What gets measured, gets managed

Strategies to Improve Service Delivery Systems

UP has a large unmet need for contraceptive services. This is primarily due to gaps in the existing health infrastructure and services and the lack of out-reach to remote areas and under-served groups. One of the main challenges for the family welfare programme in UP is to expand coverage of services by increasing their reach and improving their quality. The Government will endeavour to identify the strengths of the programme and build on them while at the same time removing weaknesses that impede its acceptance.

The roles, responsibilities, and accountability of different levels would be clearly charted out. The initiative at the state level would be to marshal resources from the Government of India and other sources, build capacity to implement the programme, and provide support for implementation activities. The district level would be the key unit of planning and programme design. At the village level, efforts would be made to identify specific unmet needs in the reproductive and child health programme and focus efforts of all departments to provide quality services. The service delivery system would have operational strategies geared to cater to the needs of rural as well as expanding urban areas. These strategies would be reviewed at regular intervals to ensure that they are implemented in an efficient manner and are continuously focused to meet client needs.

Contraceptive Service Requirements
  • To realize the goal of achieving replacement level fertility by 2016, the contraceptive prevalence rate will have to increase from the present level of 22 percent to 34 percent by 2006, to 46 by 2011, and to 52 in 2016. The percentage of couples protected by limiting and spacing methods will have to increase from the current level of 16 and 6 percent to 37 and 16 percent, respectively, in 2016. The increase in prevalence level calls for a substantial increase in the number of couples to be provided contraceptive services every year by the Department of Health and Family Welfare along with other partners.
  • The annual number of acceptors of limiting methods will increase steeply for some time before tapering off while in the case of spacing methods the annual number of acceptors will increase steadily.
State Level
  • The annual number of limiting method acceptors should rapidly increase from the current level of less than 0.5 million to 0.6 million in 2001, 1.2 million by 2006, and reach a peak of 1.3 million in 2009.
  • The annual number of couples to be provided spacing methods will be over 2 million in 2001, 3.4 million in 2006, 5.1 million in 2011, and 6.2 million in 2016
  • Panchayats will be provided funds to provide transport and other facilities for emergency delivery.
Regional Level

The reach of child health services and their acceptability have to be considerably increased in order to reduce infant mortality. Immunization of children against vaccine-preventable diseases, proper management of diarrhoea, treatment of acute respiratory infection and improved nutrition are the important measures that need to be strengthened further. There has been considerable improvement in the recent past in immunization coverage and in the use of ORS packets or home-made solutions in the case of diarrhoea.

Western Region

  • The annual number of limiting method acceptors should increase to 194,000 in 2001, 432,000 in 2006, and reach a peak of 498,000 in 2009
  • The annual number of couples to be provided spacing methods will be over 1,058,000 in 2001, 1,482,000 in 2006, 2,062,000 in 2011 and 2,205,000 in 2016

Central Region

  • The annual number of limiting method acceptors should increase to 83,000 in 2001, 193,000 in 2006, and reach a peak of 220,000 in 2008
  • The annual number of couples to be provided spacing methods will be over 401,000 in 2001, 603,000 in 2006, 868,000 in 2011, and 978,000 in 2016

Eastern Region

  • The annual number of limiting method acceptors should increase to 211,000 in 2001, 501,000 in 2006, and reach a peak of 535,000 in 2009
  • The annual number of couples to be provided spacing methods will be over 442,000 in 2001, 900,000 in 2006, 1,796,000 in 2011, and 2,407,000 in 2016

Hill Region

  • The annual number of limiting method acceptors should be about 47,000 in 2001 and remain over 40,000 thereafter
  • The annual number of couples to be provided spacing methods will be 198,000 in 2001, 238,000 in 2006, 265,000 in 2011, and 288,000 in 2016

Bundelkhand Region

  • The annual number of limiting method acceptors should increase to 43,000 in 2001, and reach a peak of 53,000 in 2005
  • The annual number of couples to be provided spacing methods will be 105,000 in 2001, 171,000 in 2006, 242,000 in 2011, and nearly 300,000 in 2016
Organization Structure

The Health and Family Welfare Department in UP has grown considerably over the years with the addition of more programmes and complexity in reporting relationships. Although most of these programmes are centrally funded they can be implemented efficiently in a large state like UP only if both financial and decision-making authority is devolved to the district level and below, and at the same time accountability for outcomes is clearly spelled out. A large and complex organization like the Health and Family Welfare Department can not produce the desired results with centralized systems. To make it more efficient the following measures will be undertaken:

  • Job functions of all officers would be reviewed and rewritten to avoid overlaps, distribute work evenly, and to maintain a manageable span of control and unity of command
  • Decision-making authority, to the extent feasible, would be decentralized to the regional, divisional, district and block levels and at the same time accountability of each level clearly spelt out
  • Deputy CMOs who are area officers would be posted at the sub-divisional level and made responsible for the performance of all health institutions in their sub-division. It would be their duty to identify and organize resources from within their area for activities like RCH camps and special campaigns
  • The Government would strengthen the infrastructure at the PHC level (institutions covering 30,000 population) and make these PHCs independent units of programme management. All health workers in the additional PHC area will directly report to the Medical Officers in Additional PHCs. Medical Officers of Additional PHCs would also be given drawing and disbursement authority after necessary training and certification from the competent authority without insisting on a specific minimum length of experience
  • A pool of medical officers consisting of a few surgical operating teams would be created at both the divisional and district levels to provide services at RCH and sterilization camps. This will enable CMOs to ensure that clinical services are made available at camps on an assured basis as per a pre-determined calendar
  • The performance appraisal of all medical officers will mainly focus on their contribution to meeting reproductive and child health needs of clients
  • The average subcentre population will be reduced from the current 7,000 to below 5,000 as per the GOI norm by creating more subcentres. This will substantially improve the access to health services in rural areas
  • District-level databases will be created, updated periodically, and utilized to develop district-specific strategies and action plans
  • Management information systems will be reviewed and redesigned to facilitate collection of adequate, complete and reliable information at all levels, to provide feedback on performance, and to encourage informed decision making
Decentralization

While changes in organization structure are necessary to make the health department more effective and responsive, in a large state like UP with 83 districts, it is essential to decentralize the planning and programme design to the district level to make it more client-oriented, need-based and cost-effective in terms of service delivery. Through a consultative process involving workers and programme managers at various levels in the districts as well as panchayat members, NGOs, community leaders, and other stakeholders, the programme would be designed with the district as a unit of planning.

  • This decentralized approach at the district level will help to tune the programme to the grass-root realities, develop management capabilities within the district, and increase the accountability of the programme to the local community
  • A district-level society with a Project Management Unit (PMU) would be set up in each district under the leadership of the District Magistrate to facilitate the flow of funds from the state level to the district level and for monitoring activities and taking corrective action
  • These district societies would support, nurture and promote innovative activities and would further help in coordinating the work of government and non-government organizations
  • District societies with the assistance from the PMUs will prepare district action plans, strive to achieve inter-sectoral coordination at all levels, and ensure convergence of services, particularly at the village level
  • Of the total annual district plan funds, 10 percent will be earmarked and disbursed to those districts that have achieved reproductive and child health and female education programme objectives in a given year
Urban Health Systems and the Role of Urban Local Bodies
  • Twenty percent of the population of UP, an estimated 35 million people, live in urban areas in the state spread over 704 towns and cities. Almost one-fourth of this population resides in slums, often unrecognized and unaccounted for by the government and thus deprived of basic education and health care facilities. By 2016, almost 30 percent of the state population would be residing in urban areas.
  • Unlike in the rural areas, where the health department has a wide network of primary health care facilities providing reproductive and child health services, the urban slums lack basic health infrastructure and outreach services. Thus, they are often bypassed even by national programmes providing immunization, safe motherhood and family planning services. The sparse health coverage provided by urban institutions like urban family welfare centres, health posts, and maternity homes in cities is used more for emergencies and curative services. Often these facilities are far from their service area, poorly staffed, with inadequate space and supply of medicines and equipment. Urban local bodies like municipal corporations and nagar panchayats are also expected to provide health care, but resource scarcity restricts them to only providing sanitation services. NGOs and private trusts are also few and far between
  • An urban woman on an average has 3.6 children but in urban slums the fertility levels are much higher and, in many cases, infant mortality rates reach close to those in remote rural areas. There is, consequently, an urgent need to develop infrastructure in urban areas to provide reproductive and child health care and outreach services and involve the elected urban local bodies to take the lead in coordinating these services
  • Urban health posts with adequate space, equipment and trained personnel will be set up on the same pattern as primary health centres in rural areas. They would be responsible for providing door-to-door service in urban slums
  • All efforts will be made to involve all health infrastructure in urban areas, other than that of the state health department in the delivery of RCH and family planning services
  • An Additional Director (AD) in the Directorate of Family Welfare will be designated as AD (Urban) and would be responsible for coordinating with municipal corporations, nagar panchayats, and other departments/agencies to ensure the availability of supplies of contraceptives and reproductive health products like DDKs, ORS and IFA, and provision of training to municipal providers
  • Private sector organizations like NGOs, corporate bodies, and trusts would be encouraged and motivated to adopt mohallas and slums to provide the entire range of health care
  • All traditional birth attendants or dais in urban centres would be trained in elements of hygiene and safe delivery practices and for counselling for family planning. They would also act as depot holders for contraceptives
  • Innovative methods of social marketing would be used for promotion and making available contraceptives and health products in slums
Linkages with Other Departments
  • A number of government departments, especially those working in the development sector, have considerable influence and infrastructure at the village level. While the Panchayat Raj system will be responsible for converging their services, these departments through their programmes can act as catalysts for the generation of demand for family planning and reproductive and child health services. For this purpose, each department could develop an action plan, and implement and monitor it on a regular basis. In order to develop this action plan, each department could set up a group with representatives from the family welfare department and an expert from outside to work out strategies, an implementing mechanism and a monitoring system.
  • Some of the major departments in the social sector would also have a role in providing services to supplement the services provided by the Department of Family Welfare. In order to ensure efficient delivery of these services and their linkage with the Health and Family Welfare Department, a group would be set up to monitor these activities at least on a quarterly basis. This group would include the Secretary and Head of Department of the concerned department and the Director General, Family Welfare
  • The role of each department, the action plan, and the specific activities to be carried out to attain population stabilization would be worked out by the department concerned within 3 months of the approval of the Population Policy
Information, Education and Communication
  • Information, education and communication have a key role to play in creating demand for services, in promoting informed choice and in increasing awareness about service delivery points. Decisions to adopt family planning methods and also to seek health care services are based on a variety of factors. Communication has a major role to play in facilitating the informed choice at both familial and community levels. A series of measures will be initiated to effectively implement communication strategies
  • Region specific communication strategies will be developed and a variety of media such as print material, folk and electronic will used to reach clients. Local cable networks will be used to convey appropriate messages
  • Health and family welfare personnel will be trained in interpersonal communication and counselling
  • All communication efforts will be coordinated with other development departments and integrated strategies will be developed to incorporate family planning messages in communication campaigns of all concerned departments
Human Resource Development

Capacity needs to be built up in UP for the delivery of quality reproductive and child health services. Human resource development is, therefore, an important aspect that needs to be addressed. Training programmes not only help in enhancing technical skills of medical officers, para-medical staff, and programme managers but also help in changing the attitudes of service providers, both of which are crucial for quality improvement and client satisfaction. Management training is also essential for more efficient management of the programme. With the recognition of the need to expand channels for service delivery by involving the private and commercial sectors, it has become even more important to change mindsets and foster the team approach, whereby together everyone achieves more. Modern research, with newer technologies and improved ways of accomplishing tasks, also calls for a continuous need to upgrade skills and knowledge through updates and refreshers

  • An apex-level institution, the Centre for Management of RCH Programmes, would be set up at the state level to provide on-going technical assistance for training in both the government and non-governmental sectors. This institution will serve as a nodal point for identifying training needs, developing training curricula, drawing up training plans, training master trainers, conducting, monitoring and evaluating specific training programmes, and maintaining a data base. It will also assess the skills and competence of trained personnel from time to time and certify them as performing to standard
  • Induction training with emphasis on reproductive child health and public health issues would be made compulsory for all government personnel entering into service. Doctors as well as male and female supervisors will receive induction training at designated institutions at the state/divisional/district levels
  • Management training, including updates on financial procedures and matters relating to district plans, budgeting, hospital management, and MIS would be provided to all those posted in-charge of all health institutions at the PHC and above levels
  • Skill-based training would be given priority to ensure that personnel are able to provide good quality counselling and services. These would include training in clinical methods like minilaparotomy, abdominal tubectomy, laparoscopy, and no-scalpel vasectomy along with refresher training for the same
  • Paramedical staff would be trained in counselling skills to promote informed choice and in clinical skills for IUCD insertions
  • TBA training with emphasis on clinical practices related to safe delivery and hygienic practices will be expanded to ensure coverage of the entire state in the next three years, and supply of DDKs will be ensured using innovative marketing strategies
  • Infection-prevention training imparting hands-on learning to enhance knowledge and practice of disinfection, decontamination, and sterilization that involves all categories of service providers would be expanded to cover all health units
  • Capacity built up for training managers and staff of NGOs, cooperatives, panchayat members, and traditional medical practitioners would be further strengthened
  • Efforts would be made to ensure that shortcomings in training programmes are identified and addressed on an on-going basis. Master trainers will be prepared and material for skill-based programmes would be regularly developed and updated, and the methodology for training would be participatory rather than pedagogical
Improving Efficiency of the Logistic System
  • The proportion of spacing methods in total contraceptive use in UP is about 30 percent, which is one of the highest in the country. This adds sophistication to the family planning programme, but also makes it imperative to have an efficient system for forecasting, procurement, transportation, stocking of condoms, oral contraceptives, IUCDs and other RCH products. If for any reason there are stock outs at any level, spacing clients are likely to drop out, adversely affecting the programme
  • The government will reset expected levels of achievement for pills, condoms, and IUCDs, based on actual users of these methods and the proportion of unmet need likely to be converted to actual use rather than on the basis of reported distribution within a particular year. This will prevent over-indenting, over-reporting and wastage of spacing contraceptives
  • To achieve the goals of the Population Policy, systemic problems in the logistics system in UP will be addressed. A Logistic Management Cell in the Department of Family Welfare will be responsible for forecasting requirements of contraceptives
  • A logistics management information system would be developed and put in place at the earliest. This would include identification of appropriate and safe storage space at railheads, divisional headquarters, and in districts to ensure effective buffer stock and timely distribution of contraceptives as per the identified needs
  • To ensure accountability for timely procurement and proper management of contraceptive stocks, an officer would be designated as Medical Officer (Logistics) in each district. MO (Logistics) would be trained in inventory management and would be responsible for ensuring proper flow of supplies within the district
Involving Female Doctors from the Private Sector
  • The cultural preference of the people for female doctors to provide RH services and the shortage of such doctors is one of the major bottlenecks in the provision of quality RH services on a regular basis at CHCs/PHCs. SIFPSA has initiated an innovative scheme for hiring of female doctors from the private sector to serve at CHCs or block PHCs. This scheme, which has been adopted by the RCH project, will be extended to the entire state
  • CMOs would be responsible for identifying, contracting, and ensuring the transportation of these female doctors from their place of stay to the service sites and for making monthly payments to them. In districts where no private lady medical officer is available, the Additional Director of the division would be responsible for ensuring the availability of doctors from the divisional headquarters or nearby districts
  • Female doctors hired under this scheme would provide outdoor services, including gynecological check up, counselling for family planning, and diagnosis and referral for RTI and STIs. They would also insert IUCDs, perform sterilization operations, and provide other services at RCH camps
  • These doctors would be trained through contraceptive technology updates and provided training for IUCD insertions and tubectomy, if necessary. The skills would be assessed every year to ensure that the doctors are performing to standard
Quality of Care
  • After the adoption of the community needs assessment approach (CNAA), the "push element" in the family planning programme has been replaced by a "pull factor" in which quality of care is of prime importance. To achieve the goals laid out in the Population Policy, the state government will make all efforts to improve quality of care
  • The government will ensure the availability of services at various health facilities by making available doctors and health workers at these facilities. This would be done by improving residential facilities at PHCs and subcentres and posting of multi-purpose health workers in centres close to their homes
  • The period of posting doctors in rural facilities at the beginning of their service will be increased from 2 years to 5 years and made mandatory for confirmation and promotion
  • It will be ensured that medical officers and health workers providing family welfare services have the necessary technical competence and professional skills
  • Government facilities would be upgraded to have an appropriate environment, necessary equipment, consumables, medicines, and other items necessary to provide quality services
  • The mobility of medical officers and supervisors would be ensured by providing additional funds for POL and maintenance of vehicles
  • Follow-up services to clients who have accepted family planning methods and other RCH services will be strengthened and strictly monitored
  • Periodic surveys will be conducted to assess quality standards maintained at various health institutions and to prepare strategies to improve quality standards on a continuous basis
New Technologies

The state government believes that an increase in contraceptive prevalence rate is a function of the number of modern methods of contraception available to people in the state. It will therefore take all steps to ensure the availability of a choice of modern methods. Sterilization services, both tubectomy and vasectomy, will be made available at all clinic sites, and providers and sites suitable for these will be promoted through the mass media. In addition, spacing services like IUCDs, oral contraceptives, and condoms would be promoted and provided at all facilities down to the subcentre. New contraceptive technologies like injectables are not yet available under the national family planning programme, though the Government of India has permitted NGOs to provide them with certain restrictions like the requirement of post-use surveillance. It has also allowed the commercial marketing of injectables.

  • The state government will include materials related to new technologies such as injectables, new types of IUCDs, etc., their advantages and disadvantages, contra-indications, and side-effects in various curricula developed for training of government and non-government sector providers under the family planning programme
  • The state government in consultation with the Government of India will conduct operations research studies to examine the possibility of introducing injectables and other new technologies in family planning services provided by the state government under the national family welfare programme
  • An active dialogue will be initiated with the Government of India for wider availability of injectables and other new technologies through private, commercial, and government channels in the state
  • The state government will promote the indigenously developed non-hormonal, once-a-week pill 'Saheli' by providing marketing support under the contraceptive social marketing programme
  • The lactation amenorrhoea method (LAM) will also be offered as a method of spacing by training government and NGO workers for post-partum counselling
User Charges
  • The Government is committed to providing health care to the people, especially those who cannot afford to pay for it. Further, since the paying capacity of a large proportion of the UP population is limited, the state government has to take the responsibility for providing hospital services at subsidized rates. This places a large burden on governmental resources and often in its desire to provide free health care and hospital services, the quality of services has to be sacrificed. To get over this problem, the state government has decided to introduce fees for services and user charges at various state government facilities. While health care will continue to remain subsidized to a large extent, the revenue earned from these user charges is expected to improve the quality of services at government facilities
  • Fifty percent of the revenue from user charges will be retained at the earning medical facility and the rest will be deposited in the government treasury

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