IMPLEMENTATION OF IMPLEMENTATION OF HEALTH CARE HEALTH CARE PROGRAMMESPROGRAMMES

B.V.L.NARAYANAB.V.L.NARAYANA

RAILWAY STAFF COLLEGERAILWAY STAFF COLLEGE

STRUCTURE OF STRUCTURE OF PRESENTATIONPRESENTATION

• DEFINITIONS• KEY MESSAGES• ROLE OF PROGRAMME CHARACTERISTICS• RESOURCE GENERATION• RESOURCE MOBILISATION• RESOURCE UTILISATION• MONITORING, EVALUATION, COURSE

CORRECTION• MODEL • CONCLUSION

Health indices comparisonHealth indices comparison

Indicator name Av. Value for India

Lowest in any state

Highest in any state

Infant mortality rate 58 13( Manipur ) 76 ( Madhya Pradesh)

Maternal mortality ratio 301 110 ( Kerala ) 517( Uttar Pradesh)

Institutional deliveries ( %) 40.7 12.2 (Nagaland) 99.5( Kerala)

Full ANC check up ( %) 50.7 16.5 ( Bihar) 96.5 ( Tamil Nadu)

Children fully immunized 43.5% 80.8 % (TN) 20.1( Nagaland)

Children breastfed at birth 23.4 % 7.2% (UP) 65.4(Mizoram)

Children underweight ( < 3) 45.9% 22.6 (Sikkim) 60.4 (Madhya Pradesh)

Utilization of government facilities by poorest

37.9% 19.4% ( Bihar) 55 % ( Karnataka)

Source: Health profile of India 2006

Motivation Motivation  

Developed countries

Developing countries

India ( average)

India (highest)

India (lowest)INDICATORS

IMR(/ 1000 live births) 9 100 58 76 13

<5 MR(/ 1000 live births) 13 114 95 130 19

UNDERWEIGHT % 3 41 46 60.4 22.6

MMR ( / Lakhs births) 40 630 301 517 110

Deaths due to TB( / Lakhs population) 5 40 27 NA NA

Deaths due to AIDS(/ Lakhs population) 31 164 6.8 NA NA

INTERVENTIONS          

Full ANC % 97 65 50.7 96.5 16.7

Safe deliveries % 98 45 40.2 99.7 12.2

Children fully immunized % 90 60 43.5 80.8 20.1

Children breast fed %  NA 32 23.4 60.4 7.2

Source : National health profile 2006, based on NFHS 3(2005-06)

Comparison of health indicesComparison of health indices state

 <5 MR Malnutrition

 MMR %TB deaths

Andhra Pradesh 88 37 195 4.6

Kerala 19 26 110 4.3

Karnataka 77 44 228 5.7

Tamil nadu 69 36 134 2.2

Punjab 67 29 158 4

Gujarat 84 44 180 3.8

Haryana 91 33 162 3.6

Maharashtra 65 51 149 4.3

West Bengal 69 47 194 3.9

Madhya Pradesh 116 57 379 3.7

Bihar 84 55 371 2.7

Uttar Pradesh 112 53 517 2.7

Rajasthan 107 52 445 3

Orissa 130 55 358 4.5

India 95 46 301 3.8

Motivation Motivation • Disparity in distribution of mortality and morbidity

– Between developed and developing countries– Between states in India

• Conditions preventable• Proven cost effective interventions available• Common health care programmes

• Why the disparity in India

• Reason : low usage of interventions

MotivationMotivation

• India and other developing countries • Investments and funding (Bajpai, Dholakia and

Sachs 2006; CMH 2001)

•Mediated through good governance (Wagstaff and Claeson 2004 )

– Institutional factors (NCMH 2005; Wagstaff and Claeson 2004)

– Service delivery mechanisms (Bajpai and Goyal

2001; Mavalankar 1999; Seshadri rao 2001; Wagstaff and Claeson 2004)

Implementation is one of the key issues

INDIA THE CONTEXTINDIA THE CONTEXT• Contributes to 20% of worlds mortality and

morbidity• High variation in mortality and morbidity• Last 60 years

– Gap between intention and reality– Unfocussed infrastructural development– Lack of a good referral system– emphasis on centrally driven and controlled

vertical disease specific programs• Communicable diseases contribute 50% of burden

(NCMH 2005)

INDIA THE CONTEXTINDIA THE CONTEXT• National health policy(2002) ; By 2010 the

goals stated to be achieved are ( sujata rao 2004):

• increase public investment from 0.95 of GDP to 2-3% of GDP

• increase utilization of primary care facilities from 19% to 75%

• reduce MMR(maternal mortality ratio) by 75%( from 540 to 135)

• reduce IMR( infant mortality rate from 62/1000 to <30/1000

• eradicate polo, eliminate leprosy• reduce deaths due to TB and malaria by 50%

ConceptsConcepts• Implementation of strategy (Wheelen and Hunger

2001).

– “the process by which strategies and policies are put into action through the development of programs, budgets and procedures”

• Policy Implementation – actions by people that are directed at achievement

of objectives set forth in the policy decision (Van meter and Van Horne 1974).

Characteristics ( Hrebiniak and Joyce 2001)

– Is a dynamic, non linear process – Multiple variables interacting, reciprocal

causality( Fajourn 2000)

– Takes time (Miller 1997) – for effect, for study

Literature review Health Literature review Health carecare

• Millions saved (what works group, CGDEV 2006)– Study of 20 successful program implementations– Identified policy level factors – Program characteristics influence implementation– No pattern of association of success in

implementation with socio-economic contexts– Even in weak policy environments effective

implementation is possible

• Secondary analysis shows role of community involvement

DEFINITIONSDEFINITIONS

• Implementation is defined – as the process of allocation of tasks – and resources and– creation of administrative mechanisms to monitor

and integrate actions required to – achieve the objectives of program/strategy,

including those which cross organizational boundaries.

• Is a process-– Sequence of events, actions and activities

unfolding over time in a context ( Pettigrew

1997)

Scope of Scope of researchresearch

Inputs Process Output

Corporate strategy

Business strategy

Action planning

Budgeting Action Outcomes

Influencingfactors

Processcharacteristics

Processoutcome

Policy ProgramProgramoutcome

Health Policy

Health careProgram

Influencingfactors

Processcharacteristics

Processoutcome

Programoutcome

OPERATIONAL FRAME WORK

Task organizationTask organization• Programme characteristics

– Type of goods/services planned– Organization of service delivery

• Inter-linkages among components• Key steps in process

– Technology used for service delivery– Implementation organization

Intensity of interactions HighLow

Req

uire

men

t of i

nten

sity

of r

esou

rce

Low

Hig

h

Small pox

AIDS

Vitamin A deficiency

TB

measles

health

fertility

Iodine deficiency

ORS

RCH

Vector control

Blindnesscontrol

Mentalhealth

Intersectoral coordination HighLow

Intr

a or

gani

satio

n co

ordi

natio

nH

igh

Low

Condom useAIDS

IDSPICDS

NLEPII

CANCER

Task organizationTask organization• Based on the degree of intangibility, a service

good can be classified as:– search goods where the customer can test it or get

information about it before deciding to buy e.g. : a test drive of a car

– experience goods where the customer has to experience the service before you can make an opinion about it e.g. a meal in a restaurant

– Credence goods where even after purchase you are not sure of the quality of the service—e.g. health care service.

• relationship between the service provider and the customer becomes important and need to be incorporated in service delivery strategy (Susan Segal horn 2001).

Task organizationTask organization

• How will service delivery be done• What activities are components of it• Who will do these activities and whose

control are they under• What technology will be used to do it• Interrelationships among activities

– Determines criticality– Determines dependencies– Determines coordination costs– Determines nature of governance mechanisms

• Identifies the implementation organization

Comparison of programmesComparison of programmes

Characteristic NBCP RNTCP NVBDCP RCH

Number of components

Two One Two Four

Technology used Mediating Long linked Intensive Long linked + intensive

Dependencies within group

Pooled Sequential Sequential Reciprocal

Dependencies across group

None None Reciprocal Reciprocal

Components under direct control

All All One Varying levels

Control mechanisms

Financial incentives

Cooperation, material incentives--skills

Cooperation Cooperation, financial incentives in some cases

Key resources Surgeons LT,MO MO,LT MO, FHW, specialists

Mechanisms to get alternate resources

Pooling, contracting

Community provision, contracting

Community provision,

Pooling, community provision, contracting

Comparison of programmesComparison of programmesCharacteristic NBCP RNTCP NVBDCP RCH

Lead/lag of impact of interventions

None Moderate, 6-9 months Moderate for vector control measures

Long lag

Requirement of skill levels

High at tertiary or secondary level

Medium at PHC level Low Low to very high

Degree of standardization of treatment

Very high High High Low to very high

Task grouping At highest level At programme unit level At field unit level At field unit level

Scope for resource transfer

Very high Restricted Minimal Minimal

Evaluation and control

At highest aggregate level

At unit level At lowest level At lowest level

Coordination costs

Low Medium Very high Very high

Facilitation by Planning, incentives, innovation in technology

Planning, standard guidelines, training, cooperation

Planning, continuous feed back, cooperation, coordination

Planning, continuous feed back, cooperation, coordination

Implementation organisation--Implementation organisation--NBCPNBCP

JD headquarters

equipment

NGOIncentives

Training ofsuregons

DH, GH,MCs,CHC

PHC

community

opthalmicassistantsscreening

camps

OPD

cataractpatients

surgery

NGO s andPP

Implementation organisation -Implementation organisation -NVBDCPNVBDCP

JD-NVBDCPstate

districtDMO

PHCs--MO,LT,MHS

SC--MMPW,FHW

villages--MLV,GAM,AWW

feversurveillance, BS

anti -larvalmeasures

anti vectormeasures

biologicalcontrol

IMN usageand

distribution

sprayingteams

vector teams

hatcheryand seeding

teams

ITM netscommunity

nets

vectordensitystudies

IRS schedule

focalspraying

blood smearcollection

PPs andCHCs

positivecases

treatment

monitoringand feed

back

community

Implementation organisation -Implementation organisation -RNTCPRNTCP

DOTSworker

PHI/MO

DMC/ LTS

MO-TCDTO

STO-stateheadquarters

contractualLTs

privateDMCs

AWW.GAM.MLV.MMP

W,FHW

PPS,

sputumexamination

OPDscreening

referral fromcommunity

for categorisation

treatment

treatment asDOTSworker

monitoringand feedback

STS--treatment follow up

STLS--Microscopy quality

training

Implementation organisation -Implementation organisation -RCHRCH

village--AWW

sub centreMMPW FHW

primary healthcentre-MO,LT,

FHSDistrict head

quarters--CDHO, RCHO

state headquarters--Addl director FW

district planactivity plan

house to housesurvey--CNAA

immunisation

MCHservices

FPmotivation

healtheducation

specialclinics

specialistservices

institutionalservices

community

services atSC level

services atPHC level,

lab tests

referrals toPHC

referrals toFRU

FRUs

capitalprojects

initiatives

facilities, equipment,staffing

targets

management ofhigh risk cases

management ofcomplications

identificationof high risk

cases

feed back

Differences in service deliveryDifferences in service delivery

Resource generationResource generation• Role of top management crucial--Attention

– Consists of polity, administrative head, technical head/heads

– Suggests possible resource generation mechanisms

– Drives all processes by identification of key resources

– Focuses on implementation– Determine the cognitive architecture of the

system—determines problem and opportunity identification and utilization

– Identifies new initiatives and incorporates

Resource distributionResource distribution• Key role of middle management--

directioning– Make available key resources at point of use– Focus on distribution mechanisms-translate

processes into activities• Motivates field staff to produce

– Analyze and identify future requirements—existing and new resources

– Ensure focus of staff, discipline

Resource utilizationResource utilization• Role of unit heads--governance• Use of resources to deliver service• Require supervision and discipline

– To maintain alignment with desired output

– Improves with participation in planning– Is a function of work load facilitation

• Micro planning, management of extra work load, scarcities, technical help, skill development

Resource utilizationResource utilization• Use of governance mechanisms to

– Control output– Discipline staff– Facilitate performance evaluation– Generate feed back

• From staff • From consumers

– Validity and reliability of data • to be used in planning• Identify new initiatives

• Governance mechanisms—– Direct control – Cooperative mechanisms

Monitoring, evaluation, Monitoring, evaluation, course correctioncourse correction

• Starts at the field level• Have process monitoring

– Identify outcomes at every step of process to monitor

– Record, analyze –identify reasons for deviation– Incorporate corrections into process

• Skill development• Technology introduction• Discipline staff

• Ensure focus of staff, unit heads, programme heads

Mega frame- mapping of factorsMega frame- mapping of factorsKey factor UNIT DISTRICT STATEService delivery   Final services   Resource delivery   Idea delivery

Motivation to produce

  Interest of staff        

  Adequacy of facilities and equipment   MO interest

  Supervision

Adequacy of resources

  Adequacy of field staff

  Adequacy of key staff   Policy directives

Alternate resources   Availability of alternate resources

  Utilization of adaptation mechanisms

  Policy directives

  Emphasis on skill development

  Learning from past experiences

Initiatives and management skills

  MO interest and Supervision

  CDHO focus and initiatives   Top management focus

Process monitoring       Emphasis on monitoring   Focus on implementation   Identification of key resources

Consistent allocation

   

Training and learning

      Incorporation of initiatives

Resource generation

       

Work load management

   

Take away messagesTake away messages• Understanding of characteristics of

service delivery—important– Determines key resources– Directs logic for governance

mechanisms• Positioning of responsibility and

attention –should be appropriate– Ability to solve problems, take

opportunities—idea, power, execution,

Take away messagesTake away messages• Resource allocation

– Ensure consistent allocation• Ability to generate• Efficiency of utilization• Management of scarcity

• Resource distribution– Ensure availability at point of use

consistently

Take away messagesTake away messages• Resource utilization

– Ensure ability to use resources appropriately• Alignment with purpose-service to be delivered

– Ensure continuous adaptation to • Changes being done in services

• Feed back systems– Listen to consumers– Listen to field staff– Ensure validity and reliability of field or primary

data– Monitor and correct processes

Take away messagesTake away messages• Maintain slack of key resources

– Helps manage scarcities– Facilitates introduction of new services

• Position mechanisms to generate key resources at short notice– Alternate resources generation– Emergency mechanisms

• Look for problems, new services demand and plausible applications as solutions

THANK YOU –ANY QUESTIONS

Resource allocation-NBCPResource allocation-NBCP

OUTCOMECATARACTSURGERY

SKILLLEVELS

SURGEONS

NGOS andPPS in

DISTRICT

GOVERNMENTDISTRICT

SURGEONS

STATEPROGRAMMEHEAD FOCUS

INCENTIVES-- monetary----

capital

TRAINING,INFRASTRUCTURE,

CONSUMABLES

SUPERVISION

Medicalcolleges

RESOURCE GENERATION AND DISTRIBUTIONRESOURCE UTILISATION

GOIresourceprovision

Resource allocation--RNTCPResource allocation--RNTCP

OUTCOME

SERVICE DELIVERYCOMPONENTS

DOTS

Categorisation

Diagnosis

SERVICEPROVIDERS

FHW/MHW

Communityworker

MO

NGOS/PPS

Pvt DMCs andContractual

LTS

DMCS andLTS

RESOURCE GENERATION and DISTRIBUTION

Provision offield workers

Provision ofcommunityworkers

Provision ofMOs

Enrollment ofNGOS/PPs

Management ofDMCs and

LTs

DISTRICTPROGRAMMEHEAD FOCUS

SUPERVISION

EQA/IQA

PHImonitoring

Supervisormonitoring

STATE HEALTHSYSTEM

RESOURCE UTILISATION

Resource allocation--NVBDCPResource allocation--NVBDCP

Number ofcases

Vectordensity

Feversurveillance

Detectionand

diagnosis

IMN

Spraying

Vectorcontrol-

biological

Vectordensitystudies

Fieldworkers

Communityworkers

LTS

Supervisors

Contractlabor

Entomologist

MO SSupervisionand workfacilitation

Provision offield workers

Provision ofcommunity

workers

Provision ofstaff

Sprayingcontracts

Consumables

IMNimpregnation

Fishhatcheries

Seedingcontracts

Entomologists

DISTRICTHEAD

FOCUS andwork

facilitation

INITIATIVES

Communityaspirations and

feed back

HEADQUARTERS

GOICONSUMABLES

SUPERVISION

Training andskill

development

RESOURCE GENERATION RESOURCE DISTRIBUTION RESOURCE UTILISATION

OUTCOMES

SERVICEDELIVERYCOMPONE

NTS

SERVICEDELIVERE

RSUNITHEAD

RESOURCEPROVISIONMECHANIS

MS

PROGRAMMESTRATEGICCONTEXT

Resource allocation -RCHResource allocation -RCH

OUTCOMES--BR,IMR,CPR

,TFR,MMRSEVICE

DELIVERYCOMPONENTS-Maternal health,

child health,RTI/STI. Health andnutrition eductaion;

FP services;

REGULAR SERVICES

EMERGENCY SERVICES

SITES OF SERVICE DELIVERY

OUT REACH

SC/PHC

SPECIALIST CLINICS

FRU s

RESOURCE PROVISIONMECHANISMS-provisionof staff, provision of MOs

and specialists, provision ofequipment, provision of

infrastructure, provision ofconsumables,

MONITORING andEVALUATION

DATA COLLECTIONand RECORDING

TRAINING and SKILLDEVELOPMENT

COMMUNITY---Aspirations and feedback

POLITICALSYSTEM

STATE HEALTHSYSTEM

LINKAGES WITH--medical colleges;

international agencies

MO S --INITIATIVES--supervision, work

facilitation, communityparticipation,

microplanning, on jobtraining and knowledge

enhancement,

TOP MANAGEMENTFOCUS

STRATEGY ANDINITIATIVES

SUPERVISION ANDMONITORING

DISTRICT HEADFOCUS

VITAL EVENTSSURVEY

CNAA

SERVICE PROVIDERSMOOTIVATION -- field

staff, MO, speciaslists

TRANSPORT

RESOURCE GENERATION RESOURCE DISTRIBUTION RESOURCE UTILISATION