Addressing Challenges in Bihar

1. Addressing Challenges in Bihar Dr.P.Padmanaban National Health Systems Resource Centre

2. Flow of presentation • Enabling environment in Bihar • Challenges • Few Initiatives in Bihar • Family Medicine programme

3. Enabling environment • NRHM support • Strong Political Will • Recruitment of additional ANMs, Nurses, Doctors • Management structure strengthened at block, district and state level • High level of motivation among health functionaries and managers • Use of appropriate technology

4. Current Challenges • Shortage of nursing personnel, doctors and specialists • Operationlising the health institutions – FRUs and Additional PHCs (to increase the birthing facilities – para medical model) • Family Welfare – dependence more on campaign / fixed days approach • Quality of services • VHSC formation and utilization of untied funds

5. Access to services • Free lab and radiology services to all those seeking care in PHCs, Referral hospitals and District hospitals • Infrastructure strengthening • TNMSC like organisation is being formed shortly to procure quality drugs • Increase in the availability of essential drugs • New born care equipments for the health facilities

6. Access to quality care contd; • Community participation ( VHSCs) in the Health Sub centre construction • Mobile medical team with modern equipments • 24 x7 Ambulance services

7. District Health Action Plan • After first round of Fast Track training programme , 38 District Health Action Plans prepared with inhouse capacity. Second round of training is in progress. • Sensitisation of district and block level functionaries • Timely release of funds & financial guidelines • Improvement in the utilization of RKS funds to upgrade patient amenities

8. Supportive supervision Issues • Existing inspection mode do not cover all facilities • Mostly easily accessible and better performing facilities are often visited • No systematic inspection system/ standard tool • No feedback mechanism • No monitoring or follow up at state level As a result; • Issues do not get highlighted • No follow up • Quality component missing • Poor spending of RKS funds

9. Supportive supervision implementation G O issued for supportive supervision State Quality Assurance Cell formed Preannounced (District) and surprise inspections (State) – annual plan prepared Inspection tool prepared and sensitisation meetings held for the programme officers Qualitative information also collected in addition to performance Joint scoring system followed Deficiencies noted during inspection are grouped into - deficiencies to be sorted out at the facility / district / state level with timeline

10. Supportive Supervision implementation • All inspection reports to reach the SQAO in 3 days time • SQAO gives monthly report to Executive Director, SHSB • Feedback meetings under the chairmanship of Director in chief of Health Services once in 3 months • Linked to district ranking • 324 facilities inspected out of 460 facilities providing IP care within 4 months by all programme officers • State level continuous monitoring – by way of dashboard indicators ( under preparation)

11. Supportive Supervision Inspection Format

12. Infrastructure I. Infrastructure

13. Infrastructure contd;

14. Infrastructure contd;

19. Equipments & Supplies Contd;

26. Qualitative response Assessment by the Inspecting officer • Condition of drainage system • General condition of toilets, whether separate toilet facilities are available for staff and OP/IP ( M/F) patients • Whether RKS funds have been used effectively to make improvements in patients amenities • Whether there is ante room for OT, whether door closes automatically, condition of windows etc. • Whether service guarantee and protocols are displayed properly at all places , use of protocols and whether services displayed are actually available • Whether monthly meetings are conducted with ASHA

29. E governance • Biometric system in selected institutions • Computerized OP registration in selected institutions • Online transmission of data • Block level computerization with facilities for online transmission of data • Streamlining of ASHA payment system under progress

30. Performance appraisal of SPMU/DPMU/BPMU Appraisal format - identification of targets mutually by the employee and supervisor The employee and supervisor can finalize any number of indicators they like for the assessment Objectively verifiable indicators developed Supervisors will ensure necessary information is generated and gathered from the data source PIP based work allocation – done Incentives / contract renewal linked for staff Regular employees evaluation same – linked with ACR

31. Performance indicators for District Ranking( proposed) Performance indicators – • % of planned versus immunizations held , • Deliveries conducted per SBA , • Number of Caesarean sessions conducted per Obstetrician , • Outpatients examined per doctor, • Cataract operations conducted per ophthalmologist, • Bed occupancy rate, • % of health facilities (APHC/BPHC/RH/SD/District) with running water facility (labour room / OT / Toilets), • % of villages where VHSCs formed, • % data uploaded by District, Average number of OPD drugs available per facility in district • Data based on HMIS - Dynamic list

32. Maternal Death Audit System (proposed) • Notification of all deaths in the reproductive age group by ASHA to the PHC MO and verification of maternal deaths • Investigation about the causes, various delays and contributory factors for maternal death ( community based audit) • Investigation of maternal deaths occurred in the institution including the medical colleges and private sector ( Institution based audit) • Conduct of maternal death review by District Magistrate in which the relatives of the deceased also participate • Findings are used to take corrective action and for training the health functionaries

33. Service guarantees ( proposed) • A framework, which enables any member of the community availing services from the respective health facility to know, what services are available in the institution , the quality of services they are entitled to and the means through which complaints regarding denial or poor quality of service can be redressed.

34. Outsourced Services – Quality issues 21 contracts signed by SHS, Bihar with private agencies Check list developed to monitor the quality of services Registers and check lists prescribed for outsourced agencies to prevent false claims

35. HR- PG reservation for Government doctors (proposed) • Shortage of specialists • 6 govt. + 2 pvt. Medical colleges – 164/290 seats • Government doctors not able to make use of the seats – no reservation, problems in getting the NOC. etc. • Non-clinical specialists needed for the new medical colleges . • 50% seats to be reserved for Govt. doctors • Course period to be considered “on duty”

36. Recognition of good performance • Who will be recognized? • District Magistrates • Civil surgeons • Medical officers • Nurses, ANMs • Paramedical functionaries • Health managers • Account managers • Source of information • District ranking, Community feedback, inspections conducted, facilities provided

37. Developing 4 districts as models • Jehanabad, Gaya, Vaishali and Nalanda districts • Develop all facilities in these districts as models • Improve patient amenities to IPHS standards/ Women friendly • Capacity building of health functionaries to deliver quality health care • Mobile nurse trainers to give hands on training to the nurses and ANMs on various protocols • Visit to these facilities by the health functionaries from other districts

38. Way Forward • APHCs to be made functional with paramedical model • One CEmONC for each district • VHSCs to be formed • Use of HSC untied funds • Community monitoring system • Use of trained anesthetists by reorientation • Rational distribution of human resources • Encourage the use of self improvement NRHM quality manual by the health facilities in the state by conduct of regional workshops • Fast tracking ASHA training programme

39. Cost of care In industrialized countries • Supply of primary care physicians was associated with lower total cost of health services. Areas with higher ratios of primary care physicians to population had lower total health care costs partly because of better preventive care and lower hospitalization rates • In contrast, supply of SPECIALISTS was associated with more spending and poorer outcomes • Countries with weaker primary care had significantly higher costs

40. Why Family Medicine? ( Resolve more and refer less) With the present trend, complete staffing of all FRU’s would remain a major problem • 37% of the 4276 CHCs could have access to an OB/GYN • The likelihood of having an OBGYN/ Anaesthetist combination would be much less. • Suppose a pregnant woman also had diabetes, what are the chances of her meeting both the OBGYN and a physician in the same FRU Even if this is achieved, cases will fall between the cracks: Psychiatry, Orthopedics, Dermatology, blood bank etc. Further there is a need for skills in health promotion and prevention Having specialist who only do a fraction of the work is expensive for the health system. Hence the need for a multi-competent specialist- the FAMILY PHYSICIAN Professional societies (FIGO) support inclusion of caesarean / obs .surgical skills in Family Medicine

41. Plan for training Family Physicians Approved by MOHFW for high focus states 2 year distance learning Diploma in Family Medicine- for knowledge & some skills (30 days contact sessions) Approximately 80 candidates expected to join in Nov 2009 Another 40 candidates expected to join in Dec 2010

42. Proposed strategy for producing a Family Physician for FRU level • 2 year Integrated Masters course in Family Medicine and Surgery • Course components • One year distance learning (summary of the 2 year Distance Learning Diploma in Family Medicine ) • One skill training residential in District Hospital (combines GOI’s EmOC, LSAS, Neonatal training and a basic surgery component) • Dr MGR University Chennai has agreed to accredit the course • Awaiting approval of MOHFW

43. Thank You

44. Family Medicine programme • Lack of specialists in FRUs and CHCs • Two year distance education programme by CMC vellore • 120 serving doctors from EAG states will be trained during first phase • Masters in integrated Family Medicine and Surgery - MGR University Chennai Skill based component consisting of GOI’s Emergency Obstetric Care training, Life Saving Anaesthesia skills

45. PG reservation for Government doctors contd; • Doctors to complete 3 years of service in a BPHC or APHC. For every completed year of service, 1 additional mark is given, to a maximum of 10 marks. • Doctors working in notified remote / difficult areas will get bonus marks; 2 marks will be given for every completed years of service, to a maximum of 10 marks • Bond – PGDiploma -35 lakhs / PGDegree - 50 lakhs • Private doctor to compulsorily work for Govt – 3 years bond – 25 lakhs

46. Specialist Availability at District and Below, JRM 2009

47. Specialists availability at CHCs functioning on March 08 -Bull Rural Health Services, 2008

48. % Increase in Shortfall of Specialists at CHC between 2007 and 2008 -Bull Rural Health Services 2007, 08

49. HMIS Design and implementation of integrated information support system for the health sector in Bihar Phase 1- HMIS implementation plan Phase 2 – HMIS strengthening plan Data bases – HR, Finance, Infrastructure, Drugs, patient care, licensing systems DHIS 2- web based, real time, facility wise data

50. Community Feedback • Objective • To get the feed back from the community about their perception on the quality of services in the health institutions and their expectations • To validate the performance report thro verification in the community - services – Immunisation, Antenatal, post natal care, newborn care, follow up care for family Welfare beneficiaries • Method Villages are selected thro 30 cluster sampling technique and quarterly survey will be organized by independent NSS volunteers, Nursing/ medical students • Feedback to districts and health facilities to bring about improvement • Used for ranking the districts