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QUALITY IN RCH. Bhubaneshwar September 4, 2009 Amit Mohan Prasad Jt. Secretary, GoI. Presentation Outline. Background Institutional arrangements Operationalisation of facilities Human resources Skill based training Quality of care Antenatal care Delivery care Postnatal care
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QUALITY IN RCH Bhubaneshwar September 4, 2009 Amit Mohan Prasad Jt. Secretary, GoI
Presentation Outline • Background • Institutional arrangements • Operationalisation of facilities • Human resources • Skill based training • Quality of care • Antenatal care • Delivery care • Postnatal care • Strengthening financial systems/ transparency in transactions • Monitoring and supervision • Way forward
1. Background • RCH II is a comprehensive sector wide flagship programme, under the umbrella of the NRHM, to deliver the targets for reduction of MMR, IMR, and TFR. • RCH II aims to reduce social and geographical disparities in access to, and utilisation of quality reproductive and child health services. • States are implementing a range of technical strategies in the core areas of MH, CH, FP and ARSH, to achieve the desired reductions in the key RCH II/ NRHM goals of MMR, IMR and TFR, and improvements in key outcomes.
Current status vis-a-vis RCH II/ NRHM goals • Note: • Data covers first year of RCH II for MMR, and first half of RCH II for IMR and TFR. • Union territories (except Delhi) have been excluded in the findings
1. Background(contd..) JSY PERFORMANCE: 2005-09
2. Institutional arrangements for QA • Mandate of Hon’ble Supreme Court of India to set up State and District QACs, and Quality Circles at the facility level. • Primary role – to ensure quality of sterilisation services; and follow up on cases of post-sterilisation deaths or failures • Review missions show: • QACs / QCs are not meeting regularly / non-functional • Need to set up mechanisms for overall QA of RCH services, including functionality of facilities and skill-based training • GoI provided guidelines (December 2007) to expand the scope of the existing QACs and quality circles • Cover MCH services at facilities, including skill-based training • Expanded membership • Provision of budget in PIPs However, inadequate progress is seen across states in revitalising the QACs and expanding their mandate.
2. Institutional arrangements for QA(contd..) • Some of the steps taken by the states for improving quality of services, include: • Pilots on quality improvement in health facilities and setting up of institutional mechanisms • Strengthening of health facilities for accreditation (NABH, etc.) • Developing quality assurance manuals • Ranking of health facilities on quality parameters • However achievements on ensuring the quality from the above activities have not yet been shared by the states.
3. Operationalisation of Facilities • Quality RCH services depend on a planned network of facilities in a district providing 24-hour services (at PHC and CHC level) for basic delivery and newborn care, with assured referral arrangements to FRUs at CHC/ SDH/ DH level. • Necessary inputs of infrastructure, equipment, and trained personnel. • Coordinated planning is essential to ensure that the inputs can be effectively provided to make the facilities functional. • Extensive data already available from states’ own facility surveys, DLHS-3, and GoI/ DP supported surveys in 10 focus states. However, review visits and PIPs appraisal show that this is still to be systematically taken up in several states.
3. Operationalisation of Facilities (contd..) Source: Data reported by 17 states during JRM-6
3. Operationalisation of Facilities (contd..) Human Resources • Availability of health personnel - a key constraint to providing quality RCH services. To address shortages of skilled personnel, states have undertaken a range of innovative strategies, e.g.: • Compulsory rural posting • Differential salary packages for remote/ difficult areas • Providing “next posting” ahead of time • Incentives for post graduate courses • However, review visits have also shown several instances where existing resources are not being effectively utilised, e.g. specialists working as MOs in PHCs, and not able to practise their skills.
3. Operationalisation of Facilities (contd..) Skill-based training • Multi-skilling of MOs introduced by GoI to address shortages of key specialities • Anaesthesia – LSAS training • Ob/ Gyn – EmOC training • Paediatrics – F-IMNCI training; SNCU training (for DH) • Additional training for “task shifting to ANMs and SNs • Delivery care – SBA training • Newborn care – Basic newborn care and resuscitation (NSSK) • Sick newborn and child care – F-IMNCI training (Staff nurses) and IMNCI (ANMs) • Considerable progress in skill-based training, however several issues to be addressed.
3. Operationalisation of Facilities (contd..) Skill-based training (contd..) 1. Selection of trainees and their subsequent posting • Instances of selected trainees being very close to retirement. • Since subsequent posting for trainees not decided ahead of time, some trainees still at the PHC/ CHC where they were originally posted. 2. Timely nomination & release of the trainees is a concern, leading to: • compromise in the skills practice • affecting the quality in services rendered. 3. Quality of training – • Training institutes are, at times, themselves not following protocols during training, which trainees are expected to follow post-training at their facilities
3. Operationalisation of Facilities (contd..) Skill-based training (contd..) 4. Modifications to training duration 5. Time required: IMNCI training to saturate a district is taking more than three years per district 6. Other issues – • Need for strengthening post-training follow-up and supervision • Underutilization of the training institutes, transfer of trained trainers, lack of structured monitoring, and delayed release of funds. • Recent review visits have also shown instances of mismatched provision of inputs
4. Quality of care Antenatal Care • DLHS-3 shows variable results (compared to DLHS-2) on some of the ANC parameters: • 1st trimester ANC registration increased from 40.4% to 45.0% • Proportion of mothers who consumed at least 100 IFA tablets increased significantly from 20.5% to 46.8% • Proportion of mothers receiving at least one TT injection during pregnancy declined from 80.2% to 73.5% • Proportion of mothers whose blood pressure was taken during pregnancy declined from 57.7% to 45.2% • Proportion of mothers who had at least 3 ANC checkups has remained static – 50.4% to 51.0%.
4. Quality of care (contd..) Antenatal Care (contd..) • With the huge network of ASHAs present throughout the country, and the large number of VHNDs being reported across states, the opportunity for getting the women into the health system early in pregnancy is not being adequately tapped. • Field visits have shown that most states have merged Immunisation days with Village Health and Nutrition Days, but the focus is still on provision of immunisation only. • VHNDs need strengthening to ensure full complement of MCH and family planning services, besides immunisation.
4. Quality of care (contd..) Delivery care • The surge in institutional deliveries seen in the past couple of years, especially as a result of JSY, has created pressure on the public health system to gear up for provision of services. However, review visits have shown that quality of delivery care needs attention: • Delivery care protocols – not available / not adhered • Cleanliness, availability of running water, and privacy in labour rooms. • Newborn care equipment – largely available but unused
4. Quality of care (contd..) Post natal care • RCH programme envisages that a woman delivering in an institution would stay at least 48 hours for the health service providers to monitor her recovery. Source: JSY evaluation, 2008
4. Quality of care (contd..) Post natal care (contd..) • A two-day stay at the health facility post delivery also provides an opportunity for essential neonatal care and post partum contraception. • Post natal home visits: Only 50.8% mothers received post natal visits within 2 weeks (DLHS-3). • Again this is a missed opportunity for early detection of danger signs in the mother and the baby, and subsequent referral.
5. Strengthening financial systems/ transparency in transactions • Huge off take of JSY, highlighting need for: • Capturing beneficiary information in prescribed formats; • Public disclosure of beneficiaries (at health facilities/ state website); • Setting up grievance redressal mechanisms at state & district levels; • Strengthening financial systems for timeliness of payments. • States are taking steps to increase transparency in payments, and grievance redressal. However, systematic efforts not seen across states. • Further, a recent JSY evaluation has highlighted areas for concern.
5. Strengthening financial systems/ transparency in transactions (contd..) • Delays in payments to beneficiaries. Source: JSY evaluation, 2008 Source: JSY evaluation, 2008 • Out-of-pocket expenses for institutional delivery.
6. Monitoring & Supervision • Critical to the success of any large programme. • Essential for motivating the staff, assessing the implementation progress/ identifying bottlenecks, and assuring the quality of services. • National level: • Bi-annual joint review missions (carried out by GoI, DPs, and states) • Assessment of quarterly progress through reported physical and financial data • State level: • Regular meetings at state and district levels • Officers given responsibility of groups of districts for monitoring • JSY has a provision of 5% of the total JSY funds for monitoring, IEC, and administrative expenses. • However, field visits show that monitoring visits by states/ districts are not regularly carried out, and checklists for monitoring quality of services are not usually available.
7. Way forward • The existing QACs and quality circles need to be revitalised. The QACs at State and district levels could be made independent bodies/ societies. Their regular meetings need to be ensured, along with monitoring of their functioning (review of meeting minutes, action taken, etc.). • State Principal Secretary (H&FW)/ Mission Director (NRHM) could call a meeting of concerned departments/ officers and assign time-bound responsibilities to consolidate facility survey findings to prepare facility operationalisation plans, ensuring coordinated provision of inputs, with periodic monitoring of progress. High volume facilities and those requiring minimal inputs, should be prioritised for operationalisation. • Regular monitoring visits to districts and facilities by officials need to be ensured. Simple monitoring checklists could be developed for the same. • Such meetings and monitoring visits need to incorporate an agenda on reviewing quality issues of the activities being implemented within the states
7. Way forward (contd..) • Dissemination of guidelines to sub-district and facility levels needs to be ensured. • Trained personnel are the most critical resource for operationalising facilities. Any mismatched inputs, especially if trained personnel are not able to utilise their skills, need to be addressed on priority. • Strengthen post-training follow-up and supervision • Skill-based training should strictly follow GoI guidelines and protocols. Any modifications to the skill-based training should be approved by GoI, to ensure that quality of training and skills acquisition are not compromised.
7. Way forward (contd..) • Trainee selection and post training posting should be done simultaneously. • Cadre review, and a structured pay and promotional package for all healthcare personnel, needs to be placed on priority since quality of services rendered is directly related to the availability of skilled personnel at the health facilities. • The quality of maternal and child care needs greater focus, with re-orientation of field level workers and monitoring of service utilisation. Service provision during VHNDs needs to be ensured comprehensively. • Strengthen financial systems for JSY to ensure timely payments for beneficiaries and ASHAs. Public disclosure of beneficiaries should be done at facilities, and steps taken to set up grievance redressal mechanisms.
