Agency : Royal Danish Embassy, New Delhi

Strengthening management of the district health system is the key to improve performance and enhance access and availability of health care. The Institute implemented an operations research project to test selected management interventions to improve the efficiency and performance of district health care delivery system. The key approach was management through problem solving. The project was implemented in Hoshangabad district of Madhya Pradesh in collaboration with the State Health and Family Welfare Department and DANIDA support unit, Madhya Pradesh. The total duration of the project was three and a half years.

The project identified six major areas of interventions: Decentralised District Health Planning and Implementation, Logistics and Supply System, Human Resource Development, Management Information System and Disease Surveillance, Community Participation and Involvement of PRIs, Community Financing and Quality Assurance. During the first phase of the project, diagnostic studies were conducted in the above key management functions. The diagnostic studies aimed at identifying the key managerial problems and constraints in the district health system. These key constraints and issues were used to develop appropriate management interventions.

The Institute facilitated the preparation of a District Health Plan through the bottom up approach and the participation of the health functionaries at the sector, block and district levels. Guidelines for preparing the District Health Plan were developed at all levels. The process involved annual performance review at the levels of primary health centres and the district in the context of the health programmes and various services, formal and structured discussions in the block level workshops to identify issues and constraints in the effective implementation of the programmes, setting the objectives and expected levels of achievements of goals, identifying critical solutions, and developing interventions and plan implementation. Training programmes at the sector, block and district levels were organised for developing skills in decentralised planning.

The project aimed at improving logistics and supply of medicines, vaccines, and other supplies. The weakest component in the chain was the stores at the PHC and the district level. The project interventions focused on improving the drug stores and procurement and distribution systems. A training programme was conducted for drug store management. Guidelines were developed for procurement, supply, and storage of drugs and medicines, especially essential medicines. The intervention succeeded in streamlining the supply and availability of medicines and equipment. One of the major achievements was the changed face of the stores in terms of improvement in the physical facilities and the system of arrangement and distribution, information about the availability of medicines to the prescribing doctors and the competence of the staff in managing the stores.

The project streamlined the existing information system by facilitating the preparation of various reports, accuracy and completeness of data, and timely flow of information at various levels in the systems. A comprehensive MIS software was developed and tested in one block of Hoshangabad district. The software provides information for all services components at the village, sector and block levels. Reports could be generated for various health services and programmes at the sub-centre, PHC and district levels. The MIS software managed to generate data even at the household level. The software can be customised to the needs of the health systems and could be used for district specific reports at the state level.

Interventions for enhancing community participation in health and family welfare services were designed and implemented. The interventions mainly focussed on the Panchayati Raj Institutions (PRIs) and non- government organisations (NGOs). The major learning from the project was that there was a perceptible enthusiasm and willingness among the PRI members to work with the community to create awareness of family welfare and RCH services, promote and encourage utilisation of these services and provide support to the health functionaries in organising campaigns and outreach camps in the villages. The PRIs were also willing to share resources and the funds available with them in enhancing the availability and utilisation of medicines and nutrients.

Community financing of health care was a major success. The people and the PRIs contributed funds for the renovation of the sub-centres in the entire district. In each block, five sub-centres, owned by the government, were identified in consultation with the district health authorities, PRIs and the local people. In all, 35 such centres were identified for renovation to make them functional. One of the lessons learned from this intervention was that the community and the PRIs were keen to ensure improved access and availability of the health and welfare services, even if they were asked to contribute financially. The other lesson was that there was no dearth of funds at the level of the community for such activities if proper utilisation was ensured with transparency and accountability.

Quality Assurance was yet another challenging intervention in the project. At various stages of the project it was revealed that the processes of health care were weak. Hence the project focused on improving the process of antenatal care, delivery of the child, postnatal care, family planning (contraceptives ' IUD and oral pills), immunisation, and ARI and diarrhoea management among children. The interventions were implemented in one block only. A whole-site training in Quality Assurance was conducted for all categories of staff to enable them to work as a team for achieving the goals. Process checklists were developed and the staff was trained in their use for various services. The use of checklists by the auxiliary nurse midwives not only improved the performance but also enhanced their skills and job satisfaction. The use of checklists also helped to improve the satisfaction of the users of the services. The lesson learned in the project was that the performance and motivation of the staff could be improved by developing their skills in performing their responsibilities and tasks. Continuous and supportive supervision made a significant influence on the motivation levels of the health care providers.