IMPLEMENTATION OF HEALTH CARE PROGRAMMES B.V.L.NARAYANA RAILWAY STAFF COLLEGE.
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Transcript of IMPLEMENTATION OF HEALTH CARE PROGRAMMES B.V.L.NARAYANA RAILWAY STAFF COLLEGE.
IMPLEMENTATION OF IMPLEMENTATION OF HEALTH CARE HEALTH CARE PROGRAMMESPROGRAMMES
B.V.L.NARAYANAB.V.L.NARAYANA
RAILWAY STAFF COLLEGERAILWAY STAFF COLLEGE
STRUCTURE OF STRUCTURE OF PRESENTATIONPRESENTATION
• DEFINITIONS• KEY MESSAGES• ROLE OF PROGRAMME CHARACTERISTICS• RESOURCE GENERATION• RESOURCE MOBILISATION• RESOURCE UTILISATION• MONITORING, EVALUATION, COURSE
CORRECTION• MODEL • CONCLUSION
Health indices comparisonHealth indices comparison
Indicator name Av. Value for India
Lowest in any state
Highest in any state
Infant mortality rate 58 13( Manipur ) 76 ( Madhya Pradesh)
Maternal mortality ratio 301 110 ( Kerala ) 517( Uttar Pradesh)
Institutional deliveries ( %) 40.7 12.2 (Nagaland) 99.5( Kerala)
Full ANC check up ( %) 50.7 16.5 ( Bihar) 96.5 ( Tamil Nadu)
Children fully immunized 43.5% 80.8 % (TN) 20.1( Nagaland)
Children breastfed at birth 23.4 % 7.2% (UP) 65.4(Mizoram)
Children underweight ( < 3) 45.9% 22.6 (Sikkim) 60.4 (Madhya Pradesh)
Utilization of government facilities by poorest
37.9% 19.4% ( Bihar) 55 % ( Karnataka)
Source: Health profile of India 2006
Motivation Motivation
Developed countries
Developing countries
India ( average)
India (highest)
India (lowest)INDICATORS
IMR(/ 1000 live births) 9 100 58 76 13
<5 MR(/ 1000 live births) 13 114 95 130 19
UNDERWEIGHT % 3 41 46 60.4 22.6
MMR ( / Lakhs births) 40 630 301 517 110
Deaths due to TB( / Lakhs population) 5 40 27 NA NA
Deaths due to AIDS(/ Lakhs population) 31 164 6.8 NA NA
INTERVENTIONS
Full ANC % 97 65 50.7 96.5 16.7
Safe deliveries % 98 45 40.2 99.7 12.2
Children fully immunized % 90 60 43.5 80.8 20.1
Children breast fed % NA 32 23.4 60.4 7.2
Source : National health profile 2006, based on NFHS 3(2005-06)
Comparison of health indicesComparison of health indices state
<5 MR Malnutrition
MMR %TB deaths
Andhra Pradesh 88 37 195 4.6
Kerala 19 26 110 4.3
Karnataka 77 44 228 5.7
Tamil nadu 69 36 134 2.2
Punjab 67 29 158 4
Gujarat 84 44 180 3.8
Haryana 91 33 162 3.6
Maharashtra 65 51 149 4.3
West Bengal 69 47 194 3.9
Madhya Pradesh 116 57 379 3.7
Bihar 84 55 371 2.7
Uttar Pradesh 112 53 517 2.7
Rajasthan 107 52 445 3
Orissa 130 55 358 4.5
India 95 46 301 3.8
Motivation Motivation • Disparity in distribution of mortality and morbidity
– Between developed and developing countries– Between states in India
• Conditions preventable• Proven cost effective interventions available• Common health care programmes
• Why the disparity in India
• Reason : low usage of interventions
MotivationMotivation
• India and other developing countries • Investments and funding (Bajpai, Dholakia and
Sachs 2006; CMH 2001)
•Mediated through good governance (Wagstaff and Claeson 2004 )
– Institutional factors (NCMH 2005; Wagstaff and Claeson 2004)
– Service delivery mechanisms (Bajpai and Goyal
2001; Mavalankar 1999; Seshadri rao 2001; Wagstaff and Claeson 2004)
Implementation is one of the key issues
INDIA THE CONTEXTINDIA THE CONTEXT• Contributes to 20% of worlds mortality and
morbidity• High variation in mortality and morbidity• Last 60 years
– Gap between intention and reality– Unfocussed infrastructural development– Lack of a good referral system– emphasis on centrally driven and controlled
vertical disease specific programs• Communicable diseases contribute 50% of burden
(NCMH 2005)
INDIA THE CONTEXTINDIA THE CONTEXT• National health policy(2002) ; By 2010 the
goals stated to be achieved are ( sujata rao 2004):
• increase public investment from 0.95 of GDP to 2-3% of GDP
• increase utilization of primary care facilities from 19% to 75%
• reduce MMR(maternal mortality ratio) by 75%( from 540 to 135)
• reduce IMR( infant mortality rate from 62/1000 to <30/1000
• eradicate polo, eliminate leprosy• reduce deaths due to TB and malaria by 50%
ConceptsConcepts• Implementation of strategy (Wheelen and Hunger
2001).
– “the process by which strategies and policies are put into action through the development of programs, budgets and procedures”
• Policy Implementation – actions by people that are directed at achievement
of objectives set forth in the policy decision (Van meter and Van Horne 1974).
Characteristics ( Hrebiniak and Joyce 2001)
– Is a dynamic, non linear process – Multiple variables interacting, reciprocal
causality( Fajourn 2000)
– Takes time (Miller 1997) – for effect, for study
Literature review Health Literature review Health carecare
• Millions saved (what works group, CGDEV 2006)– Study of 20 successful program implementations– Identified policy level factors – Program characteristics influence implementation– No pattern of association of success in
implementation with socio-economic contexts– Even in weak policy environments effective
implementation is possible
• Secondary analysis shows role of community involvement
DEFINITIONSDEFINITIONS
• Implementation is defined – as the process of allocation of tasks – and resources and– creation of administrative mechanisms to monitor
and integrate actions required to – achieve the objectives of program/strategy,
including those which cross organizational boundaries.
• Is a process-– Sequence of events, actions and activities
unfolding over time in a context ( Pettigrew
1997)
Scope of Scope of researchresearch
Inputs Process Output
Corporate strategy
Business strategy
Action planning
Budgeting Action Outcomes
Influencingfactors
Processcharacteristics
Processoutcome
Policy ProgramProgramoutcome
Health Policy
Health careProgram
Influencingfactors
Processcharacteristics
Processoutcome
Programoutcome
OPERATIONAL FRAME WORK
Task organizationTask organization• Programme characteristics
– Type of goods/services planned– Organization of service delivery
• Inter-linkages among components• Key steps in process
– Technology used for service delivery– Implementation organization
Intensity of interactions HighLow
Req
uire
men
t of i
nten
sity
of r
esou
rce
Low
Hig
h
Small pox
AIDS
Vitamin A deficiency
TB
measles
health
fertility
Iodine deficiency
ORS
RCH
Vector control
Blindnesscontrol
Mentalhealth
Intersectoral coordination HighLow
Intr
a or
gani
satio
n co
ordi
natio
nH
igh
Low
Condom useAIDS
IDSPICDS
NLEPII
CANCER
Task organizationTask organization• Based on the degree of intangibility, a service
good can be classified as:– search goods where the customer can test it or get
information about it before deciding to buy e.g. : a test drive of a car
– experience goods where the customer has to experience the service before you can make an opinion about it e.g. a meal in a restaurant
– Credence goods where even after purchase you are not sure of the quality of the service—e.g. health care service.
• relationship between the service provider and the customer becomes important and need to be incorporated in service delivery strategy (Susan Segal horn 2001).
Task organizationTask organization
• How will service delivery be done• What activities are components of it• Who will do these activities and whose
control are they under• What technology will be used to do it• Interrelationships among activities
– Determines criticality– Determines dependencies– Determines coordination costs– Determines nature of governance mechanisms
• Identifies the implementation organization
Comparison of programmesComparison of programmes
Characteristic NBCP RNTCP NVBDCP RCH
Number of components
Two One Two Four
Technology used Mediating Long linked Intensive Long linked + intensive
Dependencies within group
Pooled Sequential Sequential Reciprocal
Dependencies across group
None None Reciprocal Reciprocal
Components under direct control
All All One Varying levels
Control mechanisms
Financial incentives
Cooperation, material incentives--skills
Cooperation Cooperation, financial incentives in some cases
Key resources Surgeons LT,MO MO,LT MO, FHW, specialists
Mechanisms to get alternate resources
Pooling, contracting
Community provision, contracting
Community provision,
Pooling, community provision, contracting
Comparison of programmesComparison of programmesCharacteristic NBCP RNTCP NVBDCP RCH
Lead/lag of impact of interventions
None Moderate, 6-9 months Moderate for vector control measures
Long lag
Requirement of skill levels
High at tertiary or secondary level
Medium at PHC level Low Low to very high
Degree of standardization of treatment
Very high High High Low to very high
Task grouping At highest level At programme unit level At field unit level At field unit level
Scope for resource transfer
Very high Restricted Minimal Minimal
Evaluation and control
At highest aggregate level
At unit level At lowest level At lowest level
Coordination costs
Low Medium Very high Very high
Facilitation by Planning, incentives, innovation in technology
Planning, standard guidelines, training, cooperation
Planning, continuous feed back, cooperation, coordination
Planning, continuous feed back, cooperation, coordination
Implementation organisation--Implementation organisation--NBCPNBCP
JD headquarters
equipment
NGOIncentives
Training ofsuregons
DH, GH,MCs,CHC
PHC
community
opthalmicassistantsscreening
camps
OPD
cataractpatients
surgery
NGO s andPP
Implementation organisation -Implementation organisation -NVBDCPNVBDCP
JD-NVBDCPstate
districtDMO
PHCs--MO,LT,MHS
SC--MMPW,FHW
villages--MLV,GAM,AWW
feversurveillance, BS
anti -larvalmeasures
anti vectormeasures
biologicalcontrol
IMN usageand
distribution
sprayingteams
vector teams
hatcheryand seeding
teams
ITM netscommunity
nets
vectordensitystudies
IRS schedule
focalspraying
blood smearcollection
PPs andCHCs
positivecases
treatment
monitoringand feed
back
community
Implementation organisation -Implementation organisation -RNTCPRNTCP
DOTSworker
PHI/MO
DMC/ LTS
MO-TCDTO
STO-stateheadquarters
contractualLTs
privateDMCs
AWW.GAM.MLV.MMP
W,FHW
PPS,
sputumexamination
OPDscreening
referral fromcommunity
for categorisation
treatment
treatment asDOTSworker
monitoringand feedback
STS--treatment follow up
STLS--Microscopy quality
training
Implementation organisation -Implementation organisation -RCHRCH
village--AWW
sub centreMMPW FHW
primary healthcentre-MO,LT,
FHSDistrict head
quarters--CDHO, RCHO
state headquarters--Addl director FW
district planactivity plan
house to housesurvey--CNAA
immunisation
MCHservices
FPmotivation
healtheducation
specialclinics
specialistservices
institutionalservices
community
services atSC level
services atPHC level,
lab tests
referrals toPHC
referrals toFRU
FRUs
capitalprojects
initiatives
facilities, equipment,staffing
targets
management ofhigh risk cases
management ofcomplications
identificationof high risk
cases
feed back
Differences in service deliveryDifferences in service delivery
Resource generationResource generation• Role of top management crucial--Attention
– Consists of polity, administrative head, technical head/heads
– Suggests possible resource generation mechanisms
– Drives all processes by identification of key resources
– Focuses on implementation– Determine the cognitive architecture of the
system—determines problem and opportunity identification and utilization
– Identifies new initiatives and incorporates
Resource distributionResource distribution• Key role of middle management--
directioning– Make available key resources at point of use– Focus on distribution mechanisms-translate
processes into activities• Motivates field staff to produce
– Analyze and identify future requirements—existing and new resources
– Ensure focus of staff, discipline
Resource utilizationResource utilization• Role of unit heads--governance• Use of resources to deliver service• Require supervision and discipline
– To maintain alignment with desired output
– Improves with participation in planning– Is a function of work load facilitation
• Micro planning, management of extra work load, scarcities, technical help, skill development
Resource utilizationResource utilization• Use of governance mechanisms to
– Control output– Discipline staff– Facilitate performance evaluation– Generate feed back
• From staff • From consumers
– Validity and reliability of data • to be used in planning• Identify new initiatives
• Governance mechanisms—– Direct control – Cooperative mechanisms
Monitoring, evaluation, Monitoring, evaluation, course correctioncourse correction
• Starts at the field level• Have process monitoring
– Identify outcomes at every step of process to monitor
– Record, analyze –identify reasons for deviation– Incorporate corrections into process
• Skill development• Technology introduction• Discipline staff
• Ensure focus of staff, unit heads, programme heads
Mega frame- mapping of factorsMega frame- mapping of factorsKey factor UNIT DISTRICT STATEService delivery Final services Resource delivery Idea delivery
Motivation to produce
Interest of staff
Adequacy of facilities and equipment MO interest
Supervision
Adequacy of resources
Adequacy of field staff
Adequacy of key staff Policy directives
Alternate resources Availability of alternate resources
Utilization of adaptation mechanisms
Policy directives
Emphasis on skill development
Learning from past experiences
Initiatives and management skills
MO interest and Supervision
CDHO focus and initiatives Top management focus
Process monitoring Emphasis on monitoring Focus on implementation Identification of key resources
Consistent allocation
Training and learning
Incorporation of initiatives
Resource generation
Work load management
Take away messagesTake away messages• Understanding of characteristics of
service delivery—important– Determines key resources– Directs logic for governance
mechanisms• Positioning of responsibility and
attention –should be appropriate– Ability to solve problems, take
opportunities—idea, power, execution,
Take away messagesTake away messages• Resource allocation
– Ensure consistent allocation• Ability to generate• Efficiency of utilization• Management of scarcity
• Resource distribution– Ensure availability at point of use
consistently
Take away messagesTake away messages• Resource utilization
– Ensure ability to use resources appropriately• Alignment with purpose-service to be delivered
– Ensure continuous adaptation to • Changes being done in services
• Feed back systems– Listen to consumers– Listen to field staff– Ensure validity and reliability of field or primary
data– Monitor and correct processes
Take away messagesTake away messages• Maintain slack of key resources
– Helps manage scarcities– Facilitates introduction of new services
• Position mechanisms to generate key resources at short notice– Alternate resources generation– Emergency mechanisms
• Look for problems, new services demand and plausible applications as solutions
THANK YOU –ANY QUESTIONS
Resource allocation-NBCPResource allocation-NBCP
OUTCOMECATARACTSURGERY
SKILLLEVELS
SURGEONS
NGOS andPPS in
DISTRICT
GOVERNMENTDISTRICT
SURGEONS
STATEPROGRAMMEHEAD FOCUS
INCENTIVES-- monetary----
capital
TRAINING,INFRASTRUCTURE,
CONSUMABLES
SUPERVISION
Medicalcolleges
RESOURCE GENERATION AND DISTRIBUTIONRESOURCE UTILISATION
GOIresourceprovision
Resource allocation--RNTCPResource allocation--RNTCP
OUTCOME
SERVICE DELIVERYCOMPONENTS
DOTS
Categorisation
Diagnosis
SERVICEPROVIDERS
FHW/MHW
Communityworker
MO
NGOS/PPS
Pvt DMCs andContractual
LTS
DMCS andLTS
RESOURCE GENERATION and DISTRIBUTION
Provision offield workers
Provision ofcommunityworkers
Provision ofMOs
Enrollment ofNGOS/PPs
Management ofDMCs and
LTs
DISTRICTPROGRAMMEHEAD FOCUS
SUPERVISION
EQA/IQA
PHImonitoring
Supervisormonitoring
STATE HEALTHSYSTEM
RESOURCE UTILISATION
Resource allocation--NVBDCPResource allocation--NVBDCP
Number ofcases
Vectordensity
Feversurveillance
Detectionand
diagnosis
IMN
Spraying
Vectorcontrol-
biological
Vectordensitystudies
Fieldworkers
Communityworkers
LTS
Supervisors
Contractlabor
Entomologist
MO SSupervisionand workfacilitation
Provision offield workers
Provision ofcommunity
workers
Provision ofstaff
Sprayingcontracts
Consumables
IMNimpregnation
Fishhatcheries
Seedingcontracts
Entomologists
DISTRICTHEAD
FOCUS andwork
facilitation
INITIATIVES
Communityaspirations and
feed back
HEADQUARTERS
GOICONSUMABLES
SUPERVISION
Training andskill
development
RESOURCE GENERATION RESOURCE DISTRIBUTION RESOURCE UTILISATION
OUTCOMES
SERVICEDELIVERYCOMPONE
NTS
SERVICEDELIVERE
RSUNITHEAD
RESOURCEPROVISIONMECHANIS
MS
PROGRAMMESTRATEGICCONTEXT
Resource allocation -RCHResource allocation -RCH
OUTCOMES--BR,IMR,CPR
,TFR,MMRSEVICE
DELIVERYCOMPONENTS-Maternal health,
child health,RTI/STI. Health andnutrition eductaion;
FP services;
REGULAR SERVICES
EMERGENCY SERVICES
SITES OF SERVICE DELIVERY
OUT REACH
SC/PHC
SPECIALIST CLINICS
FRU s
RESOURCE PROVISIONMECHANISMS-provisionof staff, provision of MOs
and specialists, provision ofequipment, provision of
infrastructure, provision ofconsumables,
MONITORING andEVALUATION
DATA COLLECTIONand RECORDING
TRAINING and SKILLDEVELOPMENT
COMMUNITY---Aspirations and feedback
POLITICALSYSTEM
STATE HEALTHSYSTEM
LINKAGES WITH--medical colleges;
international agencies
MO S --INITIATIVES--supervision, work
facilitation, communityparticipation,
microplanning, on jobtraining and knowledge
enhancement,
TOP MANAGEMENTFOCUS
STRATEGY ANDINITIATIVES
SUPERVISION ANDMONITORING
DISTRICT HEADFOCUS
VITAL EVENTSSURVEY
CNAA
SERVICE PROVIDERSMOOTIVATION -- field
staff, MO, speciaslists
TRANSPORT
RESOURCE GENERATION RESOURCE DISTRIBUTION RESOURCE UTILISATION