatient 69,000 and well-baby clinics) and also in the 68,310 68,000 respective wards. All medical and
P 67,000 67,129 paramedical staff members of the MT 66,000 65,690 hospitals/PHCs are involved in raising of
er 65,000 64,734 women’s awareness of MVA;
mb 64,000 pamphlets prepared in Tamil are distributed Nu 63,000 to the women attending clinics as 62,000 2002-03 2003-04 2004-05 2005-06 outpatients, and sign boards are put up in Year the wards; hoardings are put up in prominent public places advertising the availability of MVA Methods of termination services at the local hospitals/PHCs; local cable television stations are A majority of abortions—80% to 90%—are approached for free display of line performed during the first trimester of pregnancy. advertisements during their programmes; wherever available, FM radio stations Surgical vacuum aspiration are approached for free broadcasting of messages about MVA; The standard method of pregnancy termination self-help groups and anganwadi workers in the first trimester is surgical evacuation of help to inform people about MVA and its uterine contents after cervical dilatation (vacuum availability; aspiration). When provided properly by trained through proper counselling, care is taken to personnel, vacuum aspiration is a safe procedure. In ensure that a woman does not come to rely India doctors undergo special training before being on this method instead of contraception; certified to carry out legal surgical abortions, and training of doctors on MVA is ongoing. the places where they are conducted also need to To overcome the problem of the trained be certified. doctors being transferred, more doctors, including interested male medical officers, Manual vacuum aspiration are trained in MVA; monitoring of MVA-related activities is Manual Vacuum Aspiration (MVA) is a simple undertaken by the Deputy Director of Health technique to terminate pregnancies within eight Services at the district level and by the State weeks of conception. In Tamil Nadu MVA was piloted Coordination Team at the state level. in 2004–05 under RCH I in five districts through seven medical colleges as well as through Chennai Path 2: Promotion of good- Corporation. This pilot scheme could provide 6000 quality antenatal care and MVA procedures in one year. Based on the success of the pilot scheme, RCH II/NRHM is scaling up MVA institutional deliveries services. While impressive progress toward demographic Strategy for scaling up MVA and fertility goals has been made, the trends in reproductive health goals, such as MMR and The goal of scaling up is to increase performance of IMR, while in the right direction, have not gone MVA by 5 to 10 cases per month in each participating as far or as fast as desired. There has, no doubt, health institution and so to reduce the number of later been an overall decline in both the MMR and MTP procedures. The initiatives for scaling up are: the IMR over the past three decades (see Fig. 1 in
Rhetoric to Reality: Reducing the MMR 19 Chapter 1). In the most recent decade, however, screening for high-risk factors and referral the pace of decline has slowed. In the case of the to higher-level medical facilities; IMR, stagnation is noticeable between 2005 and five antenatal visits and administration of 2006. tetanus toxoid; screening for RTIs and STIs; counselling and Paradigm shift in policy treatment; institutional deliveries and deliveries by In the mid-1990s the Government of Tamil Nadu skilled birth attendants—nurses, doctors, recognized the need for: ANMs, and VHNs; deliveries by trained “dais” universalizing access to good-quality (traditional birth attendants) will take place antenatal care; only if other skilled birth attendants are not improving access to skilled delivery care in available, and deliveries by untrained birth institutional settings; attendants will be avoided; improving the quality of essential obstetric postnatal care and infant care; care; growth monitoring; improving the quality of emergency immunization services for infants and children; obstetric care. offer of contraceptive choices and These steps are essentially designed to make counselling that satisfies clients’ needs; pregnancy safer, reduce maternal mortality, and safe abortion services. assure newborn survival. This Government Order paved the way for Antenatal care improvement in the quality of essential obstetric care through good-quality antenatal care and an The Government of Tamil Nadu issued a increase in institutional deliveries. Government Order, GO Ms. No. 353 Health and Family Welfare, dated May 30, 1995, giving clear Scenario analysis direction to its policy of promoting skilled delivery care in institutional setting and enhancing the National Family Health Survey data document nearly quality of MCH and Family Welfare services. universal antenatal care coverage in both rural and urban Tamil Nadu. An upward trend in antenatal The highlights of the Government order are: care in Tamil Nadu from 1992–93 (NFHS 1) to registration of pregnancies within 12 weeks 2005–06 (NFHS 3) can be seen in data from the of conception; National Family Health Surveys (see Table 3).
Table 3: Antenatal care performance in Tamil Nadu NFHS 1 NFHS 2 NFHS 3 1992–93 1998–99 2005–06 Indicator (percent), most recent pregnancy before survey Mothers receiving any AN care 97 99 100 Mothers with at least three AN visits during last pregnancy 88.4 90.9 96.5 Mothers who had consumed iron–folic acid for 90 days or more during last ND ND 43.2 pregnancy Deliveries assisted by a doctor/nurse/LHV/ANM/other health personnel 69.3 83.7 93.2 Births in institutions 64.3 79.3 90.4a Mothers who received postnatal care from a doctor/nurse/LHV/ANM/ ND ND 89.6 other health personnel within two days after delivery
ND, not determined; NFHS, National Family Health Survey; AN, antenatal; LHV, Lady Health Visitor; ANM, auxiliary nurse-midwife a 95.6% in 2005–06 according to state government data
20 Safer Pregnancy in Tamil Nadu: From Vision to Reality Institutional deliveries Fig. 11: Increase in percentage of deliveries taking place in Institutional delivery is promoted as a state policy. In institutions, Tamil Nadu, 1993 the state population policy, announced by the 1971–2008 State Population Council chaired by the Honourable Chief Minister of Tamil Nadu, recommended a Total deliveries 11.38 lakhs goal of 90% institutional deliveries by 2000 as one of the family welfare service packages. To 1971 1981 1991 promote institutional deliveries, incentive packages 18.8 announced included: 61.7 50.9 24.4 a payment of Rs. 50 per woman to Village 18.1 56.8 18.0 20.3 31.0 Health Nurses (VHNs)/auxiliary nurse-
midwives (ANMs) if five antenatal care visits 1996 2007-08 are provided and institutional delivery is (through Dec.)
conducted by the VHN/ANM; 20.9 an incentive of Rs. 25 if only antenatal 14.4 98.1 1.7 0.2 care is provided by the VHN/ANM but 64.7 the woman is referred for institutional delivery. Institutional deliveries Domiciliary deliveries conducted by trained This health reform has paved the way for improving personnel both the quality of antenatal care and the rate of Domiciliary deliveries institutional deliveries. conducted by untrained personnel Data show acceleration in the growth of institutional deliveries: an upward trend occurred between 1971, at 20.3%, and 1991, at 56.8%—an increase The distribution of institutional deliveries by of 36.5 percentage points in two decades; sector presents an interesting picture (see Fig. 11). by comparison, in the decade between The share of deliveries taking place at home has 1996 and 2005, there was a growth of declined over time, with a distinct shift towards nearly 30 percentage points, from 64.7% institutional delivery in the public health system. In to 94.3%. 2008 domiciliary deliveries accounted for only 2% of all deliveries. In general, deliveries at PHCs have The findings of the three rounds of the National grown dramatically between 2006 and 2008, while Family Health Survey (NFHS) are similar to the data at all other locations the percentages have declined on institutional deliveries reported by the State slightly (see Fig. 12). (see Fig.10). In several districts the distribution of deliveries Fig. 10: Trends in institutional deliveries, reveals a shift over time from the private sector to Tamil Nadu the public sector, specifically to PHCs and HSCs. The picture in Theni District is a case in point. In 100 93 95 s 91 90 90 Theni District there has been a substantial decline 80 79 87 70 64 in home deliveries, from 25.2% in 1999–2000 to 72 60 Urban 50 4.8% in 2004–2005, with a corresponding increase 50 Total 40 Rural in institutional deliveries at the primary care 30 20 level (see Fig. 13). This is a clear example of the 10 Percentage of deliverie improved quality of public-sector health care in taking place in institutions 0 NFHS INFHS 2 NFHS 3 Tamil Nadu.
Rhetoric to Reality: Reducing the MMR 21 Fig. 12: Trend in place of delivery, marketing services through “maternity Tamil Nadu, 2005–2008 picnics”; raising awareness of the essential 45 emergency first aid services for 40 Government mothers, newborns, and children 35 hospitals available at the point-of-care in Primary Private 30 institutions Health Centres; 25 PHCs promoting referral companionship, which allows a female family member 20 HSCs or friend to accompany the patient 15 Domiciliary 10 when she is transported from the Percentage of deliveries primary level to a first level referral 5 health facility. 0 2005 2006 2007 2008 Encouraging institutional delivery among women below the poverty line
What motivates the passion of public health Tamil Nadu Government special scheme for pregnant administrators and PHC providers to enhance the women. Under the Dr Muthulakshmi Reddy quality and increase the use of PHC services in Maternity Assistance Scheme, the Government of general and of maternal, newborn, and child health Tamil Nadu provides cash assistance of Rs. 6000 for services in particular? Motivating factors include the each pregnant woman from a Below Poverty Line following: (BPL) family. The payment compensates for loss of innovations piloted in a district can be wages and pays for nutritional supplementation to scaled up state-wide based on evidence prevent low birth weight babies. To operationalize and experiences; the scheme, EDD (Expected Date of Delivery) exchange visits to better performing PHCs surveillance of pregnant women is undertaken in and districts provide for on-site learning from evidence and experience; better performing administrators and PHC providers receive public recognition, which Fig. 13: Trend in institutional and home deliveries, Theni District, fosters healthy competition; Tamil Nadu, 1999–2005 elected local government representatives and ministers publicly express appreciation of public health administrators and 2005–06 providers; 2004–05 2003–04 the availability of good physical infrastructure, good training, modern 2002–03 equipment, and essential drugs and other 2001–02 2000–01 supplies encourages providers to do their 1999–00 best; Year 1998–99 under NRHM decentralization of decision- 1997–98 making on the use of flexible financing 1996–97 empowers PHC providers; 1995–96 Domicillary the public information campaign of NRHM 1994–95 Institutional services and the mass media inform the 1993–94 public and build a positive image of the 0 10 20 30 40 50 60 70 80 90 100 government health care delivery system by Percentage the following means:
22 Safer Pregnancy in Tamil Nadu: From Vision to Reality each and every village; a seniority list is maintained Nadu has introduced a birth companionship in the PHCs; and, based on the budget allocation, programme for institutional deliveries. The presence Rs. 3000 is distributed before the delivery and of a companion during childbirth is meant to ensure Rs. 3000, after the delivery. that a woman is never left alone during this intensely stressful and frightening time. She is comforted, Government of India special scheme for pregnant reassured, and encouraged throughout childbirth. women. The Janani Suraksha Yojana (JSY) under NRHM aims to reduce MMR and IMR by helping to The birth companionship programme is a low-cost support skilled attendance during childbirth for intervention that has numerous benefits: BPL families. The cash assistance under the scheme shorter duration of labour; varies with the area and place of delivery. less need for pain medication; fewer medical procedures; decreased rates of caesarean section; Institutional decreased augmentation of labour with Area delivery Home delivery oxytocin; Rural Rs. 700 Rs. 500 mothers’ increased satisfaction with the Urban Rs. 600 Rs. 500 birthing experience; better bonding between infant and mother; The BPL criteria are not applicable to scheduled increased breastfeeding success; caste (SC) and scheduled tribe (ST) families. decreased postpartum depression; reduced informal payments in the hospital. Maternity picnics promoting delivery at PHCs Previously, the environment in hospitals was quite The Department of Public Health has introduced a different. Relatives were not allowed to enter the new way to encourage more pregnant women to maternity wards, and women delivered without deliver at PHCs—“maternity picnics”. The picnics any support. Relatives normally accompanied the attract pregnant women to tour their local PHC woman to the hospital but remained outside the and see the recent improvements made in the wards until they were told about the outcome of facilities and the quality of care. During the visit labour. the women can meet the doctors and nurses and see the ultrasound scan facility, the labour room, Birth companions were first allowed in a private and the 24-hour care centre. At the same time the hospital, CMC Vellore, several years ago. Then, during woman can obtain appropriate medical tests and the extended period of RCH I, Chennai Corporation check-ups. The strategy is to show women that the started implementing this activity in two 24-hour PHCs are welcoming places with friendly staff and emergency obstetric care (EOC) centres. It appeared thus give them confidence to choose to deliver at a that women appreciated the new policy. government health institution. The service package and facilities in this programme Birth companionship programme comprise: presence of a companion during the Unfortunately, as medicine and care of women process of labour; during childbirth has become technically facilities at the hospitals for birth more advanced, in many places the role and companionship; importance of companions during childbirth seems screens between the labour boards to to have been sidelined and forgotten. Not so in ensure privacy; Tamil Nadu. seating for the birth companion.
To make institutional delivery more appealing The duty nurse counsels the birth companion before to women and to improve labour outcomes, Tamil allowing her inside the labour room. All the doctors
Rhetoric to Reality: Reducing the MMR 23 and the staff nurses are sensitized to the birth was sent to the Directorate of Medical Education companionship programme. (DME), the Directorate of Medical Services (DMS), and the Directorate of Public Health (DPH). In the Strategy for scaling up birth companionship medical colleges the services of postgraduate students are used to document this activity. In view of the impact of birth companionship on the quality of care, reducing the need for surgical Following the state-level meetings, the Heads of interventions during delivery, RCH II/NRHM has Department of Obstetrics and Gynaecology of scaled up this programme throughout the state, the medical colleges briefed the obstetricians, in all the public health facilities conducting postgraduate students, and staff nurses working deliveries. in the labour wards on the birth companionship programme. At the district headquarters hospitals, The processes in the scaling-up of birth the Joint Directors of Health Services and senior companionship in the health facilities at different civil surgeon specialists sensitized the obstetricians levels began with two state-level meetings to and staff nurses of the headquarters hospitals and sensitize the obstetricians and district officials to the the obstetricians/lady doctors of all the sub-district birth companionship programme. During the state- hospitals. In turn, the obstetricians held sensitization level meetings the participants developed: sessions for the doctors and all the staff nurses in the an action plan to implement this activity in hospitals. their hospitals; a form to obtain feedback from a sample of Gestational Diabetes Mellitus— the beneficiaries; Prevention and Control at PHCs monitoring forms to assess the impact of the programme on birth outcomes. Gestational diabetes mellitus (GDM) is a disorder that is on the increase. It causes abortion, stillbirth, Also, one senior obstetrician/senior doctor in each big baby, birth defects, respiratory distress, neonatal hospital was identified as the nodal officer for death, and, at times, even maternal death. GDM can implementing this activity and for collecting and be prevented and managed at PHCs to ensure safer submitting reports. The name of each nodal officer pregnancy and newborn survival.
Special efforts for hard-to-reach populations and communities
Improvement in access to health facilities and health services for the underprivileged sections of society, as well as the population in remote areas including the tribal population, has been one of the key goals in all the health interventions in the state. This focus is reflected in the provision of outreach services, ambulance support, waiver of charges for families below the poverty line, routine visits by the Village Heath Nurses to such communities, and the like.
The tribal populations constitute a unique segment. The majority are economically deprived, socially marginalized, and lacking resources. Their access to health care, education, employment, and other income-generation opportunities is limited. Also, the literacy level among the Scheduled Tribes is low. The health problems of the tribal people across Tamil Nadu are not uniform. Despite a number of interventions by the state government, the vulnerable tribal community is still unable to obtain access to basic health care.
In view of this, a special tribal component forms part of the RCH programme. This component has been integrated into a cohesive Tribal Development Plan along with all the other health-related programmes addressed to tribal populations, such as leprosy eradication, TB control, and on-going welfare schemes. This plan supports extensive NGO participation in health care delivery to the tribal populations in the state.
24 Safer Pregnancy in Tamil Nadu: From Vision to Reality The four-pronged strategy adopted to prevent and Fig.14: Direct and indirect causes of control GDM comprises: maternal deaths supply of semi-auto analyzers for blood sugar estimation; Maternal deaths training of doctors, laboratory technicians, and nursing staff ; patient education; awareness-raising at the community level. Direct causes Indirect causes Path 3: Reducing the likelihood of death among women who Deaths not Deaths due attributable to experience complications to obstetric direct obstetric complications, causes but resulting Pregnancy, although a normal process, carries with inadequate from disease that interventions, delay it risks of disability and death. Unfortunately, many previously existed in reaching a health women are either unaware of such risks or fail to or that developed facility/receiving or was aggravated appreciate the seriousness of the risks. treatment during pregnancy The maternal mortality ratio (MMR) in Tamil Nadu was disproportionately high before 2000 despite the positive shift towards institutional deliveries. include unwillingness to seek appropriate medical Thus additional actions were needed to lower the assistance in time, cultural constraints, and absence MMR even further. of adequate transport to reach the appropriate health facility in time. Besides promoting good-quality antenatal care and the shift to institutional deliveries, Tamil Nadu’s The poor health condition of the women, due to public health initiatives to decrease maternal deaths malnutrition, anaemia, HIV infection, or repeated geared up to: childbearing, in the absence of a woman’s freedom improve surveillance of maternal deaths; to choose whether and when to have a child, is yet conduct verbal autopsies, pinpointing the another causative factor. determinants of maternal deaths to identify preventable causes of delay; Maternal deaths can occur: initiate corrective measures. at any stage—before, during, or after delivery; The impact of these eff orts is visible in the declining at any place—at home, at the health facility, trend in the MMR since 2001. or during transit.
Causes of maternal deaths Adequate monitoring of each pregnancy and appropriate strategy to handle any emergency is Both direct and indirect causes contribute to the only way to deal with this serious issue. Most maternal deaths (see Fig. 14). Important among maternal deaths and disabilities can be averted if the direct, obstetric causes are severe bleeding, adequate care is exercised at all the diff erent stages— eclampsia, complications of unsafe abortion, pregnancy, childbirth, and the puerperium. obstructed labour, sepsis, and pregnancy-induced hypertension. If these conditions are managed and Delays in seeking care, delays in access to a health treated promptly and adequately, nearly all maternal facility, and delays in getting adequate and timely deaths can be prevented. Thus, when deaths occur, medical care all play their roles in causing maternal it is often because circumstances have prevented deaths. Lack of readiness at health facilities to handle prompt and adequate care. Such circumstances emergency situations and provide comprehensive
Rhetoric to Reality: Reducing the MMR 25 emergency obstetric care also are contributing factors, as are poor antenatal, natal, or postnatal Fig. 15: Percentage of maternal deaths, by number of institutions visited care. before death, Tamil Nadu, 2004 The three delays Percentage of maternal deaths, by number of institutions visited before death, Tamil Nadu, 2004 An analysis of the determinants of maternal deaths in 2004 revealed how much each of the “three delays” contributed (see box at right). The case studies in Four None 8% Annexure 1 illustrate how the three delays play out 9% Three in specific circumstances. One 17% 26% In view of this finding, the Government of Tamil Nadu gave the three delays the highest degree of Two attention. Appropriate interventions were designed 40% to shorten all three delays, which could make the critical difference between life and death for a pregnant woman. the first delay is shortened by the presence of a skilled birth attendant at the place of Study Report - DD RCH delivery; reducing the second delay requires emergency transport; continuum of care from the community to shortening the third delay depends on the first referral level health facility, with the skill and responsiveness of medical shortening of the Three Delays; and support staff, equipment, drugs, and around-the-clock access to emergency supplies at the first referral facility. obstetric care services at the first referral level. The same analysis revealed that multiple referrals— sending the woman on to another centre— Surveillance of maternal deaths and accounted for two thirds of maternal deaths, as estimating the actual number of shown in Fig. 15. maternal deaths
The systemic corrections initiated addressed the key Most maternal deaths can be averted even where issues: resources are limited. The right kind of information surveillance of maternal deaths; is essential, however, to guide appropriate action. Just knowledge of the levels of maternal mortality is not enough. Information is needed also on the causes and circumstances that have led to maternal The three delays in Tamil Nadu, 2004 deaths so that corrective measures can be taken.
Delay 1: Delay in deciding to seek appropriate care, Identification of maternal deaths is the first step contributing to 40% of maternal deaths in the surveillance process. Tamil Nadu initiated Delay 2: Delay in reaching a first-level referral facility, identification and compulsory reporting of contributing to 37% of maternal deaths maternal deaths in 1994. It was mandated that each and every maternal death be reported by the Delay 3: Delay in receiving adequate care at the Village Health Nurse working at the level of the referral facility, contributing to 23% of maternal Health Sub-Centre, the medical officers of primary deaths health centres, first referral unit (FRU) and non-FRU
26 Safer Pregnancy in Tamil Nadu: From Vision to Reality causes and circumstances takes place Fig. 16: Number of maternal deaths when a maternal death occurs at a health reported, Tamil Nadu, facility. Deaths are initially identified at the 1994–2007 facilities, but such reviews try to identify the contributory factors both at the facilities 1800 1628 and in the community; 1600 1432 1498 1307 1400 1297 1253 near-miss case audits. Surveys investigate 1219 1035 1200 1100 1131 1089 1014 the severe morbidity of any pregnant or 1000 905 800 recently delivered woman (within six weeks 600 640 after termination of pregnancy or after 400 delivery) whose immediate survival was 200 0 threatened and who survived, whether by chance or because of the hospital care that 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 she received; Source: PHC Records clinical audits. A quality improvement process seeks to improve patient care and government hospitals, district public health nurses, outcomes through the systematic review of and Deputy Directors of Health Services. care and identification and implementation of needed changes. The quality of the The efficacy of reporting has improved over time. care processes and outcomes of care are By 2001 all maternal deaths were being reported examined and evaluated against explicit (see Fig. 16). The apparent increase in the number criteria. Where indicated, changes are of maternal deaths between 1994 and 2001 seen in made at the individual, team, or service the graph reflects improvements in reporting due to level, with further monitoring to confirm a better surveillance system. It does not reflect an improvements. actual increase in maternal deaths. All these reviews are aimed at answering the Investigation of maternal deaths and findings following questions: why do women die of pregnancy? Along with the identification and reporting process, is it because they were unaware of the need investigations began into the causes of maternal for care or unaware of the warning signs of deaths. The investigation methods are multi- problems of pregnancy? dimensional: verbal autopsy. Community-based maternal death reviews help to identify Findings from analysis of verbal autopsies the medical and non-medical causes of of maternal deaths deaths and to ascertain the personal, family, or community factors that may have 1. Maldistribution of First Referral Units (FRUs) and contributed to the deaths of pregnant shortage of specialists women occurring outside a health facility. 2. Sub-standard care in the institutions and poor accountability of service providers In the verbal autopsy people who are knowledgeable 3. Unnecessary referrals about the events leading to death, such as family 4. Lack of emergency transport facilities members, relatives, neighbours, and traditional birth attendants, are interviewed. The public health 5. Overcrowding of FRUs nurses and medical officers of primary health centres 6. Unmet need for MTP and tubectomy services are trained to conduct verbal autopsies. 7. Poor skills of field health functionaries facility-based maternal death reviews 8. Lack of community awareness A qualitative in-depth investigation of
Rhetoric to Reality: Reducing the MMR 27 is it because the services did not exist conducting normal deliveries; or were inaccessible for reasons such as identifying complicated deliveries and distance, cost, or socio-cultural barriers? referring to CEmOC and newborn care Are women dying because the care they centres; receive is inadequate or even harmful? identifying danger signs during labour and arranging for timely transport to CEmOC The Verbal Autopsy conducted in Tamil Nadu has and newborn care centres; brought to light several key issues (see box). For attending to newborn care and services; more on maternal death audits, see Additional referring newborns with complications; Information, Part 4, Continuous monitoring and assisting medical officers in out patient periodic evaluation. clinic; inserting IUDs; Interventions to shorten the three assisting medical officers in family welfare delays surgical procedures— tubectomy and IUD insertions, both postpartum and interval; Interventions to shorten the first delay—the providing first aid to emergency cases 24x7 model reporting outside outpatient hours and referring to First Referral Unit (FRU)/CEmOC Providing safe delivery services to the pregnant and newborn care centres. woman at any point in the day requires the around- the-clock presence of qualified personnel in the The staff nurses also assist the PHC medical officers Primary Health Centres (PHCs), which are the with treatment of minor ailments, especially outside most accessible health care facilities. RCH I piloted the outpatient clinic hours. They also train the a scheme to provide 24 hour a day availability auxiliary nurse-midwives in the conduct of safe of staff nurses—three nurses on eight-hour shifts deliveries. instead of the usual two nurses—in 90 PHCs located in the remote rural areas of Madurai District. The To support the staff nurses in their service activities, scheme, known as the 24×7 model, has now been two sanitary workers have been posted to each scaled up to cover the entire state—all 1421 PHCs. PHC on a consolidated salary along with a driver to transport labour cases at the first signs of life- Staff nurses have been recruited on a contractual threatening danger. arrangement and are paid a consolidated salary of Rs. 2500 per month, along with a payment of Rs. 25 for each delivery attended. In addition, they receive This intervention has substantially improved the a bonus of Rs. 1000 for accepting a rural posting. delivery performance in the PHCs and aided in early The staff nurses have been trained in obstetric and identification of childbirth complications for timely newborn care skills through the RCH Integrated referral to FRU/CEmOC and newborn care centres. Skills Training Programme. Thus, the first delay has been shortened by the presence of a skilled birth attendant at the place of The services of the staff nurses have been of great delivery. support in conducting normal deliveries, attending to sick newborns, and referring complicated Performance analysis has found that PHCs with pregnancies to the FRU/CEmOC and newborn care these staff nurses conducted an average of 15.5 centres for management by obstetrics specialists. deliveries per month in 2003–2004. By comparison, The nurses’ responsibilities include: the average for all PHCs in the state was only 4.2 organizing antenatal clinics in PHCs; deliveries per month (see Fig. 17). blood grouping and Rh typing for pregnant women in antenatal care; Also, with the primary level handling normal recording of information on the antenatal deliveries, pressure at the secondary and tertiary card; levels for normal deliveries is enormously reduced.
28 Safer Pregnancy in Tamil Nadu: From Vision to Reality mother and baby, and counselling on appropriate Fig. 17: Average number of deliveries breastfeeding and infant feeding practices. per month per primary health centre, centres with three nurses The service package at the upgraded PHC/Block compared with state average, PHC level comprises: 2000–2004 weekly antenatal/postnatal clinics; around-the-clock availability of essential obstetric and newborn care services; 16 15.5 around-the-clock availability of emergency 14 first aid services for stabilizing obstetric 12.6 13.4 12 11.9 emergencies before referral; 10 around-the-clock availability of referral services for complicated deliveries and 8 obstetric emergencies; 6 around-the-clock availability of emergency 4 transport services; 4.4 3.2 3.8 4.2 2 breastfeeding and infant feeding counselling; around-the-clock availability of PPTCT 0 services, antiretroviral prophylaxis, and 2000-01 2001-02 2002-03 2003-04 counselling for HIV-positive mothers All PHCs Staff Nurse Posted PHCs on breastfeeding and infant feeding practices; Integrated Management of Newborn and Childhood Illnesses (IMNCI); This allows such facilities to concentrate more on a range of contraceptive services to prevent providing emergency obstetric and newborn care. unwanted pregnancies; MVA services for termination of unwanted From the economic perspective, it costs as much to pregnancies; employ one doctor as it does to pay three contracted weekly RTI/STI clinics, syndromic staff nurses. Therefore, this intervention has proved management of STIs/STDs, and treatment to be technically and economically sustainable. of opportunistic infections; community outreach services for a range Scaling up the 24x7 model of RCH services, syndromic management of STIs, and treatment of opportunistic Given such promising results, the 24×7 model has infections; been scaled up in phases. The objective is to ensure cervical cancer screening, breast self- the quality of and access to antenatal and postnatal examination, and referral services; care, 24 hour a day delivery services, BEmONC mainstreaming of the Indian System of services, and prevention of parent-to-child HIV Medicine in all RCH services; transmission (PPTCT) services in the upgraded PHCs universal precautions, infection control and Block PHCs. protocols, and biomedical waste management practices. The upgrade of public health centres to Basic Emergency Obstetric and Newborn Care (BEmONC) The European Commission, in its 2004 report Good centres has incorporated the RCH and HIV prevention Practices and Cost Effectiveness, described and convergence strategy. This strategy includes commended the 24-hour delivery care scheme promotion of safer sexual behaviour, condom use for of Tamil Nadu as a sustainable model. The report dual protection against pregnancy and STI/HIV, HIV noted: “The critical factor was 24-hour availability of counselling and testing, elective caesarean sections skilled female paramedical staff. In the PHCs which for HIV-positive women, nevirapine prophylaxis for instituted this regime, there was a large increase in
Rhetoric to Reality: Reducing the MMR 29 the number of deliveries being carried out including during the night.” Monitoring indicators for 24-hour PHCs
Support to staff nurses in the PHCs The performance of 24-hour PHCs is monitored with the following indicators: Even with a recruitment incentive of Rs. 1000, most number of antenatal clinics conducted; staff nurses have been reluctant to work in the PHCs, number of normal deliveries conducted; largely because of their rural location. Moreover, number of complicated deliveries identified the PHCs lack residential facilities, and the nurses and referred to CEmOC and newborn care have had to struggle even to find places to stay centres; in the villages. Staff nurses who are recruited on number of cases with “danger signs” consolidated salary have been paid Rs. 2500 per identified during labour and transported to month regardless of where they are posted. CEmOC and newborn care centres; number of newborns with complications This situation has resulted in large number of identified and referred to CEmOC and vacancies in the PHCs, adversely affecting the newborn care centres; delivery services and the availability of around- number of IUD insertions; the-clock basic emergency care. To correct this, it is number of family welfare operations; proposed to pay a special allowance of Rs. 1500 per number of emergencies reporting outside month to all staff nurses posted in the PHCs. out-patient hours attended, given first aid, and referred to FRUs. Some PHCs are located in remote and inaccessible places. Action has already been initiated to identify these PHCs and to declare them “difficult” PHCs. It is proposed to pay the staff nurses posted in these sounds of these bangles are said to reach the womb, difficult PHCs a further special allowance of Rs. 2000 conveying the mother’s happiness to the foetus to per month, in addition to the payment of the PHC make it happy. special allowance of Rs. 1500 per month. Traditionally, this ceremony takes place in the home A further move is on in the state to empower of the pregnant woman’s mother. In Tamil Nadu paramedical functionaries, such as the staff nurses the primary health centres conduct the bangle and auxiliary nurse-midwives, to perform life-saving ceremony for women receiving antenatal care. Thus, obstetric procedures—obstetric first aid and prompt traditional Tamil culture and modern health care management of postpartum sepsis in newborns join together to foster healthy pregnancy. A press including use of injectable antibiotics. clipping on valaikappu is reproduced on this page.
Valaikappu for pregnant women Interventions to shorten the second delay—emergency transport services The “bangle ceremony” is traditionally performed for a pregnant woman during the odd-numbered Most of the maternal deaths are due to delays in months of pregnancy and particularly during the arrival at a FRU/CEmOC and newborn care centre. seventh month. As part of the ceremony, her family Most often, lack of transport at the crucial hour has and guests give her many bangles to wear. The caused this fatal delay.
1 European Commission. Report on good practices and Even if private transport is available, the patient may their cost effectiveness (reproductive and child health), not be in a position to afford the often high cost. volume III. Government of India, Department of Family Most of the poor could not hire private transport. Welfare, and European Commission, March 2004. Online at http://www.solutionexchange-un.net.in/health/cr/ Also, precious time is lost in mobilizing resources for res29040506.pdf. transport. Furthermore, women often are brought
30 Safer Pregnancy in Tamil Nadu: From Vision to Reality to a health facility where emergency obstetric care due to fuel restrictions, the vehicles were available is not available, resulting in multiple referrals. for only a few days in each month.
Although the absence of specialists and blood in Pilot scheme the health facilities also are important contributors to maternal deaths, lack of transport of obstetric In recognition of this need, RCH I tried an innovative emergencies is the single most important non- initiative in the sub-project area of Theni district, medical cause of maternal deaths. Indeed, the establishing emergency ambulance service with two causes are closely related. Referral from one support from an NGO, Seva Nilayam Society. health facility that lacks specialists or blood to another facility increases the transport cost and the risk of Seva Nilayam, in association with the Ryder– death due to delay in the initiation of treatment. Cheshire Foundation, expressed its willingness to organize emergency transport. Hence, the Government ambulance facilities at the FRUs/ organization was identified as the sole-source CEmOC and newborn care centres and the PHCs agency to run the ambulance service in Theni have not been available around the clock. Moreover, district (see box).
NGO Seva Nilayam Operates ambulance service
Seva Nilayam Society (Home Service) is a non-profit health and development initiative located in the picturesque Theni District, about 67 km west of Madurai. British–born Dara–Mary Scarlett, MBE, established the institution in 1962, motivated by an altruistic desire to work for the medico-social betterment of the rural poor.
Nearly four decades later Seva Nilayam has moved beyond its initial focus on social service to its current status as a development organization implementing diverse health and development programmes through 450 women’s self help groups and a federation of 7000 women. All Seva Nilayam programmes are people-centred, participatory, and geared towards sustainable development. Seva Nilayam has a well-equipped hospital and laboratory, a 15-bed TB/AIDS isolation ward, and support services such as siddha and homeopathy clinics, a model herb garden, and a training centre.
Rhetoric to Reality: Reducing the MMR 31 Salient features of the referral transportation room immediately arranges for the transportation scheme are described in the Additional Information, of the emergency case to a nearby hospital. Part 1, Referral transport. Simultaneously, the control room alerts that hospital to be ready to receive and attend to the patient. Outcome (For more about the control rooms, see Additional Information, Part 1, Referral transport.) The positive outcomes of this scheme were evident: on average, 30–45 emergency cases were Interventions to shorten the third transported per month, of which 30% were delay—strengthening emergency care obstetric emergencies; all accident emergencies were transported In 2004 three quarters of all maternal deaths took free of cost; place during the natal and postnatal periods, while there was a growing demand for more one quarter occurred during the antenatal period. ambulances. The Rotary Club of Theni Available data also indicate that about one fifth of all District and the Road Transport Corporation maternal deaths occur during the process of finding came forward to provide four more vehicles transportation and travelling to an appropriate and to the NGO; affordable health facility following the onset of an other NGOs expressed their willingness to obstetric emergency. run a similar service in other districts; dead bodies also were transported in the Given these statistics, further reduction in the MMR in ambulances. the state depends crucially on provision of emergency obstetric services. Tamil Nadu has entered a phase in Despite such positive outcomes, there were also a which high-quality natal and postnatal care in health few areas of concern. The NGO reportedly incurred facilities and follow-up care in the field are essential a loss of Rs. 5000 per month in this operation. Also, to further improve rates of maternal survival. the vehicles broke down frequently because they Emergency obstetric services must be established were old. in appropriately situated institutions so that people everywhere in the state have ready access to them. Scaling up Also, the quickest possible transportation of the mother to such institutions has to be ensured. The aim is to have, with NGO partnership, a viable and efficient ambulance service around the clock Tamil Nadu has brought down the infant mortality for immediate and specialized treatment of patients rate (IMR) substantially over the years. Its IMR in need. Under the World Bank-supported Tamil in 2006, at 37 infant deaths per 1000 live births, Nadu Health System Project (TNHSP), a District is unquestionably low. It is a matter of concern, Emergency Ambulance Services Society was however, that the pace of decline has been slow or formed, with the District Collector as Chairman. stagnant recently. Further reduction in the state's The Committee identified suitable NGOs to operate IMR can come only from reduction in neonatal such services in the Districts. TNHSP provided new mortality, especially early neonatal mortality—deaths vehicles to the NGOs—one per block, for a total of occurring within the first seven days after birth. This 385 ambulances. calls for special attention to newborn care.
Referral control rooms in all districts Safe motherhood programme for strengthening First Referral Units (FRU/CEmOC Referral control rooms in each district give the public and newborn care) to provide emergency access to timely ambulance transportation to health obstetric care services services. People in need of ambulance services call the control room on a telephone helpline that has First, some preceding developments are worth the same number throughout the state. The control recalling for a proper perspective on the state
32 Safer Pregnancy in Tamil Nadu: From Vision to Reality initiatives. In 1990 the Government of India Transition from FRU to CEmOC and newborn launched the Child Survival and Safe Motherhood care in 2002–03 Programme (CSSM), with a component strengthening FRUs for emergency obstetric and Instead of equipping all FRUs to handle obstetric newborn care. Tamil Nadu followed this with emergencies, the Government of Tamil Nadu several initiatives. Of the 163 FRUs identified took a policy decision to upgrade strategically in 1994 under the Child Survival and Safe located FRUs in each District to Comprehensive Motherhood Project, 24 hour a day comprehensive Emergency Obstetric and Newborn Care (CEmOC emergency obstetric care including caesarean- and newborn care) centres. This revitalization section was available in only 30%. of the CEmOC and newborn care concept and the around-the-clock availability, accessibility, Strengthening these units involved the following and affordability of services in the centres are steps: essentially directed at bringing down the MMR and IMR in the state. the state FRU Task Force was formed in 1994 to coordinate the strengthening of 163 FRUs to provide emergency obstetric Government orders were issued for the provision and newborn care. UNICEF provided of 24-hour CEmOC and newborn care services in two support and partnership; or three hospitals in each district. Some 62 strategically located hospitals—10 teaching equipment for strengthening emergency hospitals and 52 FRU/CEmOC and newborn care obstetric and newborn care in all FRUs was centres (secondary-level hospitals)—were identified. procured in 1995, using unspent funds These facilities were chosen so that any complicated of Rs. 40 crores (Rs. 400 million) from the delivery can reach one of these hospitals within one World Bank-supported IPP V Project and hour of travel. from UNICEF/GOI funds; a Government Order was issued for Service package and support structure specialist postings in FRUs, and a special The following services are available around the clock recruitment drive was undertaken. Some 60 in the CEmOC and newborn care centres: specialists (including 45 gynaecologists and manual removal of the placenta; 15 anaesthetists) were posted in various dilatation and curettage; FRUs in 1996; instrumental vaginal deliveries; with support from UNICEF in 1995–97, 82 caesarean section; obstetricians, 103 paediatricians, and 128 management of pregnancy-induced nurses from 163 FRUs were trained for hypertension and related disorders; 21 days on skills in providing emergency management of diseases complicating obstetric and newborn care; pregnancy; a Government Order was issued for emergency laparotomy and hysterectomy; conducting death audits in all FRUs, and blood transfusion services; in 1996–97 the RCH project intensified the supporting laboratory and imaging services; reporting and investigation of maternal emergency newborn care. deaths;
review meetings were regularly held in Coordination/review meetings take place once 2000–03 at regional and state levels, with a month. They bring together the obstetricians UNICEF support, for rigorous monitoring of and superintendents of the hospitals, medical FRU services. officers of the nearby hospitals/PHCs, and Village Health Nurses. The purposes of the meetings are A mass transfer of specialists from FRUs to PHCs took to strengthen the referral system, to discuss issues place in 1999–2000 due to their promotion to Senior involved in service delivery, and to contribute to Civil Surgeons. A gap in services at FRUs resulted. mentoring and motivation.
Rhetoric to Reality: Reducing the MMR 33 Staff and infrastructure Facilities
The medical professionals in each CEmOC and Every CEmOC and newborn care centre has the newborn care centre comprise four obstetrician following facilities, services, and supplies available and gynaecologists; two general surgeons; four around the clock: paediatricians, and two anaesthetists. An obstetrician blood bank; and a paediatrician are on stay-in duty around the lab services; clock. An anaesthetist is on call duty (see box). The operating theatre; anaesthetists’ telephone numbers are available in the adequate drug supply; labour ward. The staff nurses are trained in operating linkage with ambulance services. theatre, blood bank, labour room, and newborn care services. This ensures the availability around the clock These centres have separate obstetric and paediatric of staff nurses trained in all these areas. casualty services in addition to general casualty.
Contracting-in and training assure availability of anaesthetists
There is an acute shortage of anaesthetists in the public sector. This is especially true at front-line referral Fig. 18: Contribution of hired-in private institutions (secondary-level health facilities) and also anaesthetists to performance of at the primary level, where the shortage constrains the caesarean sections in secondary- performance of sterilizations. As of early 2009, only level public institutions, 123 qualified anaesthetists are available in the 270 Tamil Nadu, 2001–2004 secondary-level referral hospitals. These anaesthetists 20000 are mostly distributed among 29 district and major sub- 2,551 district hospitals. The other doctors are not adequately 18000 2,561 skilled in administering anaesthesia for elective and 16000 2,042 emergency surgical operations. 14000 This skill shortage has been addressed to some extent 12000 by permitting the health facilities to engage private anaesthetists. All hospitals providing emergency 10000 obstetric services are permitted to hire the services of 15,818 17,294 8000 14,256 private anaesthetists whenever needed. The funds are provided under RCH II/NRHM. The key elements of the 6000 initiative are: 4000
private anaesthetists are hired for Rs. 1000 2000 per caesarean section or, for tubectomy 0 operations, per visit; 2001-02 2002-03 health facilities are permitted to hire 2003-04 whenever staff anaesthetists are not available emergency CS with Private Anaesthetists in the facilities; government anaesthetists are not eligible for the honorarium.
Figs. 18 and 19 indicate the contribution made by hired anaesthetists.
This attempt at forging a public–private partnership in a limited fashion has proved beneficial in handling emergency caesarean sections, tubectomies, and major obstetric surgeries, such as hysterectomy, in front-line referral hospitals, with a resulting reduction in the incidence of maternal deaths.
34 Safer Pregnancy in Tamil Nadu: From Vision to Reality Contracting-in and training assure Fig. 19: Numbers of tubectomies availability of anaesthetists (Contd...) performed with hired anaesthetists, Tamil Nadu, While this effort needs to continue, a long-term 2000–2004 solution lies in recruiting and training more anaesthetists in the public health system. Towards 60000 this end, the state government has initiated 50000 a programme to equip MBBS doctors with 40000 anaesthesia skills. 30000 48689 20000 25160 10000 Number of tubectomies 11246 11475 0 2000–01 2001–02 2002–03 2003–04
In each of the certified hospitals a sign board within an hour of travel. The RCH II/NRHM Programme indicates that CEmOC and newborn care services supports the upgrading of another 36 FRUs to are available. The whereabouts of 24-hour CEmOC CEmOC and newborn care centres during Phase II so and newborn care services in each district is widely as to reduce access time to half an hour or less. publicized, thereby reducing referrals to hospitals that do not provide emergency services. Blood banks
Certification of CEmOC and newborn care In the CEmOC and newborn care centres blood centres bank/blood storage centres have been established. The CEmOC and newborn care centres are certified They function around the clock. All doctors, staff and accredited by the government, following nurses, and lab technicians working in the CEmOC well-defined protocols. Certification requirements and newborn care centres have been trained in make the service providers and district managers blood grouping, cross-matching, transfusion of accountable for the provision of around-the-clock blood, and management of transfusion reactions. emergency obstetric and newborn care services. A list of volunteer blood donors and donor organizations, along with their telephone numbers, is The certification committee, drawn from the available in the blood banks/blood storage centres as medical colleges and consisting of the professor well as in the Help Line Centres at the district level. of obstetrics and gynaecology and the professor of paediatrics, is empowered to certify the CEmOC To improve the availability of blood supply for and newborn care centres. Monitoring is done at patients in need, a computerized network links the the district level by the District Collector and at major government-run blood banks in the state. the state level by the NRHM Mission Director and The network was launched in July 2004 by the Secretary (Health and Family Welfare). At the state Tamil Nadu State AIDS Control Society (TANSACS). level a committee consisting of expert resource The network links six blood banks in Chennai and persons advises the government on the functioning five in Madurai, Thanjavur, Coimbatore, Tirunelveli, of the CEmOC and newborn care centres. and Nagercoil. It is proposed to cover eventually 83 blood banks in the government sector and 123 in Partnership arrangements for strengthening the private sector. CEmOC and newborn care centres TNHSP supports strengthening of the 62 CEmOC and The network has put up a web site that enables newborn care centres that currently are reachable the administrators to monitor the stock position of
Rhetoric to Reality: Reducing the MMR 35 collected blood and to make arrangements for its the birthdays of leaders. For more on the blood supply where needed. The web site also provides donation effort, see the Additional Information, Part information about donor lists, blood donation 3, Voluntary blood donation for blood banking. camps, and the availability of kits for five mandatory tests of blood (for HIV, syphilis, hepatitis B, hepatitis Utilization of CEmOC and newborn care C, and malaria). At the district level an official centres monitors and coordinates the movement of blood Between 2001 and 2005 an average of over 235 000 to public institutions. deliveries took place each year in secondary-level institutions, including but not limited to CEmOC and Blood donation camps newborn care centres. Just over 10% of these were caesarean sections (see Fig. 20). At present the activity of organizing blood donation camps has been entrusted to the blood A survey of CEmOC and newborn care centres bank medical officers of the government hospitals. undertaken in 2004–05 produced encouraging There are many NGOs and voluntary organizations, findings. These include: in addition to TANSACS, that are willing to extend one third of the beneficiaries belonged to a helping hand in organizing the blood donation underprivileged sections of society; camps, but lack of coordination among district indicating the extent of community health officials has been the main obstacle. The field awareness, 78% of the mothers approached health staff is under the direct control of DDHSs, the centres directly; who are not directly involved in organizing the some 86% of the mothers could reach the blood donation camps. CEmOC and newborn care centres within half an hour; An innovative project was piloted in Theni District within a half hour of arrival, 83% of the under RCH I to assure timely availability of blood women admitted had received care. for emergency obstetric and other cases. The Another 12% received care in one half hour activity involves both conducting blood donation to one hour; camps throughout the year and keeping up-to- wrong referrals figured in just 18% of the date directories of blood donors who can be called cases, resulting in delays in reaching the on whenever needed. The Theni model is being centres. scaled up to cover the entire state by organizing such camps on fixed dates every month and on This baseline survey was undertaken in the teething phase of the CEmOC and newborn care programme. The current situation may prove even more encouraging. Fig. 20: Deliveries and caesarean sections in secondary-level institutions, Monitoring and review Tamil Nadu, 2001–2005
350000 On-going monitoring and periodic reviews at Caesarean deliveries different levels have helped in: 300000 Vaginal deliveries 22679 assessing performance levels at the health 250000 facilities; 32155 200000 19972 25172 rapidly identifying bottlenecks;
150000 initiating timely corrective actions; reviewing the performance of personnel in 270998
Number of deliveries 100000 different categories. 194257 192592 187149 50000
0 Monitoring reports are generated at the primary, 2001–02 2002–03 2003–04 2004–05 secondary, and tertiary levels.
36 Safer Pregnancy in Tamil Nadu: From Vision to Reality At the primary care level, the reports generated monthly report; include: maternal deaths report (within 24 hours). MCH report—outreach and institutional— based on MCH registers; The reports from the health-related departments institutional Services Monitoring Report; include: Maternal deaths report—within 24 hours, nutritional assessment reports from the by telegram, fax, or e-mail; Social Welfare Department; Integrated Management of Neonatal and births and deaths report from the Revenue Child Illness (IMNCI) reports; Department and local entities. infant death report; Reviews are conducted at different levels and with Integrated Counselling and Testing Centre varying periodicity. These include: (ICTC) report; fixed-day weekly review meeting in the RTI/STI clinics report and special clinics report; PHCs to review PHC/HSC performance; impact assessment of programme monthly review meetings of PHC medical interventions. officers and supervisors at the district level; data on special camps, such as Family monthly reviews of secondary-level Health Awareness camp and Varumun hospitals at the district level; Kappom Thittam (preventive health camps). regional reviews twice a year for secondary- level hospitals; At the secondary and tertiary care levels, the reports audits of deaths taking place in health care cover CEmOC and newborn care hospitals and institutions, at the district level. health-related departments. From the CEmOC and newborn care hospitals information is generated For more on monitoring and evaluation, see through: Additional Information, Part 4, Continuous daily reporting by telephone; monitoring and periodic evaluation.
Rhetoric to Reality: Reducing the MMR 37 5 Systems Strengthening
ehind the specific efforts to make pregnancy the number of in-patient beds at the Bsafer in Tamil Nadu, described in the previous primary level increased from 2298 in 1980 chapter, lies an overall effort to continuously improve to 7191 in 2006, more than doubling; the public health care delivery system. Important government has provided buildings to components of this effort include: 1370 PHCs; improving the health infrastructure; construction is planned for the remaining rationalizing health human resources; PHCs as well; assuring the continuous availability of of the 8683 health sub-centres (HSCs), 6510 essential drugs and supplies; are functioning in government-owned upgrading the Health Management buildings. Information System (HMIS); developing systematic monitoring and At the secondary level (district, taluk, and non-taluk review. hospitals), the in-patient bed strength has grown slightly, from 19 892 beds in 1980 to 20 763 in 2006. Infrastructure development At the tertiary level the growth is greater, a 45.7% increase; the number of in-patient beds rose from As described in Chapter 2, the state’s public health 14 689 to 21 399 over the same period. system operates at primary, secondary, and tertiary levels. The rise in patient numbers, shown in Table 4, is one indication of the level of utilization of the PHC Over the years the primary-level infrastructure has facilities. Another indication is the percentage attracted increasing attention. of deliveries taking place in PHCs, described in
Table 4: Service performance of primary health centres Total number of Average number Total number of Average number of outpatients treated/year of outpatients inpatients treated/ inpatients treated/ Year (lakhs) treated/day/PHC year (lakhs) month/PHC 2001–02 421.17 ND 1.18 ND 2002–03 498.00 ND ND ND (April 02–Feb 03) 2003–04 582.73 115 2.56 20 2004–05 (April–Dec 04) 452.70 119 2.29 18 2005–06 628.67 124 3.82 23 2006–07 716.80 141 5.51 33 ND, not determined Note: 1 lakh = 100 000 Chapter 4. The growth in the percentage of This initiative has been replicated in all PHCs. deliveries taking place in PHCs indicates that, Working with the local women’s Self-Help Groups over the years, the PHCs have become the first in this activity has helped involve the community in choice of pregnant women in rural areas because maternal and child health issues. of the quality of care available. Between 2006 and 2007 there was a 59% rise in PHC deliveries. Not Strategy to upgrade PHCs all the PHCs have performed equally impressively, however. There are a few laggards still, but efforts It has been proposed to upgrade the remaining 255 are ongoing to bolster these PHCs as well. Block-level PHCs into 30-bed health facilities. Thus, all the Block-level PHCs in the state will become The factors contributing to such an impressive 30-bed facilities to meet the growing health care performance are many: needs of the rural population. So far, 130 PHCs have availability of service 24 hours a day; been upgraded with 24 to 30 beds and equipped access to skilled personnel at all times, with with ultrasonography, ECG, and X-ray equipment, the three nurses—24x7 model; a semi-autoanalyser, and an ambulance. New training and sensitization of the doctors buildings will be constructed for the PHCs and HSCs and the staff; now in rented premises. continuous monitoring. Communications upgrade Grants to facilities Effective communication facilities play a key role Under NRHM Patient Welfare Societies (Rogi Kalyan in improving the accessibility and utilization of Samitis—RKS) are formed for better management the health facilities and also in quick data transfer of PHCs, taluk/non-taluk hospitals, and district from the field. Some of the measures undertaken or headquarters hospitals. The Patient Welfare Society proposed include: in each district headquarters hospital receives a telephones provided to PHCs and hospitals; grant of Rs. 5 lakhs (Rs. 500 000) per annum, while mobile phones for Village Heath Nurses; in taluk/non-taluk hospitals and PHCs each society a special toll-free telephone number for gets Rs. 1 lakh (Rs. 100 000) under NRHM. reporting data from CEmOC and newborn care centres; In addition, an annual maintenance grant of computers and Internet facilities at PHCs Rs. 1 lakh goes to each 24-hour BEmONC centre and hospitals, introduced in phases; for upkeep of physical infrastructure. Similarly, computer training centres in three Regional each PHC receives an annual maintenance grant of Training Centres; Rs. 50 000, and each HSC receives Rs. 10 000. This palmtop computers for data collection by funding has enabled PHCs and HSCs to provide a grass-roots health personnel (proposed). clean and safe environment including supply of potable water, uninterrupted electricity, a solar Health human resources heater to heat water for bathing of mothers and children, the pathway to the centre, and gardens Institutional distribution within the centre’s site. Of the several directorates, the Directorate of Also, under NRHM each HSC gets Rs. 10 000, while Medical and Rural Health Services (DMRHS) and a PHC is given Rs. 25 000 and a BEmONC centre, the Directorate of Public Health (DPH) together Rs. 50,000, as unrestricted grants for any health account for the major portion—63%—of the health activity that meets local demand. A few PHCs have workforce of more than 80 000 people (see Table 5). utilized this fund for innovative experiments, such The Directorate of Medical Education (DME) engages as providing nutritious meals to pregnant women another 31% of the human resources in this sector, once a week, when they come for antenatal care. mostly employed in hospitals. The rest are in the
Systems Strengthening 39 other three directorates, mostly in the Indian System counselling them on nutrition and of Medicine (ISM) but also in drug control and in providing them with iron supplements; health transportation. referring cases with complications to a PHC or a hospital; Rationalized distribution of providing postnatal care of mother and child; specialists ensuring regular immunization of infants and children; Under the World Bank-funded Tamil Nadu Health treating minor ailments; Systems Project, rationalization of service norms, human resources norms, infrastructure norms, and diagnosing suspected cases of TB and leprosy and referring them to the quality of care norms for secondary-level health authorities concerned; facilities was proposed. The government has already begun the process of rationalization of specialists participating in awareness-raising in secondary-level hospitals, in an effort to match programmes on health and social issues; supply to demand. The objective is to remove conducting domiciliary deliveries if needed; the imbalances that currently exist by shifting motivating couples to adopt temporary or obstetrics and gynaecology specialists and paediatric permanent family planning methods. specialists from PHCs and ESI hospitals to secondary- level factilies, where their services are in more demand. Although near the bottom of the ladder in the This rationalization exercise will cover 270 secondary- health system, the VHN is often much appreciated level hospitals at taluk and non-taluk levels. in the community if she offers good service. To enable her to offer good-quality service, periodic Empowerment of front-line health training sessions upgrade her skill levels. The VHN care providers—Village Health Nurses has been provided with the requisite skills to deal with common complaints such as anaemia, The Village Health Nurse (VHN) posted at the HSC in menstrual disorders, reproductive tract illnesses, rural areas is normally people’s first point of contact fever and headache, digestive disorders, arthritis with the health care system. The VHN undertakes a and body pains, skin disorders, allergies, leprosy, year and a half of training before taking up her post breast care, newborn care, and first aid. She is also at the HSC. She reports to the nearest PHC medical exposed to the Indian systems of siddha and herbal officer on a weekly basis. medicines. HSCs are now supplied with siddha and ayurvedic medicines, along with allopathic drugs. In The basic work of the VHNs involves: training sessions an attempt is also made to equip holding regular antenatal clinics for her with computer literacy, build her confidence, pregnant mothers; and address gender issues.
Table 5: Profile of public health sector workforce, 2006 Administrative/ Directorate Nursing/ Para- support Department staff Medical mid-wifery medical staff All DME 25 1 – – 262 288 Medical colleges – 2910 – 1387 2121 6418 Teaching hospitals – 1388 4579 2996 10 699 19 662 DMRHS 310 2533 5027 3427 6686 18 003 DPH 300 3076 13 952 12 375 5889 35 592 Drug control 106 – – 51 226 383 ISM – 1089 99 822 1391 3401 Health transport 7 – – – 662 669 All 748 11 017 23 657 21 058 27 936 84 416
40 Safer Pregnancy in Tamil Nadu: From Vision to Reality To increase VHNs’ mobility, in 1996 the state and undermining public confidence in the public government approved a scheme to sanction health system. The impact of mal-distribution loans to VHNs and auxiliary nurse-midwives to and irregular supply were compounded by buy mopeds. Half of the eligible field workers poor storage and careless dispensing. Usually, availed themselves of the loan. In the initial stages, facilities at the lower end of the supply chain, however, social barriers, coupled with the VHNs’ essentially the primary-level facilities, were the lack of interest in learning to drive, despite the offer worst hit. of training, proved to be a damper. The situation is improving over time. The World Health Organization’s action programme on essential drugs has emphasized such key The Health Management Information System (see factors as selection, quantification, procurement, below) simplifies the VHN's task of maintaining storage and distribution, rational drug use, and records. Record-keeping has improved greatly: also user satisfaction as the crucial attributes of The ease of documentation leads to accurate and effective drug logistics. In Tamil Nadu all these are complete reporting, and. taken care of by the drug logistics system established with support from the Danida-assisted Construction of buildings for HSCs has taken Tamil Nadu Health Care Project. Its twin objectives care of the space constraints of the VHNs, both are to: for service delivery and residential use, as she is improve drug supplies to government expected to stay at the HSC premises. This, along health facilities, ensuring continuous with skill upgrades and confidence-building, has availability; helped to increase institutional deliveries and upgrade the skill levels of service providers ensure skilled attendance in domiciliary deliveries. in drug management and usage. Data on deliveries in the state in 2005–06 revealed that the percentage of deliveries taking place at Through its three phases of operation, the Danida home had decreased to just 4.4% (see Chapter 1). project has systematically helped improve the VHNs attended nearly half of these domiciliary supply of drugs to the public health system in Tamil deliveries. Nadu. The key processes are:
supplying drug kits in the project districts Improved availability of essential and funds for HSC maintenance and proper drugs and supplies in all public storage of drugs, in Phase I; health facilities strengthening logistics to maintain the cold chain by supplying refrigerators, cold A major innovative initiative in Tamil Nadu's public rooms, and vaccine carriers for the universal health system is the significant improvement immunization programme; in drug supply to the public health facilities. setting up drug warehouses—at The improvement results from centralized Villupuram, Cuddalore, and Salem—to procurement and decentralized distribution, facilitate drug distribution to the health with the health facilities having the freedom to facilities in their command areas, in choose what they want and when they want it. Phase II; The fact that several other states in the nation are establishing the Tamil Nadu Medical now trying to replicate Tamil Nadu’s new Services Corporation Limited (TNMSC) approach is itself a testimony to the success of in 1994 to take care of drug procurement this initiative. and distribution in the entire state; The new system was instituted only after a long since 1996, pooling budgets from struggle to make do with the previous system. For all departments and procuring and years, lack of medicines at the right time in the right distributing drugs to public health facilities place was an Achilles heel, compromising quality in the state through TNMSC.
Systems Strengthening 41 The salient features of the drug logistics programme Health management are: information system compilation of an essential drugs list, comprising 271 drugs, based on the WHO Another area where the state health service has list of essential drugs and modified to made use of advances in information technology suit Tamil Nadu’s specific requirements; is streamlining recording, reporting, and surgical supplies and consumables are also monitoring systems, initiated by the Danida and procured and supplied; RCH projects. centralized procurement of the drugs through a streamlined and transparent Institutional Services Monitoring tendering system; Reporting (ISMR) strict quality control of drugs procured from the pharmaceutical companies; Until the late 1990s the monitoring system covered decentralized distribution of drugs to only outreach activities. Data on institutional the health facilities through district drug activities and events, especially regarding PHCs, warehouses, one in each district, managed were not readily or consistently available, as there by TNMSC; was no data collection and monitoring service. supply of drugs in foil/blister packs—not loose, as before—to help improve the The ISMR, introduced in April 1999, was a first credibility of public health facilities and step towards bridging this gap. Filled out by increase patient satisfaction; PHC staff under the supervision of the medical need-based drawing of required drugs officer, this report provides extensive information from the district warehouses by the health on all institutional activity at the Health Unit facilities, based on an indenting system; District (HUD)/PHC level on a monthly basis. fixing of an upper monetary limit on drugs The data collected include outpatient and drawn by each facility from the warehouse, inpatient attendance, number of deliveries, albeit with some flexibility; laboratory investigations, minor surgeries, vaccines flexibility for health facilities to make local purchases to meet emergency needs; administered, sterilizations performed, siddha outpatient attendance, utilization of ambulances continuous monitoring of drug inventory levels at the warehouses through a and PHC vehicles, and many other indicators (see computerized information system. Fig. 21 for a portion of the ISMR form).
To handle this voluminous information coming The district-level warehouses ensure continuous in from the PHCs throughout the state, Danida availability of drugs at the health facilities, provided an optical mark reader (OMR) to scan eliminating stock-outs. Indenting freedom for the the special format of the ISMR and, through health facilities avoids surpluses or wastage at the computer link, tabulate, consolidate, and the health facilities due to date expiration. Also, analyse the information. This analysis is available by procuring generic drugs, rather than branded for each level—PHC, HUD, district, and state— products, TNMSC has optimized purchases within and is provided to field-level staff through the the available drug budget. districts. The continuous availability of good-quality drugs at the health facilities, thanks to the drug logistics The system enables quick and comprehensive system, along with provision of skilled attendance, analysis and feedback. Shortfalls and lapses are has been instrumental in increasing utilization of highlighted, and queries are raised. Consistently public health facilities for obstetric care as well as good performance is also highlighted, and for other health care. For more on logistics, see achievements are recorded. The ISMR has proved to Additional Information, Part 2, Logistics and the be an excellent tool for constructive criticism that supply chain. leads to better service.
42 Safer Pregnancy in Tamil Nadu: From Vision to Reality Fig. 21: Example of institutional services monitoring report
Systems Strengthening 43 The ISMR was mainstreamed in 2003 after such as birth and death rates, IMR, and female exhaustive testing and sensitization sessions infanticide. with the health care providers at different levels. Soon after introduction the effectiveness of The surveys covered roughly one sixth of the state’s ISMR in improving health services was decisively population, with a sample of two lakh (200 000) demonstrated. The system has helped identify rural and one lakh (100 000) urban respondents in and resolve specific problems, such as long- each district. The surveys were conducted by the term vacancies—particularly where female staff of DPH, Family Welfare and the India Population medical officers are needed. The result has been Project V of the Chennai Corporation. a more balanced distribution in medical officer postings. (For more about the ISMR, see Additional Data from the VES were compared with figures Information, Part 4, Continuous monitoring and from other sources, none of which, however, was as evaluation). comprehensive. Survey results were used to work out, among other statistics, the male and female life HMIS registers expectancies in the state. They were also used by the State Planning Commission in computing the The second initiative under the HMIS scheme Human Development Index for Tamil Nadu and for was the rationalization and design of registers decentralized planning (see Chapter 2). for health service personnel. Technical working groups, comprising experts from all health The VES was discontinued after the initial phase. departments, were set up to study the record- As a follow-up, monitoring of all PHCs in the state, keeping needs of VHNs at HSCs and of other using the OMR system, was initiated. Monitoring categories of staff. reports are generated for primary, secondary, and tertiary care. Through the HMIS initiative significant changes were made in the reporting and monitoring system. Computer literacy for health staff The reporting process was streamlined, and the number of records was reduced considerably, Advanced computerized systems for reporting and avoiding duplication. The information collected is monitoring require that the health staff at various computerized at the PHC and sent to the district levels are adequately equipped to handle the level for further consolidation. tools developed. Computerization at the PHC level began in 2001 with a pilot effort. Subsequently, Danida’s Phase III mid-term review has highlighted Danida provided computers to all Block PHCs in the project districts. the benefit of the new system. The system saves many person–days of time for the VHNs, giving Initial computer training was provided for them more time for field activities and service to 2400 persons selected from all over the state, clients. The fact that the system was developed in including the health staffs in the project districts. consultation with the users has made it easy for the Subsequently, RCH provided computers to Block service providers to adopt it and has ensured both PHCs in two more districts. relevance and ease of use. Programme-specific requirements were identified and accommodated Currently, there is a proposal to provide computers in the HMIS. to all Block PHCs in the state to implement E-governance throughout the state's health system. Vital events survey Benefits of the HMIS Four vital events surveys (VES) preceded development of the ISMR and HMIS registers. The HMIS has helped to: Supported by Danida, these state-wide surveys streamline easy reporting and effective between 1996 and 1999 covered all vital indicators, monitoring;
44 Safer Pregnancy in Tamil Nadu: From Vision to Reality reduce the workload of field functionaries, Table 7: Central share in total health who can invest the time saved in improving spending, Tamil Nadu the quality of their work; Year Central share (%) provide quick feedback for critically 1985–86 13.9 examining existing conditions and 1991–92 22.5 practices and improving them; 1992–93 22.2 help decision–making for staff 1993–94 23.7 management and posting; 1994–95 23.3 make available both macro and micro 1995–96 23.6 views of health status at various levels, 1996–97 20.6 to pinpoint where corrective action is 1997–98 19.0 needed. 1998–99 17.1 Health financing 1999–2000 20.7 2000–01 21.4 2001–02 22.2 Financing of public health is organized through the state's budgetary allocations, augmented by central government funds. Budgeting for public health Health funds also come to the state from the has been rising over time in the state. Currently, national government through different channels— the budget of the Health and Family Welfare through general transfers, for vertical programmes, Department accounts for 5% of the state revenue and also through scheme-specific matching grants. budget. Two thirds of this budgetary allocation Vertical programmes are designed to achieve is spent on the salaries and wages of health nationally defined health goals. personnel (see Table 6). In a system that engages over 80 000 people of different categories, this is About 90% of the state’s family welfare programme not surprising. budget comes from the central government. The rest comes from state resources, primarily to meet Medicines, consumables, and equipment are staff salaries for implementing family welfare the other major ingredient. The Tamil Nadu programmes. Overall, the budget share coming Medical Services Corporation Limited (TNMSC), from the centre is around one fifth of the state's which is charged with procurement, storage, and budget for public health (see Table 7). distribution of drugs and supplies throughout the state, currently spends roughly Rs. 107 crores Since a large proportion of the state's health budget (Rs. 1070 million) on drugs and supplies each year. goes to salaries and wages, there is limited budget By comparison, such spending was Rs. 75 crores for such expenditure as infrastructure maintenance, (Rs. 750 million) in 1995–96. drugs and equipment, fuel, electricity, telephone, and day-to-day office expenses. This naturally impinges on service delivery. Table 6: Components of total state spending on health, Tamil Nadu, Sectoral allocation 1991–2002 Year % Salaries % Drugs % Others The allocation of the state's health budget presents 1991–92 65.8 16.4 17.8 an interesting picture: 1992–93 65.9 18.0 16.1 about 45% goes to primary health care 1993–94 65.4 19.7 14.9 services. This share has remained more or 1994–95 65.5 17.4 17.1 less unchanged over the years (see Table 8); 1998–99 74.0 15.0 11.0 there was a decline in the second half of the 2000–01 75.4 15.1 9.4 1990s in the share allocated to secondary- 2001–02 72.8 14.3 12.9 level health services.
Systems Strengthening 45 Table 8: Allocation of state health budget through the established health facilities or by by level of care, Tamil Nadu reimbursement. Such spending by the departments, % % % % however, accounts for less than 5% of the state's total Year Primary Secondary Tertiary Other health budget. Even here, central transfers account 1991–92 46.1 16.5 33.1 4.3 for roughly one quarter of the state expenditure. 1995–96 45.4 34.6 15.6 4.4 2000–01 44.2 28.2 22.3 5.3 To overcome budgetary constraints, Tamil 2001–02 45.8 25.0 24.7 4.5 Nadu has tried new initiatives in public–private participation. The government has invited industrialists and NGOs to adopt selected public Tamil Nadu, like other states in the country, facilities and undertake necessary investment to receives major financial support from national improve service delivery. The investors, mainly the government for family welfare programmes and industrialists, were given the option to adopt a various disease control programmes designed to given facility either fully or partially. achieve defined national health goals. In disease control programmes, financing varies from scheme Their expected contributions ranged from purchase to scheme. Some are fully financed, while others of equipment and medicines to construction, repair, are partially financed on a matching basis. Some of and renovation of buildings, to payment of staff the major disease control programmes of the State salaries. This initiative took off well but could not be currently address malaria, leprosy, filariasis, and TB. sustained. Of these, malaria and leprosy programmes together account for three fourths of the state's budget for Another initiative was charging user fees in disease control programmes. selected categories of health facilities. The amount collected was used for better upkeep of the The National Health Policy 2002 envisages a near facilities. This, also, could not be sustained. doubling of the central grants to the health sector in the states. The envisaged increase in central There are wide regional disparities in the state in funding will obligate the state not only to improve per capita government health spending, ranging its absorptive capacity but also to raise additional in 2002–03 from a low of Rs. 76 in Tiruvallur resources to make effective use of the additional District to a high of Rs. 245 in Madurai District. central grants. The growing burden of the state’s The variations in spending mainly reflect wide fiscal deficit, however, will limit its capacity to raise variations in the allocations to medical and public allocations to the health sector significantly. What health spending rather than allocations to family is feasible, given the constraints, is a more judicious welfare programmes. The per capita spending use of the available resources. on family welfare in 2002–03 ranged between Rs. 20 and Rs. 30, except in a few districts such Other departments of the state besides Health and as Ramnad, Sivaganga, Nilgiris, and Perambalur, Family Welfare, such as tribal welfare, nutrition, where the spending exceeded Rs. 30 per capita. personnel, labour, and education, also spend Linkages between public spending and the health on health-related activities. In addition, every status of the population are not clearly established, department provides a staff medical allowance however.
46 Safer Pregnancy in Tamil Nadu: From Vision to Reality 6 Community Sensitization on Gender-related Health Issues
ocial constraints affect the health status of a decision–making. In view of its positive impact, this Scommunity and service utilization levels. It is mode of street play was replicated in Theni District difficult to motivate people to seek and usethe under RCH I. health services offered until this root cause of poor service utilization is effectively addressed. PRI training
For women, most of the social barriers are rooted Another programme tried out was training in gender-based beliefs and practices. The low for members of the Panchayat Raj Institution status of women and strong son-preference have (PRI), sensitizing them to gender issues affecting encouraged the practice of early marriage, frequent health and to the PRI members’ role in improving pregnancies, and female infanticide in some areas community health and welfare. and communities, thus endangering women's health. Neglect of women’s nutrition and medical The strategy was to approach directly members needs have worsened the situation. Gender-based of elected bodies to educate them on health beliefs and practices have placed a low value on a and health-related issues, the various health woman’s life and health. programmes available, and their utilization for the benefit of the community. The underlying idea was Kalaipayanam to create demand for health services among the public by raising their awareness levels. Only awareness-raising in the community on various gender issues and their deleterious effects MCH care was an important topic covered in can help to promote community involvement such sessions. Sessions addressed such issues as in public health. Since the mid-1990s correcting registration of pregnancies, informing the VHN gender imbalances and reducing female infanticide about pregnancies, obtaining antenatal care, and have formed an essential component of health and facilities for emergency transport to a hospital. welfare policy in the state. Several programmes and initiatives have been tried. The Kalaipayanam, Social marketing or street theatre, was one imaginative initiative. Under the Danida Project it was tried out initially in Social marketing is yet another strategy adopted Dharmapuri district, which had a high incidence of to educate the community about health services female infanticide, and later replicated in Tiruvarur. and facilities available to them, thereby increasing the demand for public health services. The initiative The topics covered in such street plays included addressed high-risk couples, adolescent girls, dowry, violence against women, early marriage, and maternal health and mortality. Particularly 1 PRIs are the elected local bodies for local governance in rural powerful was the message on gender equality in and urban areas. panchayat members, other community leaders, and under TNHSP with the cooperation of the Tamil Nadu members of women’s Self-Help Groups. Science Forum (TNSF) and All India Radio (AIR). This project addressed adolescents in 10 Danida project Group-specific topics were addressed. For example, districts. high-risk couples were apprised of the need to limit family size and space pregnancies, The objectives of this programme were to: the risks involved in early marriage, and the familiarize adolescents in rural areas with implications of a declining sex ratio due to health-related issues—physical, emotional, strong son-preference; and social; adolescent girls were made aware of foster empowerment through collective the physical and emotional changes discussion and interaction following group of adolescence, nutrition needs, body listening to AIR broadcasts on various mapping and the reproductive system, topics; maintenance of health and hygiene, sex- forge links between the health service related infections, and the importance of providers and the community. gender equality. About 150 episodes were broadcast in 2000–2002. The impact of this initiative was noticed in: The episodes covered a wide range of topics such many men, especially the younger ones, as physical health, changes during adolescence, taking responsibility for the health of their sex, marital relationships, AIDS and other diseases, children; addictions, education, friendship, self-confidence, greater attendance at antenatal clinics; and gender issues. later age at marriage; greater readiness for sterilization after two In each district TNSF coordinators formed 10 or or three girl children; more radio listeners’ clubs, each with a membership improved health-seeking behaviour. of 10 boys and 10 girls, all adolescents. Among the members were school children, dropouts, Behaviour change communication and working children. The programme’s activities focused on these clubs. Using multiple channels to reach the individual, behaviour change communication provides Each club was given a radio-cum-cassette empowerment and skills to individuals to make recorder. Club members listened, took notes, and changes and creates a supportive environment discussed the topics after the broadcasts. Group in which individuals can make and sustain these leaders, mostly girls, were chosen from among changes. club members and trained to conduct the discussions. Effective communication is based on a thorough understanding of personal behaviour responsible In addition to the weekly club meetings, workshops for poor health outcomes, of people’s knowledge, took place at the district level; at cluster level, practices, beliefs, myths and misconceptions, and bringing together participants from three or value systems and of cultural and religious practices four districts; and also at the state level, with as well as levels of education. Not only the messages representative participants from all 10 districts. but also the modes of communication have important roles in effective communication. The programme helped bring together boys and girls who would otherwise have led narrow, gender- Radio broadcasting was tried as a means to raise segregated lives. It provided them with a forum for health awareness among adolescents. A project healthy interaction with their peers. It opened up for adolescents—the Malarnadhum Malaratha new prospects for them in several spheres, making Adolescent Health Education Project—was launched them realize that ordinary friendship with the other
48 Safer Pregnancy in Tamil Nadu: From Vision to Reality sex, without sexual implications, was possible and members and friends to adopt more rational, rewarding. gender-sensitive, and helpful behaviour. The radio programme also helped to bring several dropouts The participating adolescents learned a variety of and working children back to school. skills—the abilities to question, analyse, debate, and communicate. For the girls, in particular, the The programme had an impact on many parents experience was a liberating one, bringing them out as well. Several girls’ parents, who had earlier been of a protective, conservative family and social circle reluctant to let their children participate in such and thereby fostering self-confidence. mixed clubs, became enthusiastic supporters when they saw how it helped their children grow into The programme promoted a rational attitude, reasoning and caring adults. Parents who attended self-confidence, and a sense of equality cutting the workshops at various levels were among those across religion, caste, gender, and other social who were most enthusiastic about the clubs. restrictions. Feedback from participants indicated that many of them changed beliefs, attitudes, and The programme ran for three years. Since its practices because of the programme. Also, through termination many of the listeners’ clubs have example and persuasion, many influenced family continued as informal groups.
Community Sensitization on Gender-related Health Issues 49 7 For the Future
amil Nadu has achieved substantial success in substantial numbers of higher order Timproving the quality of antenatal care and in births; promoting institutional delivery over the years. poor male participation in contraception; Still, challenges remain. Inability to ensure readily insufficient focus on urban health issues. accessible emergency obstetric care around the clock in all areas has adversely affected maternal The following proposed initiatives address some mortality rates. The other important issue is gender of these concerns, but there is still room for discrimination in health, resulting in poorer health improvement. outcomes for females. Until this is effectively scale-up of “near miss” audits for maternal addressed, substantial further improvement in mortality to cover the entire state and women’s health is unlikely. generate lessons learnt for systemic improvements; Addressing these crucial issues forms the scale-up of use of partographs to assess the cornerstone of Tamil Nadu's health policy progress of labour; interventions in the Reproductive and Child restricted use of episiotomy; Health (RCH) programme. Under this programme active management of the third stage of a substantial management and administrative labour; structure has been established at the state level, steroid administration for premature while at the district level resources have been labour, to prevent neonatal respiratory strengthened effectively. distress syndrome; prophylactic use of antibiotics for Despite remarkable achievements over the past premature rupture of membranes; several decades, the state still has a lot of unfinished anaemia control through ISM drugs; tasks in the health field. Specific areas of concern are: protocol for the use of oxytocin; regional disparities in several indicators— use of an antishock garment for treatment institutional deliveries, skilled attendance of postpartum haemorrhage; at birth, sex ratio, health-seeking behaviour, The National Urban Health Mission is in the pipeline. and, generally, performance levels in the It will address reproductive and child health issues field; in cities and towns. lack of a significant reduction recently in neonatal mortality; With a strategic vision, Tamil Nadu has taken a number female foeticide in some areas; of initiatives to strengthen the public health systems lack of consistently high-quality antenatal at the primary level of care. Giving primary care a and postnatal care in all health facilities; human face has improved both providers’ behaviour anaemia in adolescents and pregnant and the care-seeking behaviour of the public, who women; come in increasing numbers to maternal, newborn, and child health services. Tamil Nadu will continue to that maternal, newborn and child health (MNCH) sustain this momentum to improve the quality of life programmes will only be effective if there is a of mothers and children. As articulated by WHO, continuum of care, from pregnancy through childbirth into childhood. This continuity requires “The health and well-being of women and children greatly strengthened health systems with MNCH at are completely linked. There is a strong consensus their core.”1
1 World Health Organization (WHO). World Health Report 2005: Make Every Mother and Child Count. Geneva, WHO, 2005.
For the Future 51 Additional Information 1. Referral Transport
Background lack of proper monitoring and documentation and also of feedback on Tamil Nadu has a good and well-developed health referrals; infrastructure with adequate trained manpower. poor accountability of service providers Poor access to these institutions in times of need has due to the lack of a monitoring system. been a major problem, however, in spite of the good roads and communications network in the state. Strengthening the One of the weakest links in the health care delivery referral component system is the referral system, in spite of the various initiatives taken by the government to improve it. In response to this situation, an initiative was taken in 2005 to strengthen the referral component An effectively functioning referral system will not through an effective Referral Information only reduce maternal and child morbidity and Networking System. This initiative, piloted under mortality but also reduce the cost of treatment the Reproductive and Child Health Programme for the poor. It also will lessen anxiety and tension (RCH) I, was subsequently replicated throughout during emergencies. the state.
The challenges posed by an ineffective referral The strategy system were: 24 hour a day control rooms unnecessary referrals to institutions that lacked specialists to handle the case; A 24 hour a day referral control room has been set the absence of a single agency to up in the offices of the Deputy Director of Health coordinate referrals at the district level; Services (DDHS) in each of the Health Unit Districts lack of coordination and communication (HUDs). Health inspectors run these control rooms. among various tiers of the health system; They are selected based on their aptitude for this lack of a government ambulance in type of work. A team of doctors and counsellors emergencies; trains the inspectors to manage the referral system. no advance notice to the referral hospitals about the arrival of emergency cases; A telephone with a dedicated toll-free number is poor preparedness and responsiveness installed in each control room. The control room has of the public health facilities in handling the telephone numbers of all local public hospitals, emergencies; private hospitals, private anaesthetists, government lack of awareness among both the people and private blood banks, obstetricians, ambulances and the referring institutions about the (both government and private), blood donors availability of emergency services in the clubs, and blood donors. A district map showing referral hospitals; where ambulances are stationed, with the mobile Fig. 22: Information fl ow in the referral transport system, Tamil Nadu
ANW EMERGENCY HELP LINE CONTROL ROOM SHG (located at 42 DDHS offi ces, VHN functioning around the clock) PUBLIC (VTF)
Emergency ambulances
24-hour CEmOC and Private PHCs newborn care hospitals
telephone numbers of the drivers, is available in the anganwadi functionaries, members of self- control room. help groups, and panchayat elected leaders (see Fig. 22). The information could indicate that The computer in the offices of the DDHS is used referral and/or transportation are needed for any for documentation. Referral information received of the following: from the public and from health and social for normal delivery cases to the PHCs; welfare functionaries, as well as detailed patient for obstetric emergencies to CEmOC and information that is passed on to the health newborn care centres; facilities, is entered into the computer system. for newborn emergencies to CEmOC and The district officers use this information, along newborn care centres; with details on services provided at the referral for accident victims; institutions, to monitor the functioning of the for cases in epidemic outbreaks. referral system.
Information fl ow On receiving such information, the referral room coordinator takes the following actions: The referral control room receives information the coordinator records the details in the from the general public, health functionaries, computer or register;
Additional Information 53 depending on the type of emergency, the drivers available around the clock. referral room coordinator suggests to the These vehicles are standby vehicles for caller the nearest health facility to which emergencies, in addition to the ambulances the patient can be moved. If the services stationed in the blocks in various parts of are needed for a woman in labour, she is the district; sent to a 24 hour a day PHC. The PHC is the ambulances run by NGOs are permitted advised by phone to be prepared to receive to collect transport charges from the the pregnant woman. In a separate register patient, for one way only, at the rate of the PHC records the details received from Rs. 5 per km. Pregnant women below the control room; the poverty line are given vouchers by if the pregnant woman has a problem the Village Health Nurse. The pregnant that can be handled only at a CEmOC and woman can use the vouchers instead of newborn care centre, the pregnant woman payment for ambulance transportation. will be moved to the nearest CEmOC and At the hospital the voucher is stamped newborn care centre; and handed over to the ambulance driver. (Vouchers are also given in advance the obstetrician in the CEmOC and newborn care centre is informed about to mothers below the poverty line for the details of the obstetric emergency, management of postnatal problems and including the woman’s blood group, so newborn emergencies. The NGOs are reimbursed for the vouchers); that the centre will be ready to receive the in case of any delay in getting care at the emergency case and initiate treatment referral facility, the coordinator contacts the without delay. The duty obstetrician records DDHS, the Joint Director of Health Services in the register the date and time that the (JDHS), and the Deputy Director (DD) information is received, patient details, and (Medical) through their mobile telephones other relevant information; to obtain further help; if transportation is required, the referral if needed, the numbers of referral coordinator telephones the ambulance coordinators and telephones in the control stationed in a strategic location in the room are increased; block and directs the driver to pick up the also, if needed, voluntary organizations emergency case and go to the appropriate such as the Lions and Rotary clubs are health facility; involved; if the caller wants to take the case to a depending on the response needed, more private hospital, the referral coordinator vehicles from the PHCs are put into the informs the private hospital of the patient emergency transport system. details and instructs the driver to take the case to the private hospital as the client has Publicity requested; if the CEmOC and newborn care centre The referral control room telephone numbers are needs a particular blood group for the widely displayed in all public places—anganwadi emergency, the referral coordinator centres, PHCs, HSCs, ration shops, buses, hoardings, contacts other blood banks in the district, etc. The mass media are actively involved in including the private blood banks, and publicizing the referral system. The mother and arranges for an ambulance to collect the child health cards issued to pregnant women display blood and deliver it to the CEmOC and the referral control room telephone number. The newborn care centre; telephone number also is printed in the telephone directory under “essential services”. the referral coordinator also, if needed, contacts the blood donors club or a donor Ambulance support for collection of blood during emergencies; two ambulances are stationed at the Reputable NGOs run the ambulance service in the control room in the DDHS office, with districts (see Chapter 4). The Tamil Nadu Health
54 Safer Pregnancy in Tamil Nadu: From Vision to Reality Systems Project (TNHSP) has established District District Emergency Ambulance Society meets and Emergency Ambulance Societies to oversee their reviews all the referrals received from the DDHS work and has provided a new ambulance for each offices and their outcomes. block. The ambulances are equipped with life- saving equipment and communications equipment. The referral details also are sent to the appropriate The ambulance societies also have responsibility for PHCs and municipalities for follow-up. Also, the informing the public about the services available Director of Public Health and the Director of Medical through the referral control rooms. and Rural Health Services receive a consolidated report on referral outcomes every month.
The ambulance service is a cooperative effort linking The performance of the ambulances also is regularly the NGOs and the government through two-year assessed. The indicators used for such assessment renewable contracts: are: the Government of Tamil Nadu/Tamil Nadu number of cases transported; Health Systems Project (TNHSP) provides number of emergency cases transported; ambulances with equipment free of cost to number of obstetric cases transported; the NGOs selected; number of cases of road traffic accidents TNHSP pays the cost of insurance and transported; expenses towards getting the vehicle number of non-emergency cases fitness certificate every year; transported; TNHSP also provides a nominal amount, number of poor people (below the poverty Rs. 7000 per month per vehicle, towards line) exempted from payment; topping up operating expenditures; total distance travelled, in km; TNHSP contributes a one-time grant of receipts/expenditures; Rs. 10 000 per vehicle towards creating vehicle downtime. public awareness of the services; the NGOs see that the ambulances are Advantages of the referral maintained and covered under an annual information networking system maintenance contract; The benefits include: the NGO pays the operating costs of the one-stop solution to all referral problems; ambulance; trained referral coordinators providing the NGO recruits, hires, and trains the guidance and support to patients in drivers and nurses. receiving appropriate care at the health facilities; Effective use of emergency transport has gone a long patient-friendly referral system, with the way toward avoiding or greatly reducing in-transit referral coordinators trained in counselling delays, which are one of the three major delays techniques; responsible for maternal mortality and morbidity. good coordination among various tiers of The timely availability of ambulances is linked the health system; with availability of timely, good-quality services transportation support without delay in the public health facilities. The transport service because the referral control room also helps reduce the two other delays that cause communicates with all ambulances maternal deaths—delays in seeking care and delays including private ambulances; in obtaining appropriate care once at the facility. better emergency preparedness—and thus less delay—at the referral hospitals thanks Monitoring to advance notice and basic information about the referral cases, such as the Along with efficient coordination, the robust patient’s blood group; monitoring system has contributed greatly to the improvement in the overall quality of the success of the transport system. Once a month the referrals;
Additional Information 55 close monitoring and tracking of every avoidance of unnecessary referrals; referral case; encouragement of community accountability among the service providers, participation in the referrals; due to close monitoring; sustainability of the NGO-run ambulance documentation of the entire referral services through sufficient revenue process through the computerized system; generation; feedback to various referring institutions ability to identify and recognize good about the outcome of the referrals; performers.
56 Safer Pregnancy in Tamil Nadu: From Vision to Reality 2. Logistics and the Supply Chain
Background with funding for maintenance of HSCs to ensure, among other things, proper storage of drugs. At Timely availability of medicines has been one of that time poor refrigeration at district and PHC the major problems of the public health system levels made it difficult to maintain the cold chain in Tamil Nadu. Free treatment loses its value when for storage and supply of vaccines. Under the the patient is told to buy medicines elsewhere or Universal Immunization Programme, initiated in is given drugs that have passed their expiry date. Salem District in 1985–86 and in South Arcot District Inadequate and irregular supply, poor distribution in 1987–88, Danida provided refrigerators, cold and storage, and, at times, careless dispensing all boxes, and vaccine carriers to strengthen logistics have played havoc with drug delivery in the public for immunization. health system. In Phase II there was a further increase in inputs from While all health facilities have suffered from these Danida, under a special scheme, to strengthen the problems, those at the far end of the supply chain, drug supply system. Important among these inputs that is, PHCs and HSCs, have borne the brunt. was setting up drug warehouses in Villipuram, Dumping of unwanted drugs at the health facilities Cuddalore, and Salem to facilitate drug distribution. was another irritant. All this resulted in a situation of periodic stock-outs at some times and surpluses at Still, the mid-term review of Phase II and the other times. Phase I evaluation drew attention to the persistence of irregular, inadequate, and inappropriate drug The key components of the World Health supplies at several points. It was decided that a Organization’s action programme on essential drugs major overhaul of the entire drug supply system are selection, quantification, procurement, storage was essential. This was the impetus for the and distribution, and rational drug use as well as establishment, in 1994, of the Tamil Nadu Medical user satisfaction. In Tamil Nadu Danish International Services Corporation Ltd. (TNMSC), charged with Development Assistance (Danida) has aided the implementing the essential drugs programme. state’s essential drugs programme. The focus has been on improving logistics, management, and Essential drugs programme human resource development. This effort has improved drug supply to government health The salient features of this programme are: facilities, has assuring continuous availability, and at compilation of an essential drug list, the same time has upgraded the skills of the service consisting of 271 drugs as well as surgical providers in drug management and usage. supplies and consumables; this list was based on the WHO list of essential Danida also assisted, in Phase I of its project, in the drugs, modified to meet the state's supply of drug kits in the two project districts along requirements; centralized procurement of the drugs (it was incorporated under the Companies Act in on the list by TNMSC, using streamlined 1994) with minimal staff and minimal paperwork procedures; and making effective use of information technology. establishment of district drug warehouses, Chaired by the Health Secretary, the TNMSC board managed by TNMSC, for decentralized, includes the Finance Secretary and another Indian streamlined distribution; Administrative Service officer, a general manager an indenting system, which facilitates for administration, a doctor as technical manager, a procurement of required drugs from the quality control manager, and a purchasing manager. district warehouse by the health service Much of its daily functioning, including the front facilities in its catchment area; office work and the computer section, has been fixing of an annual monetary limit (with outsourced from the beginning. some flexibility) on supplies drawn by each facility from a warehouse; More than a decade after its incorporation, flexibility for the health facilities to make TNMSC maintains its efficient functioning, with a local purchases to meet emergency needs; streamlined structure. Most of the staff members a computerized information system for are on deputation from other government continuous monitoring of inventories in the departments, thus keeping overheads low and warehouses; offering the flexibility to reduce staff size asand strict quality control of drugs purchased, when necessary. through inspection of drug manufacturing facilities and regular quality testing of Essential drugs list drugs purchased and stored. The Corporation’s brief has been to ensure both TNMSC began its procurement and distribution efficiency and flexibility in the supply of drugs. To operations towards the end of Phase II. It was in this end, TNMSC brought out an essential drugs list, Phase III, commencing in 1996, however, that much based on the WHO model list but suitably modified, of the innovative activity took place, building up the using generic names for uniformity in prescription system and making it a “Best Practice”. It was also and use. The drug list, which is the only basis for in 1996 that the drug supply management system procurement and distribution, is updated every developed for the project districts was reviewed and year. This updating promotes timely and proper replicated throughout the state. procurement and efficient storage and distribution, resulting in saving of time and money and avoiding The first step was to emphasize need for essential wastage. drug listing and rational use of drugs, and not just availability, in drug supply in the public health The compilation of the essential drugs list was an system. It was also recognized that supplying loose exercise in rationalization. It involved removing drugs meant unnecessary handling, resulting in several drugs of doubtful benefit. It also followed poor quality and loss of credibility with the public. the principle that unnecessary injections and Packaging of all drugs in foil and blister packs and antibiotics should be avoided. It put a stop to preparation of the essential drugs list were two of unjustified accumulation of certain items, such as TNMSC’s early steps. liquid paraffin. Rationalization has also ensured appropriate prescription of drugs in their proper TNMSC structure dosage and durations of administration.
From the beginning TNMSC was seen as a means The process of rationalizing the drugs list faced to ensure supply of “the best drugs in the best strong opposition from many in the medical packaging to the poorest of the poor”. It was not establishment. Having convinced the Health Ministry seen as an organization cast in the conventional and secretariat of the need for such rationalization, government mould, but rather as a corporation however, TNMSC was able to implement it. Originally
58 Safer Pregnancy in Tamil Nadu: From Vision to Reality containing 170 drugs, the list was later expanded to chain. Together, all these measures have reduced 210. Currently, the list includes 271 drugs. the cost of essential drugs. Such savings has made it possible for TNMSC to optimize its drug purchases. Transparency and quality control in Within a very short time since its establishment, procurement TNMSC had developed into a self-sustaining institution. TNMSC procures drugs through an open tender system and competitive negotiation, followed by The old method of obtaining drugs in bulk, direct supply from manufacturers and delivery to in loose form or in bottles, has been replaced its warehouses. This eliminates one leg of storage by procurement of strips or blister packs. This and delivery in bulk, from a central storage place packaging makes handling easier and prevents to the district warehouses. Direct procurement deterioration. Rigorous quality control measures, from manufacturers bypasses dealers and thus such as regular checking by independent approved reduces cost. The open tender system is also an anti- laboratories, also are followed. corruption measure that increases efficiency. A system of vendor rating and performance The tender system is an example of the detailed appraisal, through monthly meetings with vendors planning that is the hallmark of TNMSC activity. and meetings of warehouse pharmacists, was set Tenders are floated once a year. Each bidder must up in the early days of the TNMSC. This system submit two covers, A and B, the first containing provides for immediate follow-up on complaints. a technical bid and the second, a commercial bid. The technical bid has to provide notarized One initial hitch in the procurement system was information about the bidder’s years of experience incorrect assessment of requirements, leading to in the manufacture of every product in the list, any excessive ordering. Also, some companies that met convictions for drug malpractice within the last five the initial requirements were not able to maintain years, credibility in marketing in India and abroad, quality or meet delivery deadlines. With time and equipment status, manufacturing capacity, and experience the process has smoothed out. annual turnover of business operations. Scrutiny of this information is followed by inspection of the Distribution network manufacturing premises, which includes checking on water sources and their use and also on waste As noted, Phase II of the Danida project witnessed disposal. the establishment of warehouses in Villipuram, Cuddalore, and Salem. Even as TNMSC was being Only suppliers who pass this rigorous technical planned, the rented premises in Salem and test participate in the commercial bidding process. Cuddalore were replaced with newly constructed The opening of commercial bids is computerized central drug warehouses catering to the needs and open to view by all. The lowest bid is identified, of the health facilities in their districts. Later, the and there are negotiations with other close Villipuram warehouse was built. During Phase III bidders to match it. Depending on the volume of the establishment of central drug warehouses, in the requirement, orders are distributed among either newly built or rented premises, was extended a minimum of three and a maximum of nine to non-project districts as well. On demand, suppliers. manufacturers supply these warehouses with centrally purchased drugs. A computerized inventory The Corporation’s procurement of drugs is based management system supports this process. on continuous monitoring of the consumption pattern. This ensures drug availability at all times The central warehouses in the districts ensure and prevents stock surpluses as well as wastage continuous availability of drugs to the health due to expiry. Special packing with a logogram has facilities. The facilities are allowed to draw their minimized pilferage at all points in the distribution supply, based on their requirements, from the
Additional Information 59 warehouse through the indenting process. This E-governance in drug supply prevents accumulation of unneeded drugs at the health facility. Further flexibility comes from a Monitoring is another responsibility that falls system of transfer according to need both among within the Corporation’s purview. TNMSC has districts and among PHCs. This method of sending effectively used information technology such the drug where it is needed reduces storage as computerized monitoring of procurement beyond expiry date. Along with supply, storage and stocks. Internet connections for the TNMSC conditions at the health facilities also have been and the central drug warehouses, and improved. regular updating of drug stock status on its web site, enhance efficiency, speed, and Each health facility is issued a passbook indicating transparency. its annual fund allotment, within which it can draw drugs from the central drug warehouse. Each The storage system in the central warehouses time the health facility indents for drugs, its facilitates easy handling of materials. Racks are passbook is updated to indicate the balance constructed so as to avoid wasting space. Drugs are remaining. This has helped to impart a sense stored according to essential list classification and of rationalization in drug indents, curbing the arranged according to frequency of handling for temptation of health facilities to draw costly drugs storage and retrieval. Automated systems such as in excess of their needs. electric stackers are used.
There exists, however, a certain amount of The model of the racking system is fed into the flexibility. The health facilities are permitted computer, which makes a plan of drug storage to draw in excess of their fund allotment in space available whenever a note for issue of drugs is emergencies and to meet genuine requirements. generated. It is estimated that storage and retrieval The justification needs certification by higher from storage have become 30% more efficient as a authorities. result.
To improve management and develop human Other aspects of the integrated system of resources, warehouse pharmacists are trained in computerization are E-tendering through the store management and inventory control. web server; linking the chain of order placement, Pharmacists at the health facilities also are trained, suppliers, and warehouses; production of invoices; to upgrade their skills and knowledge concerning and printing of cheques. rational indenting, proper stocking, inventory management, and tracking of expiry dates. When samples from warehouses are sent to testing laboratories for quality control, the results are Drug supply management obtained through e-mail. Details of test failures are passed on to the central warehouses in the same TNMSC works on a number of fronts to improve way. and maintain efficiency in drug supply—for example, drug quantification studies, a training The Internet connection between TNMSC and the seminar for central warehouse managers and central warehouses makes possible speedy stock pharmacists in drug supply management, and monitoring. The information system links each management information systems. External warehouse with the main office for passbook and consultants have been used when necessary. order information, indents received and filled TNMSC also has assessed the pre- and in-service (subject to fund allotment), and orders placed with training needs of its staff and ensured that drug suppliers and their status. supply management is included in the training curriculum for PHC staff such as medical officers The information system also keeps track of and and pharmacists. produces reports on problem areas, such as slow
60 Safer Pregnancy in Tamil Nadu: From Vision to Reality moving transfers, expiry of drugs, unexecuted Expansion of activities includes establishment of order statements, and pending bills. It is planned to magnetic resonance imaging (MRI) centres and incorporate bar coding and video conferencing into Computerized Tomography (CT) scan centres the system soon. that provide diagnostic services at nominal rates; managing the rate contract for blood banks; An expanding institution purchasing consumables for the Tamil Nadu AIDS Control Society; supplying equipment for the The drug logistics and supply system was initially Directorate of Rehabilitation of the Physically intended for only the primary health facilities. It Handicapped and also specialty departments of has extended over the years, however, and now hospitals; and consulting for other states on drug covers: warehousing and logistics. TNMSC has also added all medical teaching institutions in the a construction wing, which manages construction state, including employees state insurance for various projects. The construction wing of (ESI) hospitals and local-body dispensaries; TNMSC has built new central drug warehouses, and medical facilities of the State Electricity it repairs and maintains the warehouses and the Board, Transport Corporation, cooperative health facilities as required. sugar factories, police, prisons, and juvenile homes; The drug logistics and supply chain operating supply of veterinary drugs to the animal successfully in Tamil Nadu has now become the husbandry department and all veterinary forerunner and model for similar ventures in several institutions in the state. other states.
Additional Information 61 3. Voluntary Blood Donation for Blood Banking
Ready availability of blood of all kinds can save lives less uniform throughout the year. But the collection during emergencies. Field experience indicates of blood is not uniform throughout the year. that there are enough volunteers willing to donate Fortunately, there are adequate numbers of willing blood during camps or on call. What is required is donors throughout the state. The blood donation to establish proper linkages between the volunteers camp addresses the requirements of blood evenly and the blood banks. throughout the year.
In Theni district in 2003, under RCH I, the Objectives Deputy Director of Health Services tried an innovative project to conduct voluntary blood The objectives of the organized voluntary blood donation campaigns systematically throughout donation campaign are to: the year, in collaboration with the government ensure ready availability of the required blood banks and the Red Cross Society. Availability group of blood 24 hours a day and 365 of blood in all the government blood banks, days a year in all the approved blood including the blood banks in the medical colleges banks; in this district, was thus ensured all through the create and update a directory of voluntary year. In view of the success of this initiative, it has donors so that the required blood can been scaled up, under RCH II, throughout Tamil be obtained on short notice and without Nadu. delay; build up the capacity of the PHC system The problem to organize blood donation camps regularly; Often in practice there is a large collection of blood generate awareness on blood donation and on special occasions, but then some of the blood its significance in saving lives in emergen- collected goes waste due to: cies, particularly obstetric emergencies and huge collection during a few months of accidents. the year but without appropriate storage conditions; Strategy the short shelf-life of blood—just 45 days; lack of blood component separation An annual plan for organizing blood donation facilities in some hospitals; camps is drawn up in each Health Unit District in lack of networking of blood banks in the consultation with the blood donors clubs, Lions state. Clubs, Rotary Clubs, Red Cross Societies, industry representatives, college authorities, and NGO The blood requirement for emergencies, especially representatives. The blood banks in the state are obstetric emergencies and accidents, is more or networked. The salient features of the strategy are to: concerned PHC medical officers and team; organize blood donation camps indian red cross society; throughout the year, on a fixed day every local community-based organizations, month, according to the district annual individual volunteers, and philanthropists; plan; National Service Scheme/Youth Red Cross organize community-based blood donation units of colleges. camps in industries, colleges, NGOs, and blood donors clubs depending on the Activities needs; develop a strategy for organizing blood Operationalizing the strategy involves: donation camps during school and college selection of villages and sites for camps; vacations; fixing of a date, 15 to 20 days in advance; assess the annual blood requirement of all logistics and mobilization of blood donors public health facilities in the district and by the Deputy Director of Health Services put in place suitable logistics to ensure and Primary Health Centre team; periodic supply of the needed blood to the technical guidance and support to blood blood banks; collection units by blood bank medical prepare a directory of voluntary donors; officers and team; create awareness on blood donation, and coordination and reimbursement of its vital importance, during the blood contingency expenditure by local sponsors; donation campaigns; blood collection by the blood bank team; strengthen the existing system of blood issuance of certificates to the donors at collection; the campsite by the blood bank medical in order to reduce wastage, develop a officer. system to monitor collection and utilization of blood on a monthly basis. During such camps community members observe and learn about blood donation and its significance All these activities are being carried out in in saving lives. consultation with the Tamil Nadu AIDS Control Society. The collected blood is subjected to mandatory tests before it is made available to patients admitted Partners in the scheme in government hospitals or, on payment of the prescribed fee, in private hospitals. The blood donation campaigns are a joint effort of the: Currently, there are in the state: joint Director of Health Services and team; 81 government blood banks; deputy Director of Health Services and 140 private blood banks; team; 26 storage centres. blood bank medical officers and team; deputy Director (Medical & Family Welfare) All the doctors and staff nurses in government and team; hospitals have received blood bank training.
Additional Information 63 4. Continuous Monitoring and Periodic Evaluation
On-going monitoring and periodic evaluations form The data on secondary and tertiary care flow from: an integral part of the interventions on pregnancy daily reporting system through the outcome in the state. The information generated in telephone; the process is used not only to track progress but Monthly Institutional Services Monitoring also to pinpoint bottlenecks in the field and the Report; actions needed to overcome them. maternal death report (within 24 hours).
This information-gathering exercise is conducted Flow of reporting through a mix of: routine reporting; The reporting process is depicted in Fig. 23. review meetings; specific surveys; Fig. 23: Flow of reporting in the feedback process. Tamil Nadu public health system Routine reporting HSC Basic Registers Monthly and other periodic reports are generated in the field at the levels of both primary care and Outreach and PHC Institutional Services secondary and tertiary care. Report Consolidation As noted in Chapter 4, the information collected at the primary level includes: Computerization of Data MCH Report (outreach and institutional), District Electronic Transfer of based on the basic MCH registers; Data to State Institutional Services Monitoring Report (ISMR), through optical mark reader forms; maternal death report to the state, within MCH report 24 hours by telegram, fax, or e-mail; Integrated Management of Neonatal and The monthly MCH report collects vital information Childhood Illness (IMNCI) reports; for monitoring MCH service delivery. The data infant death report; collected cover: Integrated Counselling and Testing Centre % of pregnant women who are (ICTC) report; registered; RTI/STI clinics report and special clinics report; data from special camps—Family Health Awareness camp and Varumun kappom 1 The number of pregnant women is estimated from the thittam. birthrate for each district and block. % of pregnant women registered within the Institutional services monitoring report first 12 weeks of pregnancy; % of pregnant women registered within Until the late 1990s the monitoring system covered 12–28 weeks of pregnancy; only outreach activities. Thus, data on institutional activities and events, especially regarding PHCs, % of pregnant women registered after 28 weeks; were not readily or consistently available. The ISMR, introduced in April 1999, was a first step % of pregnant women vaccinated with tetanus toxoid—TT-1, TT-2, or booster; towards filling this gap. Filed by PHC staff and signed by the medical officer each month, this number of antenatal visits; report provides extensive statistical information % of pregnant women with five antenatal about all institutional activity at the HUD/PHC visits; level. The ISMR is yet another new initiative in the % of pregnant women who are anaemic; Tamil Nadu Public Health System supported by % of pregnant women treated with 200 Danida. iron-folic acid tablets; % of deliveries taking place in institutions The data canvassed in the ISMR cover a wide range— (institutional deliveries); out-patient and in-patient attendance; numbers number of deliveries conducted in of deliveries, laboratory investigations, minor government hospitals; surgeries, vaccines administered, and sterilizations number of deliveries conducted in PHCs; done; siddha out-patient attendance, utilization of ambulances and PHC vehicles, and several other number of deliveries conducted in HSCs; statistics. number of deliveries conducted in private hospitals; With information coming in from all the PHCs % of deliveries taking place at home in the state, the amount of monthly data was (domiciliary deliveries); too voluminous even for computer entry and number of domiciliary deliveries attended tabulation. Hence, Danida provided the statistical by health staff; wing of the health service with the optical mark number of domiciliary deliveries conducted reader (OMR), which scans the special format of the by trained dais; ISMR and, through a computer link, makes possible number of domiciliary deliveries conducted tabulation, consolidation, and analysis. The analysis by untrained dais; is available for each level: PHC, HUD, district, and % of deliveries that received skilled state. attendance; number of low-birth-weight babies; By the 10th of every month this special format number of high-risk mothers; is sent through the district offices to the state capital. By the 15th it is scanned, consolidated, % of births that were stillborn; analysed, and sent to the Chief Minister’s office, number pregnancies terminated as per the the Health Ministry, and state-level health officials. MTP Act; By the 20th the field-level staff receives feedback % of pregnancies resulting in live births, through the district. by sex; birth order of live births and sex; A portion of the ISMR report is reproduced as number of high-risk newborns; Fig. 19 in Chapter 5. number of immunization sessions held; % of children covered with all ISMR training and fine-tuning immunizations, by sex; number of contraceptive adopters, by The introduction of the ISMR followed many months method. of planning and preparation. Several workshops
Additional Information 65 took place to finalize the format and to sensitize Simplification of the recording and staff to its use and benefits. All health-related reporting process departments, such as public health, family welfare, and medical services, were brought into the Along with introduction of the ISMR, an effort was consultation and training process. made to rationalize, redesign, and simplify the registers used by health service personnel. The For a little over a year after introduction of the major objectives were to: ISMR, the same information was also recorded in assess information needs at various levels the previous format at the PHC level, and copies of the health system; were sent to the DDHS and the Directorate of Public design an optimal recording and reporting Health (DPH). These reports were compared with system; the new format to spot mistakes and discrepancies develop suitable indicators of progress; that might occur because of the PHC staff’s limited design appropriate feedback systems; familiarity with new ISMR. Initial problems in the pre-test certain areas of the system and use of the ISMR format related mostly to inaccuracy refine them based on feedback; in shading, ink spots, smudging, and folding or define and distinguish manual and creasing of the paper, all of which made it difficult automated operations; for the optical mark reader to read the report. Once design training packages; the new format was well understood and accepted develop appropriate software for as routine work, the duplicative filing of the computerization. conventional forms was abandoned. The process was internalized in the health system with the The goals of this exercise were mainly: DPH taking receipt of the optical mark reader from simplification of records at the grassroots Danida. This mainstreaming of the ISMR system took level; place in April 2003. ensuring upward flow of data from HSCs to the state level through the computer Results and uses of the ISMR network; analysis of data at the HUD level; Within a short period after its introduction, easier analysis of data by social class and the value of the ISMR had been decisively gender; demonstrated. Covering about 12 institutional provision of feedback for rapid decision- activities, the feedback provided by the ISMR has making. sharply raised awareness of performance levels. At the district level feedback goes not only to the Some significant changes were introduced in the DDHS but also to the District Collector. Review reporting and monitoring system. There is now a meetings at both district and PHC levels discuss single report from the HSC to the various higher the results. Dramatic improvement over four years levels. For Village Health Nurses (VHN), who in overall performance figures for certain activities previously had to fill in as many as 24 registers, can be attributed in large measure to this detailed the process was streamlined and the number of monitoring and feedback, although there have records brought down to 9, greatly reducing the also been other inputs such as infrastructure workload and making it more logical, eliminating improvement. repetition.
ISMR statistics also have helped to identify The VHN's nine records comprise eight registers and specific problems, such as long-term vacancies. Form 9, which contains the consolidated records. Once identified, such vacancies have been filled, Form 9 is keyed into the computer at the PHC and particularly where female medical officers are sent to the district level for further consolidation. needed. The result has been a more balanced Transmitting the information thus became a distribution of medical officer postings. standard, once-a-week process.
66 Safer Pregnancy in Tamil Nadu: From Vision to Reality At the PHC level registers have been provided for the relatives of the dead are not involved in all the staff. In all, there are 16 modules containing the process; 102 registers. The report section of each register very little information is provided in the contains a duplicate copy on perforated paper, which audit reports on the quality of care or is removed and sent to the DDHS for consolidation about delay in the provision of care at the and forwarding to the state level. These registers institutions; cover all programmes for all the staff at the PHC often the reports blame the field-level level, both institutional and outreach. health functionaries; non-medical and other contributory factors At the next level—taluk, non-taluk, and district usually are not identified. hospitals—another 16 modules of 120 registers have been provided, covering all activities. The Verbal autopsy consolidated institutional-level monitoring report is part of this. Given this situation, a new initiative was undertaken in 2004, under RCH, to conduct verbal autopsies of A significant number of person-days per year have all maternal deaths. Here, the investigators contact been saved through this simplification process, not only the institutional staff but also the relatives enabling the service providers to concentrate more of the dead to collect crucial information on all on service delivery. factors that contributed to the death, such as lack of preparedness and delays in transit and getting Maternal death audits timely assistance at the institutions, financial constraints, and other related aspects. A detailed Two types of audit are done—the institution-based questionnaire is administered to collect the relevant maternal death audit and the verbal autopsy. information. In the former only maternal deaths occurring in institutions are reviewed, to find out the causes of The protocols for operationalizing this verbal death and the related factors. The latter cover all autopsy included: deaths—institutional or domiciliary. In the case of sensitization of health functionaries and domiciliary deaths, information is collected from line listing (online reporting) of maternal the relatives of the dead with the help of a detailed deaths; questionnaire. maternal death notification protocol; investigation of maternal deaths within Institutional death audit 15 days, using a structured format; facility-based audit and community-based The institutional audit of maternal deaths came first. maternal death audit by medical officers No doubt it helped sensitize the district officers, chief using the verbal autopsy format; medical officers, and specialists to the importance district maternal death verbal autopsy of conducting maternal death audits. Minutes of the meetings convened by the District maternal death audit meeting are regularly sent to Collector. the Commissioner, MCH and Welfare. District verbal autopsy meetings There have been a few challenges as well: there is very little motivation on the part of The District Collectors review the maternal deaths the service providers to conduct a sincere in their districts each month with all the concerned audit, and often case records are poorly officials. All the service providers, district officials, maintained; and the relatives of the deceased participate in the supervisory officers tend to protect the verbal autopsy meeting. At these meetings their subordinates rather than to find out the findings of the verbal autopsy are discussed. about lapses in service provision; Also, the relatives describe the events leading to
Additional Information 67 the death of the family member. Various delays, monthly review of secondary-level barriers in access to care, delays in providing care, hospitals at the district level; and quality of care, as well as informal payment in regional-level review meetings twice a year the institutions, are some of the topics discussed at for secondary-level hospitals; these meetings. institutional death audit review at the district level. Following the meeting: all the service providers are sensitized to Nutritional assessment reports from the Social the various delays and issues concerning Welfare Department and birth and death the quality of care; reports from the Revenue Department and all the contributory factors for each the local bodies are other sources of vital maternal death are analyzed, and the information. findings guide policy changes. Surveys Findings Surveys are conducted periodically at both The verbal autopsy reviews in 2004 pinpointed the state and district levels. The types and several weaknesses in operations at the health frequency of surveys are shown in Tables 9 facilities. These were: and 10. more deaths among the poorer families; misdistribution of First Referral Units and Table 9: Frequency of health-related specialists; surveys at the state level, sub-standard care in the institutions Tamil Nadu and poor accountability among service providers; Survey Frequency unnecessary referrals; Sample Registration System (birth Annually lack of emergency transport facilities; rate, death rate, infant mortality rate) overcrowding in First Referral Units for normal delivery; National Family Health Survey Once in 5 years (antenatal coverage, immunization, need for accreditation of more private family welfare) health facilities; Census (population, sex ratio, Once every unmet need for MTP and tubectomy literacy, etc.) 10 years services; poor skills among health functionaries; lack of empowerment of health workers to Table 10: Frequency of health-related provide obstetric first aid; surveys at the district level, lack of community awareness. Tamil Nadu Survey Frequency Review meetings Vital Events Surveya (birth rate and Once in 3–5 years other fertility indicators, death rate, Periodic review meetings are another important infant mortality rate) means of monitoring. The types of reviews RCH Household Survey (antenatal/ Once in 5 years conducted include: intranatal/postnatal services, fixed-day weekly meetings in the immunization, and family welfare) PHCs to review HSC and PHC Assessment surveys by external Whenever performance; agencies required monthly review meetings of PHC medical Coverage Evaluation Survey Annually officers and supervisors at the district Sentinel Survey for HIV Annually level; a Now suspended
68 Safer Pregnancy in Tamil Nadu: From Vision to Reality Resources at the district level for mapping of all health facilities to decide monitoring on locations for 24 hour a day CEmOC and newborn care and BEmONC services; The resources available for monitoring at the district mapping of catchment areas of the health level include: facilities; qualified statistics personnel (at the district analysis of data from the perspective of level and the block level); gender equity—e.g. immunization coverage, computer facilities; infant deaths by sex, sex ratio of births; units of the National Informatics Centre, further collection of statistics on utilization with satellite connectivity, at all district of health services in remote areas and by headquarters; the poor. video conference facilities at state and district levels. Several initiatives for performance improvement have been launched recently. These include an Monitoring of quality of care infant death verbal autopsy and a pilot initiative to audit stillbirths. The tools adopted for assessing the quality of care comprise: E-governance client satisfaction surveys and exit interviews at CEmOC and newborn care Technological support provided to the personnel in centres; the health facilities assists the monitoring process. inspection reports; It comprises: formation of Patient Welfare Societies in all telephones in all the PHCs and hospitals; the health facilities; computers and Internet connections at convergence of health programmes PHCs and hospitals, being phased in; monitoring through a single District computer training for the health functionaries; Society; computer training centres in three Regional district planning with funds released to the Training Centres; District Societies under the National Rural a special toll-free telephone number for Health Mission. CEmOC and newborn care data reporting; mobile phones for Village Health Nurses. The initiatives in this connection include: “near miss review” for serious maternal It is proposed to provide palmtop computers soon morbidity; to Village Health Nurses for data collection.
Additional Information 69 5. Urban Health
Tamil Nadu is one of the most urbanized states The situation in the country, with 44% of its population living in its urban areas. Natural increase apart, urban Only limited information is available on the status and population growth has been fuelled by the operations of urban PHCs state-wide. Information development of manufacturing and service available for Chennai Corporation points to: sectors and in-migration from the rural hinterland. shortages of human resources, both medical This has posed enormous challenges in meeting staff, including specialists, and paramedics; the people’s aspirations in respect of health care, inadequate infrastructure: Of the clean water supply, sanitation, and a healthy 93 functioning centres, only 39 have environment. maternity wards, 15 have operating theatres, and 20 have infant warmers; Health hazards confront the people in many of these poor maintenance of the existing facilities; areas, especially the people residing in slums. Of the lack of complete asepsis in labour wards; state’s urban population, one in every 10 people poor laboratory support, due to shortages resides in a slum. The challenges in urban health of technicians, equipment, and reagents; can be appreciated by examining the rural–urban divide in several health indicators in Tamil Nadu a range of diagnostic services— (see Table 11). X-ray, ECG, ultrasonography, automated blood analysis—reportedly offered at nominal charges, but in fact, of the four Salient features are: diagnostic centres functioning, only two a narrowing gap between rural and urban have ECG technicians and only one has a birth, death, and infant mortality rates, but radiographer; with a relatively slow pace of decline in urban rates; insufficient MCH care and poor high- risk care, partly due to staffing and skill an adverse trend in the stillbirth rate in constraints; urban areas; a similar trend in perinatal and neonatal lack of emergency obstetric services: Only mortality rates; two emergency obstetric care centres now functioning; a comparatively slower reduction in the general fertility rate in urban than in the insufficient staff knowledge of obstetric rural areas. emergencies, resulting in poor referrals; family health awareness campaigns and Given this situation, a strategic urban-specific mobile clinics operating only in a limited approach is essential for handling the urban health fashion; requirements. poor anaemia management; Table 11: Change and urban–rural differences in key demographic and health indicators, Tamil Nadu Indicator Rural Urban Rural–urban gap Birth rate 1981 29.7 23.9 5.8 2006 16.5 15.9 0.6 % reduction over 1981 44.5 33.5 NA Death rate 1981 13.5 7.9 5.6 2006 8.3 6.4 1.9 % reduction over 1981 38.5 25.0 NA Infant mortality rate 1981 104 55 49 2006 39 33 6 % reduction over 1981 62.5 40.0 NA Stillbirth rate 1981 9.9 4.8 +5.1 1997 11.0 13.1 -2.1 % change over 1981 +11.1 +172.9 NA Perinatal mortality rate 1981 60.6 26.2 34.4 1997 47.2 35.4 11.8 % change over 1981 -22.1 +35.1 NA Early neonatal mortality rate 1981 51.2 21.5 29.7 1997 36.6 22.6 14.0 % change over 1981 -28.5 +4.2 NA Age-specific death rate, 0–4 years 1981 42.1 17.6 24.5 1997 15.1 9.7 5.4 % reduction over 1981 64.1 44.9 NA Total fertility rate 1981 3.7 2.7 1.0 2005 1.8 1.6 0.2 % reduction over 1981 51.3 40.7 NA General fertility rate 1981 115 89.4 25.6 2005 62.1 55.2 6.9 % reduction over 1981 46.0 38.3 NA NA, not applicable
poor awareness among the public of the community Link Leaders, intended to availability of the range of services; provide this link, function in only a few unsuitable out-patient hours; places; insufficient linkages between the ineffective monitoring or evaluation of the community and the health workers; activities.
Additional Information 71 Resource constraints, limited interface between Urban health was regarded as one of the thrust areas the local body and the Health and Family Welfare of the Tenth Five Year Plan, the National Population Department, lack of a distinct focus on urban Policy 2000, and the National Health Policy 2002. health, and relatively more emphasis on solid waste The goal of the National Health Policy 2002 was management and sanitation are also constraining to provide high-quality integrated primary health factors. care services to the urban community with a focus on the vulnerable strata. The main objectives were Positive aspects of the situation in Chennai include: to: two “walk-in clinics” operating since 2004, provide an integrated and sustainable providing MTP services on demand and system for delivering primary health maintaining confidentiality; care services in urban areas to meet the the Chennai AIDS Preventive and requirements of slum populations and Control Society, set up with World Bank other vulnerable groups; assistance in 1999, offering prevention enhance the capacity of urban local bodies and care and support services such as to plan and implement such service targeted intervention for high-risk groups, delivery; awareness-raising among the general bring about an overall improvement in the population, integrated counselling urban health situation through both the and testing services, STI/RTI treatment, primary level and a strengthened referral prevention of parent-to-child transmission, system. and referral linkages with antiretroviral treatment (ART) centres for people living In Tamil Nadu there are many variations in the with HIV/AIDS. distribution of health delivery infrastructure and staffing. The variations in levels of service delivery The status of public health in other corporations and result from the: municipalities is not likely to differ significantly from influence of urban local bodies and the those in Chennai. In these circumstances, until the level of service availability; urban health policy is implemented in all respects, types of services being provided; no noteworthy improvement in the situation is extent of involvement of state government, likely. with differing levels of financial support at times. Public health Lack of sustainability after the withdrawal of donor Responsibility for health in cities and towns falls support is another problem in some areas. to the municipal corporations and municipalities dotting the state. The municipalities function within In urban Tamil Nadu the primary health facilities the framework of the Tamil Nadu Public Health are concentrated in the municipal corporations or Act 1939, Madras City Municipal Act 1919, Prevention municipalities having more than one lakh (100 000) of Food Adulteration Act 1954, Birth and Death population. There are 75 municipalities with less Registration Act 1969, and such other acts as are than one lakh population that lack adequate urban formulated from time to time. primary health infrastructure. The Public Health Act requires all municipalities to earmark 30% of income from all sources, other Tamil Nadu urban health policy, 2002 than government grants on expenditure, for advancement of public health. These health services The Government of Tamil Nadu developed an cover preventive and curative care and health urban health policy in 2002, setting forth its vision promotion, while secondary and tertiary support is for urban health. The main objective is to improve the responsibility of the Health and Family Welfare the access, equity, and quality of service delivery in Department. urban local bodies.
72 Safer Pregnancy in Tamil Nadu: From Vision to Reality Rationalization of the infrastructure norms, staffing Table 13: Staffing norms for urban primary norms, service delivery, and cost-sharing between health centres the Department of Health and Family Welfare and Staff Type A Type B the Department of Municipal Administration and Medical officer 1 2 Water Supply were the key features of this policy. Staff nurse Nil 1 Health visitor 1 1 Urban primary health centres Multipurpose health 1 per 20 000 1 per 20 000 worker population population Many health indicators suggest that urban areas are Pharmacist 1 1 slipping badly in health care vis-à-vis the rural areas. Female nursing 1 1 The causes are: assistant lack of technical guidance and supervision Lab assistant/ Nil 1 from the Directorate of Public Health, attendant Medical and Rural Health Services, Family Sanitary worker 2 2 Welfare, and Indian System of Medicine; technical officers’ lack of knowledge; multiple agencies with overlapping functions; one Urban Primary Health Centre will be set the acute resource constraints of the local up for every one lakh (100 000) population bodies, with low priority given to health to provide a systematic referral linkage services; to secondary and tertiary institutions. lack of trained and qualified personnel Municipalities having less than 1 lakh in the local bodies to tackle the current population will have Type A Urban Primary community health situation and problems; Health Centres, while the others will have a poor reporting system and poor review of Type B Urban Primary Health Centres. The health programmes; norms for establishing these centres are the preference of municipal public health shown in Table 12. In all, 82 Type A and 119 personnel to focus on conservancy and Type B Urban Primary Health Centres will solid waste management rather than health be established; services; these centres will cater to all primary lack of outreach services in urban slums, health care needs, such as maternal and leading to higher morbidity and mortality, child health care, deliveries, sterilization, particularly among mothers and children. medical termination of pregnancy, temporary methods of contraception, The new urban health care delivery policy was treatment of minor aliments, and first formulated to address these issues. The salient aid as well as surveillance and treatment features of the policy are these: of communicable diseases such as the scheme will be implemented in tuberculosis, malaria, and leprosy; all six municipal corporations and 102 the centres will also provide a variety of municipalities (since increased to 152); outreach services, such as: antenatal and postnatal care for women Table 12: Norms for distribution of urban and children; primary health centres outreach services for general public Population health; (in Lakhs) Type No. of centres <1 A 1 disease surveillance for the population 1–1.5 B 1 attached to each centre. 1.5–2.5 B 2 available buildings and other infrastructure 2.5–3.5 B 3 under the control of local bodies are to be 3.5–4.5 B 4 used for these centres and maintained by Note: 1 lakh = 100 000 the local bodies;
Additional Information 73 the norms for the staffing pattern of the surplus staff will either be phased out in different types of centres are shown in due course or redeployed within the health Table 13; unit as far as practical. Also, establishment the existing staff for health programmes of urban PHCs can be staggered depending in government, both under Medical upon redeployment and phase-out plans; Services and Public Health branches and staffing of the PHCs will be done through under urban local bodies and corporations, redeployment or through creation of new will be utilized as a common programme posts over time as posts elsewhere are unit; eliminated.
74 Safer Pregnancy in Tamil Nadu: From Vision to Reality 6. Operationalization of First Referral Units and use of GIS Mapping
Guidelines for operationalization care centres and their functionality are the key elements in promoting accessibility, coverage, and The national guidelines for operationalizing First quality. With this in mind, the health facilities were Referral Units (FRUs) stipulated that a health facility mapped using a geographic information system must be capable of three crucial functions in order (GIS) tool. See Fig. 25 and Fig. 26 for mapping of to be declared an FRU. These functions are: the catchment areas of two FRUs—Arantangi and emergency obstetric care including surgical Pudukottai—to be strengthened as CEmOC and interventions, such as caesarean sections, newborn care centres. and other medical interventions; newborn care; The criteria used for determining the selection and a blood storage facility available 24 hours strengthening of FRUs/CEmOC and newborn care a day. centres were: 1. the density and distribution of maternal In the process of applying these criteria, it was deaths and infant deaths. realized that many FRUs at the district and sub- 2. distance from other health facilities to the district levels in Tamil Nadu were, in fact, not FRU/CEmOC and newborn care centres in functional FRUs, and their services were of sub- the catchment area (see Fig. 27). optimal quality. Hence, Tamil Nadu took the initiative 3. the concentration of private-sector health to critically review the functionality of FRUs and facilities. to strengthen them as CEmOC and newborn care 4. the distribution of the population below centres to meet the three critical criteria. the poverty line (see Fig. 28).
Tamil Nadu strategy At first, FRUs/CEmOC and newborn care centres that could be reached within an hour were strengthened. First and foremost, the geographical distribution of Later, additional FRUs/CEmOC and newborn care FRUs in every district was examined. As an illustrative centres were strengthened to reduce the maximum case study, Pudukottai District was chosen. See travel time to half an hour. Fig. 24. The purpose was to select the facilities that should be upgraded so that functional FRUs/ Service norms, human resource norms, space CEmOC and newborn care centres would be readily norms, equipment norms, capacity-building accessible to the population in their catchment norms, quality assurance norms, and public areas. The availability of FRUs/CEmOC and newborn awareness norms for FRUs/CEmOC and newborn
1 Guidelines for operationalising First Referral Units. 2 World Health Organization. Service availability mapping Government of India, Ministry of Health & Family (SAM)—An application of WHO’s health mapped information Welfare, Department of Family Welfare, Maternal Health and mapping applications for public health. Geneva, World Division, 2004. Health Organization, 2005. care centres were discussed and established to facilities at all levels in the government sector, while assure quality of care. there was a concentration in the private sector.
The distribution of human resources—specialists Available human resources were initially redeployed such as obstetricians and gynaecologists, to CEmOC and newborn care centres to meet the paediatricians, anaesthetists, and surgeons—was norms for specialists. Simultaneously, the process of studied. The study revealed a mal-distribution hiring private-sector anaesthetists was initiated, to of obstetrics and gynaecology specialists and meet the needs of CEmOC and newborn care centres. paediatricians. They were concentrated in health facilities other than those designated FRUs, such An effort is currently on to address the shortage as employees state insurance (ESI) hospitals of anaesthetists by providing six months of and dispensaries, sub-district hospitals with few training in anaesthesia skills to MBBS doctors in beds, and primary health centres. In the case of the government sector. In 2008, 84 MBBS doctors anaesthetists, there was a shortage in all health received such training.
Fig. 24: Case study of Pudukkottai district Fig. 25: Catchment area for using GIS tool for decision- Aranthangi government making: Accessibility of CEmOC hospital and newborn care centres to the local population Catchment area for Provision of comprehensive emergency Aranthangi Gh-ip obstetric and newborn care
VIRALIMALAL GANTHARVA KOTTAI KUNNANDARKML
ANNAYASAL PUDUKOTTAI Pudukkattai GH Pudukkottai Karambakkudi 31.8 Km Ponnamaravathi Thirugokarnam
ARANTHANGI THIRUMAYAM ARIMALAM Aranthangl GH Aranthangi GH 30 Km Radius Thirumaayam 40 Km Radius 27.3 Km
Manamelgudi Thirupunavasal
76 Safer Pregnancy in Tamil Nadu: From Vision to Reality