Establishment of village level health units for sustaining universal health coverage in

Madhya Pradesh, IndiaRakesh Parashar, Aboli Gore, Faiz Ahmed Kidwai

 

14th World Congress of Public Health, KolkataDr Rakesh ParasharMPTAST - FHI360

Introduction: Gram Arogya Kendra (Village Health Center)

A decentralized service delivery system which caters to the last mile population with basic health services and provides a platform for convergence of health and nutrition services.

Gram Arogya Kendra (GAKs) are established at existing Anganwari Centers

Functional in about 49000 villages in the state.

The health services are delivered by ASHA (Accredited Social health Activist) on regular days and by ANM (Auxiliary nurse and midwife) on the village health and nutrition day (VHND).

Study Objectives

This study tries to inform the health planners and manager about the Gram Arogya Kendra (Village Health Centers) running in Madhya Pradesh as a mechanism for Universal Health Coverage by :

1. Assessment of utility of and acceptance of Gram Arogya Kendras in village residents and health workers

2. Understanding operational challenges in service delivery at GAKs

3. Assessment of functionality of Gram Arogya Kendras

Methodology

• Semi-structured Interviews (Purposive sampling)

50 Village residents from 20 villages20 ASHAs10 ANMs5 Medical Officers

• Status check of functional items on a 57 item checklist

350 GAKs randomly selected from 5 districts

Data collection during April-May 2014 in 5 randomly chosen districts of Madhya Pradesh

Results

Details of information displayed at the GAK

Details of additional information

Availability of medicines & consumables

Instruments/Furniture availability

Infrastructure & Basic amenities

0 10 20 30 40 50 60 70 80 90

60.1

74.9

80.1

75.9

71.3

% Current Status

Status of Gram Arogya Kendra functionality on 57 item checklist

N = 350

47

38

15 Cat A (% of GAKs Scoring 81% & above)

Cat B (% of GAKs Scoring 61% - 80%)

Cat C (% of GAKs Scoring < 60%)

Categories of 350 Gram Arogya Kendra based on the 57 item checklist score

N = 350

Scores on 4 groups of parameters on the 57 item checklist

Names and services provided by ASHA, AWW and Sahayika are

available

List of temporary methods of family planning

Information about married & target couples, pregnant women, Newborns,

under five children, malnourished children, children registered in AWC

available

Birth, Death & Marriage registration details avaialble

0.0 20.0 40.0 60.0 80.0 100.0

76.6

74.3

72.9

89.7

70.6

% Current Status

Infrastructure & Basic Amenities in %

N = 350

Bench

ANC table

Weighing machine for baby

Infantometer for newborn

Weight machine for children

Haemoglobinometer

Stethoscope

Curtains

Functional BP instrument

Hub cutter

Thermometer

Torch

Almirah

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

64.280.383.7

52.391.4

78.978.9

95.478.0

% Current Status

N = 350

Availability of Instruments and Furniture in %

All vaccines with diluents

ORS

IFA tablets - small & large

Cotrimoxazole tablets

Zinc sulphate dispersible tablets

Paracetamol tablet (500 mg)

Methyl ergomentrine tablets

Albendazole tablets (400 mg)

Dicyclomine tablets (10 mg)

Povidon Iodine onitment

0.0 20.0 40.0 60.0 80.0 100.0

95.4

93.7

79.1

93.7

93.1

81.7

71.4

% Current Status

N = 350

Availability of medicines & consumables in %

Village health register

Death related information

Register for village health committee meetings

Register for other activities being done at the Gram

arogya kendra

Sign board for AWC & GAK

Notice board for displaying information outside the

centre

0.0 20.0 40.0 60.0 80.0 100.0

86.9

79.4

66.6

71.7

% Current Status

N = 350

Details of additional information in %

Results

Key responses from the interviews of health workers and village residents

%(Villagers)How do you think the quality of services currently provided at GAK is – Good/Average/Poor

Percieved changes in role of ASHA: After running GAKs ASHA role is better now.

Is there any change in ASHA's role for the village’s health after GAK is running?

Do you think ASHA is doing correct dispensing of medicines?

Would you like to receive medicines from it in future?

What medicine did you take from GAK? (Fever, Stomach pain - 60%) (Iron -28%)

Have you/ your family member ever taken medicines from GAK?

0 20 40 60 80 100 120

70

68

78

88

96

60

76

24

28

6

Interview of Villagers

Responses from interviews of 50 village residents

Are the services adequate for basic health problems?

What do you think about your role as a health activist, Is it better after GAK is running or it was better earlier?

Are you being comfortably able to manage your duties between sitting at GAK and visiting homes in the village?

Are you confident in correctly dispensing all 16 medicines?

Have your received all 16 medicines required at GAK from ANM?

Have you been oriented for providing services at GAK

0 10 20 30 40 50 60 70 80 90 100

70

60

60

70

75

100

Interview of ASHA

Responses from ASHAs (N=20)

Are the ASHAs in your area dispensing medicines correctly?

Are all 16 provisioned medicines available in your stock for distributing to your GAKs?

Are you satisfied with the services being provided at GAKs?

0 10 20 30 40 50 60 70 80 90

60

60

80

Interview of ANM

Responses from ANMs (N=10)

As per Medical Officer % of Service utilization by villagers - Not started/ Started but little utilization / Started and good

utilization

Service availability at GAK Adequate

Have you conducted any supportive supervision rounds to any GAKs?

Have you met any VHSC members to utilize its funds to procure amenities at GAKs?

Are adequate supplies available in your sector, which can be dispensed at GAKs?

Have you received official instructions and guidelines to establish and run GAKs in your area?

0 20 40 60 80 100 120

4060

80

60

60

100

80

Interview of Medical Officer

(Little Utilization)

(Good Utilization)

Responses from Medical Officers (N=5)

Do you think provision of GAKs shall reduce health related expenditure of villagers?

Do you think GAKs can help in early primary treatment/ early referral at village level?

Do you think the monitoring of medicine distribution from block to PHC and till villages is sound?

Are ANMs visiting for the GAKs for supportive supervision during VHNDs?

Have all ASHAs been oriented about correct dispensing of medicines?

0 20 40 60 80 100 120

80

100

60

60

80

Interview of Medical Officer

Responses from Medical Officers (N=5)

Results Summary: Acceptance

An overall positive attitude and acceptance in village respondents observed, which is backed by good utilization of existing services as well as willingness of utilization in future.

The ASHAs perceive their role better now with a responsibility of providing medication to villagers

The ANMs find their workload to have reduced , however with added responsibility of monitoring ASHAs work

The Sector Medial Officers appreciate the presence of GAKs and find it a good concept to reduce geographical limitation and out of pocket expenditure for basic health problems.

ASHA : • to manage their work• seek more support from ANMs • fixed remuneration for this activity with provision of more dedicated space.

Village residents : • demand for more medicines and for more time spent by ASHA • Medical officer’s visit at least once a month.

ANMs : Rrecord updating by ASHA at GAK remains a problem.

Medical officers find management of supplies and monitoring visits by themselves and ANMs a challenge.

Results Summary: Challenges

Study Limitations

Small Sample with purposive sampling for interviews

Study doesn’t include view point of health planners and managers at higher levels

The functionality assessment is limited to infrastructure, supplies and other input parameters, doesn’t cover service utilization and service quality statistics

The researchers are not exclusive from the implementers of the GAK concept

Discussion and Conclusions

WHO Health System framework- 2007, Six building blocks of health system

Service Delivery - Village level health units, Gram Arogya KendraHealth workforceInformationMedical products, vaccines and technologyFinancingLeadership and Governance

Extended and decentralized service delivery can improve level of health equity and outcomes through improved access and coverage

Improving Access

Reducing out of pocket expenditures

Improved health outcomes

Reduced travelling for minor health issues

Avoiding local private practitioners

Early symptom check

Better early referrals

Elimination of geographical barrier

Universal Health Coverage

Village level health units in Madhya Pradesh, India have shown good acceptance by and large from the beneficiaries and health workers.

Continuity of availability of provisioned medicines and supplies with monitoring and measurement of service delivery, utilization and service quality needs to be continuously improved for effective service delivery at these village level units.

Thank You

Possible research themes in future:

Service delivery – Coverage , Utilization , Quality Outcome measurement Impact on overall village health and functioning of health system Change in social equations-dynamics related to health within the

villages Models of effective monitoring and sustaining supply chains