Management Capacity Assessment for National Health Programs: A study of RCH Program in Gujarat State

The Ministry of Health and Family Welfare, Government of India administers a large number of national health programs such as Malaria control program, Blindness control program, National AIDS control program, Reproductive and Child Health (RCH) Program and so on. However, effective management of these programs has always come under scrutiny, as these programs consume a large amount of resources. As health is a state government subject in India, it is necessary to assess the management capacity of the department of Health and Family Welfare (H & FW) in each state. In this paper, we focus on the management capacity assessment for RCH program. Based on extensive literature survey, and discussions with senior officers in charge of RCH program at the centre and several states, we have developed a conceptual framework for management capacity assessment. Central to our conceptual framework are the following determinants of management capacity at the state dept of H & FW: (1) Capacity to formulate a clear statement of the state’s RCH Policy, Goals, and a Strategic Plan to achieve the Objectives, consistent with the resources available, (2) A well designed organizational structure for the H&FW department to provide the necessary support for achieving the policy goals, (3) Capacity of the H & FW department for effective management of RCH program, (4) Clear documentation of HR policies (qualifications, transfer, promotions, training etc) for RCH managers, (5) Role of External Stakeholders (6) Management Systems for Planning, Implementation and Monitoring RCH program, and (7) Institutional Processes and procedures For each of the above determinants, we have identified a set of indicators to assess the management capacity and designed a management capacity assessment tool to estimate these indicators. A pilot survey of our management capacity assessment tool in a few states helped us to refine certain instruments in our tool and finalize the same. Our management tool has been accepted by the Ministry of H & FW, Government of India and it has asked all the states and union territories to carry out a self assessment of their management capacity for RCH program. We have also recommended a suitable structure for effective management of RCH program for each state based on its population, the number of people in the reproductive age group, expected number of childbirths, and the current status of its H&FW department in delivering RCH services. This recommended structure can be used as a guideline by each state to identify its capacity gaps and take the necessary steps to augment its management capacity.

Chikungunya Epidemic Mortality in India: Lessons from 17th Century Bills of Mortality Still Relevant

Chikungunya is a virus spread by the bite of the Aedes mosquito, which recently reemerged as a massive epidemic in the Indian Ocean islands and India. Chikungunya is generally considered self-limiting and has been reported as non-fatal but, since March 2005, one-third of the 770,000 people in the Indian Ocean Island of R�union (a French territory) have been affected by Chikungunya with 237 deaths. India reported 1.3 million cases of Chikungunya however the Government of India has not reported any deaths. However there is evidence that deaths due to Chikungunya did occur. The lack of official reports of deaths is mainly due to the poor recording of ‘Causes of Death’ in India. The London Bills of Mortality from the 17th provides a very good example of the importance of proper reporting of deaths especially during an epidemic period. This paper reflects on the London bills of mortality and modern day lessons to be drawn from it as well as the reasons behind the apparent lack of death reporting in 2006’s Chikungunya epidemic.

Management of RH Services in India and the Need for Health System Reform

For the last ten to fifteen years, a comprehensive agenda of health sector reforms and health systems development has engulfed the health system in many countries in structural and organisational changes. Experience with varying degrees and types of reforms have now been reported from many countries. In our paper, we begin by describing some important issues facing the management of RH programs in India, based on our research done in a few states over the last five years. The failures in the management of RH services are complex and multi-factorial, and cannot all be addressed through health system reform. It is therefore necessary to identify which failures in service are attributable to causes, which could be removed or changed by reform in the health system. In our paper, we identify those failures and causes which could be corrected through health system reforms and propose certain concrete steps to expedite the reforms in the health system to enable the improvement of RH services in India.

Management of Blood Transfusion Services in India: An Illustrative Study of Maharashtra and Gujarat States

Blood is a vital healthcare resource routinely used in a broad range of hospital procedures. It is also a potential vector for harmful, and sometimes fatal, infectious diseases such as HIV, HBV, and HCV. Morbidity and mortality resulting from the transfusion of infected blood have far-reaching consequences. The economic cost of a failure to control the transmission of infection is visible in countries with a high prevalence of HIV. Shortfalls in blood supply have a particular impact on women with pregnancy complications, trauma victims and children with severe life-threatening anaemia. Ensuring a safe, source and ethical supply of blood and blood products and rational clinical use of blood are important public health responsibilities of every national government. Blood transfusion services in India rely on very fragmented mix of competing independent and hospital based blood banks of different levels of sophistication, serving different types of hospitals and patients. Voluntary and non-remunerated blood is in short supply. The SACS ensure only the availability of safe blood in blood banks. Clinical use of blood is not monitored, and the use of blood components is very low. Managing blood transfusion services involves donor management, blood collection, testing, processing, storing, issue of safe blood and blood products when clinically needed, and staff training. Maharashtra Government, by setting up its State Blood Transfusion Council as an independent unit under the Department of Health, has set up an excellent example to address the above managerial issues in meeting the transfusion requirements than any fragmented system. We strongly recommend the Maharashtra model to all other states and union territories in India.

Quality of family planning programme in India: A review of public and private sector

Increasing attention has been paid to quality of care (QOC) in family planning (FP) during the last few years, and there have been several initiatives to strengthen QOC in FP in the developing world. This paper reviews the quality of the FP program in India’s public and private sectors, and examines six elements: choice of methods, information given to clients, technical competence, interpersonal relations, continuity of care and follow-up, and appropriate constellation of services. Overall, the paper finds that not much attention has been paid to QOC and hence the level is quite low. Evidence and observations indicate that QOC may be slightly better in the nongovernmental sector. In many areas adequate information is not available to assess QOC, especially in the private sector. Overall, substantial efforts are needed to improve QOC in FP in India. The paper discusses why QOC is poor and offers suggestions for improving each dimension. As the Government of India is actively considering revising its FP program strategy and adopting a reproductive health approach, it may be an opportune time to improve QOC in the family welfare program

Maternal Health Financing in Gujarat: Preliminary Results from a Household Survey of Beneficiaries under Chiranjeevi Scheme

The objective of this paper is to provide preliminary analysis of information collected at household level from beneficiaries of the Chiranjeevi scheme and from those who have not used the scheme (non-user group). The key findings have been discussed. Some of the questions which have guided this exercise are: understanding the socio-economic profile and differences of the households who have used the scheme and those who have not used the scheme, ability of scheme to target the poor and out-of-pocket expenditures incurred both users and non-users of the scheme. We have discussed this by analysing education, land holding, number of earning members in the family, possession of specific assets, age of women at the time of delivery, ANC services received, place of delivery, distance and time taken to reach the facility, status (normal or complication) of delivery, complications experienced, and cost incurred during the process. The total sample size consists of 656 respondents from 3 talukas of Dahod District. Of these total 656 respondents, 262 (40 per cent) are Chiranjeevi clients and 394 (60 per cent) comprise the non-user group. Key findings of the study are: * The Chiranjeevi scheme is being used by relatively younger mothers and having lesser number of children at the time of index delivery. * Most of the Chiranjeevi users have income levels less than Rs. 12,000 per annum indicating the scheme is able to target the poor families in these three blocks of the district, * The expenditure incurred by non-user group on index (recent) delivery at a private facility is Rs. 4000. * The average expenditure incurred by the Chiranjeevi beneficiary on their previous delivery was Rs. 3070. On index delivery a Chiranjeevi client has spent out-of- pocket on an average Rs. 727 per delivery on medicine (self Rs. 297, child Rs. 358) and transportation Rs.72 indicating that the delivery is not really cash-less. However, the average amount saved by the Chiranjeevi client by availing the benefit of the scheme is Rs 3273 (Rs. 4000 minus Rs. 727). * The average distance travelled by a Chiranjeevi client to reach the health care facility is 13.79 kms and the average time taken is 44 minutes. * The average expenditure on transportation using mostly private transport by a Chiranjeevi client is Rs.272 as compared to Rs. 200 which the Chiranjeevi client is reimbursed, * Private doctors have conducted 41 per cent of deliveries where as rest of the deliveries have been conducted by staff at the private health care facility under the Chiranjeevi scheme, * ANMs have been the source of information to 55 per cent of Chiranjeevi scheme users. Anganwadi workers provided information to 17 percent of the clients and Female Health Workers to 10 per cent of the Chiranjeevi clients. Thus, 82 per cent of the total beneficiaries of the Chiranjeevi scheme were provided information by the community health workers.

Chikungunya Fever: A Killer Epidemic in Ahmedabad City, India

Background The Chikungunya virus is an alphavirus native to tropical Africa and Asia and is transmitted to humans by the bite of infected Aedes mosquitoes. The symptoms of Chikungunya include sudden onset of fever, severe arthralgia, and maculopapular rash. Thirty percent of the population on the French R�union Island was afflicted with Chikungunya in the past year. They reported 237 deaths. India on the other hand reported 1.39 million cases of Chikungunya but no deaths. Methods Mortality data from 2002-2006 was obtained from the Ahmedabad Municipal Corporation (AMC). Actual mortality rate of 2006 was compared to the mortality rate of 2002-05 and its statistical significance tests were carried out. Findings Mortality data obtained from the Ahmedabad Municipal Corporation (AMC) suggests that 3112 excess deaths occurred in August-November (epidemic period) compared to the average deaths in the same months during the previous four years. These differences in deaths were found to be highly statistically significant. A peak in excess mortality is seen in the month of September when 1489 additional deaths were recorded. Case fatality rates for Ahmedabad also turn out to be much higher than that of the Reunion Island. Interpretation The Chikungunya epidemic was raging when the excess deaths occurred. There were no other adverse events or other epidemics that took place could explain this excess mortality. Government authorities, WHO and other international public health agencies should take these findings of excess mortality seriously and investigate into this occurrence of excess deaths to understand this reemerging disease and prevent future epidemics and mortality.

Managerial Challenges in Addressing HIV/AIDS: Gujarat State AIDS Control Society (GSACS)

The spread of HIV/AIDS is not merely a problem of public health; it is also an economic, political, and social challenge that threatens to hinder decades of progress in different parts of Gujarat. There is an urgent need to significantly scale-up public health interventions that work to make a meaningful impact. While NGOs and community based organizations have a critical role to play in implementing these interventions amongst the various population groups, the government must shoulder the overall responsibility for planning, coordinating, mobilizing, and facilitating the various HIV/AIDS prevention, care and treatment services in the state. Generally, the departments of HIV/AIDS are dominated by doctor-managers who lack training in management. This working paper was developed with objective of enhancing the skills of the program implementers. In this paper, in first three chapters we describe the overall situation of HIV/AIDS globally and nationally. Major challenges in managing sentinel surveillance, behavior surveillance, targeted interventions and its subcomponents have been described in chapter four. Issues related to integration of HIV/AIDS activities with reproductive health has also been discussed in the chapter. In chapter five, we present a few case studies from Gujarat State AIDS Control Society. These cases focus on the managerial issues in the following areas: Project Management, Blood Bank Management, VCTC/ICTC Management, Behavioral Surveillance and MIS for Targeted Interventions. These case studies bring out the ground level realities and can help participants develop insights for better management of the HIV/AIDS programme.

Study of Blood-transfusion Services in Maharashtra and Gujarat States, India

Blood-transfusion services are vital to maternal health because haemorrhage and anaemia are major causes of maternal death in South Asia. Unfortunately, due to continued governmental negligence, blood-transfusion services in India are a highly-fragmented mix of competing independent and hospital-based blood-banks, serving the needs of urban populations. This paper aims to understand the existing systems of blood-transfusion services in India focusing on Maharashtra and Gujarat states. A mix of methodologies, including literature review (including government documents), analysis of management information system data, and interviews with key officials was used. Results of analysis showed that there are many managerial challenges in blood-transfusion services, which calls for strengthening the planning and monitoring of these services. Maharashtra provides a good model for improvement. Unless this is done, access to blood in rural areas may remain poor

Using ‘Appreciative Inquiry’ in India to improve infection control practices in maternity care : a qualitative study

ACKNOWLEDGEMENTS The inputs and facilitation of field work from the Gujarat state government officials are acknowledged. We express our gratitude to the doctors, nurses and other health facility staff for actively participating in the study. Our special thanks to Dr. Pritam Pal for capacity building of the research team for appreciative inquiry and Mr. Sanjay Joshi for follow-up of the AI process. We appreciate the help of Dr. Purvi Shah in data collection and preparing transcripts for the study. The study was funded by the John D. and Catherine T. MacArthur Foundation.Peer reviewedPublisher PD