CHAPTER 7 CONCLUSION

Transcription

1 CHAPTER 7 CONCLUSION The Reproductive and Child Health programme launched by the government of India in October 1997 following the recommenda6on of the ICPD, Cairo, represents a major shift from the earlier approaches. The RCH programme provides a new vision to the population policy and recognizes the cruci;ll distinction between the overall goals of the population policy and those of the reproductive health programme. The principal goals of the reproductive health programme is to reduce unwanted fertility safely and to provide high quality health services, thereby responding to the needs of individuals, as well as to the concerns regarding population stabilization. The RCH approach replaces the numerical, method-specific targets and monetary incentives for providers with a broader system of performance measures and goals focused on a range of reproductive health services. It also involves the broadening of the package of services and improving the quality of services. Though India has demonstrated a strong policy commitment to the RCH approach, major problems are predicted in the implementation of the programme. This is especially so given the history of the programme and the nature in which the programme has been managed. An important reason for the limited success of the earlier programme has been lack of effective management for promotion and delivery of family planning services. Though socio-cultural factors and the developmental context have an influence on fertility behaviour, the family planning programme components of political will, administrative efficiency, information, education, communication (IEC) and service delivery aspects in terms of provision of easily accessible high quality services (offering a variety of methods) do have an independent impact on the family size norm and fertility behaviour. In this study we have analyzed the management of the recently introduced RCH programme in the rural government health facilities vftamil Nadu. Our study in Tamil Nadu, a state considered to be administratively better equipped for such changes, has revealed that the changes envisaged in the policy have not been 215

2 reflected in the grassroot level health institutions. Though targets are no longer prescribed to health workers, the present study has found that the procedure adopted in Tamil Nadu does not capture clients' needs properly and is a mechanical exercise. Moreover, family planning and particularly female sterilization is still given importance over other services. A number of components of the expanded service package is not yet provided in the government health facilities. Access to spacing methods, safe abortion, services for men and adolescents are not easily available in health facilities. Though services for RTI treatment have been started, it has not been able to cater to the huge demand for this service adequately. The inadequacies in the health infrastructure and poor staff attitudes towards clients contribute to the low utilization of institutional services for childbirth. \Vhile the RCH programme emphasizes quality of care and client satisfaction, the quality of services provided in government health facilities is not satisfactory. The most serious aspect of the quality of services is the poor nature of the client-provider Interaction. An important reason for the inadequate implementation of the RCH approach is that while the policy envisages a major change in the functioning of the programme, it has not been commensurate with inputs to the programme. The programme faces serious constraints with respect to infrastructure, equipment, and vehicles. The programme also has insufficient manpower who are oriented to the RCH approach and are equipped with the necessary clinical and interpersonal skills to provide services which are of high quality. A major deterrent in the implementation of the new programme has been the lack of understanding of the reproductive health approach. We have found in our study that district health administrators and the medical officers are not aware of the policy shift of the government. In such a situation, the shift in the reproductive health approach is a mere change in the nomenclature without any desired change in the field. It is essential that the training programs inform the health managers and personnel about the ideology and ethos of the programme is internalized and the programmes responsive to clients' needs arc designed and implemented. Apart from the health programmes, other stake holders such as panchayati raj members, district administrators and clients should be 216

3 informed about the shift in the programme. This can make the government machinery accountable to deliver the mandates of the RCH approach. One of the important impediments is the lack of supervision of health workers. The leadership of the PHC system - the medical officers - are preoccupied in their private practice and are not fully involved in the activities of the PHC. Their lack of involvement results in the health workers irregular and insufficient visits to the field. It is strongly recommended that the private practice of the government doctors be made illegal. The active involvement of the medical officers will result in not only in the regular functioning of the health services and reduce absenteeism but also speedier resolution of work related problems. This will result in regular and better quality of services. We observed that the sub-center network which is the first point of contact of the rural population with the health system is dysfunctional because of lack of proper buildings and absence of resident health workers. Construction of sub-center buildings should be started on a priority basis. Also, the government should spend more money on the purchase of land for constructing sub-centers at a strategic location rather than expect free land from the Panchayats which is often given only at the outskirts of the village. This will improve the accessibility of services to the rural population and facilitate the VHN to reside in the sub-center. The staying of the VHN's in the sub-centers should be stressed by the supervisors. In order to improve the accessibility of the health system to the village population, the Village Health Guide scheme can be activated in the state and such guides can be posted in every village. These guides who are picked upon from the village can act as a first point of contact between the village community and the health system. Unlike health workers, these guides can be accessible at all times and could be an invaluable asset to the village people. They can provide treatment for minor ailments, health education, stock and promote methods of family planning and refer patients to higher level facilities. With adequate training, renumeration and support of other health personnel, they can provide valuable health services to the villagers. 217

4 The inadequacies in the health infrastructure, poor staff attitudes and lay health culture among women results in low utilization of institutional services for child birth. Overcoming these deficiencies is a long term process and an effective short term intervention would be to train traditional birth attendants in every village and provide them with delivery kits. This will ensure that safe procedures are adopted during delivery in non-institutional settings. It would be unreasonable, given the present state of the public health facilities to provide certain services like safe abortion, treatment for RTI and infertility which are widely accessible to the rural population. It is essential that the government actively execute its stewardship roles by developing partnerships with the private sector for service provision and improving quality of services. Partnerships could have relatively low financial costs and offer the possibility of improving efficiency and increasing coverage without adding staff to the government. Contracting offers the prospect of increasing accountability and creating efficiencies that could not be attained with direct government provision of serv1ces. Rural Medical Practitioner (RMPs) - who do not have a medical degree or scientific paramedical training - have a formidable presence in rural areas. Due to the shortage of government health services, they provide most of the non-hospitalized care in rural areas. These practitioners can be effectively used to penetrate the rural areas and provide reproductive health care services. The Janani program- a successful NGO run program -in rural Bihar could be replicated in other parts of the country (Bishai, 2002; MOHFW, 2001). The programs uses RMPs to serve as distribution channels for condoms and contraceptive pills in rural areas. Each RMP undergoes training before they are formally induced into the programme and allowed to run a franchisee center which provides family planning, methods, counseling, reproductive health care and referral services. Th~se RMP's are supported by a network of franchised clinics in urban areas run by qualified doctors. These clinics offer treatment for RTis, clinical contraceptive services of IUD and sterilization and abortion services. Similar successful franchising programs offering reproductive health services in other parts of the world (Green Star Network in Pakistan, Blue Star Program in Bangladesh and Gold Circle Program in Indonesia) suggest that the government should promote such programmes and NGOs in Tamil 218

5 Nadu as well (MOHFW, 2001). The Draft National Strategy on Social Marketing of the Government of India zlso envisages an expanded role for such strategies in the national programme (MOHFW, 2001). The huge gap between budgetary allocations to the health programmes and the requirements contributes to the poor quality of services in government health facilities. Declining budgetary allocations and the growing requirements of financial resources to maintain and upgrade the facilities have created enormous pressure on health facilities. It is observed that the poor spend heavily to obtain treatment predominantly from the private sector. The burden of out-of-pocket expenses falls predominantly on the poor. In Tamil Nadu, the poorest 20 per cent of the population spend 41.1 per cent of the household expenditure on health compared with 3.9 per cent by the richest 20 per cent of the population (Mahal ct al., 2000). It has been estimated that one in five hospitalized persons in Tamil Nadu fall into poverty because of the high treatment costs incurred. The poor seck care from the private sector because of the poor quality of services in the public sector. User fee options can augment public health resources to provide better quality services. Though there are some user fees in the public health facilities in Tamil Nadu, the cost recovery is negligible per cent (\Vorld Bank, 2001). By increasing cost recovery ratios, revenue could be captured for public health services and quality could b.e improved, enabling the poor to access to better quality, lower cost care than they might receive in the private sector. There are other advantages of charging a fee. When people pay a fee for a service, it places accountability on the provider and the people consider it their right to demand better quality services. Community institutions such as panchayati raj institutions have played important roles in the functioning of development programmes. Expectations are limited in what governments should provide where the community institutions are weak. Programme staff and managers feel little community pressure to carry out mandated service activities and the impetus for service delivery lies almost with the service providers. 219

6 In Tamil N adu, the involvement of the panchayti raj institutions in the functioning of the health system as yet is minimal. Unlike in some states of India, there has been no formal administrative and financial powers assigned to the panchayats for the management of the health system. However, Panchayati Raj Insititutions are slowly being involved in the management of the health system. A recent government order instructed the medical officers of all the Primary Health Centers to form "Participatory Community Health Committees" comprising panchayat members and other community leaders to facilitate, advise and support the work of Primary Health Centres for providing quality health service to the people. However, during the course of our field work we found that these committees arc not functional and exist only on paper. It is necessary that these forums are activated so as to make the health system more accountable and also provide services which are required by the community. It is also noticed from the experience of other states which have involved panchayati raj institutions in the management of health programmes that the capacity of panchayats members to monitor a technical programmes such as health is very limited. It is necessary that appropriate capacity building measures be undertaken so that panchayats can play their envisaged roles. The Tamil Nadu government has achieved success with the development of autonomous bodies like the TNMSC. The TNMSC was created in part to deal with recurring drug shortages and quality concerns. This system appears to have been effective in controlling quality and preventing drug shortages. The financial and managerial autonomy granted to TNMSC has enabled it to overcome bureaucratic hurdles and increase its efficiency (Benett and Muraleedharan, 2000). Similar autonomy if provided to other hospitals can enable them to be more efficient and promote better service delivery. The case of autonomy granted to public hospitals in Rajasthan, Madhya Pradesh and Andhra Pradesh and the subsequent performance improvements indicate that similar trials should be initiated in Tamil N adu hospitals as well (Sharma et al., 2000; Chawla et al., 1996; Mohanty, 2001). The experience of these states in granting autonomy to public hospitals has resulted in greater resource availability in hospitals and greater managerial efficiency as a result of having their own administrative procedures (procurement, maintenance of medical equipment, recruitment of temporary staff, contracting out of services) rather than complicated government procedures. These have improved both access and quality of care. 220

7 One of the objectives of the study was to examine how development factors affects the functioning of the programme. Basic infrastructure such as roads, electricity, water and communication systems are essential for effective service delivery. Non-availability of appropriate transportation not only constrains out-reach activities but workers also remain out of administrative control and ovenriew. Insufficient resources 111 low development settings also results in ineffective service delivery. Our study has revealed very limited difference in the functioning of the programme between a developed (Kancheepuram district) and less developed area (Dharmapuri district). The basic factors such as political will, administrative systems and the resources allocated to the health department are same throughout Tamil Nadu and consequently in the two study districts. Further, other infrastrw:tural facilities like roads, electricity, public transportation and water supply were found to be similar in the two districts. However, differences in certain geographical factors, settlement patterns, literacy and economic status in the two districts results in some points of difference. Though Dharmapuri and Kancheepuram districts are similar, in certain parts of Dharmapuri district the smaller size of villages results in more villages to be covered by a health worker compared with Kancheepuram district. The villages are also spatially more dispersed in Dharmapuri district. These factors affect the frequency of contact of health workers with the village community, supervisory visits and also the utilization of health services by the community. The better economic status and literacy among women in Kancheepuram district also results in greater utilization of health services. The 'lay-health culture' mentioned in this study 1s less prevalent in this district compared with Kancheepuram district. It would be of interest to know the implications of the findings of this study for the other states of India especially the northern states which are characterized by low socioeconomic development, high rates of population growth and poor administrative structures to effectively implement health programmes. It is necessary that health programmes receive high level of political and administrative support so programmes are implemented effectively at the grassroots- and there is greater intersectoral collaboration. It is also essential that the states increase their spending on health. The per-capita expenditure on health in the backward states is a fraction of that in the more developed states (Rs. 57 in Bihar and Rs. 66 in Madhya Pradesh compared with Rs. 132 in Kerala and Rs. 120 in Tamil Nadu) (\'V'orld Bank, 2001). More importantly, it is necessary to 221

8 make the administrative structures more efficient for the effective implementation of health programmes. It is of vital importance that health workers and medical officers posted in rural areas are supervised properly. Supervision in other states is worse than in Tamil Nadu (Roy et al., 1999; Visaria ct a!., 1998). Health infrastructure like PHC's buildings should be improved and vacant positions of doctors and other paramedical staff be filled up on a priority basis. For instance, 40.2 per cent of the positions of medical officers in PHC's of Uttar Pradesh and 27.8 per cent of the health assistant (females) in Madhya Pradesh are vacant (MOHF\V, 2001). The procurement and distribution of medicines and other supplies can be streamlined in other states by following the TNMSC model. By creating an autonomous body to management logistics management, the frequent incidences of shortages of medicines have been eliminated in Tamil Nadu. The innovative schemes such as health camps, school health programmes and making PHC's function round the clock should also be tried out in other states which bring health services closer to the people and reduce travel, time and other incidental costs. The welfare schemes such as those aimed at improving nutrition among children and pregnant women, increasing female autonomy have also contributed to the effectiveness of health programmes and reducing fertility in Tamil Nadu. 222