Souvenir Clairvoyance 2010

8/8/2019 Souvenir Clairvoyance 2010

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School of Health System Studies

Tata Institute of Social Sciences


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TEAM CLAIRVOYANCE 2010

Faculty Coordinator:

Dr. Anil Kumar

Dr. Sandhya Krishnan

Our Student Coordinators:

Dr. Jaya Khushlani

Dr. Juhi Gautam

Dr. Khyati Tiwari

Dr. Mandar Bodas

Dr. Parag Chaudhary

Dr. Priyanka Nagdeo

Dr. Pretty Jetty

The Souvenir committee:

Chief Editor: Dr. Mathew George

Team:

Dr. Deepthi Alle

Dr. Niharika Tiwari

Dr. Sujay Bhishnu

Mr Lal Mangaih Hauzel


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Directors Message


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Clairvoyance Coordinators Message


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Deans Message


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Table of Contents

Sr.No.

TitlePageNo.

1) From Editors Desk 11

2) The Thin Line Between Advocacy and Research 13

3) Quality Management In Hospitals: Accreditation and Beyond 15

4) Quality In Hospital: Administrators Challenge 18

5) Measuring Quality- Accreditation and Beyond 24

6) Training And Development: A Key to Quality Often Missed 28

7) Patient Centric Corporatization: Making The Twain Met 33

8) MDGS In Bihar: Examining Strategies, Exploring Possibilities 38

9)A Critical Review On Functioning Of Asha With Special Reference toOrissa

44

10) The Black Window 51

11) The Valley of Flowers 53

12) The Concept of Stand and Work: A Serious Health Threat 55

13) Need of the Aged 57


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From Editors Desk

School of health systems studies proudly presents its annual event clairvoyance 2010, amega event and a platform for the Health care industry, alumni and the distinguishedscholars in the field of public health to come together and have academic deliberations onthe health care scenario of the country. Every year the issues addressed by the event areappreciated for its contextual relevance and the productive discussions and learning itgenerates. This year also the focus of the event is Healthcare in South Asia: Revisiting thelast decade, foretelling the next. The transcending of the topic of clairvoyance fromnat ional t o that of a global region i s it self an indi cati on of t he grow t h of t he School and it simpact on the policy makers and health professionals at an international level. At this junct ure, the school announces t he ini t iat ion of i t s M PH w it h speciali zat ion in H ealt h

policy, economics and finance. This is the latest addition to the ongoing Schools venturethat started with positioning its expertise in the field of hospital and health servicesadmini st rat ion by groomin g M H A prof essional s and more recent ly by ext endi ng it sexpert ise in t o the f ield of Publ ic H eath w it h special f ocus on social epidemiology.

A dhw an, t he souveni r i s a t oken of appreciat ion f or t he part icipants and a platf orm w herethe Faculty, Alumni and the Students of the School of Health Systems Studies documentt heir experiences and insight s on t he vari egat ed realm of t he healt h sector. W e are f ortunateto have the opening session by Prof Susan Rifkin on the close link between advocacy andresearch. Subsequently the souvenir brings to you the diverse orientations about quality

ranging from the challenges in translating guidelines into action and raising some pertinentquestions on the discourse of quality. The second session traces the diverse experiences ofhealt h serv ices syst em especial ly i n t he cont ext of N RH M and t he ki nd of inequit iesprevalent. Final session is about health problems of the vulnerable, viz. the elderly, thew ork ing populati on and t he w omen.

W e, t he edit orial group are ext remely grat ef ul f or t he contr ibut ors f or t heir manuscript swithin a short notice and our sincere thanks to all those who have helped us make thisventure possible. Special thanks to the sponsors who have supported through theirsponsorship.

W it h W arm Regards,

E dit ors D esk


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THE THIN LINE BETWEEN ADVOCACY AND RESEARCH

Professor Susan B. RifkinTISS Professor

Clairvoyance 2010

Recently a Phd student of mine presented the topic of his thesis. He asked the question:how can delivery of services for children and families affected by HIV/AIDS beimproved in a decentralized health system? The question assumes thatdecentralization of health services is effective and research is going to tell us how it canimprove services. Such an assumption is questioned by the increasing evidence thatdecentralization of services has had numerous problems related to costs, humanresource capacities and administrative infrastructures. It can be argued the researchquestion is tends more toward advocacy for decentralisation than research into itseffectiveness.

The advantage of working with a research student is that such a pitfall can be pointedout. In this case, the student changed to undertake to an investigation of the potentialsand limitations of a decentralized health service in providing care for HIV/AIDSfamilies.

However, the initial formulation is indicative of a trend within the sphere of healthpolicy that has a much more public face. At the Global Forum for Health Research inMumbai India in September 2005, some research papers presented findings that werebased on advocacy. An example was a study of gender and ARV (anti retrovirals) in an

African country. Instead of asking the question of whether gender played a role in the

acceptance and use of ARVs among poor populations, the study looked for evidence thatsupported their premise that gender and equity did play a role in access. (Bongololo, G.2005) This alarming trend appears to be the result of availability of funding that isbased more on belief than a rigourous research examination.

The recent report by the Center for Global Development calling for impact evaluationreflects the concern in this trend of donors, policy makers and intended beneficiaries ofsocial service programmes. The authors argue that lacking systematic collection andanalysis of information little is learned about social interventions. As a result, countlessfunds are spent on repeating mistakes at the loss of time, experiences and in the worstcases, of lives. They argue that what is needed is impact evaluation which collects andanalyses evidence within an agreed standard to enable people to learn lessons frompast mistakes. Impact evaluation asks about the difference between what happenedwith the program and what would have happened without it. ( Center for GlobalDevelopment, 2006 p.12)The argument can also be applied to research in the area of health policy and byextension programmes that emerge from these policies. Research needs first to askwhat is the evidence that a policy works then ask how it can be improved. Should the


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research investigate an intervention for improving the policy, a framework that leavesroom for evidence that the policy is not working needs to be the research basis.

Good research always allows for the negative hypothesis to be proven. By allowingadvocacy to become the center of investigation critics can easily say the findings are

ideologically biased or lack necessary scientific rigour. Replacing research withadvocacy investigations runs the same risk as forging scientific data. The results arewish lists of the investigators and are not a contribution to our knowledge about theuniverse. In addition, in the present environment, they increasingly contribute to theloss of resources that need desperately to be used to save lives and improve decimatingpoverty.

References:Bongololo, Grace, Using research to promote gender and equity in the provision of anti-retroviral therapy in Malawi WHO, Global Forum on Health Research ,2005

Center for Global Development. When will we ever learn? Improving lives throughimpact evaluation. Washington, D.C.: Center for Global Development, May, 2006.


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QUALITY MANAGEMENT IN HOSPITALS:ACCREDITATION AND BEYOND

Dr. M. Mariappan

Asst. Professor TISS

Introduction:Quality is defined in various contexts by different authors. One of the definitions onquality is the totality of features and characteristics of a product or service that bear onits ability to satisfy stated or implied needs. But the simple definition for quality isdefect free. The delivery of care should be defect free so that the patient getsappropriate care. It is to be noted that the concept of superior or inferior quality doesnot exist in health care delivery. In other words there is no possibility in grading thequality whether it is higher or lower. Further, it is a matter of perception and thereforesubjective in nature. Since healthcare is associated with several processes, it is a matter

of making services without any defect. It means that the various processes of delivery ofcare are designed and executed as per the desired specification. Further there is scopefor standardizing these processes. This we call it as accreditation.

Process-driven approach: As per the accreditation criteria the various services of the hospital is translated intoprocess-driven approach. However there are issues in defining the process. Furtherupdating the healthcare providers knowledge and skills in executing such process isnot an easy task because of cultural and behavioral aspects. In industry if the wholeproduction process is well defined and the same is strictly followed the outcome isperfect, it means no defect and the product passes through the quality check. In this

case if there is certain failure whether defining process or implementation of theprocess there would be some defect or waste that could cost money but there is no lossof human life. Assume that the same thing happens in healthcare delivery there is apossibility of human loss and loss of reputation for the hospital. So accreditation is acareful activity which requires consistent effort and hard work. The paper brings outcertain arguments which need to be addressed pre and post accreditation.

What healthcare quality demands?The quality of care demands many fundamental supports. As administrators we alwaysthink about how the quality can be achieved? What would be the benefit achieved byensuring the quality of services? But in real sense we must look at the other side like

achieving the quality of services we need to offer something such as time, effort, costand other obligations. We need to define the path of the healthcare delivery model. Herethe issue is clear alignment with clinical process and non-clinical process. It means theability of the healthcare providers to make sure that there is a strong and clearcoordination and cooperation between these groups. Further it is necessary to ensurethat the health care providers understanding about the quality and its importance. Alsomake sure that the healthcare providers intentions on providing care or following the


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process does not change under any circumstances. It means the consistency infollowing the guidelines without any compromise in a transparent manner. The abilityof the organisation is to meet the minimum requirement of healthcare providersphysical and socio psychological conditions at the work place. Many developedcountries have ensured that the work environment and quality of work is right to the

employees. The healthcare administrators have to address these issues.

What are the real benefits achieved by accomplishing healthcare quality? How dowe measure such benefits?Most of us think that by adopting the clear process and providing careful attention onthe work process shall lead to achieve the quality. But the issue is whether such qualityis primarily helping the patients or the organization. The most challenging question ishow quality can be made beneficial to both hospital and the patients mutually. One canargue that when we provide right care the patient is free from diseases. Nobody canassure that the successful delivery of care endorses life long term benefit to patients asthe patients are always prone to get affected by another illness. Hence the basic

definition of health care quality should be treated separately. Health care quality isdetermined by various factors which include human, technical, technological, social,cultural and other factors. So it is not so easy to make sure that desired level of careachieved in a specified time.

Quality Indicators:Certain parameters are used to measure Quality and are called quality indicators.

According to NABH and JCI more than 100 indicators are used to measure the qualityand most of them are in practical use. A hospital undertakes the exercise ofaccreditation by mapping the process and ensures that the suggested quality indicatorsare achieved. The primary outcome of the indicators will be known by monitoring thequality process. But actual outcome of quality should be based on the value patientsattribute to the quality services they get. Also it is the responsibility of the hospital tomake sure that the patients are prepared to accept those values and see how they arereally abiding to it. At the same time the healthcare organisation would have achievedcost reduction through quality measures.

Measuring Quality Costs:There are three important areas of cost to be found, measured and improved. They arecost of conformance, cost of non-conformance and cost of lost opportunities. The cost ofconformance has two aspects one is cost of prevention and cost of appraisal. Theprevention cost associated with prevention of failure such as design qualityimprovements, employee quality training design, quality engineering etc. The appraisalcost includes quality check of materials purchase, confiming the work process, qualityaudit, working with quality standards, inspection of tools and techniques, employeestraining, maintaining quality records, patient relations etc. The cost of non-conformance consists of three major areas. 1. Cost of internal failure such as waitingtime, delay in attending patients, errors at various level, wastage of materials includingmedicines, consumables, radiological raw materials, etc. Further the cost of internalfailure includes rectifying certain mistakes while carrying out services or after the


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completion of care. 2. Cost of external failure is associated with the rejection of patientson the particular services, doctors or hospital which arises due to poor service deliveryor the result of patient dissatisfaction. This can be against medical advice, transferpatients with their request etc. Also any amount claimed by patients due to medicalnegligence 3. Cost of exceeding the requirement such costs are associated with poor

information delivery, providing redundant copies of document, reports which are read,or some no important information shared to the patients when they need. Finally thecost of lost opportunities includes loss of existing customer or potential customer. Itmay be difficult to measure the loss potential patients. However few indicators likecancelling the appointment, shifting to other hospitals, wrong services offering to thepatients, non-availability of certain important services can give some indication aboutthe amount of lost. The cost of quality is the sum of lost of conformance, lost of non-conformance and cost of lost opportunity. It can be estimated any institution may beincurred the quality cost which ranging from 5 to 25 percent.

Conclusion:

Health care quality seems to be more subjective and measuring such quality is optional.The process of delivery of care is to be confirmed and directed towards aiming atreducing the cost, providing safety to the patients as well satisfying their needs. It isimportant to understand doing things right as well doing right things which makes lotof difference in healthcare. Healthcare administrators should prepare themselves toaccept the process of quality standards as well be able to know the mutual benefitsachieved from quality programmes. Beyond accreditation the quality management mustensure that there is a positive exchange of values between the healthcare providers andpatient community which in turn create trust on healthcare delivery.


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QUALITY IN HOSPITALS:ADMINISTRATORS CHALLENGE

Neeraj Lal,Vice President-Quality,

Shalby Hospitals, Ahmedabad,

Quality is a word that we use every day; what exactly does it mean in a Hospital?All of us want goods and services to be of a good quality or high quality if possible. Allof us know that to get anything of a high quality, more effort needs to be put in and thecost may be a little higher, yet we justify the higher efforts and cost with phrases likeNo Compromise etc. In hospitals Quality is a separate department. The present articleis based on the insights I had while Implementing Quality in Shalby Hospitals.

What is Quality?There are numerous ways of looking at Quality. Apart from being Best, Quality may

also be thought of as Value for Money. This means that we get goods or services of afairly good quality yet the cost is not very high.Naturally this idea of quality is popular with the consumer, but the supplier will have tobear higher costs to maintain quality and yet offer Quality Services at a lower cost to beconsidered Value for Money. The supplier will benefit by creating value for hisbusiness and getting the loyalty of customers.

At the basic level, getting Quality means getting exactly what is promised or offered ornamed. For example when we buy a shirt, Quality means a garment of fabric which willlast over at least a hundred washes, will not tear or fade, the fit and the stitching will beperfect, the buttons will last till the life of the shirt and it will offer protection from heatand cold to the wearer. Do the shirts that we buy offer all the listed items? Does thefabric fade? Does it tear easily? Do the buttons fall off? Is the shirt material too thin andtransparent? Answers to such and hundreds of similar questions decide quality.

Cultural BackgroundThe concept of Quality may differ from person to person and culture to culture. Theneed for Quality will also differ for different goods and services. People may accept poorquality in disposable items because ultimately they are to be thrown off. Yet the samepeople might insist on eating the most expensive type of wheat or rice because they areconcerned about their food.Some people will accept a cheaper television with fewer features because they cannotafford a costlier piece with the latest hi-fi features. This is not a compromise on qualitybut a compromise due to necessity. But the same people may spend more when it is aquestion of medical treatment for a member of the family.


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Quality in HealthcareWhat about Quality when it is a question of healthcare? Can we honestly say that a littlecompromise here and there will not affect the outcome of medical treatment given to apatient?The answer is a big NO. Any compromise in the healthcare service industry may lead to

nasty outcomes.A very unfortunate and sad example is the recent outbreak of hepatitis in Gujarat due toreuse of syringes. It is a standard protocol to discard and destroy disposable needlesand syringes. It was not done, the syringes were reused. Syringes used on infectedpatients were also used on other patients without sterilization. The result was that theother patients, innocent people, were infected with hepatitis and died. They shouldnever have been infected with hepatitis except for the fatal reuse of syringes whichshould have been destroyed and burnt after first use.In healthcare Quality has to be taken care of in infrastructure, equipment and services.The actual quality of healthcare no longer depends on how well qualified a doctor is buthow adequate his team is and how well equipped his hospital is.

Can the doctors and the paramedical staff work as a team to face emergency situations?Does the hospital have life saving equipment in working condition? An answer of YES toall these questions enables QUALITY in a hospital.

EquipmentThe better the quality of equipment, the better would be the outcome. This is soobvious, but here there is a clash between profit and commitment. The philosophy ofthe top management of a hospital will decide what equipment the hospital will buy.There are business pressures like competition, business cycles, newer technologieswhich dictate what equipment is taken. If a hospitals equipment is the best in the worldit is of course ideal. But if cost constraints do not allow the best, the equipment should

at the least be functional. It must satisfy the needs of the patients.

InfrastructureThen comes the infrastructure. Is it ideally designed? Do the patients have the leastdifficulty in reaching the hospital? Once inside the hospital is the structure safe andsolid to hold the number of people that may be expected to come? Are the electricalsystems safe? Are there adequate lifts and are they reliable? Has the relevant inspectorchecked the lifts for safety? Are the lifts certified?How is the building protected against fire? Are there enough fire extinguishers? Is thefire fighting system checked and certified by the relevant departments? Is a mock firedrill done from time to time to train the staff about how to react in case of a fire?

Is the building dust free and air conditioned? A centrally air conditioned buildingbecomes important in infection control. Pathogenic bacteria cannot flourish in coolertemperatures and hence severely burnt patients who are prone to infections are kept inchilled rooms. Also, a centrally air conditioned building will be relatively dust free andhence infection free because the minute dust particles may harbor disease producing(pathogenic) bacteria.


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There are hundreds of such questions which need to be addressed correctly before theadjective Quality can be applied to a hospital. All the above do not constitute luxury.Most of the above items are necessary basics in a multi specialty hospital.

Service

Perhaps the quality of service is the most crucial component of Quality in a hospital.Service includes not only the medical and surgical services, but also each and everyservice that a patient or his/her relative might need during hospital stay.In the times of nursing pioneers like Florence Nightingale, the concept of quality did notexist because equipment was rudimentary, infrastructure was never custom made for ahospital, any building was converted into a hospital as and when the need arose. Butwhat made Florence Nightingale a saint amongst nurses was that she dedicated herselfto serve patients. Today she is a cult figure for nurses. Nurses dedicated to nursingthink of her as a Godlike figure and follow her precepts.What is Quality in nursing care? A smile as soon as he or she enters a patients room (itmust be remembered that a nurse means both a male or a lady nurse) Talking to

patients, encouraging them to face their troubles bravely, using light humour to makepatients smile, touching them gently, washing and cleaning them with empathy andmost important of all, enjoying the work and thinking about nursing work as service tosociety and God.There are other routine procedural things like being available 24x7, informing patientsbefore any procedure, explaining patients about a procedure if it involves pain ordiscomfort for the patient and so on.

TrainingBetter Quality in nursing care is achieved through both motivation and training.Training has to be continuous. As new staff is appointed, they need to be trained to

maintain the hospital standards. Older staff needs to be updated about newer medicalmethods and techniques. All staff needs to be reminded about smiling at patients againand again as nursing is a tough profession.What is true for nursing is also true for all other ancillary services in a hospital. Apartfrom nursing, a hospital has attendants who help patients in personal matters, cateringstaff who serve food, Patient Relationship Officers who are an interface between thepatient and his/her needs, Medical Officers who monitor the patients and so on. If ahospital gives the best service to a patient, and during the discharge process if a billingperson behaves rudely, the whole treatment experience may be marred. If theambulance driver who drops the patient home or at the airport demands a tip, againthat will reflect very badly on the hospital.

AccreditationUltimately what are the rewards of Quality? Does investing more money in building anideal hospital and buying state of the art equipment and gathering the best of staff torun the hospital ensure that the best patients will come to that hospital?

Answer may be yes, provided patients come to know about the hospital. How willpeople know how good a hospital is? Is there any benchmark which shows how goodthe hospital is? Of course there is. Just as good quality food items have the AGMARK,


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well maintained hospitals who follow all the good practice procedures and protocolscan also apply for and get accreditation from the Quality Council of India throughNational Accreditation Board for Hospitals and Healthcare Providers (NABH).International bodies like Joint Committee International (JCI) also give accreditation andcertification.

Corporate Tie UpsSuch certification makes the hospital known as a good institution. This makes it easierfor corporate decision makers whether to sign a contract with a hospital for thetreatment of their employees. Thus an accredited hospital has a much higher chance ofbeing empanelled by companies which offer free or subsidized medical treatment totheir employees.There are a few more areas and departments which must be mentioned in an article onQuality in the Healthcare Service Industry.

Medical Waste Management

Hospital waste is special because it is a potential source of spreading infection. Hencefirst and foremost all hospital waste must be separated in four types of containerswhich are color coded blue, yellow, black and red. Sharp objects like needles go in onecontainer, soiled cotton wool and gauze in another, food waste has a separate containerand so has paper waste.The approximate amount of waste that may be generated by each hospital is estimatedby standard of reckoning. If a hospital generates less waste, the authorities of thathospital may be questioned as to whether they are throwing waste into garbage dumps.

Operation TheatresAlso called OTs, these are the most critical rooms in any hospital. After every surgery of

a wounded patient the OT will be cleaned and fumigated to prevent transmission ofinfection from one patient to the other. All OTs will undergo deep cleaning andfumigation once a week. All the instruments used in each and every operation must befirst washed and then sterilized as per predefined protocols before the next operation.

All the clothes that the surgeons and anesthetists wear during operations must besimilarly washed and then sterilized.


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Infection ControlThis is perhaps the most important section of any hospital. The aim is to preventtransmission of infection from one patient to the other. It is best done by preventingany accumulation of dirt anywhere. The toilets, the floors, each room and each bed forthat matter are kept hyper clean.

Medical InsuranceIn todays times most of the times the payments for medical treatment is done throughMedical Insurance. If a patient has a Medical Insurance he/she needs to claim the cost ofthe treatment from the insurance company. A good hospital will have a separate cellthat helps patients get approval and payment for treatment from their insurancecompanies. This eases the burden on the patient. The quality of food served to patientsin a hospital needs to be constantly monitored. For environmental conservation, nonrenewable natural resources like water need to be harvested from rain. All possiblemeasures must be taken to avoid the waste of both electricity and water. Thus Qualityin the Healthcare Service Industry is not a onetime investment. It is a person

independent continuous ongoing process.

Why Quality?It is but natural to ask what is the necessity of Quality in hospitals. The question will beanswered by the eye opening data found in the USA based Institute of Medicine (IOM)website (http://www.iom.edu/) on the following link:http://www.iom.edu/CMS/8089/14980.aspx

The IOM is an organization of the Us Federal Government.Healthcare: Shortcoming in Quality (USA)

Between 44,000-98,000 Americans die from medical errors annually. Only 55% of patients in a recent random sample of adults received

recommended care, with little difference found between care recommended forprevention, to address acute episodes or to treat chronic conditions

Medication-related errors for hospitalized patients cost roughly $2 billionannually.

41 million uninsured Americans exhibit consistently worse clinical outcomesthan the insured, and are at increased risk for dying prematurely.

The lag between the discovery of more effective forms of treatment and theirincorporation into routine patient care averages 17 years.

18,000 Americans die each year from heart attacks because they did not receivepreventive medications, although they were eligible for them.

Medical errors kill more people per year than breast cancer, AIDS, or motorvehicle accidents.

More than 50% of patients with diabetes, hypertension, tobacco addiction,hyperlipidemia, congestive heart failure, asthma, depression and chronic atrialfibrillation are currently managed inadequately


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Quality in IndiaIt may be noted that most of the above situations can be cured by implementing Qualityin US Healthcare. If the condition of US Healthcare is so shabby, it may be assumed thatIndian healthcare may not be much better. Except for a few centers in Indian metros,Quality is sadly missing from the Indian Healthcare Scenario.


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MEASURING QUALITY:ACCREDITATION AND BEYOND

Suvankar Mridha,

Assistant Manager Quality,Aware Global Hospitals, Hyderabad

Role of Accreditation bodies, revolution and driving factors & challenges:Healthcare Quality is a new term introduced in the field of healthcare service deliveryand with the introduction of Accreditation systems like JCI, NABH etc. , the ways ofdefining healthcare quality has changed a lot. In the late 40s when the InternationalOrganization of Standardization constituted Quality Systems came into existencenobody believed in the parameters of healthcare quality. Well, the concept of ISO andvarious Quality Management Systems Protocols had been contributing in the field ofQuality.

Various ISO principles have contributed in this regard and intention of improving thelevels of Quality in the products has introduced a culture of Globalization.

After the efforts of ISO 9001 series quality management systems and other variousaccreditation systems like ISO 14000, ISO 18000 contributed a lot in various field. Asthe healthcare needs are increasing and introduction of consumer protection Act 1986came into existence the need of customer satisfaction and customer focus has got aprime preference and it is now becoming a trend of enhancing the quality levels in thehealthcare services. Accreditation systems are one of the means of maintaining aculture of healthcare quality services. In India, the concepts of domestic accreditationsystems like NABH that is National Accreditation Board for Hospital and HealthcareProviders is now going to acquire a major and giant shape. More than 366 hospitalshave applied in the NABH accredititation but only 58 hospitals including big corporatehealthcare giants and govt. hospitals got the accreditation. Some Indian hospitals areconcentrating on achieving international accreditations like JCAHO.

Hospital Accreditation The Present ScenarioJoint Commission Internationals standards and qualifications are derived from aninternational consensus of achievable expectations for structures, outcomes, andprocesses for medical facilities. The standards are designed to accommodate cultural,religious, and legal factors within specific countries and regions. JCAHOs JointCommission International (JCI) was founded in the late 1990s to survey hospitalsoutside of the United States. JCI, which is also not-for-profit, currently accreditsfacilities in Asia, Europe, the Middle East, and South America. A January 2008 pressrelease says that since 1999, JCI has accredited more than 140 hospitals in 27 countries.In India, hospitals that are focusing on international marketing and medical tourism arekeen to get JCI accreditation which will enable them to get overseas patients who are


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interested in coming to India to get treatment in cost effective way withoutcompromising the quality & outcome of the treatment.

Quality Council of India has formed a separate and exclusive domestic accreditationsystem like NABH, NABL etc keeping the economics and various other dimensions of

Indian healthcare market. The aim of this accreditation is to reach to every level ofhealthcare system irrespective of public or private investments thus disregarding theconcept of cost as a major hindrance factor. NABHs accreditation focuses on learning,self development, improved performance and reducing risk. Its assessment relies onestablishing technically competent healthcare organization in terms of accreditationstandards and in delivering quality services with respect to its scope. It goes beyondcompliance and calls for excellence on continued basis. It is this feature, which makes itmarket driven involving all stakeholders; be it consumers, empanelling agencies,regulators and other third parties.

NABH accreditation is based on optimum standards, professional accountability and

encourages healthcare organizations to pursue continual excellence. Cardinal principlesof accreditation evaluation are as follows:

Hospital operations are based on sound principles of system-based organization,which are transparent and objective in nature.

Accreditation standards are implemented and institutionalized into hospitalfunctioning.

Patient safety and quality of care, as core values are established and owned bymanagement and staff in all functions and at all levels.

There is a structured quality improvement programme based on continuousmonitoring including feedback on patient care services.

The evaluation process incorporates interview with patients, residents and staff. It callsfor on-site visit to patient care areas and to departments addressing issues related tophysical assessment of infrastructure, medical equipment, security, infection control,etc. as required by the accreditation standards. It involves a comprehensive review ofnot only facility but also of clinical competence and operational excellence of hospital todeliver services within its scope.

Measuring Quality Essence of Accreditations Accreditation systems are based on documentations, trainings and implementation ofstandards. These days, documentation can be made with the help of various resourcesavailable in the internet and training can also be organized but when it comes toimplementation of standards the real challenge comes to existence.

Implementation of Practices for Measuring Quality is a key area which has its ownimportance and glamour. Measuring the performance like Turn around Time of anyprocess, delay time frame, working on reengineering of the process, Implementation ofcustomer feedback mechanism etc. These indicators are quantitative easurement of anyquality trait. It doesnt describes anything but it gives us a value which gives a results


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positive or negative like Compliance or Non-Compliance to the mentionedstandard.

Key Performance Indicators:Key Performance Indicator (KPI) is commonly used by an organization to evaluate its

success or the success of a particular operational activity in which it is engaged.Sometimes success is defined in terms of making progress toward strategic goals, butoften, success is simply the repeated achievement of some level of operational goal(zero defects, 10/10 customer satisfaction etc.).

Key Performance Indicators define a set of values used as a basic measure to be pittedagainst the achieved quantitative level. These raw sets of values, which are fed tosystems in charge of summarizing the information, are called indicators. Indicatorsidentifiable as possible candidates for KPIs can be summarized into the following sub-categories:

Operational Indicators:These indicators focus on enhancing the operational excellence and upgrading theefficiency of a protocol. It includes measuring Turn around Time of LAB reports, TAT ofdischarge process, Time Motion Study of OPD patients, Number of Lab Errors, BillingErrors,

Human Resources Indicators:Employee Satisfaction Rate, Attrition Rates, Absenteeism rate etc.

Patient Safety Indicators:Number of Medication Errors, Number of Adverse Drug Reactions, Number of Adverse

Anaesthesia Reaction/Events, Number of Needle Stick Injuries, Number of Securityrelated incidents (like theft), Percentage of adherence to lab safety compliance.Compliance Score of legal status like periodic renewal of licenses e.g. PNDT, BiomedicalWaste Handling rules 1998.

Financial indicators used in performance measurement and when looking atan operating index includes the variation percentage of expenses on electricity,purchase of capex and operational items etc.

KPI-Formulation & Implementation StrategiesImplementation of KPI can be done with respect to individual departments also with

various guidelines based on accreditations. If we are talking about departments thenHuman Resource Cell should monitor the Employee Satisfaction rate, Attrition Rate, No.of employee coming late etc. If we want to look at hospital infection control protocolswith respect to accreditation then Infection Control Indicators; Surgical Site InfectionRate, Respiratory Tract Infection Rate, Urinary Tract Infection Rate etc. are helpful toarrive at a definite understanding of the same. Calculation of these rates can be donewith the help of CDC guidelines, Agency for Healthcare Research and Quality. With


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implementation of patient satisfaction questionnaire or employee satisfactionquestionnaire we can monitor the satisfaction matrix of the external and internalcustomers respectively. As far as Implementation is concerned, all these indicators canbe implemented online or can be drafted in the form of MIS report (if it is departmentalindicators). If its a subjective indicator then it can be done through questionnaire or by

Occurrence Reporting Form.

Monitoring and Experience changeMonitoring is an important aspect for all these performance indicators because thesemonitoring keeps them alive and kicking. Quality is a continuous process and it shouldgo on otherwise the efforts injected in achieving an accreditation goes vain. Adesignated Quality professional with his team and various committees including fewtop management representatives can monitor and present the data along with reportmentioning about the proposed action and recommendation to be taken for turningaround each nonconformity.

This process should be continuous and mixed with various quality improvementprojects like FOCUS PDCA, Six Sigma Implementation Projects, and BPR projects etc.Prolonged monitoring of these data with a defined frequency will give trend patterns.For e.g. If we collectively analyze quarterly data of Hospital infection control rates in thehospital then we can arrive at a specific pattern which will help to change or set ourprotocols.

Change will be compelled to be introduced because these indicators give us an ideawhere we should improve and how we should proceed. With the help of domain expertand committees and implementation of required initiatives and measure all can beminimized.


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TRAINING AND DEVELOPMENT:A KEY TO QUALITY WHICH IS OFTEN MISSED

Dr. Sandeep Moolchandani

sandeep.moolchandani @tiss.edu

Training and development in todays business landscape is not just another regularorganizational requirement but a critical factor which separates high performanceorganizations from those in their downward journey.

The knowledge intensive nature of the health services mandates an ongoingcomprehensive training and development programme in a hospital which covers all thetraining requirements at institutional, departmental and individual levels. Apart fromutilitarian perspective, employees must receive training in particular areas and be able

to demonstrate their knowledge so that the hospital can receive certain types ofaccreditations and can be compliant with the industry standards.

Employees are considered to be most important asset to the organizations. The value ofan employee as an asset increases manifold, especially in a hospital setup where theemployees are directly involved in delivery of products and services. Theempowerment of the employees in hospital can serve as a major factor for achievinglong term competitive advantage.

In its 2006 State of the Industry Report, the American Society for Training &Development (ASTD) finds that leading organizations increased learning investments intwo key areas: annual expenditure per employee and learning hours". ASTD reports:

"Employee learning and development is taking center stage as business leadersincreasingly understand that a highly skilled, knowledgeable workforce is critical toachieving growth and success.

How Training and Development Works Wonders for Organizations?

Training And Development is a subsystem of an organization. It ensures thatrandomness is reduced and learning or behavioral change takes place in structuredformat. Properly trained and highly skilled human resource is perceived as the greatestasset of an organization. Skilled personnel contribute to efficiency growth, increasedproductivity and market reputation of an organization. This has been realized by

industrial, commercial, research establishments and even governments. Invariably,after realizing the importance of Training and Development many companies startedemerging with a separate department focusing mainly on training for its employees.


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Training and Development Outcomes

A sufficient investment into training and development translates not only into meetingregulatory requirements and getting/renewing accreditations but also into tangiblereturn on investment in terms of improved outcomes and increased revenues.

Even more than monetary outcomes it has been shown that perceived access totraining, social support for training, motivation to learn, and perceived benefits oftraining are positively related to commitment of the employees to the organization.Thus right employee training, development and education, at the right time, in rightamount; has a potential to provide big payoffs in terms of increased productivity,knowledge, loyalty, and contribution.

Training Requirements by some accrediting agenciesOften the organizations become clueless when the question to objectively define thetraining and development requirements arises. Here it is lot more easy to start withtraining requirements defined by various accreditation standards and agencies likeNABH, JCAHO, OSHA, AABB, CLIA etc. Some of the common areas where attention iswarranted by these are as follows:

The staff shall be well acquainted to the policies and procedures of theinstitution and of the respective departments.

Inductive and ongoing training programmes in critical areas such as infectioncontrol, disaster management, drug safety, patient safety, employee/patientsrights and responsibilities

Ongoing programme for professional training and development of the staff. Maintenance of training and development records in the employee portfolio, Assessment of staff development needs on hospital wide, departmental and

individual levels. Monitoring and evaluation of the training programme including objective

evaluation of the training outcomes and performance.

Table I in the appendix lists some of the important areas that should be a part of a goodtraining and development programme in a hospital.

Categories of training and development needs

The training and development requirements of the hospital staff can be divided intofollowing three tiers:

Tier I: Critical Areas Tier II: Soft Skills Tier III: Functional/Technical Skills


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Tier I: Critical Areas

This competency development area includes all those skill sets and required knowledgewhich is directly associated with quality of healthcare delivery. Many accreditationstandards recognize these skills and mandate the existence of training and developmentprogrammes to impart them and document the delivery.

Tier II: Soft Skills

In this era of patient centric healthcare services, it is prudent to develop positivebehavioural skills in our employees. In addition to service delivery, good soft skills arealso important for success of the organization as a whole. Organizations across theglobe have realised that professionals with just technical skills only partly complementthe essentials of being a complete professional.

Tier III: Functional/Technical Skills

These skills form the core of the services provided by healthcare service providers. Amajor chunk of these skills are imparted as functional/ technical education before theemployee joins the organization. But the organizations have the responsibility to tweakthese skills to their needs and ensure that acceptable acumen is maintained by theprovision of continued education and on the job training.

Methodologies of TrainingIt is a common practice to heavily rely on a 30 odd pages manual outlining the safetyprocedures and other standards of conduct to orient the employees. With the self-learning process involved with the hard copy manual, the expected compliance rates

are quite low.

It is always advisable to supplement with cognitive methods like lectures,demonstrations & discussions; and behavioral training methods like case studies,games & role plays.

Interactive modes which include computer based training are gaining wide popularityand acceptability in the industry. These methods have been shown to be cost effectiveand scalable while producing better results when compared to conventional means.

Training HoursThere is no prescribed number of training hours, the amount of training depends uponthe needs of the organization, the modes of training being used, the performancelacunae it wants to address, various local and national regulations to be met; and so on.It is advisable to come up with an individualized training and development plan whichis best suited for the organizations needs.

Conclusion


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Training and development is one of the crucial areas which can help the organizationsto cope up with high paced changes happening in the external environmental. But sadlyit is also one of the areas which is often missed or not given due importance inmanaging the change process in the organizations.

Lessons from the other industries is the buzz phrase we often hear. It will be apt toconclude with the same phrase and a hope that these lessons are internalized by thehealthcare industry.

AppendixTable I: Some of the important areas that should be a part of a good training anddevelopment programme in a hospital.

Training Areas stressed upon by both NABH

and JCAHO

Training areas stressed upon

by JCAHO only

Other Standards

Disaster Prevention and Management

Fire training Hospital Disaster Management Medical Gas Safety and Handling

Managing violence andaggression

Hospital Emergency Codes

Rights and Responsibilities

Vision/Mission Policy & Procedures Staff Rights and Responsibilities Patient and family rights andresponsibilitiesInfection Control and Biomedical WasteManagement

Infection Control Hand Hygiene Biomedical Waste managementCardiopulmonary Resuscitation and First

Aid

First aid training Adult basic life support for patienthandlers

Advanced Cardiac Life Support Paediatric Care Basics

Paediatric basic life support


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General Safety

Slips, trips and falls Manual handling (Control andRestraint) and Transfer of patients

Essential food hygiene for Foodhandlers Blood glucose monitoring for patienthandlers

Quality Improvement Programme

Vulnerable adults

Child protection

Sentinel Event

Error Reporting

Investigation of incidents,complaints and claims (NHSHospitals)

Medication Management

Drug administration for patienthandlers

Sedation and Pain Relief Guidelines Look-Alike Sound-Alike Medications Prescription of Medications Dispensing and Administration ofMedication

Adverse Drug EventsEmployee Safety

Basic Health & Safety Awareness (StaffOriented)

Blood handling and Blood BornePathogens for Healthcare workers

Inoculation incidents Disciplinary and Grievance handlingprocedure (General Orientation)Laboratory

Laboratory Continual EducationProgramme

Laboratory Investigations ProcessFlow

Laboratory Safety Programme Lab Quality Management OrientationRadiology

Radiology Continual EducationProgramme

Radiology Investigation Process Flow Radiation Safety Radiology Quality ManagementOrientation

HMISTraining in HospitalManagement Information

System


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PATIENT-CENTRIC CORPORATIZATION:MAKING THE TWAIN MEET

Dr. Anuja Joshi

The last decade has been a revolutionary journey for healthcare in the Indiansubcontinent, as it finally begins to take centre stage after prolonged subordination andanticipation. The excitement is palpable amongst healthcare providers, the governmentand other stakeholders alike, as Indian hospitals rise to stand up shoulder to shoulderwith world class healthcare providers. Driving this revolution is a wave of businessrestructuring - we know as Corporatization.

Some say that this is just a part of the metamorphosis most sectors undergo in a fastdeveloping economy like India. On a more critical note however, there may be more toit than meets the eye. The transformation seems well beyond apparent swankyinfrastructures and medical technology. The very perception of patients, doctors &hospitals is changing at a pace that is startling most of those involved and affected bythe same. There is a paradigm shift occurring in the way healthcare will be delivered inthe times to come. But again, should this be a matter of concern or even thoughtfuldiscussion?It should indeed, because healthcare is no ordinary sector. It is the unlikely business ofsaving lives.

Where do we start?

We could start with understanding the evolution of Corporatization in healthcare.Necessity was the most primary driver considering healthcare is an essential service insociety. Given the enormity and the diversity of the population of a country like India,this necessity probably was soon a challenge for any government to manage. As aresult, what should ideally have been a social security measure provided by the State,was opened to other organizations to provide as a service at a cost. It was at thisjuncture that healthcare was transformed into a sector subject to the formidable forcesof the market.Healthcare is probably the most input-intensive and outcome-sensitive industry. Thenew players, who started singly or in small groups, were struggling at both ends- first,to arrange for inputs whether in terms of capital or professionals and next to ensure

favorable outcomes in terms of affordable and effective treatment. Rising expectationsand paying capacities of a burgeoning middle class, started creating a demand thatcalled for organizations, much larger and more organized than islands of privateproviders. Going back to the essential nature of healthcare services, the scope forbusiness per se is both tremendous and relatively immune to typical marketfluctuations. This was a huge business opportunity in waiting. Thus was the advent of a


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new breed of players in the form of corporations who promised a restructuring of thehealthcare industry to world class standards.Some of the other major influences were lessons from the west, especially the healthsystems of the United States of America. State of the art hospitals, high paying jobs forhealthcare professionals and the best medical technology in the world were attractive

ideals to aspire for. Accreditation was another inspiration from the west. Simply put, it was aimed tobuilding and ideally running hospitals at a benchmarked uniform internationalstandard. Getting accreditation automatically offers the credibility of maintaininginternational standards for either the department or the hospital as a whole.

Impact of corporatizationInitially, corporatization translated into well planned investments; qualityinfrastructure and creating a brand image for the hospital. One of the first and keysteps to sustain such a venture was finding a pool of multiple investors for the capitaland ensuring returns on this investment, through pricing. Having had some success

with this, the next step was scaling up in terms of volumes, to generate generousmargins and cut running costs. What started with large single hospitals was nowdeveloping into a chain of corporate hospitals spread over major cities in the country.These new hospitals also embraced quality infrastructure effectively. Infact, theinteriors of most newly built hospitals could give some of the best hotels a run for theirmoney! Specially formulated healing environments for inpatient departments, a flurryof well trained attendants and great food were just some of the creature comforts forthose who could afford them.Setting standard operating protocols was the other cornerstone of corporatization.Meant to streamline the working of the organization as per evidence based standards,they also assist newer professionals to learn the right way to do things rather than rely

on trial and error.Ownership in the meantime shifted to the hands of a separate board of managementwho were not necessarily doctors but trained in hospital management or businessadministration. Everyone else became an employee, including all medical professionalswho would be bound by the policy guidelines of the hospital. The hospital was nowbigger than any of its employees.

The other side of the story At the receiving end of this transition, were patients with mixed reactions to thesituation. Many of those who could easily afford it initially patronized these hospitalsfor the promised quality on offer. The market however, did not remain monopolistic for

long, and competition was quick to set in. This competition unlike in other sectorshowever, did not lead to fall in prices. Not very adept at dealing with competition,hospitals resorted to adhoc marketing and newer service attractions, without analyzingtheir potentials leading to a paradoxical increase in prices for the end users. Very soon,the cost of corporate healthcare spiraled out of reach for the middle class. .The relative subordination of doctors in these hospitals, led to two groups: clinical andadministration, both striving to ensure their importance and decision making


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capacities. One of the probable options sought was defensive medicine, at the cost of thepatient who had little choice but to agree. Fewer patients meant tighter competitionand malpractices began to creep in the system. The hospital/patient-doctor bondtranslated into a legal customer-provider contract with patients dragging the oncedemigod doctors to courts!

In the backdrop of the situation so far, it seems apparent that the gap betweenhealthcare providers and patients is widening at an alarming rate, and needs to bebridged before the damage is irreversible.The point to note here, is that corporatization like globalization, is an evolutionaryphenomenon that is bound to have favorable and unfavorable repercussions. The catchlies in maximizing the favorable outcomes and dealing with the unfavorable ones tominimize damage.

Hence, the need for making the twain meet, the only way being a patient-centricapproach to corporatization.

Patient-centric: Ethical, Intelligent and Affordable

corporatization in that order

EthicalThe raison detre for healthcare is the patient and at stake is the patients life. Therecannot be any hospital that could justify malpractices of any magnitude under thepretext of rising costs, evidence based medicine or just blatant commercialism. Unlessthe hospital commits to ethical practices irrespective of the challenges involved, there isno way it can even attempt to regain the patients trust, leave apart loyalty.

It is also important to remember that affordability is not a trade off for ethics. Thehuman life cannot be equated with the pay potential of the patient, and acts of bothomission and commission count for unethical practices.

IntelligentThe first important aspect of intelligent planning is comprehending quality. Asdiscussed before, quality is often relative, and customizing quality to the user is the key.There are certainly places where quality may be absolute like in case of infectioncontrol, but interiors can certainly be experimented with. Sky lit domes, wellmaintained internal gardens/ potted plants and childrens paintings can be brilliant

alternatives to typical expensive interior options. The focus must remain oncutting/minimizing all avoidable input costs without compromising on the outcomes.The second important aspect is a SWOT analysis of India as a market. We are a nation ofvolumes and variations. Any hospital model must aim to reduce costs through largevolumes. These numbers may however not be easy to achieve in urban areas, simplybecause they are already saturated and land is dear. The idea then is to use thevariation. The tier 3 and 4 cities are growing faster than we can comprehend back home


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in our cities. Instead of fighting over a contracting size of the pie in these urban areas, itmakes absolute sense to reach out to the growing demands in the semi-urban and ruralareas. It is also preferable to train local residents to work for these hospitals rather thanhaggle with reluctant urban staff.

AffordableThe cost of quality healthcare is a rather interesting debate. That is because neitherinputs nor outputs can be compromised with. Given the fact that investors wouldobviously be looking for returns, it is worthwhile making them understand why it takestime to make money in healthcare. Returns are slow, but usually certain, unlessexpectations are unrealistic.

An option here would be staggering and sharing input costs over time. This can befeasible in volume based models in semi-urban and rural setups. Diagnostic facilities,support services could be shared or efficiently outsourced in the local areas at veryaffordable rates. Other overheads like administrative costs, electricity and staffing couldbe kept at minimum possible with effective technology like HMIS, telemedicine and

green hospital infrastructures.

Public private partnershipsConsidering the major players in the health market are private/corporate and publiccompanies, the most logical concept is the emerging trend for public-privatepartnerships, PPP in India. PPP, as Kent Buse and Gill Walt explain is a collaborativerelationship which transcends national borders to involve at least 3 players, out ofwhich one is a corporation (or industry) and the other, an inter-governmentorganization to achieve a shared health-creating goal on the basis of mutually agreeddivision of labor.PPPs could be of various types, either owned by public sector involving private players

like in GAVI, SIGN or RBM programs, or have NGOs involve corporate participation likeWorld heart federation. The local governments may choose to tie up with key privateproviders like Government of Chhattisgarh with Apollo and Escorts hospitals for theBal Hridaya suraksha yojana for pediatric cardiac ailments or the Government ofGujarat, with IIM-A, FOGSI, Sewa and private practicing gynecologists for theChiranjeevi yojana to ensure safe deliveries.Keeping in mind the promises PPPs offer to make, a word of caution may nonethelessbe exercised. The concept is still emerging, and there isnt yet substantial evidence toprove its capability in mass application, so a gradual, and well calculated approachwould be pertinent atleast initially. A formidable, responsible and transparentgovernance to protect from exploitation, forging of figures, and to ensure that public

interest is preserved throughout as the target of all activities.

At a closing note, the relevance of the patient-centric approach deserves a reiteration.All of the options discussed above, are expansions of this very basic ideology. Whateverhappens in healthcare must protect and benefit the patient before anyone else, becausehe is the most vulnerable of all stakeholders involved. The most reliable question forany decision-making in healthcare is whether it benefits the patient. If it does not


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benefit the patient, dont do it because it wont benefit anyone else in the long runeither!


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MDG`S IN BIHAR:EXAMINING STRATEGIES, EXPLORING POSSIBILITIES

Dr. Sujay [email protected]

Introduction:Bihar is one of the poor states when it comes to the health system of the state and so istrue for the health status. NRHM has included this state in their high focus state and iscategorised under BIMARU way back in 2005. After the whole new paradigm of MDGit is prudent to judge the state Governments actions under the lens of MDG.The State Health Society, Government of Bihar (SHSB) is committed towards promotingthe right of every woman, man and child to enjoy a life of health and equal opportunity.SHSB under the aegis of Department of health has taken steps to bring about outcomesas envisioned in Millennium Development goals, RCH II, NRHM programme and Vision

2010 Bihar. In general, it aims at minimizing intra-regional variations in the areas ofReproductive and Child Health including population stabilization through an integrated,focused and participatory programme.

The Goal:The goal to be achieved by 2010 under the above mentioned programmes is to improvequality of life of the people by:

Reducing Maternal Mortality Ratio (MMR) from 371 to 100 per 1, 00,000 livebirths,

Reducing Infant Mortality Rate (IMR) from 61 to 30 per 1000 live births, Reducing Total Fertility Rate (TFR) from 4.3 to 2.1 for population stabilization

with enhanced satisfaction of clients with medical services. The Health Department of Bihar is making all out efforts to reduce the IMR and

has initiated an innovative program.

Status and SituationIn the state important RCH indicators such as MMR, IMR and TFR are showing decliningtrends whereas institutional delivery, complete ANC and contraceptive use areincreasing steadily. The state has identified poorly performing districts and is nowfocusing on them for further improvement. The status of important RCH indicators inthe state shows the current situation.


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Indicators that have reduced

MMR has declined from 389 (1998) to 371 (SRS 2003-05) IMR has declined from 63 (Census 2001) to 61 per 1000 live births (SRS 2006-

07)

Total Fertility Rate (TFR) has decreased from 4.3 to 4.0 (NFHS-III 2005-06) to3.9 (SRS 8)

Percentage of children under age 3 who are underweight has marginallydeclined from 48 % to 47 % (GOB 2009-10)

Indicators that have Increased

Institutional deliveries have increased from 12.1 (NFHS-I 1992-93) % to 22 %(NFHS-III 2005-06) to 27.7 % (DLHS-III 2007-08)

Antenatal Care has increased from 15.9 % (NFHS-II 1998-99) to 16.9 % (NFHS-III) to 45% (DLHS-III 2007-08)

Full Immunization coverage has increased from 10.7 (NFHS-I 1992-93) % to41.4 % (DLHS-III 2007-08)

Contraceptive use has increased from 23.1 % (NFHS-I 1992-93) to 34.1 %(NFHS-III).

Sex ratio from 825 to 871 (CRS 2006-07).Strategic Direction

An examination of the various programmes in the state will help us understand thestrategies of the state of Bihar in achieving the above set targets/ goals. The HealthDepartment of Bihar has set some strategic direction that encompasses year wiseobjectives, technical strategies; interventions include program and services forimproving maternal health, child health, family planning, adolescents' health etc. Onclose analysis it can be seen that the complete programme is bifurcated into commonprogramme strategies as well as specific core program strategies for taking effectiveactions.These common strategies in turn have impact on all the components of RCH viz.maternal health, child health, family planning, adolescent health etc whereas specificcore programme strategies have wider impact on the specific programme component. Ithas been envisaged that all these strategies should converge and go hand-in-hand toachieve the outcome. To accomplish these strategies the state considers thatstrengthening institutional mechanisms, infrastructural development, ensuringadequately trained human resources etc. are fundamental requirements for gettingbetter programme outcomes. Convergence of strategies and progress is as described

below:

i) Core Strategies: As mentioned earlier some of the core themes that directly address the MMR, TFRinclude special schemes such as MUSKAN, that focus on complete RoutineImmunization and MAMTA addressing child health, incentives to health staff along withseveral others.


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ii) Common Programmatic Strategies:In addition to the above common programmatic strategies directed at capacity building,quality assurance, gender mainstreaming, community participation, serving vulnerablecommunity through mobile units etc.

iii) Strengthening Institutional Framework :Complementary to the above initiatives are mechanisms for strengthening the existinginstitutional framework like Recruitment and placement of qualified human resource,formation of a functional, accountable State/District Health Mission and an IntegratedOrganizational Structure for the Department of Health;

Brief discussions on few of their initiatives are attempted below:-

1. Free referral support for pregnant womenDescription- According to the MAPEDIR Purulia study; if we see where do the womendie? We will see that about 25% could not reach health facility. This is true for whole ofIndia. In case of Bihar the scenario is much worse, given the fact that the Maternal

Mortality Rate is very high in this state. Here comes the role of strengthening referralsystem.Objectives-

To increase institutional delivery in the state by provision of free referraltransport.

Improve the utilization of referral transport services (Dial 102) by pregnantwomen for delivery services.

To ensure safe delivery by cutting down on the second delay i.e. delay intransportation.

Reduction in Maternal Mortality Assuring 24/48 hours stay at the institution2. Chiranjeevi Yojana in Bihar

Description- The Chiranjeevi Yojana is an exemplary scheme in the area of PublicHealth which has contributed significantly in improving the access to Institutionaldeliveries for marginalized section of the society by reducing the maternal deaths. The scheme will use a voucher type of system or BPL cards to target the BPL or families.The scheme would cover the service charges for normal and complicated deliveries anddirect and indirect out-of-pocket costs such as travel and cost of accompanying personon cashless basis. With the BPL cards, the families can visit any of the empanelledprivate nursing home or private hospital for maternity services (normal or caesarean)and are not required to pay any fee.

Discussion- This initiative can do wonders for a poor state like Bihar. It has beenthoroughly researched and understood that the fear and inability to incur expendituresrelated to delivery has been one of the major impediments for institutional delivery andimpacted upon the overall impoverishment.


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On the other side of the coin this can be bane for the public health delivery system.When Governments strategy is pumping more blood into the system in terms of Humanresource and infrastructure, then this kind of voucher based financing would take thebeneficiaries towards private health care delivery system more frequently.Subsequently the poor people might end up spending more out of pocket in terms of

paying for bribes or other hidden costs.

3. Beti Bachao AbhiyaanDescription- As female foeticide is a concern both in rural and urban areas, this year,Beti Bachao Abhiyaan will be launched to sensitize people against this heinous practice.Massive awareness drive with the support of College students, womens organizationsand other voluntary associations is planned this year. Human Chain, rallies, seminars,workshops and press conferences will be organized for the same.

Discussion- The state has certainly improved their sex ratio over last decade. But still itis very much skewed against women.(elaborate this point how?) This initiative can

impinge on the stake holders to take an active part to improve the sex ratio even furtherand thereby improving the basic requirement of MDG.

4. Family friendly certification of the HospitalsDescription- A Family friendly Hospital is a health care facility where the practitionerswho provide care for women and babies adopt quality practices that aim to protect,promote and support activities conducive for the health of mother and baby viz;antenatal care, safe delivery, exclusive breastfeeding of neonate, and postnatal care inan enabling environment. The mother and child friendly hospital initiative primarilyfocused to improve the quality of maternal and newborn care in the health facilities.The certification systems proposed will help the facilities to achieve some quality

standards which will enable them to reach the ISO certification at a later date.

5. Institution Based Maternal and Infant Death Review (MIDR)Description- A Consultant Maternal and Child Health will be the nodal officer for MIDR.The Nodal officer will identify and notify names of institutions which will take upMIDRs. In the first phase, this exercise will be limited to 10 District Hospitals only.

Discussion- This is in line with NRHM directives. It has direct implication on MDG 4and 5. Further they need to expand the process to the periphery for a better communitylevel understanding and further decision making.

6. Nutritional Rehabilitation Centre (NRC)Description- Initial discussions with UNICEF on establishment of NRCs in the 2007flood affected districts resulted in the dea of NRC for the first time in Bihar. It wasthought worthwhile to pilot NRCs for treatment of children suffering from severe formsof malnutrition in two flood affected districts with support from UNICEF for supervisionand monitoring of activities, especially in the initial period of management of NRCs.


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Thus the NRCs were established in the districts of Muzaffarpur and East Champaranduring August-September 2007. The results have been very encouraging with 1444SAM children benefitting till date, of which around 98% belonged to the sociallyexcluded class. Based on these impressive results from the two piloted NRCs in themanagement of child malnutrition, it has been decided to scale these units in a phased

wise manner. A total of eight NRCs have been established in Phase-1 in districts ofMuzaffarpur, East Champaran, Samastipur, Darbhanga, Madhubani, Khagaria, Sitamarhiand Sheohar.

Discussion- Tried and tested concept in Africa and in various part of the country, nowthe project sees first day-light in Bihar. The people living in the basin of river Koshisuffers from problems like malnutrition and Poverty, which are directly causingincreased IMR. The NRCs will have direct and indirect impact on MDG 1, 4, 5 and 7.

7. MAMTA conceptDescription- Objective was to reduce the MMR and IMR. This category (whichcategory? Explain mamta) of staffs will work in the institutions only. They are thetrained dais of the villages. The selection criteria is

Age between 25-45 years From Chamar/Ravidas caste Education upto class 8 Residence within 3 km of PHCs Having not more than 2 children Not pregnant at time of selection

The responsibilities include observation of the mothers and the newborns at thehospitals up-to 48 hrs after the delivery. They will be given Rs 100 for each case. Theywere given 1 day training for this.

Discussion- There were an in-built construct of resistance in the efforts of promotionof institutional delivery. Government wants the ASHAs to bring the pregnant women tohave their delivery conducted at the public health care delivery systems.Simultaneously the Dais are also supposed to conduct safe delivery. At the communitylevel, this created a conflict of interest between the ASHAs and the Dais. The recruits ofMAMTAs are nothing but the Dais coming from the same community. In Bihar they are

given a separate role to play which is essentially in line with the broad objective of thehealth system and the conflict of interest has also been avoided.

8. Dulara se MuskanThis is an initiative whereby a household survey via community active volunteers whowill be given some small honorarium to ensure community participation will beconducted and the surveyed mother and children will be marked as DULARA. The


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objective is to track all newborn child and pregnant women, strengthening of ANC andensuring prevention of dropout of immunization-strengthening of RI (MUSKANinitiative).

Discussion- By doing this the state Government and UNICEF wants to ensurecommunity participation. In every form of RI strengthening initiative, there is alwaysexistence of one big hurdle, which is community participation. When MDG goal 8 callsfor global partnership, this is prudent to have community partnership as a mean toreach that.

Conclusion- The purpose of the above article has been to examine briefly the strategiesof the public health services of the state of Bihar towards achieving MDGs. It is obviousthat there are core strategies, common programmatic strategies and complementing tothe above two are the initiatives to strengthen the institutional framework. Here thestrategy need to be appreciated for its concerted effort towards a common goal but thereal challenge is to ensure coordination between the various strategies and how toensure strengthening of the existing health services system in the overall process.

References:

State Health Society; Government of Bihar; 2009-10; State PIP 09-10 www.mohfw.nic.in/NRHM/.../Bihar_NPCC_08_09_First_Draft.pps Aradhana Johri; MOHFW, GOI; 2009; GIM_2009_Routine

Immunization_Bihar_India_PPT.


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A CRITICAL REVIEW ON THE FUNCTIONING OF ASHA UNDER NRHM:WITH SPECIAL REFERENCE TO ORISSA

Antaryami Dash

[email protected]

The key element in NRHM is introduction of a trained female Accredited Social HealthActivist (ASHA) in every village selected by the Panchayat to create awareness, mobilizepublic participation, promoting institutional deliveries, mobilize full immunization andprepare village health plan, etc. etc. This has been one of the most important initiativesof the mission.When we discuss about ASHA, concepts like Mitanin program of Chhattisgarh (May2002) and Bare-foot doctors of China automatically come to our mind. Though theprogram was initiated as an independent initiative with many features different from

the Mitanin program, as the program expands more and more, changes make it verysimilar to the Mitanin program. ASHA, as a community health worker, was thought frommany dimensions. One of them is after the deplorable withdrawal of 1978 communityhealth worker (CHW) programme. The programme (a male and female communityhealth worker in each village) was hacked to death by uncaring bureaucrats and theapathetic Congress regime in the mid- 1980s.1Then the NRHM came as a compulsion to show the pro-poor face of the newgovernment in 2005.

The ASHA under NRHM is primarily a woman resident of the village married/widowed/ divorced, preferably in the age group of 25 to 45 years. She should be a

literate woman with formal education up to class eight. ASHAs are chosen through arigorous process of selection involving various community groups, self-help groups,

Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village HealthCommittee and the Gram Sabha. ASHA undergoes series of training episodes to acquirethe necessary knowledge, skills and confidence for performing her spelled out roles.This training includes 23 days of induction training spread over a period of 12 months.It has been recommended that the first round of training may be 7 days, to be followedby another 4 rounds, each lasting 4 days to complete induction training. This includesboth thematic and modular training for ASHAs. There is periodic retraining for at least12 days a year. 2 days once every alternative month.

She gets compensation for loss of livelihood on days when she has to work full time-like attending training and meeting. She also gets incentives linked to Nationalprograms. Very recently a budgetary provision of Rs. 7,000 to Rs. 10,000 per ASHA peryear would be made till the year 2012. (*Expected)


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The issue of honorarium and its relationship to motivation:One of the most important issues of the ASHA, in comparison to Mitanins inChhattisgarh, is honorarium. Mitanins, at its onset, were never paid any honorarium.

The reasons for demanding that the ASHA should be paid are:

Need to compensate for loss of livelihood.

One cannot secure participation of women without monetary compensation. Even if we secure participation initially it will be unable to sustain in the long

run without the motivation afforded by monetary incentives.

When everyone else in the health system is paid it would be unfair anddiscriminatory not to pay these women, who are poorest in the network ofworkers for public health.

The reasons behind Mitanin program for not paying any honorarium are: The amounts considered for payment are too meager to compensate a livelihood. The introduction of a small payment would make the entire burden of work

solely her task and the community would not participate to the extent it hasbeen envisaged.

Not paying her safeguards the selection process from pressures that wouldotherwise be inevitable and most damaging.

Here, the Mitanin (Community Health Volunteer) should not have to face anyloss of livelihood on account of her participation. Only that much of work is givenwhich can be done without loss of livelihood. Her workload is estimated at about8-10 hours weekly or about 2-3 hours per day for 3-4 days per week. However,any other work that involves livelihood loss - like attending the immunizationsession or escorting a pregnant mother to the hospital must also becompensated. It is envisaged this will come to about two days a month.

Discussion:What, if it is not money, motivates the ASHA to undertake this task?

Some of the ASHAs have young children and they see the opportunity forenhancing their own knowledge. Some educated women seek an opportunity forusing their skills and the social recognition that comes with it.

In the village (especially in tribal area), the sense of community is strong and canact as a motivating factor. In such communities, social recognition and ones owndesire to serve the community can be a powerful motivating factor.

This is not to say that these ASHAs would not welcome a monetary incentive, butthey understand the compulsions of the program. What they seek is

1. Support in the form of continued training and visits.2. Regular refill of their drug kits and3. Prompt and courteous care for the people they refer to the PHC/CHC.


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Monetary incentive would only be a fourth priority but the system finds it difficult todeliver even these three basic requirements. Delivering these three basic supports that

ASHA demands, requires a substantial monetary and effort investment- a point toooften forgotten by the Govt. In its absence even monetary compensation is neveradequate.

The ASHA program is not a cheap low cost alternative to ANMs. Ideally we expect thecost of drugs at about Rs.10, 000 per ASHA per year, i.e. an outlay of Rs.600 croresannually for the 6 lakhs ASHAs of the high focused states as a whole. If on the otherhand we pay those ASHAs (say Rs.1000 per month= Rs. 12,000 per year) in addition toother social mobilization activities the sum required would be another Rs. 720 crores.That is a total of Rs. 1320 crores and the probability that we would get the desiredoutcomes is by no means certain.

ASHA remuneration through NRHM:

(* Incentive break up for Orissa. All states do not have all the components of NRHM. Soit may vary across states)

For promoting institutional delivery under JSY= Rs 600 per institutional delivery (Rs 50 per Antenatal check up x 3 = Rs 150 Rs 200 for the service provided, Rs 250 for the mobility support) To help in the immunization session Rs 150 per session = Rs 150 per month As a drug provider for 6 months in DOTS is Rs 250 per cured patient = Rs 42 per

month per case

As motivation for female sterilization = Rs 150 per case As motivation for male sterilization = Rs 250 per case Rs 100 for one training session = Rs 100 per month To attend monthly sector meeting = RS 100 per month To attend GKS meeting = Rs 50 per month To attend Mamta Divas (VHND) = Rs 50 per month For Pulse Polio Rs 75 per day x 3 days = Rs 225 in year = Rs 19 per month For promoting cataract surgery Rs 175 (75 per case + 100 for mobility) = Rs 175

per month (if distributed evenly)


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For blood slide collection in F.T.D Rs 20 per slide = Rs 200 per month averageThe calculation shows that an ASHA can get at least Rs. 2526 per month if the area ishaving a birth rate of 24 and it has seasonal variation. If number of delivery willincrease, the final earnings will increase substantially. If number of T.B patients, fevercases, cataract cases is more, then definitely one can earn Rs. 4,000. Even if she earn Rs.1000 per month, that is enough even for a man in rural area where in the name ofNREGA they hardly get 10 days of work in a month. This has improved many ASHAssocio-economic condition. Each one has got a bicycle in Orissa and soon they will begiven a mobile phone. For some of the poorest it was a dream come true.It will be self explanatory if we will look at the recruitment of ASHA that has happenedin two different phases. In the first phase, we hardly found any 8th class passed women.Majority of them do not fit to the guideline of required age, education etc. Initially therewere fewer acceptances in the community for a job like ASHA. But recently in 2009 wehad another phase of selection, where out of 15 ASHAs selected in my block (where Iwas working), we got one B.Sc (Hons), two B.A, four +2, five 10th passed and the rest are

8th

passed. There are examples of political intervention, bribe to the Medical Officer, andlocal violence to select one particular candidate, etc. are seen for this round of selectionof ASHAs. This indicates that this has become an acceptable employment at least for therural community.If we will see the drug list we will find that she has to dispense certain drugs that rangefrom ORS packets to Chloroquine and Artesunate. We realize that an ASHA must havethat much of knowledge to read the thermometer, diagnose a case of Malaria throughblood test, diagnose pregnancy though urine test and give the exact dose ofChloroquine, Artesunate, Paracetamol, etc. in divided dose with proper advise. In theirtraining module, subjects from Malaria, T.B, and Leprosy to AIDS, Snake/Dog bite arethere. This has really become a challenging task for them. And the interesting part is

that they now love this task and want to be recognized as a savior of mankind.The entire ASHA program is now running through incentives. There is no fixed salaryfor them so far. But if we will look at the issues seriously there are certain anomalies.They are as follows:

1. ASHA gets Rs 600 for promoting one institutional delivery but she gets Rs. 150for promoting female sterilization, which is less beneficial for her. In the sameline, the mother also gets Rs. 1400 for institutional delivery while she gets onlyRs. 500 for adopting sterilization, which is less beneficial for her.

2. I have seen ASHA who prefers to bring and motivates only pregnant mothers fordelivery. Similarly, there are very poor families who want a child every year justto get Rs. 1400 and they do not care if the child dies next day. They will again tryfor next 1400 rupees, next year. And this goes on until the mother dies.

3. The focus on population stabilization is neglected by ASHAs in NRHM.


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4. The Government once again ignored the hazard of incentive based populationcontrol scheme warned by M.S Swaminathan.2 From R.C.H- I, R.C.H-II to NRHM,everything are now incentive based.

5. If a pregnant mother goes to another village or city for her delivery during theearly 3rd trimester of her pregnancy (This usually happens in our society. Themother goes back to her home and the first child born in its maternalgrandfathers house), then the ASHA does not cooperate the lady in giving herJanani Surakshya Yojona card before delivery and is very reluctant in providingproper post-natal care to the mother and child after delivery

Documents

Souvenir Clairvoyance 2010