Reproductive Health Services and Sector Reform (RHSSR) in AP

Institute of Health SystemsHACA Bhavan, Hyderabad, AP 500004, India

Reproductive Health Services and Sector

Reform (RHSSR) in AP.State Action Plan

IHS Project teamDr. Prasanta MahapatraMs. Samatha ReddyMs. Pushpa LathaMs. Swathi GayatriMs. Mary Nancy

Mr. Mukesh JanbandhuMs. Neelima

Interacted and benefited from:Ms. Nilam Sawhney, Commissioner, CFWDr. PattabhiramaiahMs. Priya Mohandas and other staff of CFW

Presentation Outline

Reproductive Health Status in APChild Health Status in APReview of RCH Programs in APResults from ANM Focus GroupsThe PHC Medical Officers Workshop.Understanding the Vision 2020 health goalsPolicy reviews - OverviewState Action Plan

RHSSR-AP

Reproductive Health Status in AP

Married19.1%

Single81.0%

India

Married4.8%

Single95.3%

Kerala

Married19.8%

Single80.3%

Maharashtra

Married6.4%

Single93.6%

Tamil Nadu

Married16.9%

Single83.0%

Karnataka

Married28.7%

Single71.3%

Madhya Pradesh

Married41.4%

Single58.6%

Andhra Pradesh

Married13.5%

Single86.5%

Orissa

Marital status of Young girls(<18 years) in AP, and other states.

Source: Median of estimates for years 1993-98 from SRS 1993-94 statement-12, p28; 1995-96 statement-11, p28; 1997-98 statement-11, p27.

Source: SRS for the period 1971-1998. Estimates for 1971-73, 1974-76 are the average total fertility rates given in SRS 1976-78 (statement no-38). Estimates for 1979-81 given in SRS 1981(statement-15)

1971 1974 1977 1980 1983 1986 1989 1992 1995 19981

2

3

4

5

6

Tota

l chi

ldre

n/W

oman

KE

TN

KA

AP

MH

MP

OR

IN

Total fertility rate (TFR) in Andhra Pradesh and other states 1971-1998

KNL

ANT

MBN

RRD

KMM

ADB

MDK

PKM

WGL

CDP

NLG

KRI

HYD

GUN

KNGNZB

SKM

CHI

VZGVZM

NLRWGD

EGD

60 70 80 90 100 110 120 130 140 150 160

Infrastructure Development Index

2.5

3

3.5

4

4.5

5

Tota

l Fer

tility

Rat

e

Source:CMIE, 2000. The computations of Infrastructure Development Index is for 1995. District level estimates of fertility and child mortality for 1991 and their interrelations with other variables. Occasional paper No.1 of 1997 RGI.

Level of Infrastructure Development in AP districts and their Total Fertility Rate.

Source: District level estimates of fertility and child mortality for 1991 and their interrelations with other variables. Occasional paper No.1 of 1997 RGI. Female literacy rates are computed from the data on No.of female literates given in Provisional population tables . Census-1991

Female literacy and TFR in the districts of Andhra Pradesh for the year 1991.

MDK

MBN

CDP

ADB

NZBNZMSKL

NLG

KNG

KNL

WGL

ANT

PKM

KMM

VZG

CHI

RRD

GUNNLR

EGDKRI

WGD

HYD

10 20 30 40 50 60

Female literacy rate

2.5

3

3.5

4

4.5

5

2.5

3

3.5

4

4.5

5

Tota

l fer

tility

rate

Source: Mahapatra, Estimating National Burden of Disease, 2000, Appendix: 3-7.1 and 3-8.1.

Major causes of death among rep. age women (15-44Y), in AP, 1991.

Cause of death Num ber of fem ale deathsRural Urban Total

All causes 44109 8049 52158M aternal CausesM aternal Hem orrhage 462 82 544M aternal sepsis 462 118 580Hypertensive disorders of pregnancy 599 4 603Obstructed labour 308 7 315Abortion 1044 56 1100Other m aternal conditions 890 389 1279Other m ajor causesSelf-inflicted injury (suicides) 8544 94 8638Fire accidents 1763 1645 3408Violence 1215 349 1564

Estim ated m aternal deaths 3765 656 4421Estim ated births in 1991 1288453 436446 1729208M at. M ort. Ratio / 100000 Live births 292 150 256

Spont. & Induced Abortion,

NFHS 1998-99.

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��AP TN KA KE MP MH OR IN

0

2

4

6

8

10

12Pe

rcen

tage

�� Induced abortion Spontaneous abortion

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

Rural 15-19 Rural 20-24 Urban 15-19 Urban 20-24

Residence and Age-group

0

5

10

15

20

25

abor

tion

rate

s��

�� Induced abortionSpontaneousabortionAP &

Neigh. States

Within AP:By Residence and Age groups

RHSSR-AP

Child Health Status in AP

Source: SRS Annual Reports, 1971 - 1999.

Infant mortality trend in AP and other neighbouring states

1971 1975 1979 1983 1987 1991 1995 19990

50

100

150

0

50

100

150

Infa

nt d

eath

s pe

r tho

usan

d liv

e bi

rths

AP

TN

KA

KE

MP

MH

OR

IN

IMR in APThe Widening Rural Urban Gap!

1970 1974 1978 1982 1986 1990 1994 1998

20

40

60

80

100

120

140

160

20

40

60

80

100

120

140

160

Infa

nt M

orta

lity

Rat

e

AP-Urban AP-Rural

Source: SRS Annual Reports, 1970 - 1999.

22 137

22 137

IMR in APInter District Disparity !

Source: SRS 1970-1998

Decomposition of IMR in AP

1971 1974 1977 1980 1983 1986 1989 1992 1995 199810

20

30

40

50

60

70

80

90

100

110

120

130In

fant

Mor

talit

yPostneonatal mortality Neonatal mortality

AP TN KA KE MP MH OR IN0

20

40

60

80

100

Mor

talit

y ra

tePost Neonatal Mortality Neonatal Mortality

And Neigh. StatesSource: NFHS 1998-99

RHSSR-AP

Review of RCH Programs in AP

None34.7%

< than 321.5%

3 or more ANCs43.8%

India

None7.6%

< than 312.3%

3 or more ANCs80.1%

Andhra Pradesh

Pregnant women by No. of Ante Natal Check ups, India & AP

Source: NFHS, 1998-99.

Antenatal care content and coverage in AP, 1998 - 2002.

Source: CFW, 2002. Annual Reports from DM&HO office. Data for 2002 is from Apr-Dec 2001. Projections are made to arrive at the 2002 data.

Iron Folic Acid Tablets

TT Immunisation

Antenatal Registration

1998 1999 2000 2001 20020.7

0.8

0.9

1

1.1

1.2

1.3

Wom

en/ L

ive

birth

Cov

erag

e

3 or more ANCs

Awareness and knowledge levels regarding TT immunistion

Source: Umadevi and Rao, 1997

��

��

��

��

��

��

Aware but no knowledge

Aware and Knowledgeable0

20

40

60

80

100

Perc

enta

ge o

f wom

en in

terv

iew

ed

Not AwareNo Knowledge

Source: SRS Annual Reports, 1970-1998.

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

Trained attendent

Health Care Institution

1970 1974 1978 1982 1986 1990 1994 1998

0

10

20

30

40

50

60

70

80

90

100

0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge o

f liv

e bi

rths

Medical Attendance at the time of Delivery. AP Time Trend

Source: SRS Annual Reports, 1970-1998. Projections are made till the year 2050

Institutional delivery projections for AP under no intervention scenario

1970 1980 1990 2000 2010 2020 2030 2040 2050

Year

0

10

20

30

40

50

60

70

80

90

100

% D

eliv

erie

s in

Hea

lth C

are

Inst

itutio

ns Observed Projected

Source: NFHS-AP 1992-93, 1998-99

Institutional Deliveries in AP, 1990s

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

32.9

49.8

1992-93 1998-99

Year of Survey

0

20

40

60

80

100

% B

irths

in H

ealth

Car

e In

stitu

tion ��

��

�� ForProfit HCI

NonProfit HCI��

��

�� Public HCI

Access to Institutional Deliveries in AP, NFHS-2, 1998-99. Standard of Living.

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

29

54.9

84.8

Low Medium High

Standard of Living Index

0

20

40

60

80

100

% B

irths

in H

ealth

Car

e In

stitu

tion

��

��


NonProfit HCI��

��

�� Public HCI

Access to Institutional Deliveries in AP, NFHS-2, 1998-99. Social Status.

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

22.3

37.6

49.5

65.7

Sch. Tribe Sch. Caste OBC Others

Caste

0

20

40

60

80

100

% B

irths

in H

ealth

Car

e In

stitu

tion

��

��


NonProfit HCI��

��

�� Public HCI

No.of deliveries in first referral hospitals (APVVP) in AP - time trend Jan 1998 to Mar 2002

Jan

96

Jul 9

6

Jan

97

Jul 9

7

Jan

98

Jul 9

8

Jan

99

Jul 9

9

Jan

00

Jul 0

0

Jan

01

Jul 0

1

Jan

02

3

4

5

6

7

8

9

10

No.

of d

eliv

erie

s in

APV

VP H

ospi

tals

in th

ousa

nds

1424 New beds added

Immunisation coverage in AP, 1991-02

Measels

Polio

DPT

BCG

1991 1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

0.8

0.9

1

1.1

1.2

0.8

0.9

1

1.1

1.2

Dos

age

/ Liv

e Bi

rthC

over

age

Cold Chain MaintenanceStudy done by Mahapatra, Gayatri and Reddy, Institute of Health Systems (IHS)

FindingsState and regional cold chain units are being maintained reasonable wellNeed for batch level accounting of vaccines and closer monitoring of the cold chain statusComputerisation of the state and regional cold chain unitsAt the district level the refrigerator mechanic is a critical linkAt the PHC level, unreliable and poor quality power supply is a major problemAppropriate design changes in choice of voltage stabiliser is recommendedMore clarity in job discriptionsPersonnel should receive continuing education at periodic intervals about vaccine storage and handling procedureMany health workers are not aware of the usefulness of Vaccine Vial Monitor (VVM)

Gastroenteritis case fatality rate in AP, 1991-2000

Source: Directorate of Health, Monthly Progress reports 1991-2000

1991 1992 1993 1994 1995 1996 1997 1998 1999 20000

0.5

1

1.5

2

2.5

3

3.5

4

Dea

ths/

100

cas

es o

f GE

Contraceptive consumption in AP, 1989-01

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

0

500

1000

1500

2000

Thou

sand

s

Condoms

��

�� OP

��

�� IUD

Source: Annual reports from DM&HO office, Family planning section, CFW, 1989-2001

Incidence of female and male sterilisations in AP. Time Trend 1966-2001

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

��

1966 1971 1976 1981 1986 1991 1996 20010

100

200

300

400

500

600

700

800

900

Thou

sand

s

��

��

�� Vasectomy Tubectomy

Medical termination of pregnancies in both the private and public institutions, AP, 1998-2001

1998 1999 2000 2001 200210

11

12

13

14

No.

of M

TPs

in th

ousa

nds

Source: CFW, 2001. Annual Reports from DM&HO office

Gaps is availability of utilities, equipment, supplies and maintenance of PHCs in AP

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

20

40

60

80

100Electricity

Laboratory

Water supply

Labour room

Vehicle

Telephone

Utility

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

20

4060

80

100Vac. carrier

Freezer

BP App.

Autoclave

Labour equip.

MTP suction

Equipment

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

20406080100

Measles Vac.

ORS Pkts

Oral Pills

Labour Rm Kit-I

IUD Kit-G

IFA Tabs

Mounted Lamp

EmOC Drug Kit

Supplies

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

��

�� 20406080100

OT Fumigation

LR Fumigation

Temp Maintd. ILRDial T'mtr. in ILR

Bldg. Maint.

Maintenance

Shaded area means all listed facilities available. Clear area is the gap.

RHSSR-AP

Results from ANM Focus Groups

ANM Focus Group DiscussionsSupport for current schemes like Sukhibhava, Natl. Maternity Benefit Scheme, Balika Samrakshana, and Arogyaraksha.But a lot of operational concerns! Lack of leadership support:

Supervisors behaving more like inspectors rather than resource persons.Janani members aloof and uninterested. As a result more of a drag and less of help.

Inadequate infrastructure support:PHC services are not reliable

ANM Focus Group contd...

ANM EffectivenessFaulty location of sub centres.Buildings available but not maintained.Operational problems in the moped scheme affecting ANM availability.Sub Ctr. pop. coverage, job chart, work load, and male worker role need comprehensive review.Too much paper work and too little stationery!Inadequate and / or inappropriate drug supply.

RHSSR-AP

Results from the PHC Medical Officers

Workshop.

Recommendations by PHC MOs

Emphasis on education, literacy and health education.Reduce population coverage by sub centres.Redeploy vaccant male health worker posts to create new sub centres.Concern about irregular and inadequate supply of drugs.Support for Round the Clock PHCs.

Understanding the AP Vision 2020 health goals

RHSSR-AP

Understanding the AP Vision 2020 health goals

Vision 2020 Targets:IMR=10/1000 live births; Child mortality = 20/1000 population

As per SRS data the CMR for the years 1996 to 98 is 4.9, 3.4 and 4 respectivelyNFHS estimate of CMR is about 21-22The West model of Coale and Demeny shows that at Level 21 the life expectancy is 70 which is closest to the life expectancy target of 70.6 in the Vision 2020. The IMR in this model is 31.4 and CMR is 8

Comparision of Vision 2020 goals with Model life table, NFHS & SRS data

SRS 1998

NFHS 2, 1998

Stated Vision 2020

Infant Mort. Rate Child Mortality Rat0

10

20

30

40

50

60

70

Prob

abilit

y of

Dea

th /

1000

Per

sons

Closest Model for Life Exp. Vision of 70.6Y(Coale and Demeny Regional Model West

Level-21)

Overview of Policy Reviews and

Recommendations

RHSSR-AP

Workforce managementObjectives

assess current workforce situationestimate demand for the next five yearsidentify training requirementssuggest career options

Methodologybrainstorming with experts, indepth key informant interviews, review of official documentsdetails about identification and selection of experts for brainstorming, the nature of their expertise, etc., not availabledetails of indepth key informant interviews not availablebibliographic citation of official documents and other references not available

Few contradictions in the set of recommendationsNo. of ANM posts

the reviewers recommend on the one hand to stick with ANM and male worker at the sub centre but propose in the subsequent recommendation to redeploy MPHA-M vacancies as ANM positions.

Primary Public health workforce availability Role of Multi-purpose health assisatant (male)

DecentralisationObjectives

review the role and effectiveness of health committees / PRIsidentify and delineate roles and responsibilities

Methodology adopted is not adequately describedformal and informal discussionsfocus group discussionsComposition of the research team for this review is not clearspeicfic details of FGDs are not given

Recommendationsdraft policy limits its examination to the advisory committees attached to various HCIs and the HAC in particularcommunity needs assessment approach adopted by the GOI envisages inceasing role for PRIs. The review does not discuss about the current role of PRIs and how they can play more effective role to improve the efficacy and accessibility of health care services.

Rational Use of InfrastructureObjectives

existing primary health infrastrucutre and gapsavailability of buildings, equipment, drugs and consumablecurrent utilisation of infrastructure, maintanace statussystem of referral between primary, secondary and tertiary health care institutions

Methodology12 district facility survey in AP by the ASCINHFS, information from CFW, field visits to facilities in Districts, in depth interviews with program officers, brainstorming with expertsadditional sources of information like field visits to facilites, in-depth interviews with program officers, brainstorming sessions with experts are not given in details

Recommendationsadopt appropriate sign postings on the main roads directing people to public hospitals and health centres and to improve the visibility of the organisationstorage shelves at every village with required supplies and equipment, pertmit ANMs to give intra muscular antibiotic injectionsestablish norm for equipment to be available at different levels of institutions and create annual appraisal systems for the adequacy

Analysis of financial systemsObjectives

current budget release mechanisms and the prevailing operational autonomy of CHCs and PHCsspatial variations - measurement, capacity to benefit from investments, and area specific allocation mechanismsPerformance assessment and linked funding mechanism.

Methodologythe review did not give any information about the study methodology, bibliographic references.

Spatial variationsthe draft policy proposes an indicator to measure absorptive capacity of district for health services. The indicator is based on literacy, and infrastructure faciliteis.Infrastructure Development Index (IDI) I is being computed by Centre for Monitoring Indian Economy (CMIE)the policy reviewers have not compared the index proposed by them with other know indicators. Hence it is difficult to assess the usefulness of this new indicator over the CMIE IDI.

State Action Plan

RHSSR-AP

Sector Reform GoalsVision 2020 Goals:

Access to responsive basic healthcare.Free healthcare for poor and vulnerable and health insurance for others.Pregnancies will be safe.Infants will not die of easily curable ailments like diarrhoea, or acute respiratory infections.

Vision 2020 Targets:IMR=10/1000 live births; Child mortality = 20/1000 children; TFR=1.5; and Pop. growth =0.8% per year.

But needs review

State Population Policy Goals:Reduce FertilityReduce Maternal MortalityReduce Infant / Child Mortality

State Population Policy Targets:

Sector Reform Goals-Contd...

2010 2020IMR 30 15MMR 1.2 1.5TFR 1.5 1.5Couple protection 70% 755Natural growth rate .8 .7Crude Birth Rate 15 13Crude Death Rate 7 6

But needs review

Overview and RecommendationsReform com ponent / schem e Am ount in crores

Capital RecurringBasic PackageBasic package of Drugs, supplies and Equip. for SCs 26.52Developm ent of ANM Practice guidelines 0.25Im provem ent of locational convenience of sub centres 10 0.25Im provem ent of locational convenience and accessibility of PHCs 2Institutional DeliveryExpanded Sukhibhava 6.6M aternity service capacity strengthening grant m anual. 0.25

Strengthening of Non profit / charitable hospitals to cater to t 6.6Strengthening of APVVP hospitals to cater to the institutional deliveries 9.09

Development of Health Maintenance Organization (HMO) based InstiInsurance Scheme 0.5

Training and Hum an Resource Developm entCom prehensive training needs assessm ent study 0.5Skill Developm ent training's for ANM s, Param edical Staff and PHC M O's 1

Training of opinion leaders, police, PRI leaders, priests etc. o 1

State wide interventions to achieve vision 2020 and state populationRe-com m issioning of Policy reviews 1.5VALUE (Vaccine Logistics M anagem ent Software) 0.5

Area specific interventionsSm all Area Program s and studies to support sm all area planning 10 0.3

Enabling Environm entDevelopm ent of Accreditation system 0.25Assured Incom ing Call (AIC) Telephone at PHCs 0.75Total (crore rupees per annum ) 24.5 53.36

Basic Package

Drugs, supplies and equipment at the subcentrethe basic package of drugs, supplies and equipment to be available at the subcentre is given.A detailed development of practice guidelines has to be developed either by the department in house or consultants may be engaged.

Improvement of locational convenience and accessibilitySubcentre

Selection of a centrally located and easily accessible site in the midst of the habitation and construction of the subcentre buildings on such a site would be the right solution.

PHCInfrastructure policy review recommends to adopt appropriate sign postings on the main roads.Provide communication and improve transport facilities to every PHC so as to improve its accessibility

Institutional DeliveriesExpanded Sukhibhava

The department may set a target to increase the coverageWe have recommended that the Sukhibhava coverage be expanded at the rate of at least one third per annum.

Strengthening of non profit/charitable hospitals to increase Institutional deliveries

The scheme may be expanded to deliveries in non profit hospitals and other charitable institutions in addition to public health care institutions.Some of these hospitals and maternity homes may also need strengthening of their capacity to be able to handle the increase in the no.of deliveries

Strengthening of APVVP hospitals to increase institutional deliveries

APVVP should be given a target of increasing the institutional deliveriesRight now they are doing about 1 lakh deliveries per annumThe number of deliveries be increased by atleast 50% every year

Training and Human Resource Development

Skill development training's for ANMs, paramedical staff and PHC medical officers

Training programmes be developed and offered to ANMs, paramedical staff in PHCs and PHC medical officersA comprehensive training needs assessment is to be doneExisting training programmes may be strengthened and few new training programmes may be introduced in an adhoc basis

Workshops and training about implementation of age at marriage laws

Training of executive magistrates and police on implementation of age at marriage lawsWorkshop for Panchayati Raj leaders on implementation of age at marriage lawsDesignation of religious institutions and Priests as Marriage Registrars and continuing legal education about age at marriage

Statewide interventions to achieve vision 2020 and state population policy goals

Re-commissioning of policy reviews and commissioning of new studies

Draft policy reviews have glaring inadequacies in the methodology, inadeqate coverage of issues.Some recommendations need more detailed work to operationalise

Vaccine Logistics Utilisation and Equipment (VALUE) mangement system

SCU and RCUs should be linked through a wide area network, solutionDistrict stores and vaccine service centres (PHCs) should be computerised.VALUE management application should be developed and deployed over wide area network linking the SCU, Regional units.

Area specific interventions to achieve vision 2020 and SPP goals

Infrastructure for small area specific planning and monitoringNeed district and divisional level estimates and area specific interventions to reduce IMR

Small Area Specific ProgrammesNeed for a regular system of prospective surveillance of Maternal Mortality and research studies commissioned to measure MMR

Accreditation SystemAssured Incoming Call (AIC) telephone at PHCs

We are recommending Public Access Telephone (PAT) for primary health centres

Thank You

Documents

Reproductive Health Services and Sector Reform (RHSSR) in AP