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Capacity building of_health_institutions

  1. 1. UN I CY N TATES AG DS E TE A TI ON O RN PM IN TE ENT USAID E AL DEV L USAID INDIA FROM THE AMERICAN PEOPLE Sustainability Equity Access Generating Demand Quality Scale-up US Agency for International Development American Embassy Chanakyapuri New Delhi – 110 021 INDIA Tel: (91-11) 2419 8000 Fax: (91-11) 2419 8612 www.usaid.gov Capacity Building of Institutions in the Health Sector Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand The Power of Innovations and Partnership APRIL 2012 This publication was prepared for review by the United States Agency for International Development. It was prepared by Futures Group International.
  2. 2. Photo credits: Jignesh Patel, Gaurang Anand, Satvir Malhotra and Health Policy Project Suggested citation: IFPS Technical Assistance Project (ITAP). 2012. Capacity Building of Institutions in the Health Sector: Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand. Gurgaon, Haryana: Futures Group, ITAP. The IFPS Technical Assistance Project is funded by the United States Agency for International Development (USAID) under Contract No. GPO-I-0I-04-000I500, beginning April 1, 2005. The project is implemented by Futures Group International in India, in partnership with Bearing Point, Sibley International, Johns Hopkins University, and QED. For further information, contact: Futures Group International, DLF Building No. 10 B, 5th Floor, DLF Cyber City, Phase II, Gurgaon - 122 002 www.futuresgroup.com Editing, Design and Printing New Concept Information Systems Pvt. Ltd. Email: communication@newconceptinfosys.com
  3. 3. Capacity Building of Institutions in the Health Sector Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand The Power of Innovations and Partnership APRIL 2012 The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
  4. 4. IN TE ENT UN I USAID CY N TATES AG DS E TE USAID INDIA ON O RN PM FOREWORD A TI AL DEV EL FROM THE AMERICAN PEOPLE FOREWORD India has made significant strides in improving its health indicators over the last few decades. Introduction of the National Rural Health Mission (NRHM) in 2005 further reinforced its commitment to improve health indicators and achieve the universal Millennium Development Goals. The United States Agency for International Development (USAID) has been a strong and committed partner as India strives to improve its family planning and reproductive health indicators across the country. USAID, in collaboration with the Government of India, launched bilateral Innovations in Family Planning Services (IFPS) Project in 1992 to design, test and expand innovative approaches for improving quality of and access to family planning and reproductive and child health services, particularly for women, rural populations, and other underserved groups. Support for developing and strengthening individual and institutional capacity has been the mainstay of all USAID programming, reflected in the implementation efforts of the IFPS Project. Programs as well as technical assistance were designed to support state societies and address their capacity needs in implementing NRHM, while generating evidence on innovative approaches to achieve health objectives. The IFPS Project has worked in close partnership with Indian institutions to build capacities of people and develop systems for quality assurance, training, strategic behavior change communication, monitoring and evaluation, and other aspects to improve health management. These efforts have paved the way for shaping leading institutions that can contribute tremendously in the implementation of health programs. This volume is a summary of the various initiatives undertaken during the course of implementation of the IFPS Project to foster, lead and manage the capacity building process to improve performance of health services. USAID hopes that this compilation will further inform state governments and institutions in their capacity building efforts. Kerry Pelzman Director Health Office U.S. Agency for International Development American Embassy Chanakyapuri New Delhi – 110021 Tel: 91-11-24198000 Fax: 91-11-24198612 www.usaid.gov/in
  5. 5. CONTENTS Acknowledgements vii Abbreviations viii Executive Summary x 1. INTRODUCTION 1 1.1 3 Purpose and Organization of the Report 2. ANALYSIS OF NEEDS 4 3. COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL 5 3.1 Series of Collaborations with National Institute of Health and Family Welfare 5 3.2 Laying the Foundation for National Health Systems Resource Center 9 4. BUILDING CAPACITIES OF THE STATE INSTITUTES OF HEALTH AND FAMILY WELFARE 10 4.1 About State Institutes of Health and Family Welfare 10 4.2 Support to Establish and Build Capacities for Sustainable SIHFW: Uttarakhand and Uttar Pradesh 10 Setting the Stage in Jharkhand 12 4.3 5. 14 5.1 Support to SHSRC in Uttarakhand 14 5.2 Strengthening Systems for Decentralized Planning 15 5.3 6. TECHNICAL SUPPORT FOR IMPLEMENTATION OF NRHM IN UTTARAKHAND AND UTTAR PRADESH Capacity Building of Rogi Kalyan Samitis in Uttarakhand 16 18 6.1 7. SUSTAINABLE INSTITUTIONS TO BRING HEALTH CLOSER TO THE PEOPLE 18 Support for Creation of State ASHA Resource Center and District ASHA Resource Centers 20 7.1 Quality Assurance Mechanisms and Programs 20 7.2 Quality Assurance for PPP Models 21 7.3 8. SETTING UP MECHANISMS FOR QUALITY ASSURANCE Quality Improvement Processes for RCH Camps in Jharkhand 23 SIFPSA: LEAVING BEHIND A LEGACY 25 8.1 Creation of an Autonomous Body for Implementation of IFPS Project in Uttar Pradesh 25 8.2 Drawing an Organizational Framework for the Society 25 Contents v
  6. 6. 8.3 26 8.4 Building Capacities and Providing Technical Assistance for a Sustainable Society 27 8.5 Transitioning and Re-aligning itself through the Course of the IFPS Project 27 8.6 Key Issues Affecting SIFPSA’s Operations 31 8.7 Elements of Success 31 8.8 9. Performance Based Disbursement Mechanism Addressing Complexities for SIFPSA’s Course Ahead 31 32 BUILDING CAPACITIES OF THE PRIVATE SECTOR 34 10.1 Identifying and Building Local Capacities 34 10.2 Enhancing Capacities of the Private Facilities for Provision of Quality Services 35 10.3 Evidence-based Planning, Design and Implementation of Programs 36 10.4 Orienting Advertising Agencies to the Development Sector 10. STRENGTHENING INSTITUTIONS TO PROMOTE FAMILY PLANNING IN JHARKHAND 36 11. CHALLENGES AND WAY FORWARD 38 REFERENCES 39 List of TABLES Table 1: Summary of Courses in Collaboration with NIHFW 7 Table 2: Summary of the Training and Content Development Support to SIHFW 12 Table 3: Clinical Trainings conducted in Uttar Pradesh as part of the IFPS Project (2004-2012) 29 Table 4: A Summary of the BCC initiatives under the IFPS Project in Uttar Pradesh (2004-2012) 30 Table 5: By the Numbers: Family Planning Fortnight 33 List of FIGURES Figure 1: Capacity Building Framework: IFPS Project Figure 2: State ASHA Support System 19 Figure 3: Organizational Structure of the State Innovations in Family Planning Services Agency 26 vi Capacity Building of Institutions in the Health Sector 2
  7. 7. ACKNOWLEDGMENTS T his report documents the efforts and contributions made by USAID through the Innovations in Family Planning Services (IFPS) Project towards capacity building and strengthening of public and private institutions in the health sector in India. The report highlights the support rendered at the national level and in three Indian states: Uttar Pradesh, Uttarakhand, and Jharkhand. The USAID funded IFPS Project is a joint US-India initiative that has worked to promote improved family planning and reproductive health for India’s poor communities and works in close collaboration with Ministry of Health and Family Welfare, Government of India as well as with state societies in Uttarakhand, Uttar Pradesh and Jharkhand. The project would like to acknowledge the collaborative efforts of the public health institutions including the Ministry of Health and Family Welfare, Government of India, state governments, apex national and state institutes (National Institute of Health and Family Welfare (NIHFW), State Institute of Health and Family Welfare (SIHFW), National Health Systems Resource Center (NHSRC) and State Health Systems Resource Centers (SHSRCs), State Program Management Units (SPMUs) and District Program Management Units (DPMUs) for National Rural Health Mission (NRHM) implementation at the state level, state societies (State Innovations in Family Planning Services Agency (SIFPSA), Uttarakhand Health and Family Welfare Society (UKHFWS) and Jharkhand Health Society (JHS) and district counterparts and several private institutions, including private health facilities, nongovernment organizations, research organizations and other creative agencies. These collaborations have resulted in strengthening of these institutions to contribute to the overall health systems strengthening in the country. We would also like to acknowledge the technical leadership and guidance provided towards the capacity building efforts by the USAID India Mission, especially Dr. Loveleen Johri, Shweta Verma and Vijay Paulraj. Tanya Liberhan, IFPS Technical Assistance Project (ITAP) (Futures Group), compiled this report with constant guidance and support from Dr. G Narayana and Shuvi Sharma. The report has been put together drawing uponseveral interviews with project staff and partners, and a range of published and unpublished project reports, documentation and databases. Several individuals contributed to the drafting of this report, including Dr. Gadde Narayana, Shuvi Sharma, Ashutosh Kandwal, Dr. Ajay Misra, Dr. Santosh Singh, and Dr. Nimisha Goel. This report has been reviewed by Dr. G Narayana, Shuvi Sharma, Dr. Suneeta Sharma, and Dr. Nidhi Choudhry and their inputs have proved to be invaluable. Acknowledgments vii
  8. 8. ABBREVIATIONS AIDS ANC ANM ASHA BCC BHEO BPL CHC CHV CMO COPE DAP DARC DGHS DHAP DivPMU DPM DPMU DQAG EAG ED FOGSI FP FRU FWC GDP GHI GoI GoUK GoUP HIV HMS IEC IEC IFPS IPC IPH Acquired Immuno Deficiency Syndrome Antenatal Care Auxiliary Nurse Mid-wife Accredited Social Health Activist Behavior Change Communication Block Health Education Officer Below Poverty Line Community Health Center Community Health Volunteer Chief Medical Officer Client Oriented and Provider Efficient District Action Plan District ASHA Resource Center Director General Health Services District Health Action Plan Divisional Program Management Unit District Program Manager District Program Management Unit District Quality Assurance Group Empowered Action Group Executive Director Federation of Obstetric and Gynecological Societies of India Family Planning First Referral Unit Family Welfare Counselor Gross Domestic Product Global Health Initiative Government of India Government of Uttarakhand Government of Uttar Pradesh Human Immuno Virus Hospital Management Society Information Education and Communication Information, Education, and Communication Innovations in Family Planning Services Interpersonal Communication Institute of Public Health viii Capacity Building of Institutions in the Health Sector
  9. 9. IPHS ITAP IUCD JSK LHV MCH M&E MDG MGHN MIS MNGO MoHFW NABH NGO NHSRC NIHFW NRHM NSV PBD PERFORM PHC PHFI PIP PMV PPP PRI QA QI RCH RH RKS SARC SHSRC SIFPSA SIHFW SNMC SPMU TAG ToT UKHFWS UP USAID USG Indian Public Health Standards IFPS Technical Assistance Project Intrauterine Contraceptive Device Jansankhya Sthirata Kosh Lady Health Visitor Maternal and Child Health Monitoring and Evaluation Millennium Development Goal Merrygold Health Network Management Information Systems Mother Nongovernmental Organization Ministry of Health and Family Welfare National Accreditation Board for Hospitals and Health Care Providers Nongovernmental Organization National Health Systems Resource Center National Institute of Health and Family Welfare National Rural Health Mission No-scalpel Vasectomy Performance Based Disbursement Program Evaluation Review for Organizational Research Mangement Primary Health Center Public Health Foundation of India Program Implementation Plan Project Management Unit Public-Private Partnership Panchayati Raj Institution Quality Assurance Quality Improvement Reproductive and Child Health Reproductive Health Rogi Kalyan Samiti State ASHA Resource Center State Health Systems Resource Center State Innovations in Family Planning Services Agency State Institute of Health and Family Welfare Sarojini Naidu Medical College State Program Management Unit Technical Advisory Group Training of Trainers Uttarakhand Health and Family Welfare Society Uttar Pradesh United States Agency for International Development United States Government Abbreviations ix
  10. 10. EXECUTIVE SUMMARY C apacity building has been one of the most important approaches used by international development organizations to achieve development objectives worldwide. It focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from realizing their developmental goals, while enhancing their abilities to achieve measurable and sustainable results. Capacity building takes place at three levels, individual, institutional, and societal. At the institutional level capacity building involves creation of new institutions or strengthening of existing institutions while at the individual level, it deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. The United States Agency for International Development (USAID) has been committed to support and strengthen capacities at individual and institutional levels through one of its early projects in India. USAID and the Government of India (GoI) collaborated to implement the Innovations in Family Planning Services (IFPS) Project, from 19922012. The project, in its first phase, focused on improving quality, access and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh, while shifting its priorities in its second phase to developing, demonstrating, x documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. In its capacity building efforts, the project has mainly focused on providing technical assistance to build capacities of key systems and strengthen local institutions in areas such as quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state, and district levels, and behavior change communication (BCC). At the national level, the IFPS Project has formed key linkages and collaborations with Indian technical organizations. A series of collaborations were formed with the National Institute of Health and Family Welfare (NIHFW) to design and conduct effective courses for health program managers on PPPs and decentralization of health systems. The IFPS Project has also provided technical assistance and support for creation and establishment of the National Health Systems Resource Center (NHSRC). Besides these efforts, significant technical expertise of health professionals has been extended to the Ministry of Health and Family Welfare (MoHFW). At the state level, support has been extended to establish and build Capacity Building of Institutions in the Health Sector capacities of the State Institutes of Health and Family Welfare (SIHFW) in Uttarakhand and Uttar Pradesh and the Institute for Public Health (Jharkhand). Specifically for Uttarakhand, the IFPS Project supported development of the organizational structure, administrative and management systems, financial management systems and human resource policies for the SIHFW. For UP, the support has been at three levels – designing training programs for health providers, conducting training, and development of training aids. The state level societies established to enable implementation of the National Rural Health Mission (NRHM) were supported by the IFPS Project to strengthen systems for decentralized planning. The states have established two units for better implementation of the Mission, i.e., State Health Systems Resource Center (SHSRC) to support innovations and monitoring and State Program Management Units (SPMU) and District Program Management Units (DPMUs) for program management. The project has supported NRHM program management units at state and district levels for preparation of District Action Plans (DAPs) as well as state Program Implementation Plans (PIPs) in Uttarakhand, Jharkhand and UP. Significant contributions have also been made through the course of the project to strengthen capacities
  11. 11. and establish systems at the micro level to bring health closer to people. This has been in the form of support for creation of State ASHA (accredited social health activist) Resource Center (SARC) and District ASHA Resource Centers (DARCs) in Uttarakhand to strengthen the ASHA support system in the state. This resulted from the successful implementation of one of the PPP models implemented as part of the IFPS Project i.e., ASHA Plus program. The project has also supported institutionalization of key mechanisms, as part of the pilot projects initiated through the course of its implementation. QA mechanisms, developed through the course of implementation of the projects in UP and Uttarakhand, will now support these states in improving the quality of service provision. These include: the QA Cell, district quality assurance groups (DQAGs) established at the state and district levels, trained health officials, a better equipped SHSRC or state level QA Cell to conduct further trainings, and mobilized health facilities trained on infection prevention practices, emergency preparedness and biomedical waste management. Also, the capacities of the private sector have been strengthened to ensure quality provision as a result of close collaborations during the implementation of some of the PPP models. The IFPS Project has been implemented through autonomous state health societies, the State Innovations in Family Planning Services Agency (SIFPSA) in UP, the Jharkhand Health Society in Jharkhand and the Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments.These autonomous societies were created to guide all project activities. SIFPSA was established during the first phase of the project in 1993, when the focus was on UP. Through the course of the project, with technical assistance and experience of implementing effective programs, SIFPSA has become an established resource for FP and RH and program implementation for the state of UP. Strong foundation has been established to take the FP program forward in Jharkhand. The IFPS Project supported the state to set up the FP Task Force, envisioned to cater to specific needs and to add value to the overall family planning endeavor at the state level. One of the mandates of the Task Force was to set up an FP Cell and develop the FP strategy for the state. The project supported the state in these activities and other activities including development of state guidelines on FP and development of information, education and communication (IEC) material on FP. Several collaborations and partnerships were established with the private sector through the implementation of the IFPS Project. Identification of key local partners and building their capacities to support program implementation and coverage was an important aspect of the IFPS Project. Several NGOs were involved, oriented, and mentored to support implementation of the PPP models in the three states. Similarly, the capacities of the private sector health providers who were part of the collaborations for implementation of certain PPP models were enhanced for provision of quality services. The project was also able to orient and strengthen capacities of research organizations and several advertising agencies through the course of its implementation. Along the way, the project addressed certain complexities and challenges working closely with state governments, autonomous institutions, state government support structures, NGOs and other private organizations such as frequent changes in leadership, administrative complexities, narrow perspective to capacity building and getting a consensual buy-in from all stakeholders. The project tapped all opportunities to strengthen the existing and new institutions, establish systems and build individual capacities to ensure sustainable institutions and enhance government ownership. The systems established as part of these institutions are envisioned to continue to meet their objectives even after the IFPS Project efforts conclude. Key mechanisms and institutions can be potentially utilized for implementation of national and state government programs. Executive Summary xi
  12. 12. Chapter 1 INTRODUCTION T ill 1990s, most international organizations used institution building or institution strengthening or organizational development approaches to achieve the objectives of development programs. With a focus on sustainable development in the past two decades, the emphasis shifted to capacity building with an enhanced scope. Capacity building focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from achieving their goals while enhancing the abilities that will allow them to achieve measurable and sustainable results. Capacity building takes place on an individual level, institutional level and the societal level. At the individual level, capacity building deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. It also calls for the establishment of conditions that will allow individuals to engage in the process of learning and adapting to change. These are achieved through a variety of mechanisms such as training programs, joint projects, sharing on-job experiences, understanding operations research, study tours etc. At the institutional level, capacity building involves creation of new institutions or strengthening of existing institutions. The main emphasis is on supporting institutions in forming sound policies, organizational structures, processes and procedures and effective methods of management and revenue control. At the societal level, capacity building supports a more interactive public administration that learns equally from its actions and feedback from the population at large. USAID commitment to capacity building The United States Agency for International Development’s (USAID) commitment to help countries improve health outcomes through strengthened systems, specifically through capacity building, reflects in its latest efforts to promote health and development around the world. The United States Government (USG) Global Health Initiative (GHI)1 launched in 2009, is the latest chapter in US efforts to promote health and development around the world. While the key principles of the initiative include, encouraging country ownership and investment in countryled plans, and building sustainability through health systems strengthening, the program has based itself upon BEST2 (Best Practices for Family Planning, Maternal and Child Health, 1 USAID’s commitment to support and strengthen institutional development and capacities of health professionals in India reflects through implementation of one of its early projects in India i.e., the Innovations in Family Planning Services (IFPS) Project, a joint effort of the Government of India (GoI) and USAID/India that has spanned over two decades (1992-2012). To begin with, the IFPS Project focused on improving quality, access, and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh (UP). With the project moving in its next phase (2004), the priorities shifted towards developing, demonstrating, documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. The project strengthened the capacity of Indian institutions to implement FP/RH programs, builds the capacity See http://www.ghi.gov/what/index.htm. 2 and Nutrition) action plan approach, which advocates supporting country capacity building and strengthening systems for sustained impact (Global Health Initiative, http://www.pepfar.gov/ ghi/index.htm; http://www.usaid.gov/ghi/ factsheet.html). See http://www.healthpolicyproject.com/basics/BEST-Sept%2021%202010.pptx Introduction 1
  13. 13. of clinical and community-level providers, reduces barriers to access quality FP/RH services, and increases awareness, demand, and use of FP/RH services.3 Of the three major thrusts for IFPS Project, one of them has been to use all opportunities to build capacities with emphasis on the sustainability quotient (USAID Global Health Fellows Program, 2007). Considering that the strengthening process for both state level and local institutions requires more time to produce results, the technical support provided through the project period serves as the foundation for sustainable institutions, the larger objective being that these institutions will further provide technical support to the public and private health systems in the country. In this context, the IFPS Project has directed efforts to provide technical assistance to build capacities of key systems and strengthen local institutions, in areas such as technical skills development, quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state and district levels, and behavior change communication (BCC). In its focus on capacity building, the IFPS Project has mainly concentrated on individual and institutional level capacity building. The basic framework that defines the capacity building efforts of the project is presented in Figure 1. The framework evolved FIGURE 1: CAPACITY BUILDING FRAMEWORK: IFPS PROJECT     Institutional Individual        Dependent Government at national, state and district levels Develop organizational framework Staff development Support Systems Technical Assistance Training of trainers Monitoring and Supervision Direct training On the job training Exposure visits Mentoring Study tours Guided NRHM at the state and district levels Assisted A P P R O A C H E S Independent National and state autonomous bodies and quasi government institutes NGOs, private sector health providers, research organizations IDENTIFIED PARTNER INDIVIDUALS, ORGANIZATIONS AND INSTITUTIONS *Adapted components on staged capacity building from the Australian AID (2006) A Staged Approach to Assess, Plan and Monitor Capacity Building. 3 See http://www.usaid.gov/in/our_work/health/rh_doc1.htm 2 Capacity Building of Institutions in the Health Sector through the three phases of the project and responded to the needs, shift in project priorities and reforms in the national health programs. The project employed a variety of capacity building approaches at both individual and institutional levels, including direct training, mentoring, and exposure visits for individual level capacity building, and developing the organizational structures and providing technical assistance for institutional level capacity building. A staged process of capacity building was envisioned, with the IFPS Project supporting and mentoring the institutions to be self-sustainable with key systems and mechanisms in place. For these efforts, along the implementation of the IFPS Project, several individuals, organizations and institutions were identified for collaborations and capacity building support. IFPS Project’s support for capacity building to NRHM With the launch of the National Rural Health Mission (NRHM) in 2005, capacity building approaches for sustainable development have received a renewed rigor in India. NRHM was launched to facilitate architectural corrections in the basic healthcare system of India. It aimed to provide accessible, affordable and accountable quality health services to the poorest household in the remotest rural region by increasing the overall public expenditure on health from 0.9 percent to 2-3 percent of the GDP (NRHM, http:// mohfw.nic.in/NRHM). The Mission recognized the need for an integrated approach to health-care service delivery. Improved management through capacity building at all levels is one of the main cornerstones
  14. 14. adopted by NRHM, others include communitization, flexible financing, monitoring against standards and innovations in human resource management. In the initial phases of the NRHM, to support the intricate and multilevel Indian public health system that extends up to the village level, establishment of quasi-government institutions at all levels was initiated. The IFPS Project supported the establishment of these institutions at the national and state levels. At the national level, the IFPS Project supported the establishment of the National Health Systems Resources Center (NHSRC) and strengthening the National Institute of Health and Family Welfare (NIHFW). Structures such as the State Program Management Unit (SPMU), Divisional Program Management Units (Div.PMUs) and District Program Management Units (DPMUs) in the states, districts and blocks were being established. The project worked with a variety of stakeholders to strengthen capacities of individuals in government and nongovernment sectors and supported the state government efforts to establish or modernize the existing institutions. The state support systems for NRHM, specifically in Uttarakhand and UP, were established and mentoring support was further extended through the project. The IFPS Project has been facilitated by the formation and strengthening of autonomous state health societies. The project is being implemented through these societies, the State Innovations in Family Planning Services Agency (SIFPSA) in UP, Jharkhand Health Society in Jharkhand and Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments. In support of this bilateral initiative, the IFPS Technical Assistance Project (ITAP), implemented by Futures Group, India and partners, facilitates multisectoral dialogue, strategic information analysis and use, in-country capacity building, and other implementation assistance. A major thrust for ITAP is to develop, design, demonstrate, document, and disseminate innovative models and financing strategies, including PPPs that reach the poor and vulnerable communities with FP and RH services. A major element distinguishing the IFPS Project from most other USAIDfinanced activities is the nature of its funding. Bilateral activities conducted under the IFPS Project are funded through a mechanism known as performance-based disbursement (PBD) (See Section 8 for details on PBD). 1.1 PURPOSE AND ORGANIZATION OF THE REPORT This report captures the contributions made by USAID through the IFPS Project, towards capacity building and strengthening of public and private institutions in the health sector in India, largely in its second and third phase. It intends to highlight the support rendered, lessons learned and recommendations developed over the course of IFPS Project and ITAP’s work on institutional capacity building. It is hoped that these experiences will offer insights into the nuances of working with public health institutions, building capacities of private institutions to foresee their participation in the health sector and strengthening these institutions to contribute to the overall health systems strengthening in the country. Section 2 of the report presents the gaps related to institutional development and capacity building. Section 3 focuses attention on the series of collaborations and support initiated through the USAID funded IFPS Project, at the national level. Section 4 presents the capacity building initiatives for State Institutes of Health and Family Welfare (SIHFW) in the USAID priority states. Section 5 presents the technical support provided through the IFPS Project for implementation of NRHM program in the states. In section 6 and 7, the support provided to establish systems for management of community level workers and mechanisms for QA have been presented. Section 8 presents the journey of SIFPSA in UP. Contributions made to establish and strengthen institutions in order to promote FP in Jharkhand are summarized in Section 9. Section 10 pulls together all experiences of capacity building of private institutions, NGOs and individuals. Amongst contributions and significant achievements detailed throughout the report, there were challenges and lessons learned, and these have been presented in the last section. Introduction 3
  15. 15. Chapter 2 ANALYSIS OF NEEDS After the initiation of the IFPS Project, PERFORM4 survey was conducted in 1995 to establish a baseline for the performance indicators of the project and generate evidence to inform project design. It was designed to measure the IFPS benchmark indicators required at three levels: (1) public and private service delivery points, (2) service providers and (3) client population. The survey provided a wealth of information on the status of family welfare services in the public and private sectors, among FP staff and about the utilization and future demand for those services by the eligible couples. The survey results provided an insight into how the levels of invested effort and resources into strengthening the family welfare service capacities of the government, nongovernment and commercial sectors should be revived. Focus on improvement in quality of service provision was identified as a key component to result in an increase in service utilization. The survey found that not enough FP staff at health facilities were trained on FP service procedures with only 44 percent of the staff at public health facilities and 14 percent at private facilities reported receiving training in the last five years (The EVALUATION Project, 1996). The readiness of health facilities and staff for high quality FP service provision could be questioned based on the survey findings. One of the key objectives of the IFPS Project in the initial phase was to strengthen capacities of staff and facilities with clinical and non-clinical training on FP, particularly contraceptive methods and client counseling. With the IFPS Project moving into its second phase in 2004, lack of provision of quality services still remained a challenge. Several other gaps were identified, which informed the objectives of the project’s next phase. One of the gaps identified was the lack of adequately trained and skilled providers in both public and private health sectors. This affected the quality of service provision, which further led to lower utilization of services by the people. Also witnessed during that period was the lack of a strong institutional base to provide technical assistance to the health sector. Autonomous quasi-government institutions, nongovernmental organizations (NGOs), and private sector health institutions could significantly contribute to address these challenges for overall health systems development. These institutions could provide technical assistance to the health system by conducting research, analyzing health policies, human resource planning and management, training health professionals, quality assurance, planning, and monitoring and evaluation. In this context, it became important that these institutions be established, strengthened, trained and sustained. As the project moved into its second phase, the period was also marked by changes in the Indian healthcare system, with the introduction of the NRHM program. The program adopted new approaches such as flexible financing, monitoring against standards, improved management through capacity building, and innovations in human resource management as its main cornerstones. With a new thinking, new cadre of health workers, community based committees and new systems in place, a need was felt to bring in new structures to manage and monitor the program. Weak institutional capacity to support management and monitoring of the NRHM activities at state and district levels was a key challenge. This was also reflected in the materialization of decentralized planning, which was the principal pivot of the program. Therefore, for better planning and implementation at the state and district levels, new institutions of governance each at national, state, district, facility and village levels were to be created. Understanding these specific needs based on the health system scenario and the strategic programmatic shifts of the GoI, the IFPS Project in its second and third phase, prioritized to address these challenges through institutional strengthening and human capacity development. Program Evaluation Review for Organizational Resource Management or PERFORM was designed and produced by The Evaluation Project of the University of North Carolina and served as one of the means of evaluation at the disposal of SIFPSA and USAID to ensure that the right and desired results are being achieved. 4 4 Capacity Building of Institutions in the Health Sector
  16. 16. Chapter 3 COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL O ne of the core elements of the IFPS Project is to develop and strengthen key institutions in both public and private sectors. As part of the project, technical assistance activities were designed to form linkages with Indian technical organizations to deepen the already strong national capacity and develop the capacity of the state and national public health sector to partner with the private sector. The IFPS Project’s mandate to strengthen these institutions has been comprehended at the national level through a series of collaborations with the NIHFW, support for creation and set up of NHSRC and significant human resource support to the Ministry of Health and Family Welfare (MoHFW). 3.1 SERIES OF COLLABORATIONS WITH NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE NIHFW is an apex technical institute, to promote health and family welfare activities in the country. It is a quasigovernmental institution and works under the auspices of MoHFW, GoI. Established nearly three decades ago, the institute addresses a wide range of issues on public health and family welfare management through its multi-disciplinary functions in research, consultancy, education and training. In-service training of middle and senior level health personnel has been one of the core focus areas of the institute. NIHFW is the nodal agency for coordinating the capacity building and training component under NRHM for the entire country. The institute organizes a variety of training courses on reproductive and child health (RCH), Human Immuno Virus and Aquired Immuno Deficiency Syndrome (HIV and AIDS), reproductive biomedicine, adolescent health, geriatric care, geographic information system, PPP, health management, hospital administration, health communication, nursing administration, educational technology, health financing/economics, statistics and demography and other areas of public health. Currently, a total of 15 SIHFW established at the state level support NIHFW in this endeavor. The institute is also involved in several operations research, applied research and evaluation studies of health and family welfare programs. On the education front, NIHFW offers three regular post graduate courses on Community Health Administration and Health Administration, and Public Health Management. NIHFW collaborates with various international agencies which are also contributing towards improving the health scenario in the country, to apprehend the larger health goals. The IFPS Project has collaborated with NIHFW to design the first conference on PPPs in the health sector, courses on decentralization, several studies, and is supporting a position at NIHFW to coordinate all such activities. Designing the first public-private partnership conference One of the core areas for the IFPS Project was to develop, demonstrate, document and leverage expansion of working models of PPPs which deliver integrated FP and RH services. To substantiate upon its objective, the IFPS Project supported the GoI in developing a PPP strategy at the national level in early 2005. Several studies on various PPP models including contracting out, mobile health vans and professional associations such as Indian Medical Association, Federation of Obstetric and Gynegological Societies of India (FOGSI), Indian Nursing Association were conducted along with a literature review of some of the other PPP models (social franchising, voucher scheme, social marketing). Based on the study analyses and literature review, the PPP strategy was developed, which was later incorporated as part of the RCH II Program5 Strategy. RCH II Program: To help achieve reproductive and child health (RCH) objectives, particularly improving access for the poor, India designed the multi-year RCH-II program in 2005, which is now part of the NRHM. 5 Collaborations and Support at the National Level 5
  17. 17. Following the development of the PPP strategy, it was important that these models be shared with representatives from different states. Therefore, in December 2005, the IFPS Project through ITAP collaborated with NIHFW to design the first conference on PPPs. The conference was designed to share PPP experiences from the entire country with policy makers, program administrators and researchers. The conference helped participants representing different states share their experiences on implementing various PPP initiatives. The effort provided insights to the members/faculty of the institute on the growing importance of PPPs for the health sector, and built their capacities to further design and implement PPP models. Collaboration for courses on public-private partnerships in the health sector NIHFW and the World Bank Institute are collaborating on a capacity development program to improve health systems policy and management. As part of this initiative, health training needs assessments were conducted in October 2007 in three focus states: Rajasthan, Orissa and UP, to identify the priority training needs of the selected states in the area of health system policy and management to ensure a more effective implementation of NRHM. The studies highlighted the need for further training at the state level on specific subjects such as PPP, human resource management and quality improvement in healthcare. Several development partners contributed to the effort, with USAID supporting the PPP training component. April 2008 through September 2011, five workshops on PPP were facilitated in a collaborative mode by USAID through the IFPS Project and NIHFW. The five day workshops oriented senior and middle level executives, and technocrats from state/district/below district levels of nine states (Rajasthan, Orissa, UP, Uttarakhand, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand and West Bengal) on implementation of PPP initiatives. A specific PPP Key resource persons for the training course on PPPs in Health Sector in Uttarakhand, 2011 6 Capacity Building of Institutions in the Health Sector initiative was identified in each of these states and personnel working in that particular initiative were invited for the workshops. The PPP experts shared the mechanism to design and implement successful PPP models, and shared success stories from the PPP models implemented and prospective challenges during implementation. The workshops offered a platform for prolific discussions with key perspectives on implementation, client satisfaction, scope for improvement and potential for replication. The initial workshops (2008-09) had international experts on PPP, as key resource persons to conduct sessions and prepare course content. The course content, in collaboration with the faculty of NIHFW, materials and presentations were shared with the representatives of development partners. The courses conducted in a collaborative mode, built the capacities of the faculty and resource persons from other agencies to conduct such courses on PPP in the future. As a result, the last two courses (2010-2011) were conducted by the faculty and resource persons from NIHFW without support from any external experts. NIHFW now has the necessary course materials and wherewithal to conduct PPP courses for health professionals in the country. Building capacities for Alternative Training Methodology for IUCD The IFPS Project efforts to mainstream intrauterine contraceptive devices (IUCD) began in its phase I activities in UP. Recognizing its importance, the MoHFW, GoI decided to revive and reposition IUCD in the country, particularly in Empowered Action Group (EAG)
  18. 18. states6 with low contraceptive prevalence rates. The effort was supported by the introduction of new IUCD technologies (380 A), which provided an opportunity to position and promote IUCD as both a limiting and a spacing method. All these efforts required an effective and quality oriented service delivery system, which would be ensured through quality training systems, and providers equipped with new skills and technology. The IFPS Project supported MoHFW to develop a separate IUCD Reference Manual for medical officers and nursing personnel, trainer’s guide, and participants’ handbook for the providers, and also drafted the ‘Guidelines for Repositioning IUCD in Family Welfare Program – Strategy, Operational Plan and Achievements’ to roll-out the IUCD training, using skill-based classroom and online computer assisted learning approaches. NIHFW collaborated with USAID through the IFPS Project for capacity building of program managers and service providers on an alternative training methodology for IUCD insertion. The expected outcome of the training was to develop the competency of service providers on the anatomical models for IUCD insertion and removal before they practice on clients. A humanistic way of training using the Pelvic (ZOE) models was imparted to enable the trainees to acquire competency in insertion of IUCD using the no-touch and withdrawal techniques without any fear of injuring the client. Representatives from MoHFW and, program managers and service providers from 12 states (identified region-wise based on the unmet need for modern spacing methods) were trained on alternative training methodology for IUCD services using pelvic models. These master trainers (NIHFW faculty, SIHFW faculty, state program managers and service providers) would further train district level trainers for training TABLE 1: SUMMARY OF COURSES IN COLLABORATION WITH NIHFW S. No. Course/Conference Target audience 1 PPP Conference 2005 PPP implementers, policy makers 1 day 2 Course on Decentralization of Heath Systems, 2007 Program managers and implementers at the state and district levels 5 days 49 3 Course on PPPs in the Health Sector, Agra, UP. 2008 Senior and middle level executives, and technocrats from state/district/below district levels 5 days 47 4 Course on PPPs in the Health Sector, Lucknow, UP 2008 Senior and middle level executives, and technocrats from state/district/below district levels 5 days 44 5 Course on PPPs in the Health Sector, Nainital, Uttarakhand 2010 Senior and middle level executives, and technocrats from state/district/below district levels 5 days 27 6 Course on PPPs in the Health Sector, Ajmer, Rajasthan Senior and middle level executives, and technocrats from state/district/below district levels 5 days 17 2011 Duration Number of participants 7 Course on PPPs in the Health Sector, Uttarakhand 2011 Senior and middle level executives, and technocrats from state/district/below district levels 5 days 22 8 Alternative Training Methodology for IUCD Representatives from Ministry of Health and Family Welfare, program managers and service providers from 12 states, resource persons from NIHFW and SIHFW 6 days 56 Source: Workshop Process Documents, ITAP The concept of EAG was initiated especially to ensure population stabilization and intersectoral convergence. EAG states are categorized as those with high fertility rates and weak socio-demographic indicators (NRHM, 2005) 6 Collaborations and Support at the National Level 7
  19. 19. the service providers (medical officers, staff nurses, lady health visitors (LHVs) and auxiliary nurse mid-wives (ANMs) of the identified pilot districts. The representatives from the Ministry who underwent the training of trainers (ToT) course provided monitoring and supervision support to the activity. The ToT was conducted by NIHFW in June 2007 in three batches. The IFPS Project with support from technical experts, identified from the field developed the reference manual, trainers’ notebook and participant handbook, and quality checklists. The master trainers went back to successfully train the service providers from respective districts, throughout the country. The Ministry representatives have been monitoring the program in different states. The materials developed by the IFPS Project have been effectively used for conducting the training at the state level. Course on decentralization of health systems Decentralized planning has been one of the core approaches introduced as part of the IFPS Project’s early efforts in UP. In 1995, the IFPS Project identified decentralization as a priority for the state in order to effectively implement all health programs. Decentralized health planning could meet specific needs of local constituencies more effectively, could inform efficient decision making processes at the local level, encourage efficient utilization of local resources and increase accountability of the health program to the local community. At the same time, major changes in the district government created a favorable environment for 8 decentralization. In 1997, the IFPS Project introduced and started a discussion on creation of District Action Plans (DAPs). A pilot was carried out in the Rampur District, based on which the model was scaled up in a phased manner to cover 33 districts in UP. The success of the DAP approach saw the GoI, adapting and implementing it across the country through the NRHM. Decentralization forms one of the key pillars of the NRHM implementation processes. Based on the experiences from UP, the IFPS Project in collaboration with NIHFW and the International Health Systems Group, Harvard School of Public Health designed a course to share Indian and international experiences in designing and implementing decentralized plans. Acclaimed resource persons from the Harvard School of Public Health conducted the course and used course modules from the World Bank Flagship Course on Health Sector Reform and Sustainable Financing, as well as created study materials (case studies) specific to the context of the course. The course presented ways of designing and implementing decentralization to best improve a health system. The course content included analytical approaches to decentralization, learning practical design and implementation issues, need to adjust and change decentralized systems and draw upon lessons from other countries’ experiences. The course provided an opportunity for the resource persons from NIHFW to build their capacities to be able to develop training material and to organize and conduct such courses. Capacity Building of Institutions in the Health Sector Collaborations on research and analyses The IFPS Project collaborated with NIHFW to conduct several studies, one of which is the cost effectiveness study of the Sambhav Voucher Scheme in Uttarakhand. The Sambhav Voucher Scheme is one of the PPP models designed and implemented by the IFPS Project in the three focus states of UP, Uttarakhand and Jharkhand. A key area of interest regarding voucher schemes is their cost-effectiveness, especially given the concerns about administrative costs for managing the programs. NIHFW has had health economics expertise but never conducted cost effectiveness studies. Cost effectiveness studies have garnered interest in recent times, and are considered important to inform policy makers of optimal utilization of resources. Several PPP models are being implemented in different states in India, but their feasibility to scale up, based on cost effectiveness analyses results, has largely remained unattended. To address these gaps, NIHFW decided to enhance its capacities to conduct such studies, in terms of the study design, preparation of data collection tools, data analysis and interpretation, and dissemination of information to policy makers and program managers. With these objectives, the cost effectiveness analysis of the Sambhav Voucher Scheme in two blocks of Hardwar district was conducted. The analysis provides insights into various dimensions that can inform policy and future strategies of the program. Expert consultants from NIHFW prepared the tools and methodology for the study with program inputs from the IFPS
  20. 20. Project. The collaborative effort helped build capacity of the team to understand the parameters important to conduct cost effectiveness analyses. 3.2 LAYING THE FOUNDATION FOR NATIONAL HEALTH SYSTEMS RESOURCE CENTER The National Health Systems Resource Center (NHSRC) was conceived as an institution for development of strategic plans and for strengthening NRHM program implementation at the national and state levels. The IFPS Project participated in the deliberations on constitution of NHSRC, prepared its structure and functions, and decided to support the institution for at least two years or till the time the government allocates its own resources to support the institution. USAID, in collaboration with other development partners, supported NHSRC and the IFPS Project acted as its secretariat for management and operational support. A pool of consultants was recruited to provide support to the technical divisions such as social marketing, FP, donor coordination, NRHM, statistics and evaluation at the MoHFW. These consultants helped the Ministry in planning and strategy development, design of new systems such as web based Management Information Systems (MIS), development of technical manuals, and also facilitated collaborative efforts with different stakeholders. In December 2006, the GoI finally decided to support NHSRC through its own resources and registered NHSRC as an autonomous body under the Chairmanship of the Secretary, MoHFW, GoI, and colocated it in the NIHFW campus. The society provides technical and capacity building support for strengthening the public health system. In the process, it has built extensive partnerships and networks with all organizations and individuals that form part of the public health system, to share the common values of health equity, decentralization and quality of care. The society operates through a limited number of functional units, each having specific functions. These units include planning, administration and coordination unit, healthcare financing/social security unit, quality management unit, PPP unit, policy development/health sector reform unit, and monitoring, evaluation and research unit. Apart from these units, state level technical cells have been established, through which the support from NHSRC is routed to the states. Separately from NHSRC, the IFPS Project continued to support the MoHFW through the pool of consultants instituted at the Ministry. Twenty six consultants have since been positioned to provide technical and secretarial support to different divisions at the Ministry. The different divisions being provided support include FP division, Monitoring and Evaluation division, Donor Coordination division, NRHM division, Health Insurance division, Statistics division, IEC division, Social Marketing division and HR cell. Collaborations and Support at the National Level 9
  21. 21. Chapter 4 BUILDING CAPACITIES OF THE STATE INSTITUTES OF HEALTH AND FAMILY WELFARE 4.1 ABOUT STATE INSTITUTES OF HEALTH AND FAMILY WELFARE The State Institutes of Health and Family Welfare are apex state level technical institutes to promote health and family welfare activities through training, research and consultancy. These quasi-government institutes are established by the state governments and work under the auspices of the Departments of Health and Family Welfare. These institutes play a vital role in supporting the state health system for all training and research requirements. The institutes support NIHFW to coordinate training activities under the NRHM program for their respective states. In order to enable NIHFW to carry out this huge task, a total of 15 State Institutes of Health and Family Welfare have been identified to liaise with the state/union territories allotted to them. These institutes provide technical support to the state health system for the following activities:  Conduct periodic training needs assessment  Develop training programs and modules based on needs assessment     In-service training for health personnel Provide technical support to other training institutes in the state for design and evaluation of training programs Provide research inputs to improve the efficiency and effectiveness of the system Conduct studies related to evaluation and impact assessment of various interventions undertaken as part of the healthcare delivery system to further inform program planners and managers. 4.2 SUPPORT TO ESTABLISH AND BUILD CAPACITIES FOR SUSTAINABLE SIHFW: UTTARAKHAND AND UTTAR PRADESH Setting the cornerstone In 2003-04, the IFPS Project supported the Government of Uttarakhand (GoUK) to conduct an initial assessment for setting up the SIHFW for Uttarakhand. The IFPS Project supported a team from the Department of Health, Uttarakhand to visit other state institutes in Rajasthan, Orissa, Andhra Pradesh and Maharashtra to study their 10 Capacity Building of Institutions in the Health Sector policies and programs, organizational structure, financial allocations, and other support systems. The study report informed the state health department’s decision to conduct a feasibility study to understand the viable options for setting up the SIHFW based on state specific needs. Meanwhile, different options for the location of the SIHFW were suggested by the State Government as well as the Health Directorate. After several deliberations within the state government and the Directorate on situating the institute within the premises of a medical college, to making it a separate body located at either Dehradun or Nainital, the idea of upgradation of the existing Regional Health and Family Welfare Training Center in Haldwani to SIHFW was proposed and sought viable. Based on the findings of the feasibility study, the IFPS Project prepared a proposal for upgradation of the Regional Health and Family Welfare Training Center in Haldwani to SIHFW. The proposal suggested modifications in the physical infrastructure including construction of a new campus, organizational structure, roles and
  22. 22. responsibilities of the staff, creation of external and internal committees to govern the SIHFW and for running day to day operations, mechanisms for coordination with other institutes in the state, and the resource allocation plan. Though the budget was sanctioned by the state government, there was a gap of two years before the institute would become operational, due to administrative complexities. During this period, GoI suggested that infrastructural development funds be accessed under NRHM, hence it should be proposed as part of the State NRHM program implementation plan (PIP). The GoUK received the funds under NRHM and subsequently the construction was completed in almost three years time and plans for recruitment of faculty finalized. Re-visiting to ensure a sustainable institution The IFPS Project continued to support the Health Directorate and the GoUK to further strengthen the SIHFW. In 2011, the Directorate planned to develop a strategy and action plan for strengthening the SIHFW in Uttarakhand. The IFPS Project helped with the procurement process to select a technical agency to conduct a needs assessment and accordingly suggest means and methods to strengthen the SIHFW. In the current context, the IFPS Project supported the state in developing a clearly defined organizational structure, administrative and management setup, financial management systems and a human resource policy. Support was Family Welfare Counselors being trained on family planning. also provided in developing the scope of work of all proposed staff members (technical and administrative). A clear strategy, including immediate actions, financial resource requirements and timeline to strengthen and operationalize the SIHFW within a time frame of six months was developed and further shared with the technical advisory group (TAG)7 for approval. The strategy proposed that an annual training plan would be prepared and the training composition would be done by the Training Implementation Committee. For the divisional training centers, guidance would be provided on how to conduct the training programs. The strategy also recommended that the training programs run at the divisional training centers be monitored and evaluated. The strategy laid emphasis on improving quality of trainings at SIHFW by networking with other training institutions and universities. The suggested mode of operation is ‘society’ mode, to provide working autonomy for effective functioning and management of day to day affairs. The strategy was approved by TAG and further presented to the Directorate. The Directorate approved the strategy with certain recommendations, based on which a detailed business plan was being worked out. Strengthening the State Institute of Health and Family Welfare in Uttar Pradesh Lack of adequately trained, skilled providers remains a challenge in both the public and private sectors. Through the course of the IFPS Project, support has been provided to the UP SIHFW for training and capacity building. Support has been at three levels: designing training programs for health providers and providing support during training sessions, support for training on BCC (planning and implementation) and development of training aids. A Technical Advisory Group (TAG) was created in Uttarakhand to provide expert guidance to, and oversight, of the NRHM activities. TAG members include top NRHM officials from the state (Director to State Program Management Unit), as well as representatives from USAID and other program partners. 7 Building Capacities of the State Institutes of Health and Family Welfare 11
  23. 23. As part of one of the NRHM activities in the state to promote FP, Family Welfare Counselors (FWCs) have been positioned at the district level hospitals throughout the state. The FWCs counsel women in the third trimester of pregnancy and during post-partum period, on adoption of FP methods. In March 2010, the IFPS Project developed a training manual and collaborated with SIHFW staff in conducting the pilot training program for FWCs. Seventeen FWCs were trained at the pilot training program. The training module developed by the IFPS Project has been adopted by the SIHFW for further training of FWCs to be placed at district level hospitals across all districts of the state. The IFPS Project, through ITAP has contributed to the yearly training plans of the SIHFW. ITAP provided support for training District Community Mobilizers, District Program Managers, PHN tutors and Block Health Education Officers (BHEOs) on BCC and information education and communication (IEC), Medical Officersin-Charge on Adolescent Reproductive and Sexual Health (specific focus on nutrition and anemia in adolescents), BHEOs on social marketing and monitoring and evaluation. In addition, support was extended for several foundation courses for BHEOs conducted in different phases from December 2010 through December 2011. ITAP was instrumental in developing training content for training of chief medical officers (CMOs), Deputy CMOs and district program managers (DPMs) on monitoring and evaluation. Table 1 provides a summary of the support provided for training and content development through the IFPS Project. 4.3 SETTING THE STAGE IN JHARKHAND The Institute of Public Health (IPH) in Jharkhand had been conceptualized as a hub of knowledge and technical TABLE 2: SUMMARY OF THE TRAINING AND CONTENT DEVELOPMENT SUPPORT TO SIHFW A Training aides and content developed for SIHFW Training Target Audience Duration Content Developed 1 Family Welfare Counseling Skills Family Welfare Counselors under NRHM 7 days Training Manual 2 BCC Planning and Implementation District Community Mobilizers and District Program Managers 5 days Training Manual 3 Monitoring and Evaluation CMOs, Dy. CMOs and DPMs Support for content finalization 4 Training of ASHAs Accredited Social Health Activists (ASHAs) Content Finalization of Module 6, 7 and 8 B Support during training Training Target Audience Duration Month/Year of the Training Training Session Supported 1 Family Welfare Counseling Skills Family Welfare Counselors 7 days March 18-24, 2010 Male and Female Reproductive organs Methods of Family Planning Communication Skills Practicums 2 Adolescent Reproductive and Sexual Health Medical Officers in/ Charge 3 days Oct 4-6, 2010 Nutrition and Anemia in Adolescents 3 Orientation of Trainers for BCC Planning and Implementation SIHFW identified trainers for BCC planning and implementation 1 day Nov 11, 2010 BCC planning and implementation 4 Foundation Course of BHEOs Block Health Education Officers 12 days Nov 29- Dec 11, 2010 Social Marketing 12 Capacity Building of Institutions in the Health Sector
  24. 24. 5 Behavior Change Communication Training for PHN Tutors PHN Tutors, Tutor In/ Charge/DHVs 5 days 3-Jan-11 Concept of IEC and BCC 6 Foundation Course of BHEOs Block Health Education Officers 12 days Jan 10-22, 2011 IEC Experiences in FP Program Communication - Definition and Processes 7 Foundation Course of BHEOs Block Health Education Officers 12 days Feb 28- March 12, 2011 IEC Experiences in FP Program Communication - Definition and Processes 8 BCC Planning and Implementation Training District Community Mobilizers and District Program Managers 5 days Nov 8-12, 2011 BCC planning and Implementation 9 Foundation Course of BHEOs Block Health Education Officers 12 days Dec 5-17, 2011 Monitoring and Evaluation Social Marketing expertise. It would play a vital role in supporting the state health system for all training and research requirements. In 2006, the IFPS Project supported the Government of Jharkhand by conducting a feasibility study to understand the status of public health institutions in the state and estimate capacity building requirements. As part of a benchmark activity, IFPS provided infrastructure support and also helped the state with recruitment of staff for the institute. After the foundation for the institute was laid with infrastructure in place, some intricacies related to operationalization remained to be worked out within the state government. After a gap of four years (2011), the state government has revived its plans to operationalize the institute and is in discussion with NIHFW and Public Health Foundation of India (PHFI), for collaboration. Building Capacities of the State Institutes of Health and Family Welfare 13
  25. 25. Chapter 5 TECHNICAL SUPPORT FOR IMPLEMENTATION OF NRHM IN UTTARAKHAND AND UTTAR PRADESH T he NRHM framework for implementation provides a robust institutional arrangement for partnership among the local, state and national governments. Decentralized planning has been the principal pivot around which the program revolves. The Mission envisaged improvements and reform in program management as one of the key elements to improved healthcare. In this regard, for better planning and implementation at state and district levels, it created new institutions of governance each at the national, state, district, facility and village levels. One of the core elements of the IFPS Project is development and strengthening of key systems. IFPS through the course of the project, has been instrumental in providing support for setting up and/or strengthening health systems in the public sector and extend technical support to build capacities of the health staff to design and manage systems. One significant example is the initiation of the District Action Planning process by the IFPS Project in UP. The District Innovations in Family Planning Agency (currently DPMU) responsible for preparation of DAPs during that period, was oriented on preparation of DAPs and budget allocations. A total of 38 DAPs were developed in a collaborative mode. The initiative corroborated with NRHM’s focus on decentralization processes and hence, was adopted by NRHM in its first year (August 2006) as the standard approach for decentralized planning and management for the country. The IFPS Project had prepared a manual on how to prepare DHAPs which was circulated to all state governments by MoHFW. In the last one year, 540 District Action Plans (DAPs) have been prepared covering almost all districts in the country –an increase from 310 in the first year of NRHM (Planning Commission, 2012). NRHM intends to further decentralize these processes of planning to the block level and below. The IFPS Project through ITAP has been supporting NRHM program management units at the state and district levels for preparation of DAPs as well as State PIPs in Uttarakhand, Jharkhand and UP. 14 Capacity Building of Institutions in the Health Sector 5.1 SUPPORT TO SHSRC IN UTTARAKHAND Each state has established state level societies to enable implementation of the rural health mission in their respective states. Based on recommendations at the time of initiating the Mission, the states established two units for better implementation of the Mission: State Health Systems Resource Center (SHSRC) to support innovations and monitoring of NRHM, and SPMU for program management. The SHSRC in Uttarakhand, was established in 2007 with support from the IFPS Project to serve as the apex body for technical assistance to facilitate the state and districts in planning and implementation of the NRHM activities as well as strengthening the program monitoring and evaluation systems. Objectives of SHSRC in Uttarakhand  Primary objective of SHSRC is to provide technical support to the State NRHM and the Directorate of Health for implementation of NRHM.  Promote the welfare of people by extending preventive, curative and
  26. 26.  rehabilitative healthcare services through the Office of Director General of Health Services (DGHS) in Uttarakhand. To adopt and evolve innovative models for providing quality healthcare services to remote areas through DGHS. The IFPS Project provided support in framing the key focus areas for the SHSRC in Uttarakhand. As part of a benchmark activity, it was suggested that the SHSRC would focus on five key areas and provide functional support to the state on Policy Analysis and Health Planning, communication (BCC and IEC), monitoring and evaluation, facilitating the implementation of PPP models and capacity building based on training needs assessments of health functionaries. The organization structure and staffing pattern for the SHSRC was developed with support from the IFPS Project. Approval was accorded to the suggested functions along with the organizational structure/staffing structure by the executive committee of UKHFWS in mid-2006. The IFPS Project extended support for recruitment of technical resource persons, bringing onboard technical staff like Consultant (Planning), Consultant (Healthcare Financing), Consultant (Monitoring and Evaluation), Consultant (Quality Improvement (QI)/QA), Consultant (Community Participation), Consultant (IEC) on the lines of the staffing structure envisaged for SHSRC, by coordinating the entire recruitment process. The positions for the initial period were financially supported through the IFPS Project. At the time of initiation, the institution was steered by the Executive Director (ED) – UKHFWS. Based on a Government Order released in 2009, a modification to the structure was suggested. The ED, UKHFWS was appointed the ex-officio Director of SHSRC, to ensure close coordination between the Department of Health and Family Welfare and UKHFWS. In 2009, the scope of work of SHSRC was revisited, and support was provided through the IFPS Project to re-develop the same as part of a benchmark activity. The suggested revisions were presented to the TAG for giving it a formal shape. Further, to support the revisions, the IFPS Project provided support for selection of a technical agency to study the present structure, hold deliberations with state and district officials, and assess the training needs. Based on their findings, a revised scope of work along with appropriate training opportunities for strengthening the SHSRC was developed. The IFPS Project was instrumental in building a strong foundation for the SHSRC in Uttarakhand, The SHSRC is providing technical support to the NRHM as mandated. However, a challenge in terms of shortage of technical staff persists and needs to be addressed to ensure a sustainable institution. 5.2 STRENGTHENING SYSTEMS FOR DECENTRALIZED PLANNING To support the management of the NRHM program at the state, district and block levels, creation of SPMU, Divisional PMUs and DPMUs were envisaged. These units have been established under the respective state health societies. To corroborate NRHM’s focus on decentralized planning, states prepare and present their PIPs to the MoHFW, GoI. Before coming up with the state PIPs, the state governments have a task of appraising the district level action plans. Significant demand projected through this exercise of decentralized planning is then incorporated in the PIP. The planning process in the states has been guided by the broad framework first used for preparation of DHAPs in 2006. The states have focused on building capacities for decentralized planning through several training exercises, handholding by NHSRC and SHSRC and taking support from professional organizations to work on the planning process. Support to institutions of management for NRHM in Uttar Pradesh and Uttarakhand The IFPS Project has been extending support for effective implementation of program implementation plans. A major activity which has been supported for the last three years has been for preparation of the state PIP as well as DAPs. A participatory process is followed each year for preparation of state PIP as well as DAPs. The IFPS Project provides technical assistance for conducting one day orientation workshops for program managers to inform an efficient PIP. Support has been extended by the IFPS Project to SPMU to prepare a set of guidelines for orientation. The IFPS Project has also been coordinating to organize orientation meetings with officials from the Directorate of Medical Health and Family Welfare. The IFPS Project has been involved in developing formats based on the PIP guidelines and framework for Technical Support for Implementation of NRHM in Uttarakhand and Uttar Pradesh 15
  27. 27. different components/sections and facilitated data collection from the Directorate. The IFPS Project has also extended support for development of DAPs. Coordinating for the orientation of program managers, the IFPS Project guided them through the process of doing a situation analysis, helped them to set objectives, identify program strategies and innovative approaches to achieve results and a mechanism to regularly monitor performance and incorporate all these components into DHAPs. The IFPS Project has also been supporting the exercise of decentralized planning based on which significant demand projected is then incorporated in the PIP. Support has been extended for district planning meetings, which are also supported by the Divisional Program Management Units (DivPMUs), based on which block and district level plans are finalized. To facilitate the process, the IFPS Project through ITAP also involves technical consultants to be part of the planning process and for compilation of the PIP. The IFPS Project has supported the preparation of budget formats, plans for budget allocation based on the PIP framework. Through the course of the last three years, the IFPS Project has been able to build capacities of the program managers in developing DAPs, PIP, and budget estimates using standardized formats. Now the program staff have acquired sufficient conceptual knowledge and skills to conduct stakeholders meetings and prepare DAPs and state PIP following consultative processes. Similarly, the IFPS Project has extended support for preparation of the state PIP in Uttarakhand for a significant period, 2008-2012. As part of the initial benchmark activities, the IFPS Project has provided support for strengthening of the SPMU and DPMUs. Also, for decentralized planning, the IFPS Project contributed for development of DAPs in 2007-08. Technical agencies were contracted by the IFPS Project to collaborate and support the development of these plans. The program managers from respective DPMUs were oriented for developing these plans. 5.3 CAPACITY BUILDING OF ROGI KALYAN SAMITIS IN UTTARAKHAND With the advancement in medical technology and increasing expectations of the people for quality healthcare, it became important to focus on provision of quality health services through the established institutions. Upgradation of the public health facilities to Indian Public Health Standards (IPHS) was strategized as an important intervention under NRHM. Hence, ensuring provision of sustainable quality care with accountability and people’s participation was envisioned by NRHM. However, it was seen that it might not be possible to achieve this unless a system was evolved to ensure a degree of permanency and sustainability. With this vision, a management structure called Rogi Kalyan Samiti (RKS) (patient welfare committee) or Hospital Management Society (HMS) was developed.8 RKS functions as a registered society which acts as a group of trustees for the hospitals to manage the affairs of the health units. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials District Action Plans being developed by the district officials 8 Rogi Kalyan Samitis: http://mohfw.nic.in/NRHM/RKS.htm 16 Capacity Building of Institutions in the Health Sector
  28. 28. from the government sector who are responsible for the proper functioning and management of the hospital/community health centers (CHCs) / first referral units (FRUs). RKS have been set up in district hospitals, sub-district hospitals, CHCs/FRUs and primary health centers (PHCs). Uttarakhand In Uttarakhand, the IFPS Project has contributed to build capacities of the RKS across the state in two phases. As part of a benchmark activity, IFPS conducted training of 2-3 members from each RKS covering a total of 55 CHCs and 239 PHCs, first in seven districts of Garwal region (2011) followed by six districts of Kumaon region (2011) for them to be able to carry out their tasks effectively. The IFPS Project conducted a needs assessment to understand the current scenario and capacity building requirements to develop systems and conduct training programs. Training modules were also developed and were shared with UKHFWS. The IFPS Project also provided monitoring support for 25 percent of the training workshops to ensure quality. A total of 926 members have been trained on the nuances of management, proper utilization of financial resources and standards to be maintained for quality healthcare. All these efforts ensured participation of stakeholders in decision-making and also helped health units to strengthen systems and to provide quality health services. Uttar Pradesh In 2008-09, UP had 133 RKS at the district level, 426 at block PHCs and 2,837 at additional PHCs.The Department of Health and Family Welfare, UP had issued guidelines to constitute RKS at district and sub-district level to decentralize management systems, to encourage people’s participation, to improve quality of services in health units and to solve problems at the local level with resources made available. However, there were some issues regarding clarity on the actual status of implementation at the ground level. In this context, the IFPS Project was requested to conduct a rapid assessment of the RKS in UP in September – October 2008 and recommend steps for strengthening these societies. The main objectives of the study were to: a) understand the constitution and composition of the Governing Bodies and the Executive Committees at the district and the sub-district levels; b) review the frequency of meetings held, decisions taken, and issues faced by these bodies; c) enlist the measures taken to improve the quality of services provided in the health units and document innovative interventions introduced; d) assess the capacity building needs of the Samitis for resource mobilization, QA, material and equipment management, financial management, human resource management, community participation, and legal/ethical aspects of hospital management; e) assess the financial resources available, their utilization and constraints in use of resources; f) understand existing monitoring systems for reviewing the performance of RKS at the state and district levels; and g) elicit opinions from different stakeholders on how to improve the functioning of RKS. The study recommended that there was a need for orientation and further capacity building on the use of guidelines, need to develop mechanisms for representation and active participation of all members, ensure proper documentation of meetings and decisions taken for accountability, focus on patient welfare besides facility upgradation, develop yearly financial planning and disbursement schedule, community reporting of RKS activities which was important and develop a grievance redressal mechanism. The state has used these recommendations to strengthen the RKS in UP (ITAP, 2008). Recognizing the potential of RKS as a decentralized, local autonomous society with community involvement and accountability, the IFPS Project has provided support through the above activities. However, there is a need to provide further inputs in both Uttarakhand and UP so that these societies emerge as a strong institution base at the community level. Technical Support for Implementation of NRHM in Uttarakhand and Uttar Pradesh 17
  29. 29. Chapter 6 SUSTAINABLE INSTITUTIONS TO BRING HEALTH CLOSER TO THE PEOPLE I ASHA should be in place for 1000 population. The ASHA program was designed to facilitate access to health services, mobilize communities to adopt positive health seeking behaviors, and provide community level care for a number of health priorities where such intervention could save lives and improve health. This includes counseling on improved health practices, and prevention of illness and complications, and appropriate curative care or referrals in pregnant women, newborn babies, and young children as also for malaria, tuberculosis and other conditions that are location specific. According to the NRHM guidelines, one The program made significant contributions to expanding access to healthcare in rural communities across India. However, ASHAs in Uttarakhand faced challenges in providing uniform services to the population due to the state’s hilly terrain with small and scattered settlements covering a large geographical area. The program needed to be modified and tailored to the special context of Uttarakhand to maximize impact. The GoUK asked the IFPS Project to design a pilot project to improve the effectiveness of the ASHA program. After several consultations with the stakeholders at the state, district and block levels and assessing local conditions, the IFPS Project designed the ASHA Plus program. The program piloted by UKHFWS for two years (2007-09), introduced flexible population coverage for the ASHA Plus workers and rendered remuneration for an increased number of services. The program was implemented under a PPP mechanism, engaging NGOs to lead the selection, training, mentoring and support of the ASHA Plus workers. Training was one of the most n 2005, the GoI introduced a new cadre of community health workers known as accredited social health activists (ASHAs), at the community level as an architectural reform to health systems. With an objective to strengthen the community process, introduction of ASHAs was one of the many programs initiated by NRHM. These programs included Village Health and Sanitation Committee (VHSC), RKS at CHC, PHC and district hospital levels, use of untied funds at all levels, community monitoring program, and district and state health societies (Planning Commission, 2012). 18 Capacity Building of Institutions in the Health Sector 18 Capacity Building of Institutions in the Health Sector important aspects of the program and ASHA Plus workers were trained to facilitate IPC with target groups, usage of micro planning tools and MIS. The IFPS Project provided support for selection of project intervention areas, NGOs and supported the NGOs’ activities. The IFPS Project used the GoI training modules to develop more interactive training material for ASHAs along with job aids, provided technical assistance for training of ASHA Plus workers and was involved in monitoring and review of the program. 6.1 SUPPORT FOR CREATION OF STATE ASHA RESOURCE CENTER AND DISTRICT ASHA RESOURCE CENTERS Learning from the pilot’s success, the GoUK, in an effort to replicate the NGO model of support and mentoring for ASHAs, introduced an ASHA Support System, reaching from the village to the state level. To facilitate this State ASHA Resource Center (SARC), State ASHA Mentoring Group and District ASHA Resource Centers (DARCs) were established in 2008-09 with support from the IFPS Project. The SARC is the technical agency that provides inputs and supportive mechanisms
  30. 30. to the ASHAs under NRHM at the state level, while DARCs provide technical support and are responsible for mentoring and training the ASHAs. Looking at the improvement in health indicators in the ASHA Plus intervention blocks, the state government was encouraged to scale up the program across six districts and accordingly strengthened the SARC and DARCs in those districts. The centers were strengthened in the form of additional human resource support and further by building their capacities. Technical inputs for scale up were provided by the IFPS Project. According to the GoI guidelines, the SARC in Uttarakhand was initially staffed by two people, a project manager and a data assistant. As part of program scale-up, this team was further strengthened by hiring two regional coordinators for Garhwal and Kumaon regions. The main responsibility of these regional managers is to support the district managers in strengthening the district centers. ASHA workers undergo orientation training at the District ASHA Resource Center At the district level, GoI accredited mother NGOs (MNGOs) were selected to serve as DARCs, following the model of the NGOs that had managed the ASHA Plus program at the block level during the pilot. The IFPS Project supported UKHFWS in the development and FIGURE 2: STATE ASHA SUPPORT SYSTEM State Health Department State Nodal Officer Program Manager State ASHA Resource Center Regional Coordinators Community Mobilizer (DARC) Data Assistant design of a training curriculum, training needs assessment and training of SARC and DARCs. The training curriculum was designed for institutional strengthening of the SARC and DARCs. The training needs assessment was conducted to determine the technical and managerial skills, and training requirements of the SARC and DARCs staff. Based on the identified gaps, the IFPS Project contributed in development of a training plan for the staff, with clearly defined indicators for measuring training effectiveness along with a monitoring plan. The training modules developed to aid training were pre-tested. Institutional strengthening for this program was a collective effort to train all stakeholders involved with the ASHA program, whether from the government or from the NGOs. Sustainable Institutions to Bring Health Closer to the People 19
  31. 31. Chapter 7 SETTING UP MECHANISMS FOR QUALITY ASSURANCE I ncreased emphasis under NRHM/ RCH-II on quality of care in the RH field paved the way for strategizing, defining criteria and developing methodologies to assess and improve the quality of health services in the existing public health system. The RCH II Monitoring and Evaluation (M & E) framework advocates for a subsystem approach of which QA is one of the key sub-elements among others. The IFPS Project aligned itself to the NRHM/RCH-II framework and supported GoI to design strategies and establish procedures that adequately assess and improve quality. Quality assurance mechanisms were designed and tested in UP, Uttarakhand and Jharkhand in collaboration with the state governments and state societies. Several guidelines and mechanisms were developed as part of the PPP models designed and implemented through the IFPS Project, in order to ensure quality of care and service provision. 7.1 QUALITY ASSURANCE MECHANISMS AND PROGRAMS In June 2002, the IFPS Project along with the GoUP supported the initiation of a pilot project with the aim of establishing systems to address issues related to quality improvement. The pilot was launched in Sitapur and Saharanpur districts of UP, with a total of 18 sites covering one women’s hospital, seven CHCs and 10 PHCs. During the course of implementation, a checklist was developed which scored sites on 100 quality indicators from infrastructure, staffing, client management to IEC and MIS. At the district level, a two-day workshop was held for orientation of District Medical Officers who supervise all health facilities in the district. Besides, one day workshops were held at each of the selected sites where district and site supervisors were trained in Client Oriented and Provider Efficient (COPE) techniques and facilitative supervision skills. COPE techniques helped the supervisors in problem identification, developing action plans, and results orientation. As part of the program, the IFPS Project supported the formation of QI circles at each site. The QI circles included members representing all levels in staff hierarchy and were assigned oversight responsibility for key aspects of quality. One of the motivating factors of the program was that the sites scoring 90 points and above on all four quarterly assessments were given quality certificates. Top five scoring sites were rewarded with flexible 20 Capacity Building of Institutions in the Health Sector funds of Rs. 200,000 (~ USD 4,545) for use in QI activities. The IFPS Project piloted QA programs in two districts of UP (Bareilly and Gorakhpur, 200708), one district of Uttarakhand (Dehradun, 2007) and two districts of Jharkhand (Palamu and Pakur, 2008-09). Some of the key components of the project design which are now established as key resources for the states include the following:  QA methodology: MoHFW along with several development partners designed the methodology to assess and address gaps in health services at all levels of the public health facilities. Using the QA checklists, four quality assessments were carried out, quarterly or bi-annually at the pilot sites in all three project states. The facilities were assessed using the QA checklist (refer below) and voluntary exit interviews with clients. Action plans for the program were designed according to the assessment results analyzed at monthly DQAG (refer below) meetings.
  32. 32.    QA Checklist: Quality of care was measured on nine criterions, including five generic (service environment, client provider interaction, informed decision making, integration of services and women’s participation) and four service specific (access to services, equipment and supplies, professional standards and technical competence and continuity of care). Six specific checklists were developed for CHCs/PHCs, subcenters and RCH camps. These checklists form the basis for the quality assessment of facilities. These checklists list critical indicators of service quality, such as facilities and equipment/ supplies for RCH services and client satisfaction QA Training Manual: GoI along with development partners also developed a training manual based on the pilot and other experiences from the COPE approach and QI project in UP. The manual was developed to standardize the process across districts on assessment visits and feedback mechanism at CHCs/ PHCs, sub-centers and RCH camps. DQAGs and Quality Improvement Committees: DQAGs were established in the pilot districts to manage the implementation of QA. Each group constituted 6-8 members including state and district health mission officers. The members of the DQAGs were responsible for conducting the QA assessments and ensure implementation of the QI activities. Also, as part of the program, QI committees were established at each facility to manage and implement the  QA activities in the facility based on the recommendations of the QA assessment.. In terms of supervision and coordination between the DQAG and QA team, and state and district health missions, a State QA Nodal Officer and QA Nodal Officer were appointed. Capacity Building: Trainings and orientation workshops were a key component of the IFPS Project, to set up QA as a system within the public health framework. Stakeholders from various districts (MS/MOs-IC from PHCs and CHCs) and DQAG members were oriented to QA and trained to implement the program through various multi-day workshops. Trainings and orientation workshops on a variety of subjects under QA including orientation towards roles of key players, emergency preparedness, infection prevention, biomedical waste management, usage of QA instruments and tools, usage of assessment forms based on checklists, development and implementation of action plans, and specifically for DQAG members, orientation on development of QI Committees at each site. Following the success of the pilot projects, the QA activities in Uttarakhand were scaled up in six districts in 2008-09 and an additional six districts in 2009-10. The GoUK has now scaled up the activities to all 13 districts. Through the course of implementation of these projects, USAID has been able to support institutionalization of QA in these states. Some of the key systems and mechanisms put in place as part of these pilot programs are resourceful assets to improve quality of services, for these states today. These include, the State QA Cell, DQAGs established at district levels, trained health officials, a better equipped SHSRC or State level QA Cell to conduct further trainings, and mobilized health facilities trained on infection prevention practices, emergency preparedness and biomedical waste management. 7.2 QUALITY ASSURANCE FOR PPP MODELS Sambhav Voucher Schemes in UP, Uttarakhand and Jharkhand As part of the PPP models designed and implemented under the IFPS Project, Sambhav Voucher Schemes were piloted in all three states (Uttarakhand, Jharkhand and Uttar Pradesh) from 2006-2012.The voucher schemes were mandated to provide high-quality RH services to the poor. Several quality assurance and quality improvement mechanisms formed part of the design and implementation of the Voucher Schemes. Provider accreditation was one of the processes established as part of these voucher schemes. This process set standards for private providers to be eligible to participate in the scheme and served as a means for monitoring quality over time. During the initial pilot design in Agra, the Sarojini Naidu. Medical College (SNMC)—with inputs from the IFPS Project — played an important role in adapting accreditation guidelines based on National Accreditation Board for Hospitals and Health Care Providers (NABH) standards and evaluating providers against Setting up Mechanisms for Quality Assurance 21
  33. 33. the criteria. These guidelines and a methodology for conducting clinical audits were finalized in Agra. Building on these early efforts, the IFPS Project assisted partners to adapt and apply the standards, training, and monitoring materials in the other pilot sites. Accreditation was undertaken by SNMC in Agra and experts from Chhatrapati Shahuji Maharaj Medical University (Lucknow) for Kanpur Nagar. In Haridwar, the DQAG conducted the accreditation visits (ITAP, 2012 b). Medical audits of private nursing homes/hospitals helped ensure accountability for maintaining quality standards. The IFPS Project designed tools for the audits that assessed delivery of clinical services against the standards outlined in the accreditation criteria and protocols for each service. The audit teams comprised medical specialists, such as gynecologists and pediatricians, public health and community medicine specialists, and representatives from the IFPS Project. At periodic intervals, the audit teams investigated a sample of cases at each facility, considering the completeness of patient records, types of tests and services provided, adherence to national standards and guidelines, the nature of complications and how they were managed, and the impact on health outcomes (e.g., maternal and neonatal deaths averted), among others. The assessment team shared feedback with facilities for corrective action, and those that could not maintain accreditation standards were discontinued from the voucher program (ITAP, 2012 b). The IFPS Project was able to revive the DQAGs to accredit and monitor the services provided by the private providers. These DQAG teams have been trained on checklists for accreditation and medical audit. The capacities of the DQAGs have been built such that they can now conduct accreditation and medical audits for the health facilities in the state independently. The IFPS Project has been able to 22 Capacity Building of Institutions in the Health Sector contribute to the development of guidelines, checklists, and conduct audits and client satisfaction surveys by effectively involving the state systems. Societies, their corresponding voucher management units as well as implementing partners have been leading the process of conducting these studies and audits. As a result, the state systems are now well equipped with these QA mechanisms, to independently conduct these audits and surveys. Social franchising, one of the other PPP models initiated by the IFPS Project in UP from 2007-2012, was a unique partnership with the private health sector and was developed as a sustainable model to provide health services in rural areas. The social franchising network developed, managed and sustained by Hindustan Latex Family Planning Promotion Trust (HLFPPT) (the Franchisor) was branded as the Merrygold Health Network (MGHN). This network consisted of 67 Level 1 franchisees(Merrygold) at district level. While Level 2 comprised of 367 fractional franchisees (Merrysilver) established at sub-district or block level, Level 3 (Merrytarang) comprised of 10,000 community-based providers like ANMs, ASHAs and AYUSH, and acted as a first point of contact with the community as also referral support to Merrysilver and Merrygold facilities.The key to any healthcare services’ delivery model lies in ensuring consistency of quality services delivered by the network. Over a period of four years, MGHN has standardized the key components of the franchise system that may be implemented and operated successfully by trained personnel. To set systems for quality assurance under MGHN,
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