Transcript health system preparedness for universal health coverage

HEALTH SYSTEM PREPAREDNESS FOR
UNIVERSAL HEALTH COVERAGE
P ROVI SI ON O F R MNCH+A A N D T B I N P U B LI C H EA LTH FA C I LI T I ES I N O D I SHA
ODISHA VIKASH CONCLAVE | 20 SEPTEMBER 2016 | ODISHA
PUBLIC HEALTH FOUNDATION OF
INDIA NEW DELHI
Dr Rajmohan Panda
Dr Rajna Mishra
Ms Apurva Rastogi
Dr Ravi Kumar
Ms Divya Persai
1
Overview
I
• Background
• About the study
• Methodology
II
• Accessibility of services
• Availability of services
• Affordability of services
III
• Recommendations
2
Maternal Health
Due to pregnancy related causes
100,000 women die each year in India despite a 65%
reduction in maternal deaths since 1990
India
Odisha
Source: SRS Bulletin, Sample Registration System, Registrar General, Ministry of Home Affairs, Government of India
Child Health
1 out of every 20 children die within
first year of life despite reduction in
infant deaths by 50%
India
Odisha
Source: SRS Bulletin, Sample Registration System, Registrar General, Ministry of Home Affairs, Government of India
3
Adolescent Health
Tuberculosis
35% of global burden of disease
The second largest killer after HIV
has roots in adolescence.
9% of
TFR accounted by
adolescents 15-19 years of which
only 7 % use contraception*
Maternal conditions account for
13% of the deaths**
Source:
*Population Reference Bureau (2012)
**Causes of Death, Registrar General of India, Ministry of
Home Affairs, Government of India
India has highest burden of TB where
1 of every 4 TB patients die each year
Odisha in 2014
Case Detection Rate 55% against the
norm of 70%
Success Rate 86% against the norm of
85%
Source: RNTCP 2014
4
Goal for Achieving Universal Health
Coverage
“People are able to receive quality health services that they need without suffering
from any financial hardships when paying for them”
Rolling
out
UHC
need to
5
Objectives of the Study
 Assess current status of physical infrastructure & availability of essential drugs and
equipment
 Analyze capacity and capability of health systems in terms of available trained human
resource and adherence to quality & clinical protocols
 Understand the patients and providers perspectives about quality of services provided
6
Sampling Strategy
6 DISTRICTS SELECTED ----- 111 FACILITIES SELECTED
Low
Performing
Medium
Performing
High
Performing
Koraput
Mayurbhanj
Balangir
Dhenkanal
Bargarh
Jharsuguda
DH
1
1
1
1
1
1
SDH
1
1
1
1
0
1
SC
10
17
7
5
6
3
PHC
6
10
5
4
6
2
CHC
3
6
4
2
3
1
Total
21
35
18
13
16
8
6
5
48
33
19
111
7
Methods
Facility assessment tool at SC, PHC, CHC, SDH and DH
Client exit interviews
Quantitative
Budget tracking
Costing
In-depth interview with services users of RMNCH+A and TB services
In-depth interviews with service providers of JSY/JSSK scheme, ARSH program and
RNTCP program at state, district, block and community level
Qualitative
In-depth interviews with NHM officials
Medical Case Vignettes
Focus group discussion with community leaders
8
Accessibility of services
 All facilities connected by approachable road
 Average distance
◦ farthest SC to PHC 14 kms
◦ farthest SC to CHC 34 Kms
Patients of very remote area are unable to come to
the hospital. Lack of transportation facility, mainly
communication problems is the major issue.”
CHC Medical Officer
9
AVAILIBILITY OF SERVICES: Infrastructure
Computer with internet facility
Habitable quarters for Mos
Usable functional toilets
Sewage facility
Regular power supply
Regular water supply
Connect by approachable road
Function in government premises
13
50
63
13
75
25
100
100
Infrastructure at 24x7 PHCs (n=8, units in percentage)
Functional SNCU
Functional New born stabilization…
Labour table with macintoh
Emergency drug tray in labor room
7
9
10
11
Services at SDH/DHH for emergency and new born care (n=11, units in actual numbers)
10
Nutrition Rehabilitation Centers (NRCs): Clinical management of
undernourished children
Play area with toys
3
Toilets /bathrooms
3
Hand washing facility
3
Dish washing basins
2
Separate kitchen
2
3 NRCs out
of 19 CHCs
Facilities available in NRCs at CHC level (n=3, units in actual numbers)
Play area with toys
4
Toilets /bathrooms
7
Hand washing facility
6
Dish washing basins
6
Separate kitchen
6
7 NRCs out
of 11 SDHs
and DHHs
Facilities available in NRCs at SDH/DHH level (n=7, units in actual numbers)
11
AVAILIBILITY OF SERVICES: Human Resource
 Shortage of manpower across all sampled facilities.
 Multitasking and increased work load affected work
performance and quality of services provided.
 ANMs trained in IMNCI, immunization, family planning
and TB, lacked training in identification of EmOC
services
Anesthetists are not available and thus it’s difficult to conduct Csections. In this regard, we have taken few steps to introduce
trainings on life saving anesthetic skills and personal
development skills for developing confidence among
obstetrician/gynecologists conducting C-section deliveries.”
- District Nodal Officer
 MOs trained in NSSK, RTI/STI, ARSH, DOTS, Less than
half were trained on EmOC and BmOC
12
AVAILIBILITY OF SERVICES: Human Resource
(shortfall)
19
17
19
19
19
19
15
13
8
5
Prescribed Nos. under IPHS
1
According to Odisha economic
survey 2014-15, there are about
10 government doctors per 1
lakh population
Paediatrician
(11)
Anaesthetist
(4)
O&G
(6)
Surgery
(2)
Medicine
specialist/Physic
ian
Total
MO-IC
(18)
Shortfall
(14)
Availability of human resource at CHCs (n=19, units in actual numbers)
24
17 19
17 15
11 9
2
17
17 18
17
11
2
11
6
11 11
0
11
0
Prescribed Nos. under IPHS
Orthopaedic
s
(1)
AYUSH
Paediatrician
(7)
Anaesthetist
O&G
(2)
Surgery
Medicine
specialist/Ph
ysician
Total
MO-IC
19
Shortfall
Availability of human resource at SDHs/DHHs (n=11, units in actual numbers)
13
AVAILIBILITY OF SERVICES: Technical competency of
medical officers (medical vignettes)
Management of Maternal and Child Health cases
◦ MOs at SDH/DHH demonstrated better competencies than at CHCs & PHC in managing emergency
obstetric, new born & child illness .
◦ Need for periodic trainings on RTI/STI management at all levels
Management of Tuberculosis cases
◦ All MOs follow treatment protocols
◦ Testing for drug sensitivity and management through ATT and ART not commonly done
◦ Trainings for management of drug resistance and latent TB infections required
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AVAILIBILITY OF SERVICES: Drugs, Consumables and Equipment
 75% facilities had copy of Essential Drug List, incidence of stock
outs vary seasonally
 The diagnosis facilities were mostly available at SDHs and
DHHs only
 Lack of functional equipment such as microscope, centrifuge
and hemoglobin meter at most of the PHCs
 Prescription audits: Mostly prescribed generic drugs rather
than fixed dose combinations drugs (3%).
Expenditure on medicines
accounts for major share of
OOP in public hospitals (72.6%
in rural and 77% in urban
areas), which is much higher
than the national average
(66.5% and 62% respectively)
- TMST, Odisha, 2011
15
Referral transport
 Ambulances, 102 and 108 services – transport
sick
neonates and pregnant mothers from home to health
institution, drop back home and transfer to higher level
facilities for complications
◦ PHC – No referral transport provided
◦ PHC and CHC – No in-house ambulance facility
◦ SDH and DHH – In-house ambulances functional round the clock
“The 108 and 102 are most used referral
transport. In hard-to-reach areas we provide
facilities such as autorikshaws etc. and they
may come with ASHA and AWWs.”
PHC Medical Officer
 Call-center facilities were functional in all the districts
except Bargarh
16
Quality Control Practices
SDH/DHH
CHC
PHC
120
100
80
Quality control practices followed
at different levels
60
(PHC-33, CHC-19, SDH/DHH-11,
units in percentage)
40
20
0
Patients’
Charter
Registered RKS
Internal
routine
monitoring
External
monitoring
Grievance
redressal
Waste disposal
practices
Infection
control
practices
17
Provision of RMNCH services at different levels of care
(CHC=16, FRU=3, SDH/DHH=11)
(Units in actual numbers)
16
11
3
4
Functional
newborn
stabilization
unit
11 11
3
Functional
SNCU
16
11
3
11
10 10
2
16
3
16
11
3
11
3
11
4
2
1
0
Vehicle for
Free drop
Functional Functional
OT
Blood storage Blood bank
pregnant
back after delivery room labour room Gynaecology
women & sick delivery
neonate
FRUs
CHCs
DHH/SDH
18
Availability of services: Provision of Adolescent Health services
SDH/DHH
Availability of trained counsellor
CHC
64%
37%
67%
PHC
64%
SDH/DHH
IEC material displayed
CHC
47%
67%
PHC
SDH/DHH
Separate room for adolescents' examination
CHC
91%
“I feel that there should be a complete separate
arrangement for ARSH like separate room,
separate medicines, separate storage facilities
and separate days.”
PHC Medical Officer
53%
0
ARSH services at different levels (PHC-33, CHC-19, SDH/DHH-11)
19
Availability of services: Provision of TB services
 CHCs act as focal point for delivering TB care, SDHs/DHHs for
second line investigations & diagnostics, DOTS centers
available at SCs
Adequate availability of drugs & consumables for the
management of TB case at all levels
 Inadequate supply of pediatric dosage and second line of
drugs
 All service providers trained and had fair knowledge of
RNTCP
Regular supply of medicines, well-defined hierarchies and
treatment completion - success factors
Shortage of staff, heavy workload, delay in receiving
incentives, careless attitude of patients, illiteracy - barriers
2 % OP cases sputum
examined
17
Hand washing facility
19
Trained technician
19
Funtional lab
19
Designated Microscopic
Centre (DMCs)
19
Availability of TB services at CHCs/FRUs (n=19,
unit in actual numbers)
20
Recommendations
Capacity building of available human resource
◦ Knowledge based training for community health workers through collaborations with non-governmental
organizations
◦ Skill based hands-on training, refresher trainings and short term online web based trainings on regular basis
Strengthen referral transport in hard-to-reach areas
◦ Collaborate with NGOs to provide referral services
Strengthen existing infrastructure
◦ PPP mechanisms such as contracting out of services
◦ Establishing local monitoring mechanism for infrastructure development
21
Recommendations (provision of RMNCH, Adolescent and RNTCP services)
Enhance quality of Health Management Information System
◦ Innovative IT-based systems in place – mobile based device for ANMs
◦ Regular entry of MCTS
Strengthen adolescent health service
◦ Ensure privacy through provision of separate room
◦ Availability of essential drugs and consumables
Strengthen PPP role in TB service provision
◦ Incentivize NGOs and private players for case detection
◦ Strengthen logistics management through contracting out services
22