SDHS_PROJECT_FINAL_REPORT-FOR PUBLICATION

Indian Institute of Health Management Research, Jaipur
Strengthening District Health System in Madhya Pradesh through Management Interventions
STRENGTHENING DISTRICT HEALTH SYSTEM:
EXPERIENCE FROM HOSHANGABAD DISTRICT,
MADHYA PRADESH, INDIA
Prepared by
Indian Institute of Health Management Research
1
STRENGTHENING DISTRICT HEALTH SYSTEM IN
HOSHANGABAD DISTRICT, MADHYA PRADESH
EXPERIENCES FROM IMPLEMENTATION
Prepared
By
Indian Institute of Health Management Research
Jaipur

PROJECT TEAM
S. D. Gupta, Team Leader
P. C. Dash, Project Coordinator, SDHS
T. P. Sharma, Project Advisor
Research Officers
Rohini Jinsiwale
Hemant Kumar Mishra
2

FORWARD
3

PREFACE
4

LIST OF ABBREVIATIONS
ASO Assistant Statistical Officer
AIDS Acquired Immuno Deficiency Syndrome
ANC Ante Natal Care
ANM Auxiliary Nurse Midwives
ARI Acute Respiratory Infection
AWW Angana Wadi Worker
BEE Block Extension Educator
BHT Block Health Team
BMO Block Medical Officer
BPHC Block Primary Health Center
CEO Chief Executive Officer
CH Civil Hospital
CHC Community Health Center
CIDA Canadian International Development Agency
CMHO Chief Medical and Health Officer
CMO Chief Medical Officer
CNAA Community Needs Assessment
CPT Core Project Team
CSSM Child Survival and Safe Motherhood
DA Dearness Allowance
DANIDA Danish International Development Agency
DH District Hospital
DHS District Health Systems
DHT District Health Team
DIC District Implementation Committee
DIO District Immunization Officer
DPC District Planning Committee
DTC District Training Center
EC Eligible Couple
ELA Expected Level of Achievement
EOC Emergency Obstetrics Care
FEFO First Expiry First Out
FIFO First In First Out
FINNIDA Finnish International Development Agency
FP Family Planning
FRU First Referral Units
GDI Gender Related Development Index
GSK Gramin Swasthya Kendra
GSKK Gramin Swasthya Kalyan Kendra
HIS Health Information System
HRD Human Resources Development
IDRC International Development Research Center
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IFA Iron and Folic Acid
IIHMR Indian Institute of Health Management Research
IPD Inpatient Department
IUD Intra Uterine Device
JICA Japanese International Corporation Agency
JSR Jana Swasthya Rakshya
LFA Logical Frame of the Activities
LHV Lady Health Visitor
LILO Last In Last Out
LTF Logistics Task Force
MCH Maternal and Child Health
MIS Management of Information System
MO Medical Officer
MP Madhya Pradesh
MPW Multi Purpose Workers
NGO Non Governmental Organisation
NORAD Narwegian Agency for International Development
ODA Overseas Development Administration
OPD Out Patient Department
ORS Oral Rehydration Salt
ORT Oral Rehydration Therapy
PAC Project Advisory Committee
PHC Primary Health Center
PNC Post Natal Care
PP Post Partum
PRI Panchayati Raj Institutions
QA Quality Assurance
RCH Reproductive and Child Health
RDE Royal Danish Embassy
RKS Rogi Kalyan Samittee
RO Research Officer
RRT Resident Research Team
RTI Reproductive Tract Infection
SAO Senior Accounts Officer
SC Sub Center
SC Scheduled Caste
SDHS Strengthening District Health Systems
SHC Sub Health Center
SHCT Sub Health Center Team
SIDA Swedish International Development Authority
ST Scheduled Tribe
STD Sexually Transmitted Disease
STI Sexually Transmitted Infection
TA Traveling Allowance
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TB Tuberculosis
TCR Target Couple Register
TOR Terms of Reference
TT Tetanus Toxide
USSR United Soviet Socialist Republic
VED Vital Essential and Desirable
VHC Village Health Center
VHT Village Health Team
WHO World Health Organisation
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LIST OF TABLES
Tables Page
3.1: Administrative units and towns in Hoshangabad district
3.2: Socio demographic profile of Hoshangabad district
3.3: Agricultural production in Hoshangabad
3.4. Block wise distribution of number of CHCs, PHCs and SHCs in Hoshangabad
3.5. Manpower availability in Hoshangabad district
3.6. Utilization of various services provided by the government run health
facilities in Hoshangabad district
3.7. Value of various performance indicators (block wise and other hospitals) in
Hoshangabad district
5.1: Status and source of finance for drug store renovation at block level
5.2: Outcome at a glance
5.3: Status of drug stores as per the feedback received during follow up workshop
5.4: Roster of supply from district to block
5.5: Major findings of rapid assessment
6.1: Outcome of the intervention at a glance
6.2: Number of respondents received training (by source) before the project
6.3: Reports prepared by the health workers
6.4: Accuracy Checking of data before submission
6.5: Type of improvement observed by the health workers
7.1: Summary of contribution from PRIs/NGOs, Community and indirect cost of
supervision for SHC renovation
7.2: Summary of contribution from project for SHC renovation
7.3: Achievements on sub center renovation
7.4: Status of village health centers in the district
7.5: Name of the villages where GSKK established and amount deposited
7.6: Role of the respondents (who told yes) for their role in renovation
process
7.7: Reasons for visiting the sub-center during the reference period
7.8: Amount contributed by the respondents for GSKK
7.9: Types of services the respondents would like to avail from GSKK
8.1: Profile of Panchayati Raj Institutions in Hoshangabad District
8.2: Status of PRIs in Pipariya Block
8.3: Socio-demographic Profile of Pipariya Block and Hoshangabad District
8.4: Performance at a glance
8.5: Age wise classification of respondents
8.6: Position of the respondents in the present Panchayat
8.7: Perception of the respondents regarding the changes observed after the
intervention related to PRI in Health Sector by SDHS Project team
9.1: Achievements at a glance
9.2: Work experience in Health Department
9.3: Use of the provided checklist by category
9.4: Duration of use of checklist
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9.5: Acceptance and use of checklists by years of experience
9.6: Number of clients served before and after the use of checklist
9.7: Antenatal services and improvements in services delivery
9.8: Status of intra natal services before and after the intervention
9.9: Status of PNC services before and after the intervention
9.10: Status of Immunization services before and after the intervention
9.11: Status of ARI services before and after the intervention
9.12: Status of Diarrhea services before and after the intervention
9.13: Status of FP services (Oral Pills) before and after intervention
9.14: Status of Family Planning services (IUD) before and after intervention
9.15: Distribution of sample households on the basis of services received from the
ANMs.
9.16: Services ever received
9.17: Clients’ perception on improvement of services delivery after intervention
9.18: Type of changes observed
9.19: Satisfaction of clients on the service delivery of ANMs
9.20: Clients communicated observed changes to others
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LIST OF ANNEXURES
Annexure Page
2.1: Terms of Reference for DHT
2.2: TOR for Block Health Teams (BHT)
2.3: Guidelines for DHT and BHT meetings
2.4: TOR for Sub Health Center Team (SHCT)
2.5: TOR for Village Health Team
4.1: Proceeding of Sector Level Training Programs
4.2: Guidelines for Decentralized Planning
4.3: Guidelines for Monitoring and Supervision of Planned Activities
5.1: Proceeding of the Management Training Program for DHT and BHT
5.2: Proceeding of the Management Training Program for Store Keepers
5.3: Follow- up Training of Compounder/ Store Keeper
5.4: Logistics Task Force
5.5: Proceedings of the Meeting with Logistics Task Force
5.6: List of Essential Drugs for SHC
6.1: Training on Form 6 Imparted to the Health Workers at Block Level
6.2: The Efforts of the Project Team and Impact on HIS
6.3: Impact of Introduction of Village wise information format: Example of
Babadiya Bhau Sector of Seoni Malwa Block
6.4: Terms of Reference (TOR) of MIS Task Force
7.1: TOR for Sub Health Centers Team
7.2: TOR fro Village Health Center (VHC)
7.3: TOR for Village Health Team (VHT) and GSKK
7.4: Panch Sarpanch Checklist
7.5: Work Plan
7.6: Contribution of PRIs and Communication for Sub Center Renovation
7.7: Status of Sub Centers Renovation in different Blocks
7.8: Status of the Village Health Centers in different Blocks
8.1: TOR for Gramin Swasthya Kalyan Team and Gramin Swasthya
Kalyan Kosh
8.2: TOR for Gramin Swasthya Kendra
8.3: PRI Checklist
8.4: TOR for Sub Health Center Team
8.5: Terms of Reference (TOR) for Health Camp
9.1: Quality Check Lists
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CONTENTS
Forward
Preface
List of abbreviations
List of tables
List of Annexure
Page
CHAPTER 1: INTRODUCTION TO THE PROJECT
1.1. Background
1.2. Defining District Health System
1.3. Districts in India
1.4. Problems in District Health System: Indian Scenario
1.5. Strengthening DHS in Hoshangabad
1.6. Critical Management Areas
1.7. Objectives of the Project
1.8. Organisation of the report
CHAPTER 2: ORGANIZATIONAL SETUP
2.1. Background
2.2. State Level
2.3. District Level
2.4. Project Level
2.5. Organizational Set-up as per Projects Requirement
2.6. Lessons Learnt
2.7. Conclusion
CHAPTER 3: HOSHANGABAD DISTRICT: A PROFILE
3.1. Background
3.2. Profile of the District
3.2.1. General Profile
3.2.2. Socio Demographic Profile
3.2.3. Socio Economic Profile
3.2.4. Health Scenario
3.2.5. Health Care Delivery System
3.2.6. Health Manpower Position
3.2.7. Utilization of Health Services
3.3. Conclusion
CHAPTER 4: DECENTRALIZED HEALTH PLANNING
4.1. Background
4.2. Objectives
4.3. Planning Process- Problems and Issues
4.3.1. Backward of planning
4.4. Interventions
4.5. Outcomes
4.6. Lessons Learnt and Sustainability
4.7. Conclusions
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CHAPTER 5: LOGISTICS MANAGEMENT: IMPROVING MANAGEMENT OF
DRUG STORES
5.1. Background
5.2. Objectives
5.3. Diagnostic Study- Problems and Issues
5.4. Interventions
5.5. Outcomes
5.6. Post Intervention Assessment
5.7. Lessons Learnt
5.7.1. Sustainability
5.8. Conclusion
CHAPTER 6: IMPROVING MANAGEMENT OF HEALTH INFORMATION
SYSTEM (HIS)
6.1.Background
6.2.Objectives
6.3.HIS in the District
6.3.1. Data Generation and Recording Mechanism
6.3.2. Reporting Mechanism
6.3.3. Data Flow Mechanism
6.3.4. Feedback Mechanism
6.4.Diagnostic Study- Problems and Issues
6.5.Interventions
6.6.Outcomes
6.6.1. Analysis of achievements through secondary data
6.7.Post Intervention Assessment
6.7.1.Salient findings
6.8.Lessons Learnt
6.8.1.Sustainability
6.9.Conclusion
CHAPTER 7:COMMUNITY FINANCING: RENOVATION OF SUB HEALTH
CENTERS FOR ENHANCING ACCESSIBILITY AND
UTILIZATION
OF HEALTH SERVICES
7.1. Background
7.2. Objectives
7.3. Diagnostic Studies- Problems and Issues
7.4. Interventions
7.5. Implementation Process
7.6. Financing Mechanism
7.7. Outcomes
7.8.1.Salient Findings
7.9. Lessons Learnt
7.9.1. Sustainability
7.10. Conclusion
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CHAPTER 8: PANCHAYATI RAJ INSTITUTIONS: ENHANCING
PARTICIPATION
IN PRIMARY HEALTH CARE
8.1. Background
8.2. Present PRI Structure
8.3. Diagnostic Study: Problems and Issues
8.4. Interventions
8.5. Implementation
8.5.1. About the Block: Pipariya
8.6. Replicability in Other Blocks
8.7. Outcomes
8.10. Conclusion
CHAPTER 9: QUALITY ASSURANCE INTERVENTION
9.1. Background
9.2. Objectives
9.3. Diagnostic Studies: Problems and Issues
9.4. Interventions
9.5. Outcomes
9.6.1. Methodology and Sampling
9.6.2. Salient Findings
9.6.2a.Services Providers Prospective
9.6.2b.Clients Prospective on Quality Change
9.8. Conclusion
CHAPTER 10: CONCLUSION AND FUTURE DIRECTIONS
BIBLIOGRAPHY
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CHAPTER 1
INTRODUCTION TO THE PROJECT
1.1. BACKGROUND
The main focus of the World Health Organisation (WHO) is the attainment by all peoples
of the highest possible level of health, as it is one of the fundamental rights of every
human being. After finding out the alarming health situation of its member countries in
1977, the World Health Assembly passed a resolution stating that the main social target
of governments and of WHO in the coming decades would aim at attainment of all the
people of the world by the year 2000 a level of health that would permit them to lead a
socially and economically productive life. This was followed by Alma Ata declaration of
Health For All by the year 2000, which was held in the former USSR. India is a signatory
to this declaration.
After the declaration, many countries worked in the direction to achieve the targets. It
was really disappointing to note that most of the attempts to achieve the target of health
for all resulted in changes at national level e.g., the development of policy, management
capability, training etc., or at the local level, in the organisation of community action,
training and utilization of health workers. It was recognized that weakness in national
efforts to pursue the goal of health for all has mostly been due to the problems of
organisation and management at the district level, as well as lack of adoptability to
change and the changes faced by Ministries of health at policy level. This approach
resulted in potential reduction in the realization of benefits at grass root level.
In view of the above situation, during May 1986, the World Health Assembly further
reviewed the health situation and found that, while in some countries substantial progress
have been made in strengthening health infrastructure and in coverage by health services,
in majority of them there had been a diffuse expansion of health infrastructure resulting
in frightening managerial and financial problems in trying to provide for even minimum
elements of primary health care. The planning and management of primary health care
programmes were still carried out at the central level with little understanding of the
problems and constraints at community level. India was not an exception to it.
The above-mentioned issues associated with the resource constraints which different
countries were facing due to financial crisis, gave birth to the concept of “District Health
System”. In May 1986, the World Health Assembly passed a resolution in which it urged
its countries to further strengthen the health system infrastructure based on primary health
care, focusing on manageable units – i.e., geographical areas small enough to permit
effective and efficient management, yet large enough to make it feasible to include all the
ingredients required for self-reliant health care. These organizational units were called
districts. On the basis of above considerations the WHO’s division of Strengthening of
Health Services initiated its districts health systems program.
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1.2. DEFINING DISTRICT HEALTH SYSTEM (DHS)
In order to facilitate a common understanding the WHO Global Programme Committee
in 1986 defined the district health system based on primary health care as “a self
contained segment of the national health system comprised of well defined population
living within a clearly delineated administrative and geographical area, whether urban or
rural. It includes all the institutions and individuals providing health care in the
district….A district health system therefore consists of a large variety of interrelated
elements that contribute to health in homes, schools, work places and communities,
through the health and other related sectors. It includes self-care and all health care
workers and facilities, up to and including the hospitals at the first referral level and
appropriate laboratory, other diagnostic, and logistics support services. Its component
elements need to be well coordinated by an officer assigned to this function in order to
draw together all these elements and institutions into a fully comprehensive range of
promotive, preventive, curative and rehabilitative health activities” (WHO, 1995)
It was widely believed that the district, which is the peripheral organizational unit of
national health systems, is particularly suitable as a channel for services to communities
as it helps in:
• Coordinating top-down and bottom-up planning
• Organizing community involvement in planning and implementation
• Improving coordination of government and Private health care.
• Bringing communities together for solving the problems at their own level
Thus the concept of district health system is not a new idea as decentralization and
central control have long been important political and organizational strategies. The
management of health services for well-defined geographical areas from regional or
district centers has been a common feature of most health systems in developed and
underdeveloped countries. Yet, it is precisely in this area of organisation and
management at the district level that many countries are weak.
1.3. DISTRICTS IN INDIA
For the purpose of understanding and analytical convenience, we have divided a typical
district in India into three setups:
(a) Administrative set up
Administratively, the district is divided into several segments (blocks / Tahsils / sub
divisions). District Collector, who is usually a civil servant, heads the district and looks
after overall developmental activities in the district. Similar kind of activities at block /
sub division level are carried out by Block Development Officers / Sub divisional
Magistrates. Though the health officials are not directly responsible to these
administrative authorities, they are indirectly linked and accountable to district or
block/sub divisional administration as health is one component of development.
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(b) PRI set up
After the initiation of decentralization process, the Panchayati Raj set up in the district
plays a key role in carrying out various developmental activities in the district. The
Panchayat Raj bodies execute most of the developmental activities at village level. Under
this set up the District Panchayat (Zilla Panchayat) is headed by Chief Executive Officer
(CEO) who is a senior state level officer or a Junior level officer selected through Indian
Administrative Services. The organisation below the district level is similar to
administrative set up; with the block level Panchayats (known as Janpad Panchayats)
being managed by Chief Executive Officers. The Janpad Panchayats are responsible for
managing the activities at village level. Sarpanch carries out developmental activities at
village level1
.
(c) Health care set up
In India, for administrative convenience, the country is divided in to several states and
each state is divided into several districts. At the country level, the central health ministry
is responsible for looking after the matters related to health sector. In Indian context
Health being a state subject, majority of decisions are taken at the state level. However,
the decisions at state or central level are mostly related to changes in policy and resources
allocation. The health ministry at central as well as state level is assisted by number of
Civil Servants, who are usually senior level beaurocrats. However, the ministries are not
directly responsible for implementation of the activities related to health sector. Chief
Medical and Health Officer (CMHO), who is usually a senior doctor, manage the health
care activities at the district level. The CMHO is assisted by a number of program
officers to implement the health programs in the district. The allocation of resources for
the health sector is usually made at the state level. Therefore, the CHMO has no or little
control over this. Further, for the implementation of health programs, the district is
divided into several blocks with the Block Medical Officer being in overall in charge of
blocks for carrying out health care activities. A block is divided into several Primary
Health Centers / Sectors (the nomenclature varies from state to state and within districts).
In an ideal situation, the Primary Health Centers should be equipped with necessary
infrastructure required for primary health care. Each PHC is divided into number of sub
centers where the health workers (male and Female) are posted for delivering the health
care at the village level. It is quite unfortunate that in most of the districts the health
infrastructure at PHC and sub center level is quite poor, thus affecting the delivery of
health care to a large extent.
To summarize, the health care set up in India is a multi tier system with the central
government at the apex and the sub centers at bottom. The implementation of all the
activities is carried out at the sub center, PHC and block level. The center and state deal
with the policy matters and make necessary arrangement for resources allocation. Thus,
the district, which lies between the apex (center and state) and bottom (block, PHC and
sub center) of the present set up, plays an important role in bringing coordination
between the policy and implementation. The whole system of managing the health
1
A single or a number villages (depending upon the size of the population)
constitute a Panchayat. The Sarpanch is a person who is elected by the village members.
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services primarily lies with the district health authorities and any mismanagement at this
level would lead to failure in health services delivery at the grass root level. It is at this
level where the management of health services is extremely poor.
1.4. PROBLEMS IN DISTRICT HEALTH SYSTEM: INDIAN SCENARIO
(a) Resource Allocation
As mentioned earlier, the district health authorities have little / no role to play in the
process of resources allocation. The resources are usually allocated from the center or the
state based on some pre defined criteria (i.e., population). Burden of diseases and socio
economic profile of the districts, which are vital for making decisions on resources
allocation, is not given due importance. This results in inequitable distribution of
available resources among the districts. Moreover, the level of autonomy for spending the
allocated resources (funds) is extremely low at the district level, as a major chunk of the
allocated resources constitutes the salary component. Majority of drugs and other
supplies are supplied from the state without any due consideration to the requirements of
the districts. The donations to the districts that are provided by nongovernmental
organizations and international agencies are mostly in kind. Given the present economic
scenario and privatization, there is a little scope for bringing any improvement in the
process of resources allocation.
(b) Organisation and Management
The health system in a district is organized as per the policy of the state or central
government (as mentioned in Section 1.2). Any external agency has a little role to play in
this regard.
As mentioned above, the district is an appropriate level for bringing coordination
between the policy and implementation level. Therefore, it is essential that the district
health system have a good management structure for effective implementation of primary
health care at the village level. Though policies for effective management have been
developed, the district health managers do not put adequate attention on them. This acts
as a major obstacle during implementation of health care programs framed at the policy
level. It is at the management level, where the interventions could be framed and
improvements in the district health system could be brought about. This forms the basis
of the present project.
1.5. STRENGTHENING DHS IN HOSHANGABAD
It is with this philosophy and background that the Indian Institute of Health Management
Research (IIHMR) submitted a proposal to Royal Danish Embassy (RDE), New Delhi to
undertake the task of Strengthening the District Health System through Management
Interventions in Madhya Pradesh” during June 2000. IIHMR being a WHO collaborating
center on District Health Systems, RDE agreed to fund this project and the agreement
between RDE and IIHMR was signed during July 2000. Initially it was proposed that
Guna district of Madhya Pradesh would be taken as the study area. Later on, the district
was changed because another organization "European Commission" was working in a
similar kind of project in Guna. In order to avoid the duplicity of the activities and misuse
of resources, IIHMR, in consultation with Royal Danish Embassy and Health Department
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of Madhya Pradesh changed the project area from Guna to Hoshangabad. However, the
selection of district was made with commonly agreed criterion:
• District should be compact, moderate in size and accessible thorough rail and bus.
• Population of district and geographical areas should be representative of the state
as such.
• District should have fairly well developed health infrastructure.
• The district health administration should be willing to strengthen its health
system.
The proposed project period was from July 2000 through December 2003.
1.6. CRITICAL MANAGEMENT AREAS
Since the introduction of WHO programme, a number of areas of critical importance for
the success of primary health care strategy at the district level have been identified and
addressed through various interventions.
1. Decentralized Planning: Planning has a key role to play in the management of
health services at district level, as it is the primary function before implementation
of any health programs. Unfortunately in most of the district health systems in
India the top down method is followed. The evidences from different countries
show that in most of the cases the plans are made at the top level and passed on to
the bottom. This results in wastage of financial as well as human resources. This
is an area where the managerial interventions could be designed and implemented
for rectifying deep-rooted old habit of planning process.
2. Health information system: The effective decentralization of planning and
decision-making is dependent upon a sound information base. The development
of a health information system at district level is therefore an important
component of activities aimed at improving management. The critical issues
related to information system include; the use of information already being
produced, the quality of available information, data collection and information
formats and procedures. Unfortunately, in most of the countries including India,
information system is not so well developed and the conclusions drawn from
information received are not fed back to the original source. Though the system of
data generation, dissemination and feedback mechanism already exists at the
district level, practically they are not used at all.
3. Logistics and supply management: Most of the district health systems face
frequent shortage of required Logistics and other supplies. The supply, storage
and distribution of drugs do not follow the prescribed norms. The policy makers
decide the supply of drugs and other consumables and the district health
authorities are given minimum autonomy in this regard. As a result, the district
health authorities take no interest in an appropriate procedure of procurement,
storage and distribution. Moreover, due to poor drug store management, the
wastage is found to be high at all levels of district health system.
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4. Management of human resources / Capacity Building: The development of
human resources and capacity building has its own role in the effective and
efficient delivery of quality health care. Despite its importance, no adequate
attention is paid by the district authorities to conduct training and orientation
programs at regular intervals. This has affected the efficiency as well as the
effectiveness of service delivery to a large extent. Though the district training
centers exist in almost all the districts, most of the district training centers
operates without an annual training calendar.
5. Community involvement in Health: Community involvement in health has
received widespread support and has been accepted as fundamental to health
development. As the clients of health services are from the communities, their
involvement in planning, financing and management of primary health care plays
a vital role in strengthening district health system. Despite numerous activities on
the subject during past one and half decade, wide spread and effective community
involvement is still a long way off and its overall development has been
extremely slow.
6. Quality Assurance: Quality assurance is a relatively new issue in the domain of
district health systems. So far it has been mostly confined to the most obvious
components in such systems, viz., hospital activities, though various meetings
have taken place under the auspices of WHO’s regional offices for South-East
Asia together with the District Health Systems unit of the Organization’s division
of Strengthening of Health Services for focusing the issue of quality assurance of
primary health care activities such as maternal and child health. In most of the
cases, the improvement in quality is understood as expansion of health
infrastructure rather than following the prescribed norms.
7. Intersectoral action: The establishment and functioning of effective, efficient
and equitable district health system, and the implementation of primary care
strategy itself, require the full participation of population and a wide range of
organizations and institutions. Given the present process of decentralization and
increased role of Panchayati Raj institutions, initiatives are to be taken for
involving these people for improving the health care delivery in the district.
Furthermore, the role of non-governmental organizations in the delivery of
primary health care could also not be ignored.
What was attempted in this project?
• As mentioned elsewhere in the document, it is not possible to allocate more
resources to the district health system as the decision regarding the same lies with
the policy makers. Therefore, the present project aimed at maximizing the health
benefits with available resources and did not attempt to fill up the resource gap in
the health system.
• Restructuring the present health care set up was almost impossible within the
limited period. Moreover, redefining the existing management structure and
getting acceptance of the same is almost an impossible task. Therefore, the project
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did not attempt to change the existing management structure, rather tried to
strengthen them with the necessary managerial inputs.
• Since the inception of the concept of district health systems, several International
Aid agencies i.e., Canadian International Development Agency (CIDA), Danish
International Development Agency (DANIDA), Finnish International
Development Agency (FINNIDA), International Development Research Center
(IDRC), Japanese International Corporation Agency (JICA), Narwegian Agency
for International Development (NORAD), Overseas Development Administration
(ODA), Swedish International Development Authority (SIDA) etc., have been
funding for selected interventions for strengthening the district health system in
different countries (WHO 1995). Under this project a comprehensive attempt was
made to address most of the major issues, which could possibly be solved through
management interventions.
To be more specific, the present project had the following objectives:
1.7. OBJECTIVES OF THE PROJECT
Developmental Objective
Managerial Capacity of the district health system developed so that efficiency and
effectiveness of primary health care delivery system is improved within existing
resources.
Immediate Objectives
• Mechanisms for problem identification and designing implementing solutions are
developed and established.
• Key management process e.g., Logistics and supply, Management of Information
System, Human Resource Management etc. are developed and implemented.
• Decentralized planning process and strategy development is established.
• Quality Assurance system is developed and established.
• Approaches to involve PRI’s, NGO’s, Private Sector and Community are
developed.
• Community Financing Mechanisms are tried out in selected areas.
Based on project objectives and activities a logical frame of the activity (LFA) was
submitted to funding agency. The project activities span over a period of three and half
years. Project activities were implemented in two phases. The first phase of the project
was devoted for establishing organizations at various levels for facilitating the project
activities, carrying out diagnostic studies and designing appropriate solutions to the
problems identified through these studies. The second phase, which started in the second
year of the project, was devoted for implementing the strategies and interventions
designed during the first phase.
1.8. ORGANIZATION OF THE REPORT
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The present report gives the details of the interventions carried out during the project
period relating to the management areas mentioned in the above paragraphs. The
organisation of the report is as follows:
The first chapter of the report gives a brief introduction about the project and its
objectives. Various organizations that were set up at state, district and implementing
agency level for facilitating the implementation of the project are described in Chapter 2.
Chapter 3 gives a brief profile of the project area i.e., Hoshangabad. Separate reports on
the problems, interventions and outcomes related to key management areas of the district
health system is presented from Chapter 4 on wards. Chapter 4 gives the details of the
report on Decentralized planning, Chapter 5 on Logistics Management, Chapter 6 on
Health Information System, Chapter 7 on community financing, Chapter 8 on role of
PRIs, and Chapter 9 on quality Assurance. The concluding remarks are given at the end
of the report.
21

CHAPTER 2
ORGANIZATIONAL SETUP
2.1. BACKGROUND
In a project, a group of people works together in a particular place to achieve the set
objectives within a limited time. Therefore a prime requirement of any project is to set up
organizations at appropriate levels, which would facilitate the project activities in order to
achieve the goals and objectives of the project in the stipulated time. Given the
importance of appropriate organizational setup, the project established organizations at
State, District, and implementing agency level for effective implementation of the
project.
2.2. STATE LEVEL
In order to assist the project team for the successful implementation of the project and
provide necessary guidelines, the Project Advisory Committee was constituted at state
level under the chairmanship of principal secretary health vide letter no-
3326/3840/2000/2 dated 10th
October 2000. The PAC reviewed the progress of the
project and guided implementation process of the proposed activities
2.3. DISTRICT LEVEL
A similar type of committee named District Implementation Committee (DIC) was
formed at the district level under the chairmanship of District Collector. The order of the
same was issued by District Collector on 22nd
December 2001. The major function of
DIC was to monitor and guide the implementation process of the project.
2.4. PROJECT LEVEL
(a) Core Project Team (CPT)
A team consisting of specialists on different areas was constituted at the Head Office of
the Implementing agency (i.e., Indian Institute of Health Management Research), which
is located at Jaipur. The director of the head office was the team leader. As the team
leader is a busy person, the overall activities of the resident research team were assigned
to a senior professor at IIHMR, designated as Project Coordinator, M.P. The following
responsibilities were assigned to the core project team:
• Visiting the field area at regular intervals for monitoring the activities of RRT
• Assisting the project team for keeping coordination with the state level officials
• Making necessary arrangements for PAC meetings at regular intervals
• As the funding agency was directly releasing the funds to the head office, the CPT
was responsible for allocating the necessary funds for carrying out the activities at
field level.
22

• Acting as resource persons for various training programs organized at state,
district and block level.
The progress of the project as well as implementation activities were closely monitored
by the CPT through their frequent visits to the field and meetings with project staff
employed for carrying out implementation activities in the field.
(b) Resident research team (RRT)
For day-to-day operation of the project, project offices equipped with necessary research,
administrative and other supportive staff and necessary logistics were opened at two
places, one at State Capital (Bhopal) and another at the field area (Hoshangabad). The
project office at Bhopal was opened to keep close contacts with the state level officials
and seek their necessary support for the successful implementation of the project. The
office at Hoshangabad was opened to carryout the project activities in the field with the
collaboration of district health authorities. The overall charge of these two offices was
given to project coordinator appointed by the Core Project Team (CPT). All the research
staffs were posted at Hoshangabad for carrying out field activities on a day-to-day basis.
The research staff carried out their activities in their respective areas allocated by the
project coordinator.
The activities of the project staff was closely monitored by the project coordinator on a
weekly basis through their weekly progress report submitted to the project coordinator. In
addition regular monthly meetings of all the project staff were held at the project office
Hoshangabad with all the project staff participating in the meeting. During the monthly
meetings of RRT discussions regarding the difficulties faced at the field and initiation of
the new activities, which could be carried out during the Project period, were discussed.
In addition the RRT was also submitted future activity plan (on monthly basis) to the
project coordinator.
2.5. ORGANIZATION SET-UP AS PER PROJECT'S REQUIREMENT
In order to assess the progress a detailed mid-term review of the project was carried out
by an independent consultant (Dr. T. P. Sharma, Retired Director of Health Services
Government of Madhya Pradesh and Ex-DANIDA Advisor) to identify the areas of
improvement in the operational management of the project. The project was reviewed
based on the proposed Log-frame. As per the review, the organizations, which were set
up at, state (i.e., PAC) and district (DIC) were almost non functional and the involvement
of district health functionaries was minimal. As the desired support from the state as well
as district level committees were lacking, the review suggested to setup organizations at
district, block, sub center and village level with active involvement of the health
functionaries at all levels. In addition, the review also suggested the involvement of
Panchayati Raj Institutions and NGOs in the committees. Accordingly following
committees were formed at various levels for effective project implementation.
(a) District Health Team (DHT) Block Health Teams (BHT)
District Health Team and Block Health Teams were formed to review the performance
and facilitate the implementation of the project at the district and block level respectively.
Chief Medical and Health Officer of the district was given the responsibility of heading
district level team and the responsibility of heading the block level teams was delegated
23

to respective block medical officers. The official letters regarding the formation of teams
were issued on 30th
January 2003 vide office order number SN/ASO/03-1123 (for DHT)
and SN/ASO/03-1124 (For BHT). (Annexure –2.1 and 2.2)
The formation of these health teams was expected to provide necessary impetus to the
project through the active involvement of district and block health functionaries.
Therefore these teams consisted of only the major health functionaries from district as
well as block levels. The meetings of DHT as well as BHT held regularly on a monthly
basis. During the meetings the problems related to the implementation of different project
activities were discussed and Team Approach was followed to solve them in a
participatory manner. (Annexure – 2.3)
(b) Sub Health Center Team (SHCT)
To sensitize and involve the Panchayati Raj Institutions in health sector a Sub health
center teams were formed at SHC level. The main purpose of this team is to delegate the
responsibility and ownership of the SHC to the community for proper functioning of the
SHC. Terms of Reference (TOR) for SHCT are given in Annexure –2.4.
(c) Village Health Team (VHT)
To provide better health care services at village level the project formed village health
teams in remote areas. The main aim of the team is to create awareness among the
community about clean environment of their villages focusing on prevention and
promotion. Terms of Reference (TOR) for VHT are given in Annexure –2.5.
2.6. LESSONS LEARNT
1. During the project period it was observed that the PAC took little interest in the
project activities, as the members of PAC were mostly the state level officials
who are usually busy with other works related to health department. As a net
result the Project Advisory Committee (PAC) could meet only twice during the
project period.
2. The district collector was the chairperson of DIC. The collector being a busy
person, the meeting of the DIC could be held only twice. Moreover, the
involvement of district and lower level health functionaries in a meeting chaired
by the District collector created embarrassing situations for health functionaries.
3. It was therefore felt that in a district health systems project the direct involvement
of health functionaries could make the implementation process easier. Our
experience from the project gives us strong evidence that setting up of project
organizations at the district level with the involvement of health officials at
district and block level is more effective way of managing a district health
systems project. Carrying out the implementation activities through the formation
of DHT, BHT was easier as the cooperation at the district level was found to be
more.
4. The implementation activities could be better carried out with the help of
Panchayat Raj institutions and community through the formation of SHCT and
VHT.
24

2.7. CONCLUSION
There is no doubt that the formation of committees at state and district level with the
administrative authorities as chairpersons could provide support for effective
implementation of district health systems project. Unfortunately, as these administrative
authorities are usually busy, it is difficult to get their support in time. Therefore, from the
beginning of the project, more importance should be given to district health authorities
and the project organizations should involve the people from the health department of the
district rather than policy makers. Needless to add that the organisation, planning,
monitoring and implementation of the project activities still lies at the hands of the
implementing agency. For the successful implementation of the project, the team
members should be adequately trained on project management and should be made clear
about the aims and objectives of the project.
25

ANNEXURE – 2.1
TERMS OF REFERENCE FOR DHT
Composition: Order issued by CMHO
Terms of Reference
• Meet once a month on first Monday
• Review and Monitor the progress of the previous month
• Prepare a Plan of Action for the district according to the project LFA. The district
plans will be based on the block plans
• The District Health Team will maintain the minutes of its meeting and prepare a
monthly progress report
• The Project Co-coordinator will act as a facilitator and help the district Health
Team in implementing the action plan
Activities at the district
(a) District Drug Store
• Cleanliness
• Renovation
• White Washing
• Provision of Almirahs and racks
• Training of Store officers in drug store management
• Record keeping which includes provision of registers
• The Medical officer in charge of stores will do a weekly check
(b) Management of Information System
• Training of ASO and sector supervisors along with computers from the block
Information analysis, gathering, recording, reporting and feedback
• Provision of registers
• Installation of computers at block level
• Training of ASO and computers in computer management
• Registers to be supplied for record keeping of hospital (OPD/lab etc)
(c) Human Resources Development
• Problem Solving meetings-Class IV, Class III and Class II staff at district level
• Maintenance of Attendance register
• Maintenance of TA claim register
• Maintenance of Medical Claim register
26

27

ANNEXURE – 2.2
TOR FOR BLOCK HEALTH TEAMS (BHTS)
Composition: Orders issued by CMHO
Terms of Reference:
• Meet once a month on fixed days
• Review and Monitor the progress of the previous month
• Prepare a Plan of Action for the block according to the project LFA.
• The Block Health Team will maintain the minutes of its meeting and prepare a
monthly progress report
• The Research officer will act as a facilitator and help the Block Health Team in
implementing the action plan
Activities
(a) Block Drug Store:
• Cleanliness
• Renovation
• White Washing
• Provision of Almirahs and racks
• Training of Store officers in drug store management
• Record keeping, which includes provision of registers
• The Medical officer in charge of stores will do a weekly check
(b) Management of Health Information System
• Training of sector supervisors along with computers from the block in
information, gathering, recording, reporting and feedback
• Installation of computers at block level
• Training of computers in computer management
• Registers to be supplied for record keeping of hospital (OPD/lab etc)
(c) Human Resources Development
• Problem Solving meetings-Class IV, Class III and Class II staff at block level
• Maintenance of Attendance register
• Maintenance of TA claim register
28

• Maintenance of Medical Claim register
(d) Sub center Level
• Identify five sub centers with government building and MPW for cleanliness/
renovation/provision of registers/white washing/provision of furniture/almirahs
and racks/drinking water/delivery rooms/fencing with the help of gram Panchayat
and community financing
• MIS: Training of MPW and supervisors in information analysis, gathering,
recording, reporting and feedback in each block at the sector level
• Efforts to be made to get one sub center constructed with the help of PRI and
community financing
• Training in utilization of Sub health center maintenance and utilization of
equipment
(e) Sector Level
(i) Sector level meetings to be conducted in each section in rotation
(ii) Supervisors will check the logistics/records and will prepare a checklist
for supervision
29

ANNEXURE – 2.3
GUIDELINES FOR DHT AND BHT MEETINGS
Objective
Objective is to improve performance through a Team Approach by identifying problems
arising out of the day-to-day work situation and finding solutions / Managerial
interventions to solve the problems.
Need for DHT- BHT:
• One of the basic things for decision-making is the recognition and definition of
problem.
• DHT-BHT meetings are held regularly on a fixed day of every month.
• During the interval between two scheduled meetings, effort should be made to
collect information and ideas needed to develop the agenda for the coming (Next)
meeting.
• It depends on the Team Leader to make the meeting interesting enough for his
team to attend.
Agenda
• The agenda for the meeting should be prepared and circulated to all members
sufficiently in advance, so that the staff members can come prepared to the
meeting and contribute to the achievement of the objectives.
• It is essentials to stick to the agenda including starting and ending the meeting on
time.
Participation of Team Members
The team members should study the agenda and note the objectives to be achieved by
sharing their experience during the meetings. The members should feel free to make
suggestions and state opinions to facilitate the progress.
Suggestions to make DHT-BHT meeting more interesting, meaningful, and
effective:
• RRT members should impress upon the team leaders of DHT and BHT about why
the DHT-BHT has been formulated and the functions of DHT-BHT.
• Build up the leadership qualities of the DHT-BHT leaders. This can be done if
RRT members have a regular dialogue with the team leaders informally,
communicate with them, and build a rapport with the DHT-BHT.
• Decisions taken at the DHT-BHT meetings should be followed up and an action
taken report should be prepared and circulated along with the agenda, for the next
meeting the follow up should be done essentially by the DHT-BHT members but
RRT should supervise help and guide the members.
RRT members should ensure that:
• Agenda is prepared,
• Action taken report is prepared,
• Minutes of the last meeting and decisions taken are circulated in advance to the
members of DHT/BHT.
30

ANNEXURE – 2.4
TOR FOR SUB HEALTH CENTER TEAM (SHCT)
Constitution
Sub health center team constituted by the order from the BMOs of respective blocks.
Composition
• Health Supervisor’s
• MPW’s
• JSR
• AWW
• Trained Dai
• The Sarpanch or Panch of the village shall lead the SHC team, where the SHC is
located.
Terms of Reference (TOR)
The SHC team shall meet every month and discuss problems of:
• SHC Maintenance
• Drug Store
• MIS (Analysis of Form-6)
• HRD problems
• Coordinate with JSR/AWW/Trained Dai
• SHC team shall address the Gram Sabha on following issues
 Hygiene
 Sanitation
 Safe water
 MCH
• Check records and reports to be sent.
The Field officer of SDHS project shall be present during the SHC team meeting and help
and guide the SHCT. A register shall be provided by the SDHS project for maintaining
the record of SHCT meeting at the SHC.
The Field officer shall report separately to the SDHS project about the decisions taken at
the meeting.
The Research Officer to ensure that the order of the same is issued by the BMOs and
regular meetings of team members are held
31

32

ANNEXURE – 2.5
TOR FOR VILLAGE HEALTH TEAM
Background
Government of Madhya Pradesh has taken a policy decision to have a -
 Trained Dai in the every village
 Trained Jan Swasthya Rakshak in every village
 Trained Anganwadi Worker in every village
Government of Madhya Pradesh is one of the few states to Establish Panchayat Raj in the
state. In addition, has decentralized health administration and management to the Gram
Panchayat.
Reduction of Infant Mortality Rate and Maternal Mortality Rate is one the priority of the
Government of Madhya Pradesh
Strengthening District health System project. (SDHS)
• The District comprises of villages. Some of these villages are unapproachable and
difficult to reach. The nearest health facility might be kilometers away.
• The SDHS project has been in operation since July 2000. The very name of the
project signifies the objectives of the project “Strengthening District Health System”
• SDHS endeavors to achieve its objective by identifying the health problems and
finding local solutions to solve the problems with local efforts through Team
Approach.
District Block and SHC health teams have been formed.
An effort is being made to form a Village Health Team so that people in the village can
identify their own health problems and find solutions to solve them.
Responsibility: NGO
Compositions: Panch, JSR, AWW, Trained Dai, NGO representative
Criteria for Selecting the Village
• It should be difficult to reach village
• It should be at least 3 Km. away from nearest health facility.
• The people are informed about the formation and TOR of the VHT.
33

Terms of Reference (TOR)
• VHT shall meet initially to identify the health problems and issues of the village
and inform the same to health workers (MPWs)
• VHT shall try to find local solutions by discussing with people and in Gram
Sabha.
• With the co-operation of the people a Village Health Center shall be opened.
• VHC shall be operated by JSR/AWW and trained Dai every morning.
• A list of medicine shall be supplied from the CHC. (Responsibility- Project staff
during the project period and Health workers after the Project)
• Basic equipments required are kept in the JSR kit and Trained Dai kit. AWW also
has been supplied a kit.
• VHC shall also act as a Depot Holder and should have the following:
 Bleaching Powder
 ORS
 Chlorine Tablets
 Chloroquine Tablet
 Nirodh etc.
34

CHAPTER 3
HOSHANGABAD DISTRICT: A PROFILE
3.1. BACKGROUND
Before entering into the details of the activities carried out under the project, a brief
profile of the district is highly essential, as it would act as a background material on
justifying various interventions carried out under this project. The present chapter gives a
brief profile of the district, which will help the reader in understanding the general, socio
economic, demographic, and health profile of the district.
3.2. PROFILE OF THE DISTRICT
3.2.1. General Profile
The district of Hoshangabad is situated in the southern part of the state of Madhya
Pradesh. The district is topographically marked by hilly and forests terrain covering
nearly 50 per cent of the district. The climate of the district is monsoon tropical one, with
high forest cover of around 45 per cent rendering a typical hot and humid effect. The
district usually has a high rainfall with around 700 to 900 mm in average per annum. The
annual range of temperature varies between a high 45’ C to a low 8’ C except Panchmarhi
35

where the temperature lies between 1 to 2’C during the winter. One of the most beautiful
places in Madhya Pradesh and the most famous tourist attraction is Panchmarhi.
Popularly known as the “Queen of the Satpuras”, Panchmarhi is situated in the
southeastern flanks of the district adjoining Chhindwara district. The place is famous for
its Mystique Mountains, dense tropical deciduous forest rich in flora and fauna.
The administrative headquarter of the district is located at Hoshangabad town. The
district is administratively divided into seven blocks. There are eight towns in the district
with the population ranging from 14000 to 120,000. The rest of the population is spread
over 935 villages (Table 3.1).
Table 3.1: Administrative units and towns in Hoshangabad District
Blocks Towns Assembly Segments
Seoni Malawi Hoshangabad Hoshangabad
Kesla Itarsi Itarsi
Dolariya Pipariya Pipariya
Babai Babai Seoni-Malwa
Sohagpur Sohagpur
Pipariya Tawanagar
Bankhedi Seoni-Malwa
Panchmarhi
Source: The Encyclopaedia District Gazetteers Handbook of India, 1997
3.2.2. Socio-Demographic Profile
Hoshangabad is spread over an area of 8370 sq. km with its share of 1.8 per cent of the
total population of Madhya Pradesh. Hoshangabad is one of the 14 districts where the sex
ratio as per the 2001 census in less than 900 (898) and ranks 32nd
in the overall rankings
of districts in the state. Hoshangabad also ranks 32nd
in term of the population size in the
state (10,85,011). Rankings by population density (number of persons per square km), the
district ranks 29th
(162) in the state. The decadal growth rate of population of the district
is 22.40 per cent. Table 3.2.
In the district literacy rate is very low among the women i.e. 58.02 per cent women are
literate. A rural urban comparison of the figures gives an indication that only 48.91 per
cent are literate among the rural population. Due to illiteracy associated with unmet needs
among the couple, couple protection rate is also low which is just 48.5 per cent. Because
of non-approachability and low accessibility to family planning methods, the birth rate of
the district is 27.9 per thousand. As per 2001 census figures, maternal morality rate is
four per thousand live births and infant mortality rate is 92 per thousand live births and
couple protection rate is 48.5 per cent (Table 3.2).
36

Table 3.2: Socio-demographic profile of Hoshangabad district
Characteristics Hoshangabad State
Population 2001
Total Persons
Male
Female
Rural Persons
Male
Female
Urban Persons
Male
Female
10,85,011
5,71,796
5,13,215
7,96,085
4,83,608
4,37,087
2,99,545
1,62,711
6,03,85,118
31,456,873
2,89,28,243
5,08,42,333
2,61,64,353
3,46,77,980
1,53,38,837
81,02,940
7,23,597
Population (0 to 6 yrs)
Total
Males
Females
172,326
89,423
82,903
106,18,323
550,04422
511,3901
Sex Ratio 898 920
Area (sq.km.) 8,370 1,73,054
Population Density 1991
(persons/sq.km) 2001
132
162
158
196
Decadal Growth Rate (1991-01)
%
+22.40 +24.34
Distribution of Sch. Caste % 16.3
Distribution of Sch.Tribe % 17.4
Crude Birth Rate (CBR) per
1000
27.8 31.9
Total Fertility Rate (TFR) 5 4
Couple Protection Rate (CPR)
%
48.5 38.51
Crude Death Rate (CDR) per
1000
8.0 11
Infant Mortality Rate (IMR) per
1000 live births
92 94
Maternal mortality rate per
1000 live births
4 per thousand
Still Birth Rate 234 Not Available
Abortion rate 324 Not Available
Life expectancy at birth 55 Not Available
Age at Marriage (F) 15-19 15-19
Literacy rate
Persons
Male
Female
70.36
81.36
58.02
64.11
76.78
50.28
Source: Census 2001,provisional totals, Vital statistics GoMP1998
37

3.2.3. Socio Economic Profile
The predominant occupation in the district is agriculture as more than 70 per cent of the
households depends on this activity for their livelihood. In spite of strong climatic
variations and the dense forest cover, the region has shown some progress on agriculture
due to the improved irrigation, fertile soil and high rainfall. The major crops of the region
are; Soybean, Rice, Wheat and Jawar and Vegetables and Grams (Table 3.3).
Table 3.3: Agricultural Production in Hoshangabad (1989- 99)
Crops Area
(In hectare)
Production
(In Metric tons.)
Average Yield
(Kg. per hectare)
Wheat 159825 280278 1827
Rice 11466 11645 1069
Soybean 1175 67450 716
Gram and Vegetables 1075 NA 714
Jawar 23180 22687 979
Source: The Encyclopedia District Gazetteers Handbook of India (1997) and Krishi Vigyan Kendra,
Hoshangabad (1999-2000)
Hoshangabad is a relatively better off district in the state. This is reflected in the
estimated rank of the district in terms of human development index, which ranks districts
according to their performance with reference to selected indicators (education, health
and income etc.). According to a recently published report on the state's human
development, Hoshangabad ranks 13th among all the districts. However, the picture is
not so impressive when one looks at the Gender related development index (GDI), which
takes into account women's status in education, health, and job opportunities vis-à-vis its
male counterpart. According to the same report, Hoshangabad ranks 28th in Gender
related development Index.
3.2.4. Health Scenario
A study on burden of disease was carried out in the district during May 2001 in order to
find out the mortality and morbidity due to various diseases in the district. The key
conclusions of this study are mentioned below:
• Acute morbidity load was found to be higher in rural areas as compared to urban
areas, which may be due to poor sanitary condition, illiteracy and low socio-
economic status, but chronic morbidity load was found to be higher in urban
areas.
• Acute respiratory infection was found to be more common among the acute
diseases and cataract was more common amongst the chronic diseases in the
surveyed population.
• Acute morbidity was found to decrease and chronic morbidity was found to
increase with increase in age.
• Malaria was found to be a major problem in this district with 31.03 per cent of the
Malaria slides tested positive out of 116 peripheral blood smears collected in this
survey.
38

• Anaemia was found to be more common problem in females. Vitamin - A,
Vitamin - B, Vitamin - D deficiency was found to be higher in males as compared
to females.
• Mortality in Hoshangabad was found to be 8.37 per 1000 population, which is
less than the national figure. Main cause of mortality was found to be cardiac
diseases in urban area and Diarrhea in rural areas.
3.2.5. Health Care Delivery System
To provide better health services to the people Government health department
established one district hospital at Hoshangabad, two civil hospitals; one at Itarsi and
other at Panchmarhi. These are the large hospitals having all the indoor and outdoor
facilities. Apart from this seven block primary health centers are established in seven
developmental blocks, thirteen primary health centers at sector level and one hundred
fifty three sub health centers are operational in the district. Along with this, the Indian
System of Medicines has also established 34 institutions in this district. Moreover,
around 25 private nursing homes are also operational in the district
The organizational structure of the healthcare delivery system is similar to Madhya
Pradesh. However, in the absence of any medical college in the district, the district has a
two tier health care delivery system with PHCs and sub-centers at the bottom and the
district hospitals at the apex.
3.2.5a.Primary Health Care
The primary health care in the district is delivered through the community health centers
primary health centers and sub-centers. The Chief Medical and Health Officer (CMHO)
of the district manage this component of the health care. He manages the planning and
monitoring of various national and state level programs related to primary health care.
Table 3.4: Block wise distribution of number of CHCs, PHCs and SHCs in
Hoshangabad
Blocks CHC/BPHC Number of
sectors
Sector PHC Sub Health
Centers
Babai 1 5 1 19
Bankhedi 1 4 1 16
Dolariya 1 4 2 18
Pipariya 1 4 1 22
Seoni Malwa 1 7 3 26
Sohagpur 1 5 3 19
Sukhtawa 1 7 2 33
Total 7 36 13 153
Source: The Chief Medical and Health Office, Hoshangabad.
39

Exhibit 3.1: Organizational chart of primary health care delivery system in
Hoshangabad
40
Chief Medical Health Officer
District Program Officers
Immunization
RCH
Training
Community Health Centers
Block Medical Officer
Sector Level PHC
MO In-charge
Block Level PHC
With PP & FRU Units
ANM and MPWs functioning at the
sub center level for implementing
various health programs at village
level
TB
Leprosy

The Chief Medical Health Officer (CMHO) heads the district health system supported
by a team of District Program Officers, District Health Officers and other key officials in
the district. Exhibit 3.1 shows the organisation of primary health care delivery system in
the district. Number of health care institutions (location wise) and other statistics related
to primary health care is given in Tables 3.4.
3.2.5b.Secondary Level Health Care
District Hospital of Hoshangabad is running in a 200 years building located in the heart
of the town. It is a 140-bedded facility with miserable infrastructure. A recent facility
survey by Indian Institute of Health Management Research indicates that the hospital
suffers from various problems such as lack of staff and equipment, poor waste disposal
and MIS system, corruption and malpractice by staff, repetitive political interference and
the consequent frequent staff transfers etc. As a result, the utilization as well as the
quality has come down simultaneously.
On the other hand, the Civil Hospital Itarsi (named as Jan Sewa Roganalay, Itarsi) has
shown commendable progress in the delivery of referral services in the recent years. It
provides specialized services in the fields of Surgery, Medicine, and other important
specialties. The utilization of the services has been high because of good leadership,
motivated manpower and over all initiative of the hospital staff to make the hospital as a
pioneer institution in the district. In addition, the hospital has set an example for
resource generation through user fees. Recently the hospital has been able to open its
own blood bank through the funds generated by its Rogi Kalyan Samittee.
Civil hospital Panchmarhi has received a step motherly attitude by the health authorities.
The hospital is one of the most neglected referral units in the district with lack of
manpower and necessary resources. Though the hospital covers a larger catchment area,
the utilization of the services is very poor.
3.2.6. Health Manpower Position
In the district, total 657 health staff is posted against the sanctioned post of 773. For the
administration and implementation of the programs one Chief Medical and Health
Officer (CMHO) is posted in the district supported by one district health officer and civil
surgeon. In addition, seven programme officers are posted at district level and held
responsible for managing various national programs. To provide the services at grass root
level seven Block Medical Officers are posted in seven blocks who are supported by 10
sector level medical officers. To provide the health services at village level 304 multi
purpose health workers (male/Female) are posted at sub center levels, who are supervised
by 56 health supervisors (male/female). Table 3.5
41

Table 3.5: Manpower availability in Hoshangabad District
Category Posts Sanctioned In Position Vacant
1. Medical officer 82 72 10
2. Specialists
a) Anesthetist 0 0 0
b) Gynecologist 4 3 1
c) Pediatrician 3 3 0
d) Pathologist 0 0 0
e) Dental Surgeon 0 0 0
f) Gen. Surgeon 4 2 2
3. Staff Nurses / Mid Wife 58 58 0
4. Pharmacist/Compounder 35 28 7
5. Lab Tech/ Lab Asst. 33 31 2
6. Radiographer 8 7 1
7. Computer 7 8 1
8. Driver 19 19 0
9. Paramedical Supervisor
a) Malaria Inspector 5 5 0
b) BEE 7 4 3
c) PHN/LHV 35 38 0
d) HA 0 0 0
Multipurpose workers
a. Male 155 141 14
b. Female 189 184 5
Source: Records from CMHO’s Office Hoshangabad
3.2.7. Utilization of Health Services
As a result of lack of adequate infrastructure associated with obvious managerial
problems related to Logistics and supply, quality of care, human resources have largely
contributed to the poor utilisation of government health care services in the district.
Though the detailed data on lower level facilities such as PHCs and sub centres were not
available, an attempt was made to collect the information at CHC level and above. The
details of the 10 major facilities available in the district and their performance as per the
performance indicators are given in Tables 3.6 and 3.7.
42

Table 3.6: Utilization of various services provided by the government run health facilities in Hoshangabad district
Indicators Babai Sohagpur Pipariya Bankhedi Dolariya Seoni
Malwa
Sukhtawa CH
Panchmarhi
JSR Itarsi DH
Hoshangab
ad
No. of OPD attendance 31561 * 95377 34621 8727 21972 14044 39385 123233 102122
No. of hospital admissions (IPD) 880 1818 3076 - 140 1347 437 464 10408 9504
No. of Emergency admission - * - - 140 - 91 464 - -
No. of Minor Surgeries 181 467 - - 14 - 128 - 465 335
No. of Major Surgeries 700 515 - 491 - - - - 346 236
No. of Deliveries Conducted 398 615 1119 142 31 263 45 34 - -
No. of Cesarean Sections - - - - - - - - 235 131
No. of Blood Examination 18088 71 29908 21998 - 24752 - 2224 8604 5505
No. of Sputum Examination 117 172 426 780 16 465 - 94 - -
No. of Stool Examination - - - - - - - 11 56 11
No. of Urine Examination 700 550 2681 278 - 1002 - 602 2588 1944
No. of X-ray Examination 156 - 1030 460 - 691 - - 1426 2578
No. of ECG Examination - - - - - - - -- 415 316
No. of Ultra Sound examination - - - - - - - - - -
No. Blood Bottles made available for
transfusion
- - - - - - - - - -
No. Patients Discharged
Discharges after medical advice (DAMA)
Regular Discharge
880 2052
- 2600
2600
140
1011 358
- - -
Postmortems Performed 40 44 95 49 1 73 - - 160 -
*Figures not made available by the hospital authorities.
3.7: Value of various performance indicators (block wise and other hospitals) in Hoshangabad district
Indicators/
Year
Name of the Blocks
Babai Sohagpur Pipariya Bankhedi Dolariya
BOR BTR ALS BOR BTR ALS BOR BTR ALS BOR BTR ALS BOR BTR ALS
2001-02 60.9 88 2.53 31.9 90.9 1.28 63.6 76.9 3.02 25.8 86.7 1.1 6.36 0
Seoni Malwa Sukhtawa CH Panchmarhi JSR Itarsi DH Hoshangabad
36 44.9 3 * 14.56 * 106.9 65.1 6 111.6 67.8 6
43

3.3. CONCLUSION
The major intention of this chapter was to give a brief profile of Hoshangabad district,
which would help us justifying it as an appropriate district for intervention area. In this
context the general, socio economic, socio demographic, health scenario, status of health
care delivery system and the utilization of health services at various institutions of the
district was presented. A detailed look at the indicators given in this chapter gives us the
indication that the district is; moderate in size, representative in terms of its population
and geographical areas, having fairly well developed health infrastructure, thus justifying
its appropriateness for the implementation of the project. Moreover, the experiences from
the district can act as a model for other districts of the state as well as the country.
44

CHAPTER 4
DECENTRALIZED HEALTH PLANNING
4.1. BACKGROUND
The district health plan is an archive of policy decisions and modus operandi for the
functions of the district health services vis-a-vis the health programs that are to be
followed in the year ahead. It contains the strategies to be followed, the areas of concern,
as well as the strategies to improve the delivery of health services in the district. Like
any other plan the district health plan states the areas where the health programs and the
health service delivery have to be strengthened. The objectives of the district health plan
are as follows:
• To plan for the health services as per community’s need. Therefore, the essential
pre condition of a decentralized district health plan is the involvement of the
community and lower level health functionaries in the process of plan
formulation.
• To identify the functional areas where the district health system has to improve
upon it’s performance chalked out from previous years achievements and other
performance indicators
• To identify the problem areas where the previous years have shown relatively
poor performance in achieving the targets as set and stressing on to improve the
performance in terms of equity, efficiency and coverage
• To plan better management of the health services delivery in terms of cost
efficiency, logistics, manpower planning, quality assurance, etc.
• To reduce the burden of diseases in the community and bring better and efficient
health services within the reach of all members of the community, particularly
the disadvantaged sections
• To introduce more and more micro planning and enhance decentralization so that
the community based and community specific health care needs can be met; and
• To set carefully benchmarked achievable targets for the district in terms of
delivery of services and to consider the scope of improvement in the programs
continuing in terms of quality and micro planning.
Under the Royal Danish Funded “Strengthening District Health Systems” project an
intervention was carried out by Indian Institute of Health Management research, the
implementing agency, to initiate decentralized health planning process in Hoshangabad
district. The present report describes the whole process of preparation of district health
plan, its implementation and monitoring and the outcomes of the process. The succeeding
Section describes the objectives of the present intervention. Section 4.3 deals with the
existing health planning process and their problems in the district. Section 4.4 gives a
45

detailed outline of the interventions undertaken in this regard and the outcomes of the
intervention are presented in Section 4.5. Lessons learnt and sustainability of the
activities initiated under this project is described in Section 4.6. The report ends with
some concluding remarks, which are useful for future researchers.
4.2. OBJECTIVES
As could be seen from the next section that the decentralized planning is already
incorporated in the current health sector reform process. Unfortunately, due to one reason
or other, the concept of decentralization is not incorporated while preparing the annual
health plans for the district. The present project did not make any attempt to introduce
any new planning tool or format, rather, it attempted to systematize the existing tools and
guidelines in order to improve the present planning process and prepare a realistic plan on
the basis of ground reality. Therefore the basic objective was to prepare the district health
plan with a bottom up approach, starting from sub center to the district; discuss the same
with the district authorities, implement the plan in the field and assess the results of this
effort. Following objectives were set in order to make this intervention successful and
effective:
1. Orientating the health functionaries towards decentralized planning process
2. Develop and initiate decentralized planning process within the district health
system in collaboration with the health functionaries at various levels
3. Prepare the district health plan in collaboration with the health functionaries at
various levels and getting them officially approved
4. Share the plan documents at all levels (sub center, block and district) and develop
appropriate strategy for its implementation
5. Implementing the plan in the field and assess the change in the system
4.3. PLANNING PROCESS – PROBLEMS AND ISSUES
Before describing the interventions undertaken by the project team with regard to
decentralized planning it is necessary that a few lines on the existing planning process is
described and problems identified. It is equally important to note that no diagnostic study
was conduced by the project team with regard to decentralized planning. The problems
were identified in a participatory approach through the interactions with district and block
health authorities and health workers at grass root level.
4.3.1. Background of Planning
When the family planning program was initiated in the 1970’s, the stress was purely on
sterilization. Since this met with a lot of resistance, the Family Welfare program was
started from 1985-90. The Child Survival and Safe Motherhood Campaign (CSSM) were
implemented from 1992-93. This was ultimately replaced with the Reproductive Child
Health (RCH) program in 1994 with emphasis on providing the right choice of
contraceptives to eligible couples to stabilize the population growth rate. Initially, the
trend was to set the targets, which used to flow from the top to bottom but soon it was
realized that this approach had major flaws namely-
46

• If the beneficiary is not provided with the contraceptive of his choice, then it is
difficult to achieve the targets set in this regard.
• Quality of service provided is of poor standards
• Manipulation of targets by the health workers at the grass root level
Considering the above points, the ‘Target Free approach’ was initiated in April 1996.
Though the concept of Target Free Approach and subsequently the Community Needs
Assessment Approach is being articulated since 1996, it has not been appreciated in the
true sense and has not percolated down to grass root level health workers. For example,
the average health worker still perceives the targets as being set from the top. He/she has
to get the target figures for himself/herself from the higher authorities and meet them
within a stipulated time. It is necessary to understand that “Target Free” does not mean
that no targets would be set. Instead, the MPW posted at the sub center now have the
responsibility of formulating the targets at the beginning of the year in active consultation
with the PRI representatives, which would then be consolidated at the PHC, CHC and the
District level. This simply indicates that the plans are to be prepared at the grass root (sub
center) level and flow to higher levels. Though the above changes have already been
made at the policy level, the district health authorities have not realized the importance of
the same and never tried to update themselves with the policy change. To be more
specific the following problems were identified relating to decentralized planning:
• The concept of target free approach have either not been understood by the
higher-level health officials of the district / they do not want to change their old
habit of setting the targets from the top level.
• The top (district level) health officials set their targets by making a 10 per cent
increase over the past years’ performance2
which is usually a faulty approach
• At no level of plan formulation the health functionaries are consulted. This
resulted in an over/under estimate of the actual situation.
• As the lower level health functionaries are not involved in the process of plan
formulation, the plans prepared before the initiation of the project were not need
based. Rather the target based planning, with the targets set at higher level was
followed.
• No mechanisms are established at district or block level to monitor the activities
of the lower level health functionaries. This resulted in false / under reporting of
the actual situation thus, creating another loop hole in the management of health
information system
2
The performance data usually obtained from the health functionaries suffers from the following drawbacks:
• At each level the data on various indicators are collected and compiled only to send them to their respective higher authorities
without verifying the accuracy and the utility of the data being collected. This has ultimately led to inflation and exaggeration of
figures at all levels in order to show higher performance.
• Feedback system is extremely poor at all the levels. The supervisors do not give any feedback to the health workers on accuracy
of data generated. In similar fashion, there is no feedback from BEE to supervisors and so on.
• No attempt to establish relationship between MIS and output achieved
• Lack of resources (especially stationery at the section and sector level)
47

Thus, there is dilution of the basic philosophy of decentralized planning and the same is
transmitted to the lower level.
4.4. INTERVENTIONS
The interventions initiated by the project team aimed at addressing the above-mentioned
problems.
Formulation of sub center level health plan being one of the basic objectives of
Decentralized Planning, it requires that the health system functionaries right down to the
grass root level be oriented and sensitized in this regard. Therefore, the interventions
aimed at:
• Orientation and Capacity building of health functionaries on preparing health
plan with a bottom up approach – Guidelines for preparation of decentralized
district health plan.
• Compilation of sub center plan to Block and District Health Plan and sharing
workshops
• Monitoring the planned activities and preparation of guidelines for monitoring
and supervision
INTERVENTION 1: ORIENTATION AND CAPACITY BUILDING OF HEALTH
FUNCTIONARIES ON DECENTRALIZED PLANNING
PROCESS
(a) Trainings and Workshops outside the District
At initial phase of the present intervention, there was severe resistance from district as
well as block level health authorities to change the existing process of planning. A 5 days
Training cum workshop was organized at Jaipur to orient them about the decentralized
planning process. The workshop was attended by the Health officials from the district as
well as the Block Medical Officers from different blocks of the district.
As Health Information System is closely linked with planning, during the Training
Workshops on MIS, the district as well as block level health functionaries were oriented
on preparation and benefits of decentralized plan. This training was conducted at Bhopal
and the participants were organized in three batches (three days training to each batch).
Sector Medical Officers, Health Supervisors, BEE's and staff dealing with the data
section in CMHO office participated in the training program, which was conducted in
Bhopal.
(b) District level workshops
Two workshops cum training programs (one for District Health Team and Block Health
Teams, and another for the major health functionaries at the block level dealing with
planning) were organized at District Training Center, Hoshangabad for orienting the
health functionaries on appropriate MIS and importance of decentralized planning for
appropriate delivery of health care.
48

(c) Block Level Workshops
During the project period, the project team attended all the monthly meetings, which are
usually held at block headquarters. As all the health functionaries of the block attend this
meeting, it was used as a forum for imparting necessary training to all the block level
health functionaries on decentralized planning. As the planning process starts during
March-April of each year, the trainings were imparted in the monthly meetings of March
and April during the project period.
(d) Sector Level Workshop cum Training Programs
In order to seek active participation of the lower level health functionaries (health
supervisors and workers), the project team put substantial effort to conduct the training
programs at the sector headquarters of each block. Training of the grass root level
multipurpose workers (male and female) was carried out subsequent to the training
program at Bhopal and Block Headquarters. Consent and support was solicited from the
Block Medical Officers and Block Extension Educators in this regard. At some blocks,
the supervisors also acted as trainers for these training programs. The project team did
overall coordination of the training programs at sector level. The training programs were
conducted in a participatory manner. The active participation of the lower level health
functionaries was solicited through understanding their field level problems and finding
out local solutions to them (Details are given in Annexure - 4.1.). As per the guidelines
of government of India, the sub center level planning for the year ahead is submitted
through Form 1. Therefore, the major focus of the training was to explain the participants
on the details of Form 1. Accordingly, Form 1 was distributed among the participants and
the definition of each row in the form was explained to them. The method of estimating
the figures for each column in Form 1 was explained to them in detail. Annexure - 4.2.
gives the details of the training imparted on decentralized planning at sector level and the
guidelines provided to them in this regard.
INTERVENTION 2: COMPILATION OF SUB CENTER PLAN TO BLOCK AND
DISTRICT HEALTH PLANS AND SHARING WORKSHOPS
The sub center level plan prepared in the above manner was used as the basis for the
preparation of sector; block and district level health plans. It is worth mentioning that the
workers prepared the sub center level plans during the workshop cum training programs
conducted at sector levels. As preparation of Sector (PHC), Block and District level plans
were just summation of the sub center level plans, the project team helped the health
functionaries to compile them for their respective sectors/blocks. The figures were
compiled in prescribed format (Form 2 for sector and 3 for Block). The block level plans
thus prepared were shared with the block level officials in the special meeting organized
by the project team. Discussions on the block level plan document were made and the
necessary suggestions were incorporated before their submission to the district. The
district health plan was just the compilation of the block level plans. The project team in
consultation with the block and district level health officials carried out the compilation
work. The district health plan for each year (during the project period) was finalized in a
combined workshop of all district and block level health officials organized at district
level.
49

INTERVENTION 3: MONITORING THE PLAN ACTIVITIES AND PREPARATION OF
GUIDELINES FOR MONITORING AND SUPERVISION
Decentralization, like any other organizational change, needs to be carefully monitored
evaluated in order to ensure that the desired results are achieved and the emerging side
effects are considered and addressed. The activities of the project team did not end with
the preparation of plan document for each financial year during the project period.
Substantial efforts were initiated by the project team to bring the prepared plan into
action. Accordingly, the final figures of target were distributed among all the health
workers of the district. In addition, the project team fixed village wise targets with the
help of health workers. The monitoring of the planned activities was made in consultation
and collaboration of district health authorities. The district authorities were of the opinion
that a feedback of every visit of the field team should be submitted to them so that
corrective measures on implementation could be taken. In addition, they suggested that
one of the district official should accompany the project team for facilitating the
monitoring activities. Accordingly a tour plan of the project team was submitted to the
Chief Medical and Health Officer (CMHO) of the district and a copy of each visit report
was submitted to CMHO for taking corrective measures in case there was any problem in
implementing the planned activities. The involvement of district authorities made the
monitoring activity as a successful event. Nearly 60 per cent of the sub centers that were
not following the planned activities started rectifying themselves and planned their
activities accordingly. The monitoring was mostly done through the participation of the
project team in the sector, block and district level meetings. In addition, a supervisory
checklist was prepared and handed over to the district for proper monitoring and
supervision (Annexure - 4.3).
4.5. OUTCOMES
Performance of Activities
Process indicators Number
Number of training programs outside the district 2
Number of district level training programs 2
Number of block level workshops / training sessions 28
Number of sector level training programs 72
Number of District level workshops 2
Number of Block level workshops 14
Number of Sector level meeting attended by project team 144
Number of block level monthly meeting attended by project team 147
Number of Block health plans prepared and approved 14
Number of District health plans approved by district and state 2 Years
Number of health worker trained on decentralized planning 306
Average number of participants per training 15
Number of district health plan guidelines distributed 153
Number of sub centers who prepared their own plan during 2003-04 153
50

4.6. LESSONS LEARNT AND SUSTAINABILITY
• Within the district health system, it is important that the bottom level health
functionaries are involved during the process of preparation and execution of the
plan so that the benefits of decentralized planning process initiated in the district
could be fully realized and the system can lead to modifications and changes, as
required.
• Sustaining the commitment of the district health functionaries and other health
workers to achieving the goals and objectives of the health system, their
involvement in planning health services and action is highly essential. Explicit
discussions on the objectives and goals of the health system and the ways to
achieve them through appropriate planning in a participatory way would certainly
lead to better results.
• There is an urgent need for wide dissemination of information about national
priorities, goals, objectives and strategies
• Participation of health providers and clients in the process of problem
identification and their local solutions would certainly help bringing proper
coordination between the community and health system
• The formulation of district health plan should be made in active participation
with the health workers, public and PRIs. The approach should essentially be
participatory rather than enforcing
• The preparation of village level health plan needs the support from the village
level health providers e.g., Anganwadi Workers and Jana Swasthya Rakshyaks
(JSR) and private practitioners working at the village level. Appropriate
mechanism need to be developed for their active involvement during the process
of plan formulation.
• Development and use of operational work plans that specify activities, targets
and the time frame within which they have to be fulfilled, as well as assigning
clear responsibilities to teams and individual workers would help monitoring the
planned activities in a better way
• Development of appropriate managerial styles that facilitate a free flow of
information in all directions would certainly help in sustaining the initiated
activities in the district
4.7. CONCLUSIONS
Though the concept of decentralization has gained prominence worldwide, the concept
has not yet been understood by majority of the health functionaries in Hoshangabad
district. This has led to repetition of old method of preparing the district health plan –
preparing the plan at the top level and enforcing the same to bottom level health
functionaries of the district. The SDHS project attempted to bring a change in the system
by making the health functionaries understand the importance of decentralized planning.
It was certainly a hard task for the project to a change in the system. After repeated
51

orientation and training programs the project able to change the minds of health
functionaries and initiate the decentralized planning process in the district. During the
project period necessary trainings were imparted and guidelines were developed and
distributed among the health functionaries for preparation of district health plan with
bottom up approach. The training sessions on the method of plan formulation were
conducted at sub center levels in order to seek their active participation. No doubt, such
exercises helped the project team to change their old habits of planning and introduction
of actual decentralized planning process in the district. During the year 2001-02 and
2002-03 ample amount of time were invested for this exercise. However, it is
encouraging noting that during the year 2003-04, the sub center level health plans were
prepared by the health workers themselves and the same plan was percolated to block and
district levels. There is a sea of change in this respect. However, as other interventions
carried out under this project, the question of sustainability remains at the hands of health
functionaries at the district level.
52

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