Capacity building of_health_institutions

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TATES AG
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USAID

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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.

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

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.

IN TE

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USAID INDIA

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FOREWORD
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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

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

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

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

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

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

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


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

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

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

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


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

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

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


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

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


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)

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

Lucknow, UP 2008

levels

5 days

44

5

Nainital, Uttarakhand 2010

levels

5 days

27

6

Ajmer, Rajasthan

levels

5 days

17

2011

Duration

Number of
participants

7

Uttarakhand 2011

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


7

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.


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

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.


9

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

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

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


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

Officers

12 days

Jan 10-22, 2011

IEC Experiences in FP Program
Communication - Definition and
Processes

7

Foundation
Course of BHEOs

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

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

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.


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



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

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


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

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).


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

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

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


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.







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

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


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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