Capacity building of_health_institutions

USAIDFROM THE AMERICAN PEOPLE

UN

ITED STATES AGEN

CY

INT

ER

N

ATIONAL DEVELOP

ME

NT

USAID INDIA

US Agency for International DevelopmentAmerican Embassy

ChanakyapuriNew Delhi – 110 021

INDIATel: (91-11) 2419 8000Fax: (91-11) 2419 8612

www.usaid.gov

Capacity Building of Institutions in the Health SectorReview of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand

The Power of

Innovations and

Partnership

APRIL 2012This publication was prepared for review by the United States Agency for International Development. It was prepared by Futures Group International.

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Suggested citation: IFPS Technical Assistance Project (ITAP). 2012. Capacity Building of Institutions in the Health Sector: Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand. Gurgaon, Haryana: Futures Group, ITAP.

The IFPS Technical Assistance Project is funded by the United States Agency for International Development (USAID) under Contract No. GPO-I-0I-04-000I500, beginning April 1, 2005. The project is implemented by Futures Group International in India, in partnership with Bearing Point, Sibley International, Johns Hopkins University, and QED.

For further information, contact: Futures Group International, DLF Building No. 10 B, 5th Floor, DLF Cyber City, Phase II, Gurgaon - 122 002www.futuresgroup.com

The Power of

Innovations and

Partnership

APRIL 2012The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Capacity Building of Institutions in the Health Sector

Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand

FOREWORDUSAIDFROM THE AMERICAN PEOPLE

UN

ITED STATES AGEN

CY

INT

ER

N

ATIONAL DEVELOP

ME

NT

USAID INDIA

FOREWORD

U.S. Agency for International DevelopmentAmerican Embassy Tel: 91-11-24198000Chanakyapuri Fax: 91-11-24198612New Delhi – 110021 www.usaid.gov/in

India has made significant strides in improving its health indicators over the last few decades. Introduction of the National Rural Health Mission (NRHM) in 2005 further reinforced its commitment to improve health indicators and achieve the universal Millennium Development Goals. The United States Agency for International Development (USAID) has been a strong and committed partner as India strives to improve its family planning and reproductive health indicators across the country.

USAID, in collaboration with the Government of India, launched bilateral Innovations in Family Planning Services (IFPS) Project in 1992 to design, test and expand innovative approaches for improving quality of and access to family planning and reproductive and child health services, particularly for women, rural populations, and other underserved groups. Support for developing and strengthening individual and institutional capacity has been the mainstay of all USAID programming, reflected in the implementation efforts of the IFPS Project. Programs as well as technical assistance were designed to support state societies and address their capacity needs in implementing NRHM, while generating evidence on innovative approaches to achieve health objectives.

The IFPS Project has worked in close partnership with Indian institutions to build capacities of people and develop systems for quality assurance, training, strategic behavior change communication, monitoring and evaluation, and other aspects to improve health management. These efforts have paved the way for shaping leading institutions that can contribute tremendously in the implementation of health programs.

This volume is a summary of the various initiatives undertaken during the course of implementation of the IFPS Project to foster, lead and manage the capacity building process to improve performance of health services. USAID hopes that this compilation will further inform state governments and institutions in their capacity building efforts.

Kerry PelzmanDirector

Health Office

v

Acknowledgements vii

Abbreviations viii

Executive Summary x

1. INTRODUCTION 1

1.1 Purpose and Organization of the Report 3

2. ANALYSIS OF NEEDS 4

3. COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL 5

3.1 Series of Collaborations with National Institute of Health and Family Welfare 5

3.2 Laying the Foundation for National Health Systems Resource Center 9

4. BUILDING CAPACITIES OF THE STATE INSTITUTES OF HEALTH AND FAMILY WELFARE 10

4.1 About State Institutes of Health and Family Welfare 10

4.2 Support to Establish and Build Capacities for Sustainable SIHFW: Uttarakhand and Uttar Pradesh 10

4.3 Setting the Stage in Jharkhand 12

5. TECHNICAL SUPPORT FOR IMPLEMENTATION OF NRHM IN UTTARAKHAND AND UTTAR PRADESH 14

5.1 Support to SHSRC in Uttarakhand 14

5.2 Strengthening Systems for Decentralized Planning 15

5.3 Capacity Building of Rogi Kalyan Samitis in Uttarakhand 16

6. SUSTAINABLE INSTITUTIONS TO BRING HEALTH CLOSER TO THE PEOPLE 18

6.1 Support for Creation of State ASHA Resource Center and District ASHA Resource Centers 18

7. SETTING UP MECHANISMS FOR QUALITY ASSURANCE 20

7.1 Quality Assurance Mechanisms and Programs 20

7.2 Quality Assurance for PPP Models 21

7.3 Quality Improvement Processes for RCH Camps in Jharkhand 23

8. SIFPSA: LEAVING BEHIND A LEGACY 25

8.1 Creation of an Autonomous Body for Implementation of IFPS Project in Uttar Pradesh 25

8.2 Drawing an Organizational Framework for the Society 25

CONTENTS

Contents

vi Capacity Building of Institutions in the Health Sector

8.3 Performance Based Disbursement Mechanism 26

8.4 Building Capacities and Providing Technical Assistance for a Sustainable Society 27

8.5 Transitioning and Re-aligning itself through the Course of the IFPS Project 27

8.6 Key Issues Affecting SIFPSA’s Operations 31

8.7 Elements of Success 31

8.8 Addressing Complexities for SIFPSA’s Course Ahead 31

9. STRENGTHENING INSTITUTIONS TO PROMOTE FAMILY PLANNING IN JHARKHAND 32

10. BUILDING CAPACITIES OF THE PRIVATE SECTOR 34

10.1 Identifying and Building Local Capacities 34

10.2 Enhancing Capacities of the Private Facilities for Provision of Quality Services 35

10.3 Evidence-based Planning, Design and Implementation of Programs 36

10.4 Orienting Advertising Agencies to the Development Sector 36

11. CHALLENGES AND WAY FORWARD 38

REFERENCES 39

List of TABLES

Table 1: Summary of Courses in Collaboration with NIHFW 7

Table 2: Summary of the Training and Content Development Support to SIHFW 12

Table 3: Clinical Trainings conducted in Uttar Pradesh as part of the IFPS Project (2004-2012) 29

Table 4: A Summary of the BCC initiatives under the IFPS Project in Uttar Pradesh (2004-2012) 30

Table 5: By the Numbers: Family Planning Fortnight 33

List of FIGURES

Figure 1: Capacity Building Framework: IFPS Project 2

Figure 2: State ASHA Support System 19

Figure 3: Organizational Structure of the State Innovations in Family Planning Services Agency 26

viiAcknowledgments

This report documents the efforts and contributions made

by USAID through the Innovations in Family Planning Services (IFPS) Project towards capacity building and strengthening of public and private institutions in the health sector in India. The report highlights the support rendered at the national level and in three Indian states: Uttar Pradesh, Uttarakhand, and Jharkhand. The USAID funded IFPS Project is a joint US-India initiative that has worked to promote improved family planning and reproductive health for India’s poor communities and works in close collaboration with Ministry of Health and Family Welfare, Government of India as well as with state societies in Uttarakhand, Uttar Pradesh and Jharkhand.

The project would like to acknowledge the collaborative efforts of the public health institutions including the Ministry of Health and Family Welfare, Government of India,

ACKNOWLEDGMENTS

state governments, apex national and state institutes (National Institute of Health and Family Welfare (NIHFW), State Institute of Health and Family Welfare (SIHFW), National Health Systems Resource Center (NHSRC) and State Health Systems Resource Centers (SHSRCs), State Program Management Units (SPMUs) and District Program Management Units (DPMUs) for National Rural Health Mission (NRHM) implementation at the state level, state societies (State Innovations in Family Planning Services Agency (SIFPSA), Uttarakhand Health and Family Welfare Society (UKHFWS) and Jharkhand Health Society (JHS) and district counterparts and several private institutions, including private health facilities, nongovernment organizations, research organizations and other creative agencies. These collaborations have resulted in strengthening of these institutions to contribute to the overall health systems strengthening in the country.

We would also like to acknowledge the technical leadership and guidance provided towards the capacity building efforts by the USAID India Mission, especially Dr. Loveleen Johri, Shweta Verma and Vijay Paulraj.

Tanya Liberhan, IFPS Technical Assistance Project (ITAP) (Futures Group), compiled this report with constant guidance and support from Dr. G Narayana and Shuvi Sharma. The report has been put together drawing uponseveral interviews with project staff and partners, and a range of published and unpublished project reports, documentation and databases. Several individuals contributed to the drafting of this report, including Dr. Gadde Narayana, Shuvi Sharma, Ashutosh Kandwal, Dr. Ajay Misra, Dr. Santosh Singh, and Dr. Nimisha Goel. This report has been reviewed by Dr. G Narayana, Shuvi Sharma, Dr. Suneeta Sharma, and Dr. Nidhi Choudhry and their inputs have proved to be invaluable.

viii Capacity Building of Institutions in the Health Sector

AIDS Acquired Immuno Deficiency SyndromeANC Antenatal CareANM Auxiliary Nurse Mid-wifeASHA Accredited Social Health ActivistBCC Behavior Change CommunicationBHEO Block Health Education OfficerBPL Below Poverty LineCHC Community Health CenterCHV Community Health VolunteerCMO Chief Medical OfficerCOPE Client Oriented and Provider EfficientDAP District Action PlanDARC District ASHA Resource CenterDGHS Director General Health ServicesDHAP District Health Action PlanDivPMU Divisional Program Management UnitDPM District Program ManagerDPMU District Program Management UnitDQAG District Quality Assurance GroupEAG Empowered Action GroupED Executive DirectorFOGSI Federation of Obstetric and Gynecological Societies of IndiaFP Family PlanningFRU First Referral UnitFWC Family Welfare CounselorGDP Gross Domestic Product GHI Global Health InitiativeGoI Government of IndiaGoUK Government of UttarakhandGoUP Government of Uttar PradeshHIV Human Immuno VirusHMS Hospital Management SocietyIEC Information Education and CommunicationIEC Information, Education, and CommunicationIFPS Innovations in Family Planning ServicesIPC Interpersonal CommunicationIPH Institute of Public Health

ABBREVIATIONS

ixAbbreviations

IPHS Indian Public Health StandardsITAP IFPS Technical Assistance ProjectIUCD Intrauterine Contraceptive DeviceJSK Jansankhya Sthirata KoshLHV Lady Health VisitorMCH Maternal and Child HealthM&E Monitoring and EvaluationMDG Millennium Development GoalMGHN Merrygold Health NetworkMIS Management Information SystemsMNGO Mother Nongovernmental OrganizationMoHFW Ministry of Health and Family WelfareNABH National Accreditation Board for Hospitals and Health Care ProvidersNGO Nongovernmental OrganizationNHSRC National Health Systems Resource CenterNIHFW National Institute of Health and Family WelfareNRHM National Rural Health MissionNSV No-scalpel Vasectomy PBD Performance Based DisbursementPERFORM Program Evaluation Review for Organizational Research MangementPHC Primary Health CenterPHFI Public Health Foundation of IndiaPIP Program Implementation PlanPMV Project Management UnitPPP Public-Private PartnershipPRI Panchayati Raj InstitutionQA Quality AssuranceQI Quality Improvement RCH Reproductive and Child HealthRH Reproductive HealthRKS Rogi Kalyan SamitiSARC State ASHA Resource CenterSHSRC State Health Systems Resource CenterSIFPSA State Innovations in Family Planning Services AgencySIHFW State Institute of Health and Family WelfareSNMC Sarojini Naidu Medical CollegeSPMU State Program Management UnitTAG Technical Advisory GroupToT Training of TrainersUKHFWS Uttarakhand Health and Family Welfare SocietyUP Uttar PradeshUSAID United States Agency for International DevelopmentUSG United States Government

x Capacity Building of Institutions in the Health Sector

Capacity building has been one of the most important approaches

used by international development organizations to achieve development objectives worldwide. It focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from realizing their developmental goals, while enhancing their abilities to achieve measurable and sustainable results.

Capacity building takes place at three levels, individual, institutional, and societal. At the institutional level capacity building involves creation of new institutions or strengthening of existing institutions while at the individual level, it deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. The United States Agency for International Development (USAID) has been committed to support and strengthen capacities at individual and institutional levels through one of its early projects in India. USAID and the Government of India (GoI) collaborated to implement the Innovations in Family Planning Services (IFPS) Project, from 1992-2012. The project, in its first phase, focused on improving quality, access and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh, while shifting its priorities in its second phase to developing, demonstrating,

EXECUTIVE SUMMARY

documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. In its capacity building efforts, the project has mainly focused on providing technical assistance to build capacities of key systems and strengthen local institutions in areas such as quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state, and district levels, and behavior change communication (BCC).

At the national level, the IFPS Project has formed key linkages and collaborations with Indian technical organizations. A series of collaborations were formed with the National Institute of Health and Family Welfare (NIHFW) to design and conduct effective courses for health program managers on PPPs and decentralization of health systems. The IFPS Project has also provided technical assistance and support for creation and establishment of the National Health Systems Resource Center (NHSRC). Besides these efforts, significant technical expertise of health professionals has been extended to the Ministry of Health and Family Welfare (MoHFW).

At the state level, support has been extended to establish and build

capacities of the State Institutes of Health and Family Welfare (SIHFW) in Uttarakhand and Uttar Pradesh and the Institute for Public Health (Jharkhand). Specifically for Uttarakhand, the IFPS Project supported development of the organizational structure, administrative and management systems, financial management systems and human resource policies for the SIHFW. For UP, the support has been at three levels – designing training programs for health providers, conducting training, and development of training aids.

The state level societies established to enable implementation of the National Rural Health Mission (NRHM) were supported by the IFPS Project to strengthen systems for decentralized planning. The states have established two units for better implementation of the Mission, i.e., State Health Systems Resource Center (SHSRC) to support innovations and monitoring and State Program Management Units (SPMU) and District Program Management Units (DPMUs) for program management. The project has supported NRHM program management units at state and district levels for preparation of District Action Plans (DAPs) as well as state Program Implementation Plans (PIPs) in Uttarakhand, Jharkhand and UP.

Significant contributions have also been made through the course of the project to strengthen capacities

xiExecutive Summary

and establish systems at the micro level to bring health closer to people. This has been in the form of support for creation of State ASHA (accredited social health activist) Resource Center (SARC) and District ASHA Resource Centers (DARCs) in Uttarakhand to strengthen the ASHA support system in the state. This resulted from the successful implementation of one of the PPP models implemented as part of the IFPS Project i.e., ASHA Plus program.

The project has also supported institutionalization of key mechanisms, as part of the pilot projects initiated through the course of its implementation. QA mechanisms, developed through the course of implementation of the projects in UP and Uttarakhand, will now support these states in improving the quality of service provision. These include: the QA Cell, district quality assurance groups (DQAGs) established at the state and district levels, trained health officials, a better equipped SHSRC or state level QA Cell to conduct further trainings, and mobilized health facilities trained on infection prevention practices, emergency preparedness and biomedical waste management. Also, the capacities of the private sector have been strengthened to ensure quality provision as a result of close collaborations during the implementation of some of the PPP models.

The IFPS Project has been implemented through autonomous state health societies, the State

Innovations in Family Planning Services Agency (SIFPSA) in UP, the Jharkhand Health Society in Jharkhand and the Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments.These autonomous societies were created to guide all project activities. SIFPSA was established during the first phase of the project in 1993, when the focus was on UP. Through the course of the project, with technical assistance and experience of implementing effective programs, SIFPSA has become an established resource for FP and RH and program implementation for the state of UP.

Strong foundation has been established to take the FP program forward in Jharkhand. The IFPS Project supported the state to set up the FP Task Force, envisioned to cater to specific needs and to add value to the overall family planning endeavor at the state level. One of the mandates of the Task Force was to set up an FP Cell and develop the FP strategy for the state. The project supported the state in these activities and other activities including development of state guidelines on FP and development of information, education and communication (IEC) material on FP.

Several collaborations and partnerships were established with the private sector through the implementation of the IFPS Project. Identification of key local partners

and building their capacities to support program implementation and coverage was an important aspect of the IFPS Project. Several NGOs were involved, oriented, and mentored to support implementation of the PPP models in the three states. Similarly, the capacities of the private sector health providers who were part of the collaborations for implementation of certain PPP models were enhanced for provision of quality services. The project was also able to orient and strengthen capacities of research organizations and several advertising agencies through the course of its implementation.

Along the way, the project addressed certain complexities and challenges working closely with state governments, autonomous institutions, state government support structures, NGOs and other private organizations such as frequent changes in leadership, administrative complexities, narrow perspective to capacity building and getting a consensual buy-in from all stakeholders. The project tapped all opportunities to strengthen the existing and new institutions, establish systems and build individual capacities to ensure sustainable institutions and enhance government ownership. The systems established as part of these institutions are envisioned to continue to meet their objectives even after the IFPS Project efforts conclude. Key mechanisms and institutions can be potentially utilized for implementation of national and state government programs.

Chapter 1

INTRODUCTION

Till 1990s, most international organizations used institution

building or institution strengthening or organizational development approaches to achieve the objectives of development programs. With a focus on sustainable development in the past two decades, the emphasis shifted to capacity building with an enhanced scope. Capacity building focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from achieving their goals while enhancing the abilities that will allow them to achieve measurable and sustainable results. Capacity building takes place on an individual level, institutional level and the societal level. At the individual level, capacity building deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. It also calls for the establishment of conditions that will allow individuals to engage in the process of learning and adapting to change. These are achieved through a variety of mechanisms such as training programs, joint projects, sharing on-job experiences, understanding operations research, study tours etc. At the institutional level, capacity building involves

creation of new institutions or strengthening of existing institutions. The main emphasis is on supporting institutions in forming sound policies, organizational structures, processes and procedures and effective methods of management and revenue control. At the societal level, capacity building supports a more interactive public administration that learns equally from its actions and feedback from the population at large.

USAID commitment to capacity buildingThe United States Agency for International Development’s (USAID) commitment to help countries improve health outcomes through strengthened systems, specifically through capacity building, reflects in its latest efforts to promote health and development around the world. The United States Government (USG) Global Health Initiative (GHI)1 launched in 2009, is the latest chapter in US efforts to promote health and development around the world. While the key principles of the initiative include, encouraging country ownership and investment in country-led plans, and building sustainability through health systems strengthening, the program has based itself upon BEST2 (Best Practices for Family Planning, Maternal and Child Health,

and Nutrition) action plan approach, which advocates supporting country capacity building and strengthening systems for sustained impact (Global Health Initiative, http://www.pepfar.gov/ghi/index.htm; http://www.usaid.gov/ghi/factsheet.html).

USAID’s commitment to support and strengthen institutional development and capacities of health professionals in India reflects through implementation of one of its early projects in India i.e., the Innovations in Family Planning Services (IFPS) Project, a joint effort of the Government of India (GoI) and USAID/India that has spanned over two decades (1992-2012). To begin with, the IFPS Project focused on improving quality, access, and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh (UP). With the project moving in its next phase (2004), the priorities shifted towards developing, demonstrating, documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. The project strengthened the capacity of Indian institutions to implement FP/RH programs, builds the capacity

Introduction 1

1 See http://www.ghi.gov/what/index.htm.2 See http://www.healthpolicyproject.com/basics/BEST-Sept%2021%202010.pptx

2 Capacity Building of Institutions in the Health Sector

of clinical and community-level providers, reduces barriers to access quality FP/RH services, and increases awareness, demand, and use of FP/RH services.3

Of the three major thrusts for IFPS Project, one of them has been to use all opportunities to build capacities with emphasis on the sustainability quotient (USAID Global Health Fellows Program, 2007). Considering that the strengthening process for both state level and local institutions requires more time to produce results, the technical support provided through the project period serves as the foundation for sustainable institutions, the larger objective being that these institutions will further provide technical support to the

public and private health systems in the country. In this context, the IFPS Project has directed efforts to provide technical assistance to build capacities of key systems and strengthen local institutions, in areas such as technical skills development, quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state and district levels, and behavior change communication (BCC).

In its focus on capacity building, the IFPS Project has mainly concentrated on individual and institutional level capacity building. The basic framework that defines the capacity building efforts of the project is presented in Figure 1. The framework evolved

through the three phases of the project and responded to the needs, shift in project priorities and reforms in the national health programs.

The project employed a variety of capacity building approaches at both individual and institutional levels, including direct training, mentoring, and exposure visits for individual level capacity building, and developing the organizational structures and providing technical assistance for institutional level capacity building. A staged process of capacity building was envisioned, with the IFPS Project supporting and mentoring the institutions to be self-sustainable with key systems and mechanisms in place. For these efforts, along the implementation of the IFPS Project, several individuals, organizations and institutions were identified for collaborations and capacity building support.

IFPS Project’s support for capacity building to NRHMWith the launch of the National Rural Health Mission (NRHM) in 2005, capacity building approaches for sustainable development have received a renewed rigor in India. NRHM was launched to facilitate architectural corrections in the basic healthcare system of India. It aimed to provide accessible, affordable and accountable quality health services to the poorest household in the remotest rural region by increasing the overall public expenditure on health from 0.9 percent to 2-3 percent of the GDP (NRHM, http://mohfw.nic.in/NRHM). The Mission recognized the need for an integrated approach to health-care service delivery. Improved management through capacity building at all levels is one of the main cornerstones 3 See http://www.usaid.gov/in/our_work/health/rh_doc1.htm

FIGURE 1: CAPACITY BUILDING FRAMEWORK: IFPS PROJECT

Institutional

Individual

Develop organizational framework Staff development Support Systems Technical Assistance Training of trainers Monitoring and Supervision

Direct training On the job training Exposure visits Mentoring Study tours

APPROACHES

Dependent Guided Assisted Independent

Government at national, state and

district levels

NRHM at the state and district levels

National and state autonomous bodies and

quasi government institutes

NGOs, private sector health providers,

research organizations

IDENTIFIED PARTNER INDIVIDUALS, ORGANIZATIONS AND INSTITUTIONS

*Adapted components on staged capacity building from the Australian AID (2006) A Staged Approach to Assess, Plan and Monitor Capacity Building.

3Introduction

adopted by NRHM, others include communitization, flexible financing, monitoring against standards and innovations in human resource management.

In the initial phases of the NRHM, to support the intricate and multi-level Indian public health system that extends up to the village level, establishment of quasi-government institutions at all levels was initiated. The IFPS Project supported the establishment of these institutions at the national and state levels. At the national level, the IFPS Project supported the establishment of the National Health Systems Resources Center (NHSRC) and strengthening the National Institute of Health and Family Welfare (NIHFW). Structures such as the State Program Management Unit (SPMU), Divisional Program Management Units (Div.PMUs) and District Program Management Units (DPMUs) in the states, districts and blocks were being established. The project worked with a variety of stakeholders to strengthen capacities of individuals in government and non-government sectors and supported the state government efforts to establish or modernize the existing institutions. The state support systems for NRHM, specifically in Uttarakhand and UP, were established and mentoring support was further extended through the project.

The IFPS Project has been facilitated by the formation and strengthening of autonomous state

health societies. The project is being implemented through these societies, the State Innovations in Family Planning Services Agency (SIFPSA) in UP, Jharkhand Health Society in Jharkhand and Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments. In support of this bilateral initiative, the IFPS Technical Assistance Project (ITAP), implemented by Futures Group, India and partners, facilitates multisectoral dialogue, strategic information analysis and use, in-country capacity building, and other implementation assistance. A major thrust for ITAP is to develop, design, demonstrate, document, and disseminate innovative models and financing strategies, including PPPs that reach the poor and vulnerable communities with FP and RH services. A major element distinguishing the IFPS Project from most other USAID-financed activities is the nature of its funding. Bilateral activities conducted under the IFPS Project are funded through a mechanism known as performance-based disbursement (PBD) (See Section 8 for details on PBD).

1.1 PURPOSE AND ORGANIZATION OF THE REPORTThis report captures the contributions made by USAID through the IFPS Project, towards capacity building and strengthening of public and private institutions in the health sector in India, largely in its second and third phase. It intends to highlight the

support rendered, lessons learned and recommendations developed over the course of IFPS Project and ITAP’s work on institutional capacity building. It is hoped that these experiences will offer insights into the nuances of working with public health institutions, building capacities of private institutions to foresee their participation in the health sector and strengthening these institutions to contribute to the overall health systems strengthening in the country. Section 2 of the report presents the gaps related to institutional development and capacity building. Section 3 focuses attention on the series of collaborations and support initiated through the USAID funded IFPS Project, at the national level. Section 4 presents the capacity building initiatives for State Institutes of Health and Family Welfare (SIHFW) in the USAID priority states. Section 5 presents the technical support provided through the IFPS Project for implementation of NRHM program in the states. In section 6 and 7, the support provided to establish systems for management of community level workers and mechanisms for QA have been presented. Section 8 presents the journey of SIFPSA in UP. Contributions made to establish and strengthen institutions in order to promote FP in Jharkhand are summarized in Section 9. Section 10 pulls together all experiences of capacity building of private institutions, NGOs and individuals. Amongst contributions and significant achievements detailed throughout the report, there were challenges and lessons learned, and these have been presented in the last section.

Chapter 2

ANALYSIS OF NEEDS

After the initiation of the IFPS Project, PERFORM4 survey was conducted in 1995 to establish a baseline for the performance indicators of the project and generate evidence to inform project design. It was designed to measure the IFPS benchmark indicators required at three levels: (1) public and private service delivery points, (2) service providers and (3) client population. The survey provided a wealth of information on the status of family welfare services in the public and private sectors, among FP staff and about the utilization and future demand for those services by the eligible couples. The survey results provided an insight into how the levels of invested effort and resources into strengthening the family welfare service capacities of the government, nongovernment and commercial sectors should be revived. Focus on improvement in quality of service provision was identified as a key component to result in an increase in service utilization. The survey found that not enough FP staff at health facilities were trained on FP service procedures with only 44 percent of the staff at public health facilities and 14 percent at private facilities reported receiving training in the last five years (The EVALUATION Project, 1996). The readiness of health facilities and staff for high quality FP service provision could be questioned based on the survey findings. One of the key objectives of the IFPS Project in the initial phase was to strengthen

capacities of staff and facilities with clinical and non-clinical training on FP, particularly contraceptive methods and client counseling.

With the IFPS Project moving into its second phase in 2004, lack of provision of quality services still remained a challenge. Several other gaps were identified, which informed the objectives of the project’s next phase. One of the gaps identified was the lack of adequately trained and skilled providers in both public and private health sectors. This affected the quality of service provision, which further led to lower utilization of services by the people. Also witnessed during that period was the lack of a strong institutional base to provide technical assistance to the health sector.

Autonomous quasi-government institutions, nongovernmental organizations (NGOs), and private sector health institutions could significantly contribute to address these challenges for overall health systems development. These institutions could provide technical assistance to the health system by conducting research, analyzing health policies, human resource planning and management, training health professionals, quality assurance, planning, and monitoring and evaluation. In this context, it became important that these institutions be established, strengthened, trained and sustained.

As the project moved into its second phase, the period was also marked by changes in the Indian healthcare system, with the introduction of the NRHM program. The program adopted new approaches such as flexible financing, monitoring against standards, improved management through capacity building, and innovations in human resource management as its main cornerstones. With a new thinking, new cadre of health workers, community based committees and new systems in place, a need was felt to bring in new structures to manage and monitor the program. Weak institutional capacity to support management and monitoring of the NRHM activities at state and district levels was a key challenge. This was also reflected in the materialization of decentralized planning, which was the principal pivot of the program. Therefore, for better planning and implementation at the state and district levels, new institutions of governance each at national, state, district, facility and village levels were to be created.

Understanding these specific needs based on the health system scenario and the strategic programmatic shifts of the GoI, the IFPS Project in its second and third phase, prioritized to address these challenges through institutional strengthening and human capacity development.

Capacity Building of Institutions in the Health Sector4

4 Program Evaluation Review for Organizational Resource Management or PERFORM was designed and produced by The Evaluation Project of the University of North Carolina and served as one of the means of evaluation at the disposal of SIFPSA and USAID to ensure that the right and desired results are being achieved.

5Collaborations and Support at the National Level

Chapter 3

COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL

One of the core elements of the IFPS Project is to develop and

strengthen key institutions in both public and private sectors. As part of the project, technical assistance activities were designed to form linkages with Indian technical organizations to deepen the already strong national capacity and develop the capacity of the state and national public health sector to partner with the private sector.

The IFPS Project’s mandate to strengthen these institutions has been comprehended at the national level through a series of collaborations with the NIHFW, support for creation and set up of NHSRC and significant human resource support to the Ministry of Health and Family Welfare (MoHFW).

3.1 SERIES OF COLLABORATIONS WITH NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE

NIHFW is an apex technical institute, to promote health and family welfare activities in the country. It is a quasi-governmental institution and works under the auspices of MoHFW, GoI. Established nearly three decades ago, the institute addresses a wide range of issues on public health and family welfare management through its multi-disciplinary functions in

research, consultancy, education and training.

In-service training of middle and senior level health personnel has been one of the core focus areas of the institute. NIHFW is the nodal agency for coordinating the capacity building and training component under NRHM for the entire country. The institute organizes a variety of training courses on reproductive and child health (RCH), Human Immuno Virus and Aquired Immuno Deficiency Syndrome (HIV and AIDS), reproductive biomedicine, adolescent health, geriatric care, geographic information system, PPP, health management, hospital administration, health communication, nursing administration, educational technology, health financing/economics, statistics and demography and other areas of public health. Currently, a total of 15 SIHFW established at the state level support NIHFW in this endeavor. The institute is also involved in several operations research, applied research and evaluation studies of health and family welfare programs. On the education front, NIHFW offers three regular post graduate courses on Community Health Administration and Health Administration, and Public Health Management.

NIHFW collaborates with various international agencies which are also

contributing towards improving the health scenario in the country, to apprehend the larger health goals. The IFPS Project has collaborated with NIHFW to design the first conference on PPPs in the health sector, courses on decentralization, several studies, and is supporting a position at NIHFW to coordinate all such activities.

Designing the first public-private partnership conferenceOne of the core areas for the IFPS Project was to develop, demonstrate, document and leverage expansion of working models of PPPs which deliver integrated FP and RH services. To substantiate upon its objective, the IFPS Project supported the GoI in developing a PPP strategy at the national level in early 2005. Several studies on various PPP models including contracting out, mobile health vans and professional associations such as Indian Medical Association, Federation of Obstetric and Gynegological Societies of India (FOGSI), Indian Nursing Association were conducted along with a literature review of some of the other PPP models (social franchising, voucher scheme, social marketing). Based on the study analyses and literature review, the PPP strategy was developed, which was later incorporated as part of the RCH II Program5 Strategy.

5 RCH II Program: To help achieve reproductive and child health (RCH) objectives, particularly improving access for the poor, India designed the multi-year RCH-II program in 2005, which is now part of the NRHM.


Following the development of the PPP strategy, it was important that these models be shared with representatives from different states. Therefore, in December 2005, the IFPS Project through ITAP collaborated with NIHFW to design the first conference on PPPs. The conference was designed to share PPP experiences from the entire country with policy makers, program administrators and researchers. The conference helped participants representing different states share their experiences on implementing various PPP initiatives. The effort provided insights to the members/faculty of the institute on the growing importance of PPPs for the health sector, and built their capacities to further design and implement PPP models.

Collaboration for courses on public-private partnerships in the health sectorNIHFW and the World Bank Institute are collaborating on a capacity development program to improve health systems policy and

Key resource persons for the training course on PPPs in Health Sector in Uttarakhand, 2011

management. As part of this initiative, health training needs assessments were conducted in October 2007 in three focus states: Rajasthan, Orissa and UP, to identify the priority training needs of the selected states in the area of health system policy and management to ensure a more effective implementation of NRHM. The studies highlighted the need for further training at the state level on specific subjects such as PPP, human resource management and quality improvement in healthcare. Several development partners contributed to the effort, with USAID supporting the PPP training component. April 2008 through September 2011, five workshops on PPP were facilitated in a collaborative mode by USAID through the IFPS Project and NIHFW. The five day workshops oriented senior and middle level executives, and technocrats from state/district/below district levels of nine states (Rajasthan, Orissa, UP, Uttarakhand, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand and West Bengal) on implementation of PPP initiatives. A specific PPP

initiative was identified in each of these states and personnel working in that particular initiative were invited for the workshops. The PPP experts shared the mechanism to design and implement successful PPP models, and shared success stories from the PPP models implemented and prospective challenges during implementation. The workshops offered a platform for prolific discussions with key perspectives on implementation, client satisfaction, scope for improvement and potential for replication.

The initial workshops (2008-09) had international experts on PPP, as key resource persons to conduct sessions and prepare course content. The course content, in collaboration with the faculty of NIHFW, materials and presentations were shared with the representatives of development partners. The courses conducted in a collaborative mode, built the capacities of the faculty and resource persons from other agencies to conduct such courses on PPP in the future. As a result, the last two courses (2010-2011) were conducted by the faculty and resource persons from NIHFW without support from any external experts. NIHFW now has the necessary course materials and wherewithal to conduct PPP courses for health professionals in the country.

Building capacities for Alternative Training Methodology for IUCDThe IFPS Project efforts to mainstream intrauterine contraceptive devices (IUCD) began in its phase I activities in UP. Recognizing its importance, the MoHFW, GoI decided to revive and reposition IUCD in the country, particularly in Empowered Action Group (EAG)


states6 with low contraceptive prevalence rates. The effort was supported by the introduction of new IUCD technologies (380 A), which provided an opportunity to position and promote IUCD as both a limiting and a spacing method. All these efforts required an effective and quality oriented service delivery system, which would be ensured through quality training systems, and providers equipped with new skills and technology. The IFPS Project supported MoHFW to develop a separate IUCD Reference Manual for medical officers and nursing personnel, trainer’s guide, and participants’ handbook for the providers, and also drafted

the ‘Guidelines for Repositioning IUCD in Family Welfare Program – Strategy, Operational Plan and Achievements’ to roll-out the IUCD training, using skill-based classroom and online computer assisted learning approaches.

NIHFW collaborated with USAID through the IFPS Project for capacity building of program managers and service providers on an alternative training methodology for IUCD insertion. The expected outcome of the training was to develop the competency of service providers on the anatomical models for IUCD insertion and removal before they practice on clients. A humanistic way

of training using the Pelvic (ZOE) models was imparted to enable the trainees to acquire competency in insertion of IUCD using the no-touch and withdrawal techniques without any fear of injuring the client.

Representatives from MoHFW and, program managers and service providers from 12 states (identified region-wise based on the unmet need for modern spacing methods) were trained on alternative training methodology for IUCD services using pelvic models. These master trainers (NIHFW faculty, SIHFW faculty, state program managers and service providers) would further train district level trainers for training

6 The concept of EAG was initiated especially to ensure population stabilization and intersectoral convergence. EAG states are categorized as those with high fertility rates and weak socio-demographic indicators (NRHM, 2005)

TABLE 1: SUMMARY OF COURSES IN COLLABORATION WITH NIHFW

S. No.

Course/Conference Target audience Duration Number of participants

1 PPP Conference 2005 PPP implementers, policy makers 1 day

2 Course on Decentralization of Heath Systems, 2007

Program managers and implementers at the state and district levels

5 days 49

3 Course on PPPs in the Health Sector, Agra, UP. 2008

Senior and middle level executives, and technocrats from state/district/below district levels

5 days 47

4 Course on PPPs in the Health Sector, Lucknow, UP 2008


5 days 44

5 Course on PPPs in the Health Sector, Nainital, Uttarakhand 2010


5 days 27

6 Course on PPPs in the Health Sector, Ajmer, Rajasthan

2011


5 days 17

7 Course on PPPs in the Health Sector, Uttarakhand 2011


5 days 22

8 Alternative Training Methodology for IUCD

Representatives from Ministry of Health and Family Welfare, program managers and service providers from 12 states, resource persons from NIHFW and SIHFW

6 days 56

Source: Workshop Process Documents, ITAP


the service providers (medical officers, staff nurses, lady health visitors (LHVs) and auxiliary nurse mid-wives (ANMs) of the identified pilot districts. The representatives from the Ministry who underwent the training of trainers (ToT) course provided monitoring and supervision support to the activity. The ToT was conducted by NIHFW in June 2007 in three batches. The IFPS Project with support from technical experts, identified from the field developed the reference manual, trainers’ notebook and participant handbook, and quality checklists.

The master trainers went back to successfully train the service providers from respective districts, throughout the country. The Ministry representatives have been monitoring the program in different states. The materials developed by the IFPS Project have been effectively used for conducting the training at the state level.

Course on decentralization of health systemsDecentralized planning has been one of the core approaches introduced as part of the IFPS Project’s early efforts in UP. In 1995, the IFPS Project identified decentralization as a priority for the state in order to effectively implement all health programs. Decentralized health planning could meet specific needs of local constituencies more effectively, could inform efficient decision making processes at the local level, encourage efficient utilization of local resources and increase accountability of the health program to the local community. At the same time, major changes in the district government created a favorable environment for

decentralization. In 1997, the IFPS Project introduced and started a discussion on creation of District Action Plans (DAPs). A pilot was carried out in the Rampur District, based on which the model was scaled up in a phased manner to cover 33 districts in UP. The success of the DAP approach saw the GoI, adapting and implementing it across the country through the NRHM. Decentralization forms one of the key pillars of the NRHM implementation processes.

Based on the experiences from UP, the IFPS Project in collaboration with NIHFW and the International Health Systems Group, Harvard School of Public Health designed a course to share Indian and international experiences in designing and implementing decentralized plans. Acclaimed resource persons from the Harvard School of Public Health conducted the course and used course modules from the World Bank Flagship Course on Health Sector Reform and Sustainable Financing, as well as created study materials (case studies) specific to the context of the course. The course presented ways of designing and implementing decentralization to best improve a health system. The course content included analytical approaches to decentralization, learning practical design and implementation issues, need to adjust and change decentralized systems and draw upon lessons from other countries’ experiences. The course provided an opportunity for the resource persons from NIHFW to build their capacities to be able to develop training material and to organize and conduct such courses.

Collaborations on research and analysesThe IFPS Project collaborated with NIHFW to conduct several studies, one of which is the cost effectiveness study of the Sambhav Voucher Scheme in Uttarakhand. The Sambhav Voucher Scheme is one of the PPP models designed and implemented by the IFPS Project in the three focus states of UP, Uttarakhand and Jharkhand. A key area of interest regarding voucher schemes is their cost-effectiveness, especially given the concerns about administrative costs for managing the programs.

NIHFW has had health economics expertise but never conducted cost effectiveness studies. Cost effectiveness studies have garnered interest in recent times, and are considered important to inform policy makers of optimal utilization of resources. Several PPP models are being implemented in different states in India, but their feasibility to scale up, based on cost effectiveness analyses results, has largely remained unattended. To address these gaps, NIHFW decided to enhance its capacities to conduct such studies, in terms of the study design, preparation of data collection tools, data analysis and interpretation, and dissemination of information to policy makers and program managers.

With these objectives, the cost effectiveness analysis of the Sambhav Voucher Scheme in two blocks of Hardwar district was conducted. The analysis provides insights into various dimensions that can inform policy and future strategies of the program. Expert consultants from NIHFW prepared the tools and methodology for the study with program inputs from the IFPS


Project. The collaborative effort helped build capacity of the team to understand the parameters important to conduct cost effectiveness analyses.

3.2 LAYING THE FOUNDATION FOR NATIONAL HEALTH SYSTEMS RESOURCE CENTERThe National Health Systems Resource Center (NHSRC) was conceived as an institution for development of strategic plans and for strengthening NRHM program implementation at the national and state levels. The IFPS Project participated in the deliberations on constitution of NHSRC, prepared its structure and functions, and decided to support the institution for at least two years or till the time the government allocates its own resources to support the institution. USAID, in collaboration with other development partners, supported NHSRC and the IFPS Project acted as its secretariat for management and operational support. A pool of consultants was recruited to provide

support to the technical divisions such as social marketing, FP, donor coordination, NRHM, statistics and evaluation at the MoHFW. These consultants helped the Ministry in planning and strategy development, design of new systems such as web based Management Information Systems (MIS), development of technical manuals, and also facilitated collaborative efforts with different stakeholders. In December 2006, the GoI finally decided to support NHSRC through its own resources and registered NHSRC as an autonomous body under the Chairmanship of the Secretary, MoHFW, GoI, and co-located it in the NIHFW campus.

The society provides technical and capacity building support for strengthening the public health system. In the process, it has built extensive partnerships and networks with all organizations and individuals that form part of the public health system, to share the common values of health equity, decentralization and quality of care. The society operates through a limited number

of functional units, each having specific functions. These units include planning, administration and coordination unit, healthcare financing/social security unit, quality management unit, PPP unit, policy development/health sector reform unit, and monitoring, evaluation and research unit. Apart from these units, state level technical cells have been established, through which the support from NHSRC is routed to the states.

Separately from NHSRC, the IFPS Project continued to support the MoHFW through the pool of consultants instituted at the Ministry. Twenty six consultants have since been positioned to provide technical and secretarial support to different divisions at the Ministry. The different divisions being provided support include FP division, Monitoring and Evaluation division, Donor Coordination division, NRHM division, Health Insurance division, Statistics division, IEC division, Social Marketing division and HR cell.

Chapter 4

BUILDING CAPACITIES OF THE STATE INSTITUTES OF HEALTH AND FAMILY WELFARE

4.1 ABOUT STATE INSTITUTES OF HEALTH AND FAMILY WELFAREThe State Institutes of Health and Family Welfare are apex state level technical institutes to promote health and family welfare activities through training, research and consultancy. These quasi-government institutes are established by the state governments and work under the auspices of the Departments of Health and Family Welfare. These institutes play a vital role in supporting the state health system for all training and research requirements. The institutes support NIHFW to coordinate training activities under the NRHM program for their respective states. In order to enable NIHFW to carry out this huge task, a total of 15 State Institutes of Health and Family Welfare have been identified to liaise with the state/union territories allotted to them.

These institutes provide technical support to the state health system for the following activities: Conduct periodic training needs

assessment Develop training programs

and modules based on needs assessment

In-service training for health personnel

Provide technical support to other training institutes in the state for design and evaluation of training programs

Provide research inputs to improve the efficiency and effectiveness of the system

Conduct studies related to evaluation and impact assessment of various interventions undertaken as part of the healthcare delivery system to further inform program planners and managers.

4.2 SUPPORT TO ESTABLISH AND BUILD CAPACITIES FOR SUSTAINABLE SIHFW: UTTARAKHAND AND UTTAR PRADESHSetting the cornerstoneIn 2003-04, the IFPS Project supported the Government of Uttarakhand (GoUK) to conduct an initial assessment for setting up the SIHFW for Uttarakhand. The IFPS Project supported a team from the Department of Health, Uttarakhand to visit other state institutes in Rajasthan, Orissa, Andhra Pradesh and Maharashtra to study their

policies and programs, organizational structure, financial allocations, and other support systems. The study report informed the state health department’s decision to conduct a feasibility study to understand the viable options for setting up the SIHFW based on state specific needs. Meanwhile, different options for the location of the SIHFW were suggested by the State Government as well as the Health Directorate. After several deliberations within the state government and the Directorate on situating the institute within the premises of a medical college, to making it a separate body located at either Dehradun or Nainital, the idea of upgradation of the existing Regional Health and Family Welfare Training Center in Haldwani to SIHFW was proposed and sought viable.

Based on the findings of the feasibility study, the IFPS Project prepared a proposal for upgradation of the Regional Health and Family Welfare Training Center in Haldwani to SIHFW. The proposal suggested modifications in the physical infrastructure including construction of a new campus, organizational structure, roles and


11Building Capacities of the State Institutes of Health and Family Welfare

responsibilities of the staff, creation of external and internal committees to govern the SIHFW and for running day to day operations, mechanisms for coordination with other institutes in the state, and the resource allocation plan.

Though the budget was sanctioned by the state government, there was a gap of two years before the institute would become operational, due to administrative complexities. During this period, GoI suggested that infrastructural development funds be accessed under NRHM, hence it should be proposed as part of the State NRHM program implementation plan (PIP). The GoUK received the funds under NRHM and subsequently the construction was completed in almost three years time and plans for recruitment of faculty finalized.

Re-visiting to ensure a sustainable institutionThe IFPS Project continued to support the Health Directorate and the GoUK to further strengthen the SIHFW. In 2011, the Directorate planned to develop a strategy and action plan for strengthening the SIHFW in Uttarakhand. The IFPS Project helped with the procurement process to select a technical agency to conduct a needs assessment and accordingly suggest means and methods to strengthen the SIHFW.

In the current context, the IFPS Project supported the state in developing a clearly defined organizational structure, administrative and management setup, financial management systems and a human resource policy. Support was

also provided in developing the scope of work of all proposed staff members (technical and administrative). A clear strategy, including immediate actions, financial resource requirements and timeline to strengthen and operationalize the SIHFW within a time frame of six months was developed and further shared with the technical advisory group (TAG)7 for approval. The strategy proposed that an annual training plan would be prepared and the training composition would be done by the Training Implementation Committee. For the divisional training centers, guidance would be provided on how to conduct the training programs. The strategy also recommended that the training programs run at the divisional training centers be monitored and evaluated. The strategy laid emphasis on improving quality of trainings at SIHFW by networking with other training institutions and universities. The suggested mode of operation is ‘society’ mode, to provide working

autonomy for effective functioning and management of day to day affairs.

The strategy was approved by TAG and further presented to the Directorate. The Directorate approved the strategy with certain recommendations, based on which a detailed business plan was being worked out.

Strengthening the State Institute of Health and Family Welfare in Uttar PradeshLack of adequately trained, skilled providers remains a challenge in both the public and private sectors. Through the course of the IFPS Project, support has been provided to the UP SIHFW for training and capacity building. Support has been at three levels: designing training programs for health providers and providing support during training sessions, support for training on BCC (planning and implementation) and development of training aids.

Family Welfare Counselors being trained on family planning.

7 A Technical Advisory Group (TAG) was created in Uttarakhand to provide expert guidance to, and oversight, of the NRHM activities. TAG members include top NRHM officials from the state (Director to State Program Management Unit), as well as representatives from USAID and other program partners.


As part of one of the NRHM activities in the state to promote FP, Family Welfare Counselors (FWCs) have been positioned at the district level hospitals throughout the state. The FWCs counsel women in the third trimester of pregnancy and during post-partum period, on adoption of FP methods. In March 2010, the IFPS Project developed a training manual and collaborated with SIHFW staff in conducting the pilot training program for FWCs. Seventeen FWCs were trained at the pilot training program. The training module developed by the IFPS Project has been adopted by the SIHFW for further training of FWCs

to be placed at district level hospitals across all districts of the state.

The IFPS Project, through ITAP has contributed to the yearly training plans of the SIHFW. ITAP provided support for training District Community Mobilizers, District Program Managers, PHN tutors and Block Health Education Officers (BHEOs) on BCC and information education and communication (IEC), Medical Officers-in-Charge on Adolescent Reproductive and Sexual Health (specific focus on nutrition and anemia in adolescents), BHEOs on social marketing and monitoring and evaluation. In addition, support was extended for several

TABLE 2: SUMMARY OF THE TRAINING AND CONTENT DEVELOPMENT SUPPORT TO SIHFW

A Training aides and content developed for SIHFW

Training Target Audience Duration Content Developed

1 Family Welfare Counseling Skills

Family Welfare Counselors under NRHM

7 days Training Manual

2 BCC Planning and Implementation

District Community Mobilizers and District Program Managers

5 days Training Manual

3 Monitoring and Evaluation

CMOs, Dy. CMOs and DPMs

Support for content finalization

4 Training of ASHAs

Accredited Social Health Activists (ASHAs)

Content Finalization of Module 6, 7 and 8

B Support during training

Training Target Audience Duration Month/Year of the Training

Training Session Supported

1 Family Welfare Counseling Skills

Family Welfare Counselors

7 days March 18-24, 2010 Male and Female Reproductive organs Methods of Family Planning Communication Skills Practicums

2 Adolescent Reproductive and Sexual Health

Medical Officers in/Charge

3 days Oct 4-6, 2010 Nutrition and Anemia in Adolescents

3 Orientation of Trainers for BCC Planning and Implementation

SIHFW identified trainers for BCC planning and implementation

1 day Nov 11, 2010 BCC planning and implementation

4 Foundation Course of BHEOs

Block Health Education Officers

12 days Nov 29- Dec 11, 2010 Social Marketing

foundation courses for BHEOs conducted in different phases from December 2010 through December 2011. ITAP was instrumental in developing training content for training of chief medical officers (CMOs), Deputy CMOs and district program managers (DPMs) on monitoring and evaluation. Table 1 provides a summary of the support provided for training and content development through the IFPS Project.

4.3 SETTING THE STAGE IN JHARKHANDThe Institute of Public Health (IPH) in Jharkhand had been conceptualized as a hub of knowledge and technical

13Building Capacities of the State Institutes of Health and Family Welfare

expertise. It would play a vital role in supporting the state health system for all training and research requirements. In 2006, the IFPS Project supported the Government of Jharkhand by conducting a feasibility study to understand the status of public health institutions in the state and estimate capacity

5 Behavior Change Communication Training for PHN Tutors

PHN Tutors, Tutor In/Charge/DHVs

5 days 3-Jan-11 Concept of IEC and BCC



12 days Jan 10-22, 2011 IEC Experiences in FP Program Communication - Definition and Processes



12 days Feb 28- March 12, 2011

IEC Experiences in FP Program Communication - Definition and Processes

8 BCC Planning and Implementation Training

District Community Mobilizers and District Program Managers

5 days Nov 8-12, 2011 BCC planning and Implementation



12 days Dec 5-17, 2011 Monitoring and Evaluation Social Marketing

building requirements. As part of a benchmark activity, IFPS provided infrastructure support and also helped the state with recruitment of staff for the institute. After the foundation for the institute was laid with infrastructure in place, some intricacies related to operationalization remained to

be worked out within the state government.

After a gap of four years (2011), the state government has revived its plans to operationalize the institute and is in discussion with NIHFW and Public Health Foundation of India (PHFI), for collaboration.

Chapter 5

TECHNICAL SUPPORT FOR IMPLEMENTATION OF NRHM IN UTTARAKHAND AND UTTAR PRADESH

The NRHM framework for implementation provides a

robust institutional arrangement for partnership among the local, state and national governments. Decentralized planning has been the principal pivot around which the program revolves. The Mission envisaged improvements and reform in program management as one of the key elements to improved healthcare. In this regard, for better planning and implementation at state and district levels, it created new institutions of governance each at the national, state, district, facility and village levels.

One of the core elements of the IFPS Project is development and strengthening of key systems. IFPS through the course of the project, has been instrumental in providing support for setting up and/or strengthening health systems in the public sector and extend technical support to build capacities of the health staff to design and manage systems. One significant example is the initiation of the District Action Planning process by the IFPS Project in UP. The District Innovations in

Family Planning Agency (currently DPMU) responsible for preparation of DAPs during that period, was oriented on preparation of DAPs and budget allocations. A total of 38 DAPs were developed in a collaborative mode. The initiative corroborated with NRHM’s focus on decentralization processes and hence, was adopted by NRHM in its first year (August 2006) as the standard approach for decentralized planning and management for the country. The IFPS Project had prepared a manual on how to prepare DHAPs which was circulated to all state governments by MoHFW. In the last one year, 540 District Action Plans (DAPs) have been prepared covering almost all districts in the country –an increase from 310 in the first year of NRHM (Planning Commission, 2012). NRHM intends to further decentralize these processes of planning to the block level and below.

The IFPS Project through ITAP has been supporting NRHM program management units at the state and district levels for preparation of DAPs as well as State PIPs in Uttarakhand, Jharkhand and UP.

5.1 SUPPORT TO SHSRC IN UTTARAKHANDEach state has established state level societies to enable implementation of the rural health mission in their respective states. Based on recommendations at the time of initiating the Mission, the states established two units for better implementation of the Mission: State Health Systems Resource Center (SHSRC) to support innovations and monitoring of NRHM, and SPMU for program management.

The SHSRC in Uttarakhand, was established in 2007 with support from the IFPS Project to serve as the apex body for technical assistance to facilitate the state and districts in planning and implementation of the NRHM activities as well as strengthening the program monitoring and evaluation systems.

Objectives of SHSRC in Uttarakhand Primary objective of SHSRC is to

provide technical support to the State NRHM and the Directorate of Health for implementation of NRHM.

Promote the welfare of people by extending preventive, curative and


15Technical Support for Implementation of NRHM in Uttarakhand and Uttar Pradesh

rehabilitative healthcare services through the Office of Director General of Health Services (DGHS) in Uttarakhand.

To adopt and evolve innovative models for providing quality healthcare services to remote areas through DGHS.

The IFPS Project provided support in framing the key focus areas for the SHSRC in Uttarakhand. As part of a benchmark activity, it was suggested that the SHSRC would focus on five key areas and provide functional support to the state on Policy Analysis and Health Planning, communication (BCC and IEC), monitoring and evaluation, facilitating the implementation of PPP models and capacity building based on training needs assessments of health functionaries. The organization structure and staffing pattern for the SHSRC was developed with support from the IFPS Project. Approval was accorded to the suggested functions along with the organizational structure/staffing structure by the executive committee of UKHFWS in mid-2006.

The IFPS Project extended support for recruitment of technical resource persons, bringing on-board technical staff like Consultant (Planning), Consultant (Healthcare Financing), Consultant (Monitoring and Evaluation), Consultant (Quality Improvement (QI)/QA), Consultant (Community Participation), Consultant (IEC) on the lines of the staffing structure envisaged for SHSRC, by coordinating the entire recruitment process. The positions for the initial period were financially supported through the IFPS Project. At the time of initiation, the institution was steered by the

Executive Director (ED) – UKHFWS. Based on a Government Order released in 2009, a modification to the structure was suggested. The ED, UKHFWS was appointed the ex-officio Director of SHSRC, to ensure close coordination between the Department of Health and Family Welfare and UKHFWS.

In 2009, the scope of work of SHSRC was revisited, and support was provided through the IFPS Project to re-develop the same as part of a benchmark activity. The suggested revisions were presented to the TAG for giving it a formal shape. Further, to support the revisions, the IFPS Project provided support for selection of a technical agency to study the present structure, hold deliberations with state and district officials, and assess the training needs. Based on their findings, a revised scope of work along with appropriate training opportunities for strengthening the SHSRC was developed.

The IFPS Project was instrumental in building a strong foundation for the SHSRC in Uttarakhand, The SHSRC is providing technical support to the NRHM as mandated. However, a challenge in terms of shortage of technical staff persists and needs to be addressed to ensure a sustainable institution.

5.2 STRENGTHENING SYSTEMS FOR DECENTRALIZED PLANNINGTo support the management of the NRHM program at the state, district and block levels, creation of SPMU, Divisional PMUs and DPMUs were envisaged. These units have been established under the respective state health societies. To corroborate NRHM’s focus

on decentralized planning, states prepare and present their PIPs to the MoHFW, GoI. Before coming up with the state PIPs, the state governments have a task of appraising the district level action plans. Significant demand projected through this exercise of decentralized planning is then incorporated in the PIP.

The planning process in the states has been guided by the broad framework first used for preparation of DHAPs in 2006. The states have focused on building capacities for decentralized planning through several training exercises, handholding by NHSRC and SHSRC and taking support from professional organizations to work on the planning process.

Support to institutions of management for NRHM in Uttar Pradesh and UttarakhandThe IFPS Project has been extending support for effective implementation of program implementation plans. A major activity which has been supported for the last three years has been for preparation of the state PIP as well as DAPs. A participatory process is followed each year for preparation of state PIP as well as DAPs. The IFPS Project provides technical assistance for conducting one day orientation workshops for program managers to inform an efficient PIP. Support has been extended by the IFPS Project to SPMU to prepare a set of guidelines for orientation. The IFPS Project has also been coordinating to organize orientation meetings with officials from the Directorate of Medical Health and Family Welfare. The IFPS Project has been involved in developing formats based on the PIP guidelines and framework for


different components/sections and facilitated data collection from the Directorate.

The IFPS Project has also extended support for development of DAPs. Coordinating for the orientation of program managers, the IFPS Project guided them through the process of doing a situation analysis, helped them to set objectives, identify program strategies and innovative approaches to achieve results and a mechanism to regularly monitor performance and incorporate all these components into DHAPs.

The IFPS Project has also been supporting the exercise of decentralized planning based on which significant demand projected is then incorporated in the PIP. Support has been extended for district planning meetings, which are also supported by the Divisional Program Management Units (DivPMUs), based on which block and district level plans are finalized. To facilitate

the process, the IFPS Project through ITAP also involves technical consultants to be part of the planning process and for compilation of the PIP. The IFPS Project has supported the preparation of budget formats, plans for budget allocation based on the PIP framework.

Through the course of the last three years, the IFPS Project has been able to build capacities of the program managers in developing DAPs, PIP, and budget estimates using standardized formats. Now the program staff have acquired sufficient conceptual knowledge and skills to conduct stakeholders meetings and prepare DAPs and state PIP following consultative processes.

Similarly, the IFPS Project has extended support for preparation of the state PIP in Uttarakhand for a significant period, 2008-2012. As part of the initial benchmark activities, the IFPS Project has provided support for strengthening of the SPMU and

DPMUs. Also, for decentralized planning, the IFPS Project contributed for development of DAPs in 2007-08. Technical agencies were contracted by the IFPS Project to collaborate and support the development of these plans. The program managers from respective DPMUs were oriented for developing these plans.

5.3 CAPACITY BUILDING OF ROGI KALYAN SAMITIS IN UTTARAKHANDWith the advancement in medical technology and increasing expectations of the people for quality healthcare, it became important to focus on provision of quality health services through the established institutions. Upgradation of the public health facilities to Indian Public Health Standards (IPHS) was strategized as an important intervention under NRHM. Hence, ensuring provision of sustainable quality care with accountability and people’s participation was envisioned by NRHM. However, it was seen that it might not be possible to achieve this unless a system was evolved to ensure a degree of permanency and sustainability. With this vision, a management structure called Rogi Kalyan Samiti (RKS) (patient welfare committee) or Hospital Management Society (HMS) was developed.8

RKS functions as a registered society which acts as a group of trustees for the hospitals to manage the affairs of the health units. It consists of members from local Panchayati Raj Institutions (PRIs), NGOs, local elected representatives and officials

District Action Plans being developed by the district officials

8 Rogi Kalyan Samitis: http://mohfw.nic.in/NRHM/RKS.htm

17Technical Support for Implementation of NRHM in Uttarakhand and Uttar Pradesh

from the government sector who are responsible for the proper functioning and management of the hospital/community health centers (CHCs) / first referral units (FRUs). RKS have been set up in district hospitals, sub-district hospitals, CHCs/FRUs and primary health centers (PHCs).

UttarakhandIn Uttarakhand, the IFPS Project has contributed to build capacities of the RKS across the state in two phases. As part of a benchmark activity, IFPS conducted training of 2-3 members from each RKS covering a total of 55 CHCs and 239 PHCs, first in seven districts of Garwal region (2011) followed by six districts of Kumaon region (2011) for them to be able to carry out their tasks effectively. The IFPS Project conducted a needs assessment to understand the current scenario and capacity building requirements to develop systems and conduct training programs. Training modules were also developed and were shared with UKHFWS. The IFPS Project also provided monitoring support for 25 percent of the training workshops to ensure quality. A total of 926 members have been trained on the nuances of management, proper utilization of financial resources and standards to be maintained for quality healthcare.

All these efforts ensured participation of stakeholders in decision-making and also helped health units to

strengthen systems and to provide quality health services.

Uttar PradeshIn 2008-09, UP had 133 RKS at the district level, 426 at block PHCs and 2,837 at additional PHCs.The Department of Health and Family Welfare, UP had issued guidelines to constitute RKS at district and sub-district level to decentralize management systems, to encourage people’s participation, to improve quality of services in health units and to solve problems at the local level with resources made available. However, there were some issues regarding clarity on the actual status of implementation at the ground level. In this context, the IFPS Project was requested to conduct a rapid assessment of the RKS in UP in September – October 2008 and recommend steps for strengthening these societies. The main objectives of the study were to: a) understand the constitution and composition of the Governing Bodies and the Executive Committees at the district and the sub-district levels; b) review the frequency of meetings held, decisions taken, and issues faced by these bodies; c) enlist the measures taken to improve the quality of services provided in the health units and document innovative interventions introduced; d) assess the capacity building needs of the Samitis for resource mobilization, QA, material and equipment management, financial management, human

resource management, community participation, and legal/ethical aspects of hospital management; e) assess the financial resources available, their utilization and constraints in use of resources; f) understand existing monitoring systems for reviewing the performance of RKS at the state and district levels; and g) elicit opinions from different stakeholders on how to improve the functioning of RKS.

The study recommended that there was a need for orientation and further capacity building on the use of guidelines, need to develop mechanisms for representation and active participation of all members, ensure proper documentation of meetings and decisions taken for accountability, focus on patient welfare besides facility upgradation, develop yearly financial planning and disbursement schedule, community reporting of RKS activities which was important and develop a grievance redressal mechanism. The state has used these recommendations to strengthen the RKS in UP (ITAP, 2008).

Recognizing the potential of RKS as a decentralized, local autonomous society with community involvement and accountability, the IFPS Project has provided support through the above activities. However, there is a need to provide further inputs in both Uttarakhand and UP so that these societies emerge as a strong institution base at the community level.


Chapter 6

SUSTAINABLE INSTITUTIONS TO BRING HEALTH CLOSER TO THE PEOPLE

In 2005, the GoI introduced a new cadre of community health workers

known as accredited social health activists (ASHAs), at the community level as an architectural reform to health systems. With an objective to strengthen the community process, introduction of ASHAs was one of the many programs initiated by NRHM. These programs included Village Health and Sanitation Committee (VHSC), RKS at CHC, PHC and district hospital levels, use of untied funds at all levels, community monitoring program, and district and state health societies (Planning Commission, 2012).

The ASHA program was designed to facilitate access to health services, mobilize communities to adopt positive health seeking behaviors, and provide community level care for a number of health priorities where such intervention could save lives and improve health. This includes counseling on improved health practices, and prevention of illness and complications, and appropriate curative care or referrals in pregnant women, newborn babies, and young children as also for malaria, tuberculosis and other conditions that are location specific. According to the NRHM guidelines, one

ASHA should be in place for 1000 population.

The program made significant contributions to expanding access to healthcare in rural communities across India. However, ASHAs in Uttarakhand faced challenges in providing uniform services to the population due to the state’s hilly terrain with small and scattered settlements covering a large geographical area. The program needed to be modified and tailored to the special context of Uttarakhand to maximize impact. The GoUK asked the IFPS Project to design a pilot project to improve the effectiveness of the ASHA program. After several consultations with the stakeholders at the state, district and block levels and assessing local conditions, the IFPS Project designed the ASHA Plus program. The program piloted by UKHFWS for two years (2007-09), introduced flexible population coverage for the ASHA Plus workers and rendered remuneration for an increased number of services. The program was implemented under a PPP mechanism, engaging NGOs to lead the selection, training, mentoring and support of the ASHA Plus workers. Training was one of the most

important aspects of the program and ASHA Plus workers were trained to facilitate IPC with target groups, usage of micro planning tools and MIS. The IFPS Project provided support for selection of project intervention areas, NGOs and supported the NGOs’ activities. The IFPS Project used the GoI training modules to develop more interactive training material for ASHAs along with job aids, provided technical assistance for training of ASHA Plus workers and was involved in monitoring and review of the program.

6.1 SUPPORT FOR CREATION OF STATE ASHA RESOURCE CENTER AND DISTRICT ASHA RESOURCE CENTERSLearning from the pilot’s success, the GoUK, in an effort to replicate the NGO model of support and mentoring for ASHAs, introduced an ASHA Support System, reaching from the village to the state level. To facilitate this State ASHA Resource Center (SARC), State ASHA Mentoring Group and District ASHA Resource Centers (DARCs) were established in 2008-09 with support from the IFPS Project. The SARC is the technical agency that provides inputs and supportive mechanisms


19Sustainable Institutions to Bring Health Closer to the People

ASHA workers undergo orientation training at the District ASHA Resource Center

to the ASHAs under NRHM at the state level, while DARCs provide technical support and are responsible for mentoring and training the ASHAs. Looking at the improvement in health indicators in the ASHA Plus intervention blocks, the state government was encouraged to scale up the program across six districts and accordingly strengthened the SARC and DARCs in those districts. The centers were strengthened in the form of additional human resource support and further by building their capacities. Technical inputs for scale up were provided by the IFPS Project. According to the GoI guidelines, the SARC in Uttarakhand was initially staffed by two people, a project manager and a data assistant. As part of program scale-up, this team was further strengthened by hiring two regional coordinators for Garhwal and Kumaon regions. The main responsibility of these regional managers is to support the district managers in strengthening the district centers.

At the district level, GoI accredited mother NGOs (MNGOs) were selected to serve as DARCs, following the model of the NGOs that had managed the ASHA Plus program at the block level during the pilot.

The IFPS Project supported UKHFWS in the development and

design of a training curriculum, training needs assessment and training of SARC and DARCs. The training curriculum was designed for institutional strengthening of the SARC and DARCs. The training needs assessment was conducted to determine the technical and managerial skills, and training requirements of the SARC and DARCs staff. Based on the identified gaps, the IFPS Project contributed in development of a training plan for the staff, with clearly defined indicators for measuring training effectiveness along with a monitoring plan. The training modules developed to aid training were pre-tested. Institutional strengthening for this program was a collective effort to train all stakeholders involved with the ASHA program, whether from the government or from the NGOs.

FIGURE 2: STATE ASHA SUPPORT SYSTEM

State Nodal Officer

Data Assistant

Program Manager

Regional Coordinators

Community Mobilizer (DARC)

State Health Department

State ASHA Resource Center

Chapter 7

SETTING UP MECHANISMS FOR QUALITY ASSURANCE

Increased emphasis under NRHM/RCH-II on quality of care in the RH

field paved the way for strategizing, defining criteria and developing methodologies to assess and improve the quality of health services in the existing public health system. The RCH II Monitoring and Evaluation (M & E) framework advocates for a subsystem approach of which QA is one of the key sub-elements among others. The IFPS Project aligned itself to the NRHM/RCH-II framework and supported GoI to design strategies and establish procedures that adequately assess and improve quality. Quality assurance mechanisms were designed and tested in UP, Uttarakhand and Jharkhand in collaboration with the state governments and state societies. Several guidelines and mechanisms were developed as part of the PPP models designed and implemented through the IFPS Project, in order to ensure quality of care and service provision.

7.1 QUALITY ASSURANCE MECHANISMS AND PROGRAMSIn June 2002, the IFPS Project along with the GoUP supported the initiation of a pilot project with the aim of establishing systems to address issues related to quality

improvement. The pilot was launched in Sitapur and Saharanpur districts of UP, with a total of 18 sites covering one women’s hospital, seven CHCs and 10 PHCs. During the course of implementation, a checklist was developed which scored sites on 100 quality indicators from infrastructure, staffing, client management to IEC and MIS. At the district level, a two-day workshop was held for orientation of District Medical Officers who supervise all health facilities in the district. Besides, one day workshops were held at each of the selected sites where district and site supervisors were trained in Client Oriented and Provider Efficient (COPE) techniques and facilitative supervision skills. COPE techniques helped the supervisors in problem identification, developing action plans, and results orientation. As part of the program, the IFPS Project supported the formation of QI circles at each site. The QI circles included members representing all levels in staff hierarchy and were assigned oversight responsibility for key aspects of quality. One of the motivating factors of the program was that the sites scoring 90 points and above on all four quarterly assessments were given quality certificates. Top five scoring sites were rewarded with flexible

funds of Rs. 200,000 (~ USD 4,545) for use in QI activities.

The IFPS Project piloted QA programs in two districts of UP (Bareilly and Gorakhpur, 2007-08), one district of Uttarakhand (Dehradun, 2007) and two districts of Jharkhand (Palamu and Pakur, 2008-09).

Some of the key components of the project design which are now established as key resources for the states include the following: QA methodology: MoHFW along

with several development partners designed the methodology to assess and address gaps in health services at all levels of the public health facilities.

Using the QA checklists, four quality assessments were carried out, quarterly or bi-annually at the pilot sites in all three project states. The facilities were assessed using the QA checklist (refer below) and voluntary exit interviews with clients. Action plans for the program were designed according to the assessment results analyzed at monthly DQAG (refer below) meetings.


21Setting up Mechanisms for Quality Assurance

QA Checklist: Quality of care was measured on nine criterions, including five generic (service environment, client provider interaction, informed decision making, integration of services and women’s participation) and four service specific (access to services, equipment and supplies, professional standards and technical competence and continuity of care).

Six specific checklists were developed for CHCs/PHCs, sub-centers and RCH camps. These checklists form the basis for the quality assessment of facilities. These checklists list critical indicators of service quality, such as facilities and equipment/ supplies for RCH services and client satisfaction

QA Training Manual: GoI along with development partners also developed a training manual based on the pilot and other experiences from the COPE approach and QI project in UP. The manual was developed to standardize the process across districts on assessment visits and feedback mechanism at CHCs/PHCs, sub-centers and RCH camps.

DQAGs and Quality Improvement Committees: DQAGs were established in the pilot districts to manage the implementation of QA. Each group constituted 6-8 members including state and district health mission officers. The members of the DQAGs were responsible for conducting the QA assessments and ensure implementation of the QI activities. Also, as part of the program, QI committees were established at each facility to manage and implement the

QA activities in the facility based on the recommendations of the QA assessment.. In terms of supervision and coordination between the DQAG and QA team, and state and district health missions, a State QA Nodal Officer and QA Nodal Officer were appointed.

Capacity Building: Trainings and orientation workshops were a key component of the IFPS Project, to set up QA as a system within the public health framework. Stakeholders from various districts (MS/MOs-IC from PHCs and CHCs) and DQAG members were oriented to QA and trained to implement the program through various multi-day workshops. Trainings and orientation workshops on a variety of subjects under QA including orientation towards roles of key players, emergency preparedness, infection prevention, biomedical waste management, usage of QA instruments and tools, usage of assessment forms based on checklists, development and implementation of action plans, and specifically for DQAG members, orientation on development of QI Committees at each site.

Following the success of the pilot projects, the QA activities in Uttarakhand were scaled up in six districts in 2008-09 and an additional six districts in 2009-10. The GoUK has now scaled up the activities to all 13 districts.

Through the course of implementation of these projects, USAID has been able to support institutionalization of QA in these

states. Some of the key systems and mechanisms put in place as part of these pilot programs are resourceful assets to improve quality of services, for these states today. These include, the State QA Cell, DQAGs established at district levels, trained health officials, a better equipped SHSRC or State level QA Cell to conduct further trainings, and mobilized health facilities trained on infection prevention practices, emergency preparedness and biomedical waste management.

7.2 QUALITY ASSURANCE FOR PPP MODELSSambhav Voucher Schemes in UP, Uttarakhand and JharkhandAs part of the PPP models designed and implemented under the IFPS Project, Sambhav Voucher Schemes were piloted in all three states (Uttarakhand, Jharkhand and Uttar Pradesh) from 2006-2012.The voucher schemes were mandated to provide high-quality RH services to the poor. Several quality assurance and quality improvement mechanisms formed part of the design and implementation of the Voucher Schemes.

Provider accreditation was one of the processes established as part of these voucher schemes. This process set standards for private providers to be eligible to participate in the scheme and served as a means for monitoring quality over time. During the initial pilot design in Agra, the Sarojini Naidu. Medical College (SNMC)—with inputs from the IFPS Project — played an important role in adapting accreditation guidelines based on National Accreditation Board for Hospitals and Health Care Providers (NABH) standards and evaluating providers against


the criteria. These guidelines and a methodology for conducting clinical audits were finalized in Agra. Building on these early efforts, the IFPS Project assisted partners to adapt and apply the standards, training, and monitoring materials in the other pilot sites. Accreditation was undertaken by SNMC in Agra and experts from Chhatrapati Shahuji Maharaj Medical University (Lucknow) for Kanpur Nagar. In Haridwar, the DQAG conducted the accreditation visits (ITAP, 2012 b).

Medical audits of private nursing homes/hospitals helped ensure accountability for maintaining quality standards. The IFPS Project designed tools for the audits that assessed delivery of clinical services against the standards outlined in the accreditation criteria and protocols for each service. The audit teams comprised medical specialists, such as gynecologists and pediatricians, public health and community medicine specialists, and representatives from the IFPS Project. At periodic intervals, the

audit teams investigated a sample of cases at each facility, considering the completeness of patient records, types of tests and services provided, adherence to national standards and guidelines, the nature of complications and how they were managed, and the impact on health outcomes (e.g., maternal and neonatal deaths averted), among others. The assessment team shared feedback with facilities for corrective action, and those that could not maintain accreditation standards were discontinued from the voucher program (ITAP, 2012 b).

The IFPS Project was able to revive the DQAGs to accredit and monitor the services provided by the private providers. These DQAG teams have been trained on checklists for accreditation and medical audit. The capacities of the DQAGs have been built such that they can now conduct accreditation and medical audits for the health facilities in the state independently. The IFPS Project has been able to

contribute to the development of guidelines, checklists, and conduct audits and client satisfaction surveys by effectively involving the state systems. Societies, their corresponding voucher management units as well as implementing partners have been leading the process of conducting these studies and audits. As a result, the state systems are now well equipped with these QA mechanisms, to independently conduct these audits and surveys.

Social franchising, one of the other PPP models initiated by the IFPS Project in UP from 2007-2012, was a unique partnership with the private health sector and was developed as a sustainable model to provide health services in rural areas. The social franchising network developed, managed and sustained by Hindustan Latex Family Planning Promotion Trust (HLFPPT) (the Franchisor) was branded as the Merrygold Health Network (MGHN). This network consisted of 67 Level 1 franchisees(Merrygold) at district level. While Level 2 comprised of 367 fractional franchisees (Merrysilver) established at sub-district or block level, Level 3 (Merrytarang) comprised of 10,000 community-based providers like ANMs, ASHAs and AYUSH, and acted as a first point of contact with the community as also referral support to Merrysilver and Merrygold facilities.The key to any healthcare services’ delivery model lies in ensuring consistency of quality services delivered by the network. Over a period of four years, MGHN has standardized the key components of the franchise system that may be implemented and operated successfully by trained personnel. To set systems for quality assurance under MGHN,

23Setting up Mechanisms for Quality Assurance

in order to ensure consistent quality of care and standardization of patient outcomes, the franchisor with support from ITAP developed training modules elaborating upon 13 protocols. These include:clinical obstetrics, family planning, general hospital, personnel service, customer service, medication, quality, marketing, billing, budgeting and accounting, material management, and operation (ITAP, 2012 a).

The project provided mentoring support to the franchisor in conducting extensive trainings on these protocols for the franchisees. The larger objective was to attain ISO 9001-2000 certification and NABH certification for the different levels of facilities.

In addition, quarterly medical audits were conducted by teams at Merrygold as well as at the Merrysilver facilities. The project also supported the development of checklists based on quality indicators, namely facility readiness assessment, orientation of providers to client’s rights, quality of clinical services and infection and waste management, which were used for assessment.

Based on the results of two studies conducted in 2009 and 2011 respectively, quality improvement at the franchisee facility was achieved through the analysis of the QA checklists with the providers, capacity building of doctors and paramedical staff at the facility, regular medical audits and continuous follow-up. Approximately, 80 percent of the franchisees were satisfied with the quality of training provided to their staff members and the quality assurance system managed by franchisor.

The IFPS Project will be seen instrumental in leaving behind these quality assurance mechanisms for the state to envisage further partnerships with the private sector, in terms of involvement of these facilities from the network, in provision of quality services to the people of the state.

7.3 QUALITY IMPROVEMENT PROCESSES FOR RCH CAMPS IN JHARKHANDThe IFPS Project supported the state of Jharkhand to improve the quality and utilization of reproductive and child health (RCH) camps in three districts (Giridih, Simdega and Chaibasa) of Jharkhand. The IFPS Project conducted a quality assessment of RCH camps being conducted in Girdih, Simdega, and Chaibasa districts in order to formulate an improvement plan based on the assessment findings. Following the assessment, the project helped the Government of Jharkhand to formulate a strategy to help improve the organization of RCH camps in Jharkhand, for them to be

able to provide services at a level commensurate with GoI standards.

One of the main recommendations stated that the state should start holding camps at facilities and continue with outreach camps at the same time. It was suggested that RCH camps be conducted at those facilities which are equipped to render the services as per GoI norms for RCH camps. Comprehensive guidelines detailing the required service and support elements were developed with technical assistance from the IFPS Project. The RCH camps were now allocated a budget of Rs 25, 000 (USD 500) for each camp against an earlier budget of Rs. 5,000 (USD 100). The guidelines also provided details of budget heads and allocation, based on the gaps identified in the assessment, i.e. provision of outsourcing specialist health providers, transportation facility for clients, and provision for purchase of essential drugs (ITAP, 2011). These guidelines and budget were approved by the Government of Jharkhand and shared for implementation with the

Services being provided at an RCH camp


three districts. IFPS also provided support to district level officials in operationalizing the guidelines, by orienting them to the new approaches and mentoring them to plan the process for conducting the camps.

As a result, 50 improved camps were held in these three districts from December 2011 to January 2012 (19 in Chaibasa, 17 in Giridih and 14 in Simdega). The services

offered at the camps were utilized by 4047 clients, out of which 933 clients opted for sterilization services (99 NSVs and 834 TLs performed), and 361 women opted for IUCD insertion. The uptake of condoms and OCPs was also very high. As many as 331 clients availed ANC check-up and 411 children were immunized (Benchmark Documentation, IFPS Project).The IFPS Project has been able

to contribute positively, with the state government adapting the fixed facility camp approach in the PIP for the year 2012-13. The guidelines have proven useful for the state officials to plan for camps efficiently. Availability of trained providers at camps, provision of quality healthcare services and the plan for transportation of clients have added to improving the quality of camps.

Chapter 8

SIFPSA: LEAVING BEHIND A LEGACY

It has been well established that project interventions become more

effective as they increase the self-reliance of institutions they work with.

The IFPS Project design had three key features; a) creation of an autonomous agency/society to guide all project activities; b) focus on results and accountability through a performance based distribution (PBD) system; and c) emphasis on capacity building through technical assistance by cooperating agencies. The autonomous society was envisioned to transform and enhance its ability through the course of the project to sustain itself beyond the life of USAID funding.

8.1 CREATION OF AN AUTONOMOUS BODY FOR IMPLEMENTATION OF IFPS PROJECT IN UTTAR PRADESHBased on the project design, the IFPS Project was facilitated by the formation and strengthening of an autonomous state health society in UP. In 1992, the project began with a focus on increasing access to, improving quality of and expanding demand for FP/RH services in a significant portion of the state of Uttar Pradesh. To support implementation of the IFPS Project, USAID helped

establish State Innovations in Family Planning Services Agency (SIFPSA), a quasi-governmental society that could act both with and independently of UP state authorities.

USAID supported creation of this society to enable responsiveness and strengthen capacities of state structure for implementation of such a large project, and fund management and monitoring. SIFPSA was established in 1993 with the following mission statement:

“SIFPSA seeks to facilitate—through innovative means and partnerships with government and other agencies—the goal of ‘Health for All’ in Uttar Pradesh, by improving the quality, demand, access, and delivery of family planning and maternal and child health services and also improving other related quality-of-life parameters, including the status of women” (Oot et al., 1996).

8.2 DRAWING AN ORGANIZATIONAL FRAMEWORK FOR THE SOCIETYSIFPSA drew into its functioning, the expertise, experience and infrastructure of numerous stakeholders within the health system.

It was structured to circumvent the delays associated with working with the government sector and yet it was highly dependent on the state’s public health system to provide FP/RH services. The top two posts, the Executive Director (ED) and the Additional Executive Director were delegated from the Indian Administrative Service (IAS). SIFPSA was designed to function through 11 departments including three support departments related to finance, human resource and audit. The work areas included FP and RH services, covering:a. public sector – for activities in

public sector domain;b. private sector – for activities

related to private sector and other agencies like NGOs;

c. training and capacity building; and d. support to NRHM (Constella

Futures, 2006).

The 11 departments were headed by General Manager (GM)/Deputy General Manager (DGM) level of officers who reported to the ED. The 11 departments included: public sector private sector, contraceptive social marketing, training, IEC; District Action Plans; research and evaluation; family planning information system; finance; internal audit; human resources;

SIFPSA: Leaving Behind a Legacy 25


administration and procurement (Figure 2). Currently, a total staff strength of 74 members, based in Lucknow forms the technical team of the agency with assistance at the divisional level from 18 District Innovations in Family Planning Services Agencies (DIFPSAs). DIFPSAs were established by the IFPS Project to oversee implementation of the district action plans (DAPs). Each DIFPSA was chaired by the District Magistrate and had a governing board consisting of representatives from major public and private sector agencies concerned with RH work. The Project Management Unit (PMU) housed the staff responsible for implementing the DAPs.

The project activities are monitored by a Governing Board composed of representatives from GoI and GoUP, state government agencies, USAID, India, prominent private sector experts and the NGO sector. The governing board serves as the policymaking body for SIFPSA and approves the annual plans and budgets.

The IFPS Project was instrumental in setting up the organizational structure for SIFPSA, which is envisioned to become an independent society providing technical assistance for FP and RH, and is acknowledged as a leader in FP, district level action

planning, BCC and training and management.

8.3 PERFORMANCE-BASED DISBURSEMENT MECHANISMIt was decided that PBD mechanism will be used to provide funds to the Society, rather than paying project implementation costs directly. Under this funding mechanism, a set of targeted results was agreed upon between USAID and SIFPSA. A dollar value was attached to the activities that would produce those results. The benchmarks were incorporated into the overall project management. The process is known as establishing a benchmark for a specific result or

FIGURE 3: ORGANIZATIONAL STRUCTURE OF THE STATE INNOVATIONS IN FAMILY PLANNING SERVICES AGENCY

Project Appraisal Committee Governing Body Executive Committee

Policy Making

Executive Director

Additional Executive Director Ongoing Operations

GM (PS) GM (DAP) GM (T) GM (CSS) GM (HAP) GM

(PVT SEC)

GM (IEC) GM (R&E) GM (T) GM (CSM)

DEO Analyst (1)

DGM (PS) PC (2) (6)

APC (2)

DGM (PS) PC (2) (6)

DGM (PS) PC (2) (6)

DGM (PS) PC (2) (6)

APC (1)

DGM (T) DGM (2)

Officer (HR) (2)

PC (2) PC (2)

PA (1) APC (1)

Manager (1)

Officer (4)

DGM/Sr. PC (1)

PC (7)

APC (3)

PA (1)

DGM

PC (3)

APC (2)

DGM

PC (2)

APC (2)

Librarian (1)

DGM (T)

PC (3)

APC (1)

DGM (2)

PC (2)

PA (1)

DGM (PFIS)

DA (1)

PC (2)

PA (1)

Review project proposals & technical writing

Personnel & Procurement Administration

27SIFSA: Leaving Behind a Legacy

group of results. When the results were achieved and verified, payment of the benchmark’s value was made to central government and the funds were disbursed to SIFPSA as payment for the activities that resulted in the achievements outlined in the benchmark. The targets for achievement were set at an achievable yet ambitious level to emphasize the focus on achieving results.

USAID and SIFPSA set mutually agreed upon outcomes (benchmarks) linked to specific payment amounts, which were further released upon completion of the entire outcome. The fund flow process was such that the funds would flow from USAID through GoI to SIFPSA.

8.4 BUILDING CAPACITIES AND PROVIDING TECHNICAL ASSISTANCE FOR A SUSTAINABLE SOCIETYAs part of the planning for the IFPS Project, USAID had identified certain cooperating agencies to provide technical assistance to the project and also support SIFPSA to undertake various activities. The organizations, with recognized capacities also provided support to other USAID projects world-wide. These included The POLICY Project-Futures Group International, Futures Group/Commercial Marketing Strategies, CEDPA, JHPIEGO, IntraHealth International, University of North Carolina, John Hopkins University (JHU)/Population Communication Services (PCS), John Snow Inc./DELIVER Project, ORC Macro, Population Council, and Engender Health.

From 1992 to 2004, with technical assistance from the cooperating agencies, SIFPSA gained credit

for support in formulation and implementation of DAPs by local institutions, community based distribution of FP information and services by local NGOs, and state-wide social marketing efforts. Some of these interventions and management systems informed as models for broader use/replication in India and hence, SIFPSA became a recognized resource in the state for FP and program implementation (Constella Futures, 2006).

Key project accomplishments through Phase I, include decentralization of RCH program planning by engaging local government leaders and other stakeholders to develop and implement DAPs in 33 districts-nearly half of UP’s 70 districts, trained more than 27,000 public sector providers in family planning clinical and counseling skills, plus more than 10,000 ANMs in IUCD insertion and family planning counseling, and broadened private sector participation in RCH services through projects with more than 150 NGOs, more than 5,000 village level dairy cooperatives, urban development agencies, and employer groups. These community based projects covered about 24 million people (Constella Futures, 2006).

8.5 TRANSITIONING AND RE-ALIGNING ITSELF THROUGH THE COURSE OF THE IFPS PROJECTFollowing IFPS Project in Phase I, there was a shift in the approach and strategy from 2004-2009 with an emphasis on provisioning of quality FP/RH services through PPP mechanisms. The activities were reoriented towards development, demonstration, documentation, and leveraging expansion of working models of PPPs for provision of

integrated FP and RH services. A new technical assistance component was added to the project, in the form of ITAP. SIFPSA re-aligned itself to the refocused approach with technical assistance from ITAP.

At that point in time, a changing context in the system of delivery of primary health services to the rural poor in India was being witnessed. In 2003, the GoI initiated a transformation in the health service delivery system and established NRHM in 2005. NRHM in UP was marked by a delay in establishment of relevant structures (SPMU and SHSRC) due to the complex political environment, elections and frequent transfer of senior officials. SIFPSA was perceived as a well-established resource for implementation of NRHM in UP and for the GoUP.

Suggestions from the Principal Secretary, to nominate SIFPSA as SPMU and/or SHSRC for implementation and monitoring of the NRHM program were put forth. Another route for SIFPSA would be to pursue an independent role and continue to support programs in UP with support from USAID. It was clear that SIFPSA would have to work to ensure an effective interaction in the new state environment. Based on the changes in the IFPS Project mandate and government programs, in 2006, the IFPS Project undertook a reorganization study and recommended a number of restructuring processes in order to enhance the profile and efficiency of SIFPSA. Post recommendations from the reorganization study to restructure SIFPSA and align it to the NRHM program; there were delays in decision making on SIFPSA’s role and SIFPSA continued with its existing structure.


Meanwhile, the IFPS Project from 2004-2009 evolved to achieve policy consistency and convergence with the objectives of NRHM. The IFPS Project in collaboration with SIFPSA initiated several innovative PPP pilot programs (Sambhav voucher scheme, Social Franchising, NGO based programs) and as a result SIFPSA gained considerable experience in design, implementation and evaluation of PPP projects.

By the time the IFPS Project moved into its extended phase (2009-2012), SIFPSA had done comprehensive work in the entire state in the mandated areas and also achieved results as portrayed by the IFPS evaluation studies (USAID Global Health Fellows Program, 2007). It had developed expertise as an organization in the areas of FP and RH, and also established effective systems and mechanisms for implementing quality work in the entire state, and monitoring capabilities for its activities at the ground level (Global Health Technical Assistance Project USAID, 2007).

Through 2009 to 2011, all program implementation activities were taken forward by SIFPSA. With the

programs designed and tested and, mechanisms for implementation and monitoring established in the previous phase, SIFPSA focused on the following: Institutions and human capacity

development: As part of the support provided to NRHM, SIFPSA was designated as the nodal agency for certain types of clinical trainings. Table 3 presents a summary of the clinical trainings conducted through SIFPSA in UP.

After ten divisional level women hospitals were strengthened as Divisional Clinical Training Centers (DCTCs) in the second phase of the project, the remaining eight divisional women hospitals were taken for strengthening as DCTCs during the current phase. Support was also provided for training Village Health and Sanitation Committee (VHSC) members in two districts of Shahjahanpur and Kanpur Nagar. About 17,000 VHSC members were trained in 25 blocks of the two districts (Benchmark documentation, IFPS Project). The successful implementation informed SIFPSA’s decision to scale up the training

efforts for VHSC members in five decentralized participatory planning (DPP) districts, with the initiative being supported by the GoI. Behavior Change Communication:

SIFPSA was instrumental in initiating some BCC activities including mass media support and campaigns for various program components at the state level. BCC activities in the state culminated in the development of a BCC strategy for the NRHM (2008) and a companion implementation guide for district and block level health program managers addressing priority health behaviors. The need for a comprehensive BCC Strategy was envisioned by the then Mission Director, NRHM. UP was one of the first states in India to initiate a state level BCC strategy for NRHM. Based on the request, the IFPS Project rendered support for development of BCC strategy, which was developed through a multi-stakeholder consultation process. The strategy intended to provide a blueprint for focused BCC interventions to achieve the goals of NRHM. BCC guidelines for effective IPC, group and mass media interventions were also developed as part of the strategy document. The BCC strategy was well appreciated by the GoI and accordingly shared with other states for adaptation.

Numerous BCC campaigns were developed and activities initiated to increase knowledge and awareness of, and demand for FP/RH products and services. Additional activities were conducted to advocate for improved service access and utilization, and to build capacity among mid-level health program managers within the state, districts,


TABLE 3: CLINICAL TRAININGS CONDUCTED IN UTTAR PRADESH AS PART OF THE IFPS PROJECT (2004-2012)

Name of the Training

Participants Duration of Training

Training Site Numbers Trained

Laparoscopic TOT Training

Experienced Certified Laparoscopists & Staff Nurses

6 Days Meerut, Kanpur & Lucknow Medical Colleges

64

Laparoscopic Induction Training

MS/MD/DGO in OB/GYN or General Surgeon & Staff Nurses

12 Days Meerut & Lucknow Medical Colleges/DCTCs

94

Laparoscopic Refresher Training

Already trained but non-performing Laparoscopists

3 Days DCTCs 22

Abdominal Tubectomy TOT Training

Experienced Certified Providers & Staff Nurses

6 Days Agra Medical College 35

Abdominal Tubectomy Induction Training

Medical Officers & Staff Nurses 12 Days DWH Jhansi & Agra/DCTCs 26

Abdominal Tubectomy Refresher Training

Already trained but non-performing AT providers

3 Days DCTCs 13

IUCD TOT for Divisional Trainers

Trained Experienced divisional level Medical Officers & Paramedics

6 Days DCTCs 62

IUCD TOT for District Trainers

Trained Experienced district level Medical Officers & Paramedics

6 Days District Women Hospitals 474

IUCD Training Medical Officers & ANM/LHV/SN/PHN

2 Days DCTC/CHC/PHC 37

Postpartum IUCD Training

Medical Officers & Staff Nurses 3 Days Lucknow Medical College 103

Skilled Birth Attendant Training

Medical Officers 10 Days Six Medical Colleges of UP 44

NSV TOT Training Trained Experienced Provider 3 Days COE Lucknow 7

NSV Refresher Training

Non-performing NSV Providers 3 Days COE Lucknow/NSV Satellite Centers at 3 Medical Colleges of UP/Camp Settings

80

NSV Induction Training

Medical Officers 3 Days COE Lucknow/NSV Satellite Centers at 3 Medical Colleges of UP/Camp Settings

144

Infection Prevention (ToT)

Medical Officers 6 Days District Level Facilities 87

Infection Prevention

On-site-whole-site

Whole-site staff 2 Days DH/PHC/CHC 3317

EmOC & NBC ToT Faculity of Medical Colleges 6 Days Lucknow Medical College 21

EmOC & NBC Induction

Doctors and Paramedics 21 Days 374

blocks and frontline healthcare workers such as accredited social health activists (ASHAs) and

auxiliary nurse midwives (ANMs). The programs engaged the private sector and employed mass media,

entertainment-education (EE), community mobilization and capacity building strategies (ITAP, 2012).


Strengthening community-based delivery of FP/RH services: SIFPSA supported 170 NGO projects in the first phase of the IFPS Project. The NGOs played a vital role in community mobilization by creating awareness through interpersonal counseling and provision of information and services on family planning in rural areas. As the IFPS Project moved to its next phase in 2005, the year also witnessed the launch of NRHM and ASHA scheme. It was felt that the community based approach alone would not be able to cater to a wider range of services and population. As a result, the IFPS Project designed NGO projects to cover a wide range of services and innovative local approaches and interventions, promotion of informed choices, mobilizing communities and creating a demand for RH and FP services. As part of this project, SIFPSA, through 24 NGOs covered 45 rural blocks and two urban slum areas in 11 districts of UP for increasing contraceptive use, institutional delivery, complete

TABLE 4: A SUMMARY OF THE BCC INITIATIVES UNDER THE IFPS PROJECT IN UTTAR PRADESH (2004-2012)

Strategies developed

BCC Campaigns/Material Development BCC Capacity Building BCC in Social Marketing/ Franchising

Mass media Mid-media

IPC/ Community Level

NRHM BCC Strategy 2008

Multimedia Sterilization Campaign

2004

Radio Series –Sanwarte Sapne-Sunahri Rahen

Comprehensive Poster on Family Planning

ASHA Newsletter

Immunization – Jachcha-Bachcha Raksha Card

Folk Media - Street Plays, Puppet and Magic Shows

Saloni Diary Distance Learning Program

NRHM Flipbook for ASHA

Saloni Teachers’ Training Manual

Family Welfare Counselors Training Module

Regional BCC Capacity Building

Communication Plan for MGHN

Brand Equity and Barrier Analysis Study

Voucher Scheme

antenatal check-ups, and complete immunization.

Completion, evaluation and documentation of existing PPP models: SIFPSA continued to support the PPP models initiated in the second phase, including the Sambhav Voucher Scheme, which was piloted in urban slums of Kanpur Nagar with technical assistance from the IFPS Project. In this phase, SIFPSA initiated expansion of the voucher scheme to all KAVAL towns of UP i.e. Agra, Varanasi, Allahabad and Lucknow, for reaching the urban poor with slight modifications.The scale-up expands the urban slum voucher scheme from 368 slums in one city (Kanpur) to 1,562 slums in five cities (Kanpur, Allahabad, Varanasi, Agra, and Lucknow). The scaled-up voucher system was effectively launched in October 2010 in Allahabad and Varanasi, in December 2010 in Lucknow, in August 2011 in Kanpur, and in December 2011 in Agra. The expanded program has accredited 53 private nursing homes/hospitals and mobilized

about 1,300 CHVs to date, with NGOs and the District Urban Development Association (DUDA) supporting voucher distribution to the CHVs. In Kanpur and Allahabad, local NGOs support the program as the voucher distributing agencies (ITAP, 2012 a).

SIFPSA had facilitated the Social Franchising project in the second phase, to bring together a large number of private sector healthcare providers under one brand ‘Merrygold’,and built linkages to provide high-quality healthcare services, with a consistent pricing policy’, developed concentrated network (Merrygold Health Network (MGHN) of three tier hospitals, clinics and referral links (L1, L2s and L3s) within each district, and focused on brand promotion and services promotion through BCC activities. In the current phase, the MGHN has expanded and is now operational in 36 districts across UP. It has been successful in bringing together more than 430 hitherto disaggregated private health service providers


and nearly 10,000 community level workers into the folds of the network, making it one of the largest networks in India (Schlein, 2011). Given its geographical spread and reach into rural areas as well, the Network has been able to provide comprehensive FP/ RH services across districts. From October 2007 till February 2012, the Network has provided more than 756,100 antenatal checkups, nearly 133,900 deliveries, more than 10,600 sterilizations and nearly 38,200 IUCD insertions. In addition, with condom and oral contraceptive pills, the Network has generated more than one million couple years of protection. (MGHN MIS, 2012). Periodic reviews, assessments and surveys conducted for MGHN indicate that the network has made progress as highlighted in following sections (ITAP, 2012 d).

8.6 KEY ISSUES AFFECTING SIFPSA’S OPERATIONSCertain issues related to decision making and reorganization have affected SIFPSA’s operations through the course of the project. SIFPSA’s role in the future can be positively informed by bringing in some changes in its operations and management to ensure effective interaction with the state government and effective partnering with a variety of other organizations.

One of the key issues that have affected SIFPSA’s operations through the course of the project has been related to lack of consistent leadership. Frequent transfers of the Executive Director and Additional Executive Director have affected the operations of the society. Currently, there are no systems in place for collaboration with the Directorate

of Health and Family Welfare, GoUP and SPMU for implementation of NRHM activities. All activities implemented as part of the NRHM are performed on piecemeal basis. Therefore, the relationship between SIFPSA, the Directorate and SPMU needs to be substantially strengthened and strategically taken forward to successfully implement NRHM activities, and establish an encouraging environment for state level collaboration.

8.7 ELEMENTS OF SUCCESSSIFPSA’s success is founded in its unique organizational structure and the underlying principles. SIFPSA has had a comprehensive structure with distinctive governance, executive and operational roles. Through the course of its establishment and project duration, SIFPSA has taken diverse roles including innovation, facilitation, strengthening, funding, coordination and monitoring. Another key element of its success has been the benchmark based performance ‘management’ and funding. SIFPSA supported project based interventions with continuous monitoring and reporting mechanisms. A transparent and decentralized funds management system was instituted for the agency. As a result of the interventions made and management systems established by SIFPSA, it is a recognized resource for FP and program implementation in the state of UP.

8.8 ADDRESSING COMPLEXITIES FOR SIFPSA’S COURSE AHEADWith the IFPS Project coming to an end in March 2012, it became important to assist SIFPSA in developing a transition plan so that it could continue as a sustainable

organization making valuable contributions in the desired areas. In 2011, the IFPS Project supported the development of a redesigned structure for SIFPSA along with a transition plan. The transition plan was developed after an assessment of the overall fund requirements including the operational and administrative requirements; after determining a minimum level of field program to be funded by SIFPSA each year from its own sources and after exploring other funding sources including interest earned on the corpus funds, other potential donors and NRHM UP.

SIFPSA has a corpus fund of nearly USD 40 million generated through savings from different benchmarks under the PBD mechanism. Recommendations have been made by USAID and ITAP on utilization of the corpus in a way such that SIFPSA sustains itself as an independent society and continues its programmatic work in FP and RH.

Reaching out to a large population through program interventions in 20 years, in 33 districts of Uttar Pradesh, with numerous public and private partnerships fostered, program interventions piloted and scaled up, SIFPSA has been instrumental in contributing to the state’s efforts on FP and RH. With these achievements in its stride, SIFPSA is an established resource for FP and RH, and program implementation for the state of Uttar Pradesh. It will be important to see how the active efforts to transition SIFPSA and plans for efficient utilization of corpus funds, institutionalize SIFPSA as a continued resource in UP.

Chapter 9

STRENGTHEINING INSTITUTIONS TO PROMOTE FAMILY PLANNING IN JHARKHAND

Jharkhand formulated its State Health Policy and the Reproductive Health and Population Policy in 2004 with the objectives of achieving a total fertility rate (TFR) of 2.1 children by 2020 and a contraceptive prevalence rate (CPR) of 60 percent by 2015 (Government of Jharkhand, 2010). Despite policy directions, the population growth rate remained well above the national average, with fertility and unmet need for FP (23.1% for the state; 26.2% rural and 13.4% urban) being critically high (NFHS 2, 2005-06).

Responding to the need of the hour, the state decided to set up a Family Planning (FP) Task Force. The Task Force was envisioned to cater to specific needs and also to provide value addition to the overall FP endeavor at the state level. There was a need to understand the health service delivery scenario in the state, in terms of quality of services provided at government facilities and to assess the training requirements. It was thought important that the state approach towards provision of various FP services (IUCD, condoms and OCP) and expansion of the basket of contraceptives be understood

with reference to the ground situation and accordingly solutions be proposed. The need to cash in on the opportunities of convergence at the grassroots level to enhance FP outcomes was also foreseen. Support was required for understanding the monitoring and evaluation process to be able to identify gaps and propose solutions.

Based on these needs the Task Force was assigned to review the state FP program, identify gaps and propose solutions, and keep the FP objective of the state salient among all stakeholders.

The IFPS Project has emphasized on its broad objective of provision of high quality FP and RH services in three states including Jharkhand. The IFPS Project strengthens capacity of Indian institutions to implement FP/ RH programs. In this capacity, the project provided significant support to set up the FP Task Force.

The Task Force was constituted as a multisectoral advisory group consisting of representatives from the state government (MD, NRHM,

Director in Chief, Additional Director (FP), State RCH officer), development partners and implementing partners (A to Z, PFI, PSI,UNICEF ITAP, Vistaar, JHEPIEGO, IRH) in the state. The IFPS Project coordinated and participated in the first meeting to constitute the Task Force members, discuss and finalize the role of the Task Force and to identify key priorities in family planning and develop plans for follow up. The IFPS Project has been instrumental in organizing the Task Force meetings at regular intervals to strengthen the FP program.

One of the mandates of the Task Force was to develop a State FP Strategy and set up an FP Cell. The IFPS Project has done a detailed analysis of all the national health survey results and a qualitative assessment was undertaken in six districts of Jharkhand. Specifically, to inform and support Government of Jharkhand’s strategy development process, the project interviewed approximately

100 stakeholders including policymakers, program managers, supervisors, service providers,


33Strengthening Institutions to Promote Family Planning in Jharkhand

frontline workers, community leaders, and FP clients;

conducted demographic projections to help develop realistic FP goals based on contraceptive and sources for obtaining services/products.;

facilitated a strategic planning exercise for FP taskforce members to share the findings from the quantitative and qualitative assessments, help draft strategic approaches, and identify specific actions for improving family planning performance.; and

supported the GoJH to develop a final strategy that aims to achieve replacement-level fertility by 2020 and outlines three strategic directions for improving family planning performance. These include health systems strengthening, strategic program interventions, and an operational plan for low-performing districts.

In August 2010, the strategy was approved by the State Mission Director, NRHM. The strategy envisaged a state level FP Cell to provide leadership for implementation of the strategy. The FP Cell was instituted at the State RCH office and functioned under the leadership of the Secretary, Department of Health and Family Welfare. The IFPS Project provided support for preparation of scope of work and recruitment of the cell members proposed, based on the organizational structure. The selected staff members were oriented on the FP strategy by the IFPS Project. To support the initial activities undertaken by the cell members, the IFPS Project convened quarterly FP Task force meetings and developed the annual work plan for the FP Cell in consultation with the cell members. The IFPS Project has provided support for compilation of

the FP component for the state PIP for 2011-12 and 2012-13. Support has been provided for several other activities including development and circulation of state guidelines on FP and development of IEC material to be displayed across the state.

One significant contribution made by the IFPS Project has been the support provided for planning and coordination for FP fortnight. The FP fortnight (July 2011) was planned to corroborate with the World Population Day. The program was conducted across three districts as a 14-day activity following the health camp approach, where FP services and counseling were being provided.

The fortnight achieved marked results in service uptake.

The IFPS Project has been instrumental in establishing strong ground work in Jharkhand for taking the FP program forward. Emphasizing one of IFPS Project’s key objectives, i.e. instilling state ownership, the FP Cell now works under the auspices of the State Health Society. The concept of establishing an FP Cell as a sustainable institution to promote family planning in the state is one of the first initiatives taken by a state in India. The concept can be replicated for other states as well to promote areas of health that need to be focused upon based on state specific needs.

TABLE 5: BY THE NUMBERS: FAMILY PLANNING FORTNIGHT

S no. Service provided Number

1 TT 11343

2 NSV 5349

3 IUCD 26965

4 OCPs distributed 207364

5 Condoms distributed 1658080

Source: ITAP MIS, 2010-11

Chapter 10

BUILDING CAPACITIES OF THE PRIVATE SECTOR

Through the course of the IFPS Project several collaborations and partnerships were established for better implementation of the programs. For effective implementation of any program, it is important to establish partnerships with the local counterparts, build their capacities and orient them to the program needs.

10.1 IDENTIFYING AND BUILDING LOCAL CAPACITIESAs part of the PPP models initiated and implemented under the IFPS Project, several local NGOs were identified. The project interventions were designed in a way such that NGOs would be a part of the design and implementation processes. Local NGOs brought with them the experience of working with the community and had a better understanding of their needs. NGOs were identified and oriented to their roles for each of the PPP models including, ARSH UDAAN and ASHA Support system in Uttarakhand, MHVs in Uttarakhand, Voucher Schemes in UP, Uttarakhand and Jharkhand, Social Franchising and Social Marketing in Uttar Pradesh.

Given the importance of reaching BPL families in the communities

where they live, the Sambhav voucher programs involved NGOs as partners. Under the voucher scheme, primary responsibilities of the NGOs included training community-level health workers to implement the voucher scheme, conducting monthly meetings with them to provide support, distribution of vouchers, collect records, and pay remuneration based on levels of performance, facilitating communication and community mobilization events, reporting to the VMU on block-level performance. Through the IFPS Project NGOs were trained to provide them with the knowledge and skills required to train community level health workers about their role in the voucher scheme. Training modules were also provided to aid the NGOs in their training sessions. The IFPS Project also prepared and distributed a software program and forms to facilitate tracking of the NGOs’ distribution of vouchers to the NGOs. In Agra, the voucher management unit (VMU) contracted two NGOs that were already implementing SIFPSA-supported activities (except in Shamsabad, where there was no SIFPSA NGO). In Kanpur Nagar, HLFPPT was the VMU and served as a nodal NGO managing the activities of three NGOs (Award, Aameen


Welfare Trust and Krishi Evam Shaikshik Prabandh Sansthan), each covering about 120 slums. In the case of Haridwar, DGUS was selected to support the VMU, until the time the VMU was operationalized. DGUS performed all the functions of the VMU, including managing relationships with the government and providers, as well as distributed vouchers to and supported the ASHAs. Similarly, in Gumla, the NGO Vikas Bharti, after a competitive process, was selected as the VMU and also served as the link to community-level health workers.

For the ASHA Plus program, ITAP supported UKHFWS in selecting the partner NGOs. Potential partner NGOs were identified on the basis of their entrenchment within the community as well as their credibility and reputation. The NGOs recruited, trained, and supervised the ASHA Plus workers, and coordinated with both communities and the UKHFWS. Block Coordinators were also hired by NGOs to provide overall supervision and monitoring of the ASHA Plus workers. The four NGOs selected for the project districts included Organization for Prosperity, Education and Nurture (OPEN), Jai Nanda Devi Swarozgar Shikshan Sansthan (JANDESH), Himalayan

35Building Capacities of the Private Sector

Society for Alternative Development (HIMAD) and Kumaon Agriculture and Greenery Advancement Society (KAGAS).

Once selected, the NGOs were sensitized and trained on a set of benchmarks to ensure smooth implementation of the pilot project. The NGO staff was also trained on the ASHA Plus curriculum, supervisory and communication skills so that they could perform their tasks as trainers and supervisors. The four NGOs were a strong support system for the ASHAPlus workers.

As part of the activities implemented in UP with clinic based NGOs, 21 NGOs covered 40 rural blocks in 10 districts for increasing contraceptive use, institutional delivery, complete antenatal check-ups, and complete immunization. To make FP and RH services including counseling easily accessible to people, Comprehensive Health and Counseling Services (CHACS) was introduced. A community health supervisor (CHS) was placed in a cluster consisting of about 20,000 populations. An appropriate location in terms of access and convenience for the community was identified for organizing CHACS on a regular basis.

Similarly, recognizing that the day-to-day implementation activities could be best managed by organizations with extensive presence and integration within local communities, the ARSH UDAAN program in Uttarakhand was designed for close partnership with local NGOs. At the block level, local NGOs were selected to function as the primary implementation agencies in the field.

In the pilot phase, the NGOs were selected by a committee coordinated by the State Nodal Agency (SNA) based on their experience within local communities and work on RH issues. Subsequently, each NGO signed a Memorandum of Understanding (MoU) with District Health and Family Welfare Societies. Their work was monitored by the SNA. Working within each block, the NGOs assumed several implementation responsibilities. The SNA and NGO partners were oriented to provide Adolescent Friendly Health Services. These included identifying and training PGEs, forming and mentoring adolescent groups, establishing AFCs and organizing their activities, working with health officials at the sub-center level to organize health camps and Adolescent Health Days, coordinating and facilitating adolescent services within schools, conducting advocacy with parents with the support of local Panchayati Raj Institutions (PRIs), maintaining the supply chain for drugs and social marketing products, managing social marketing activities, facilitating district Project

Advisory Group (PAG) meetings, and establishing adolescent Health Monitoring Information Systems (HMIS) at all levels.

10.2 ENHANCING CAPACITIES OF THE PRIVATE FACILITIES FOR PROVISION OF QUALITY SERVICESThe initiation of the PPP models as part of the IFPS Project saw collaborative efforts between the public and private sectors with clear, mutually agreed upon roles, shared objectives, and specified performance indicators. Several private providers have been involved for delivery of quality services at a negotiated reduced price. Specifically for Sambhav Voucher Schemes in UP, Uttarakhand and Jharkhand and the MGHN as part of the social franchising initiative in UP, the IFPS Project helped to enhance the capacities of the private providers and their staff were trained on infection prevention, bio-medical waste management and hospital management. As part of this association, continuous medical education (CME) sessions were also arranged for the doctors

NGO workers undergo training in Uttarakhand


on GoI management guidelines, IUCD insertion and emergency contraceptive pills (ECPs). Accreditation guidelines were prepared by the IFPS Project, based on which private providers were able to participate in the programs. Also, regular client satisfaction surveys, medical audits of the accredited facilities and follow up mechanisms, helped promote quality improvement (ITAP, 2012b). With these established standards, the private providers in the project intervention areas are mobilized and equipped to provide quality services to the people of the states of UP, Jharkhand and Uttarakhand.

10.3 EVIDENCE BASED PLANNING, DESIGN AND IMPLEMENTATION OF PROGRAMSOne of the key mandates of the IFPS Project has been to focus on evidence based planning, design and implementation of projects. A variety of surveys/studies have been designed and conducted to understand project intervention areas (situation analysis, baseline surveys), measure impact of the program mid-way or to inform scale-up (mid-line assessments), to understand program impact at the end of the program (endline surveys), client satisfaction surveys, medical audits, qualitative surveys to inform BCC campaigns’ design, cost effectiveness studies, specific program assessments to improvise program implementation (mobile health vans). Through the course of these surveys and studies, the IFPS Project has been able to enhance capacities at two levels:

Capacities of apex institutions like NIHFW, UKHFWS, SIHFW, and SIFPSA have been strengthened to understand the processes involved, including selection of agencies, designing a research study (tools and methodology) and data collection, to undertake such studies.

A number of collaborations with research organizations were established for conducting various studies. The IFPS Project has been able to contribute in enhancing the capacities of these organizations on sample design, administering tools, data entry packages and data interpretation, quality data collection and analysis, data validation and report compilation.

10.4 ORIENTING ADVERTISING AGENCIES TO THE DEVELOPMENT SECTORAs part of the IFPS Project, over 40 mass media campaign commercials, 20 multimedia campaigns and multiple communication campaigns have been designed (ITAP, 2012). The project has worked with a number of creative agencies in the process, to design content for these campaigns and research agencies to conduct formative studies and pre-test materials and messages. While these collaborations resulted in effective BCC campaigns and materials, the IFPS Project has been instrumental in driving these agencies to the development sector. Their capacities have been built in the following ways: Understanding of the health

scenario: The project sent out

creative briefs which contained detailed background of the health issues, the barriers and enabling factors, the communication objectives, guidelines for communication and conducting a pretest. This document helped the creative agencies understand the heath scenario and come up with creative ideas to communicate the messages effectively. For e.g. an agency developed two television and radio spots on family planning and in the process won an assignment to create a 20-minute film on non-scalpel vasectomy under another USAID funded project.

Marrying content and creative: One of the biggest challenges is to ensure that the content and creative treatment are intertwined seamlessly otherwise the content tends to become either too message heavy or misses out on key messages while trying to be creative. Under the project, agencies worked with the project team through interactive discussions, to arrive at the best creative route to highlight the key messages.

Understanding the importance of subliminal messaging: The project has always encouraged producers to use subliminal messages like interspousal communication, joint decision making, gender equality, etc., in the creative treatment of the films.

37Building Capacities of the Private Sector

“We really appreciate the way the IFPS Project uses research to inform the creative briefs which are well formulated, quite detailed and in-depth. It really helped us in identifying the correct insights for our communication strategy.”

Shailendra Chaturvedi- DDB health and LifeStyle

“We have had the opportunity to work with the IFPS Project on assignments related to research and behavior change communication. It has been a pleasure to work with the team. The intensive interaction with team members has enabled a significant learning for our team on both the strategic aspect of research and communication design and the specific operational components.”

Divya Shivpuri – Saarthak Development and Business Solutions Pvt. Ltd.

“We used the barrier analysis and brand equity for the first time in the social sector and to see that the findings are used to improve public health is satisfying.

We are today much more confident of undertaking many such large and challenging studies in the social sector.”

Priyanka Singh – Market Xcel

DISCUSSION AND WAY FORWARD

Working with stakeholders at various levels, including the government at the national level, state governments and support structures, autonomous institutions, NGOs, and other private organizations, the IFPS Project has been able to significantly contribute to build institutional and individual capacities with extended support for mentoring these key systems.

In its efforts to provide technical assistance to build capacities of these key systems, the project addressed complexities and challenges through the course of its implementation.Working closely with the state governments of the project intervention areas, the IFPS Project faced challenges due to frequent changes in leadership. The changes in leadership and administrative complexities caused delays in decision making and further delay in implementation of key initiatives. Lack of systematic deployment of human resources in the public health institutions is a key issue, such that it leads to repetition in training and capacity building. In the public health system in India, capacity building at all levels has been perceived with a narrow scope i.e. as only training. It was a challenge to broaden the perceptions at all levels to view

capacity building as inclusive of establishing new institutions, mentoring existing and new institutions, importance of training stakeholders at all levels and strengthening systems of these institutions. A challenging task was also to get a consensual buy-in from stakeholders at all levels, which was important to ensure state ownership of the institutions and initiatives.

Addressing these challenges through the course of the project, all opportunities to build capacities of these institutions were mobilized, with an aim to strengthen the existing and new institutions, systems, individuals, to foster the sustainability quotient and enhance government ownership.The technical assistance provided to support and strengthen SIHFW in Uttarakhand and UP, has served as the foundation for sustainable institutions in these states. The stage has been set for Jharkhand with the revival of plans to operationalize IPH and promotion of FP through the FP Cell. The onus lies with the state on how to efficiently utilize these resources. Technical support provided for implementation, management and monitoring of NRHM in Uttarakhand and UP, has helped in strengthening the capacities of the SHSRC in Uttarakhand and SPMUs and

DPMUs in both the states. It will be interesting to see how SIFPSA through its transition phase takes on a larger role to serve as an established resource for FP and RH for the state of UP. The partnerships and collaborations at the national level with MoHFW, NIHFW and NHSRC will deepen the already strong national capacity and also help harness opportunities of further partnerships with the private sector.

The capacity building efforts were garnered to establish systems as part of these institutions, envisioned to continue to meet their objectives even after the conclusion of the IFPS Project. Key mechanisms on quality assurance, training aids, course materials and best practice experiences have been left behind with the institutions and the government as assets, to adapt and utilize for new initiatives and efforts. The potential of these mechanisms and institutions can be harnessed for implementation of the NRHM program. At the same time, with the foundation laid for the relatively new institutions (SIHFW, SHSRC, SARC and DARCs), a certain level of handholding and mentoring through a technical support agency is recommended. It will be important to see how these efforts are taken forward by the state governments.

Chapter 11


References

REFERENCES

PUBLISHEDConstella Futures. 2006. Ideas, Insights, and Innovations: Achievements and Lessons Learned from the Innovations in Family Planning Services (IFPS) Project, 1992-2004. New Delhi, India: Constella Futures.

Global Health Technical Assistance Project, USAID. 2007. IFPS II Evaluation. India: USAID.

Government of Jharkhand. 2010. Family Planning Strategy of Jharkhand 2010-2020.Jharkhand. Government of Jharkhand

ITAP. 2012. Behavior Change Communication Activities and Achievements: Lessons Learned, Best Practices and Promising Approaches. New Delhi: Futures Group.

ITAP. 2012a. Community-based Workers Improve Health Outcomes in Uttarakhand, India. New Delhi: Futures Group.

ITAP. 2012b. SAMBHAV: Vouchers Make High-Quality Reproductive Health Services Possible for India’s Poor. New Delhi: Futures Group.

NRHM. 2005. NRHM 2005-2012:Mission Document. New Delhi: Government of India

NRHM. The Progress So Far. Retrieved from http://mohfw.nic.in/NRHM. Accessed on March 2012.

Oot,D., et al.1996. The Innovations in Family Planning Services (IFPS) Project Management Review. Report to USAID/India. New Delhi, India:USAID/India

Planning Commission. 2012. Report of the Working Group on National Rural Health Mission (NRHM) for the Twelfth Five Year Plan (2012-2017). New Delhi: Government of India.

Reddy KS, Patel V, Jha P, Paul VK, Kumar AS, and Dandona L. Towards achievement of universal healthcare in India by 2020: A Call To Action. Lancet. 2011. 377 (9796): 760-768.

Schlein, K., Drasser, K. and Montagu, D. 2011. Clinical Social Franchising Compendium: An Annual Survey of Program, 2011. University of California, San Fransisco

The EVALUATION Project. 1996. Performance Indicators for the Innovations in Family Planning Services Project: 1995 PERFORM Survey in Uttar Pradesh. Uttar Pradesh: USAID.

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USAID. 2007. Priorities and Actions for IFPS 2.2: September 2008-September 2012/15. New Delhi: USAID Global Health Fellows Program.

USAID.Global Health Initiative. Retrieved from http://www.pepfar.gov/ghi/index.htm;http://www.usaid.gov/ghi/factsheet.html. Accessed on March 2012)

WHO SEARO. Country Health System Profile: India. Retrieved from http://www.searo.who.int/en/Section313/Section1519_10853.htm.Accessed March 2012.

UNPUBLISHEDBossert, Thomas J. 2000. Module on Decentralization of Health Systems: Sharing Resources and Responsibilities. Boston: International Health Systems Group, Harvard School of Public Health

Capacity Building: Framework documents

ITAP. 2008. Rapid Assessment of Rogi Kalyan Samitis in Uttar Pradesh: ITAP

ITAP. 2011. Assessment of RCH Camps: Jharkhand. New Delhi: Futures Group.

ITAP.2012c. Summative Report. New Delhi: Futures Group.

ITAP. 2012d. Social Franchising as a Public Private Partnership Model: Lessons Learned from the Merrygold Health Network of Uttar Pradesh, India. New Delhi: Futures Group.

Market Excel. 2011. Brand Imagery: Merrygold Hospital and its Competition. Qualitative Findings.IFPS Technical Assistance Project.Gurgaon. India

MoHFW. 2009. National Health Bill Working Draft: Version January 2009. New Delhi: Government of India.

Nielsen. 2009. Mid Term Evaluation of Social Franchises Project in Uttar Pradesh. SIFPSA. Lucknow. India

NIHFW. 2006. Midterm Evaluation Report of the Alternative Training Methodology for IUCD in the 12 States (15 Districts). New Delhi: NIHFW.

Editing, Design and PrintingNew Concept Information Systems Pvt. Ltd.Email: [email protected]

Photo credits: Jignesh Patel, Gaurang Anand, Satvir Malhotra and Health Policy Project

Suggested citation: IFPS Technical Assistance Project (ITAP). 2012. Capacity Building of Institutions in the Health Sector: Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand. Gurgaon, Haryana: Futures Group, ITAP.

The IFPS Technical Assistance Project is funded by the United States Agency for International Development (USAID) under Contract No. GPO-I-0I-04-000I500, beginning April 1, 2005. The project is implemented by Futures Group International in India, in partnership with Bearing Point, Sibley International, Johns Hopkins University, and QED.

For further information, contact: Futures Group International, DLF Building No. 10 B, 5th Floor, DLF Cyber City, Phase II, Gurgaon - 122 002www.futuresgroup.com

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USAID INDIA

US Agency for International DevelopmentAmerican Embassy

ChanakyapuriNew Delhi – 110 021

INDIATel: (91-11) 2419 8000Fax: (91-11) 2419 8612

www.usaid.gov

Capacity Building of Institutions in the Health SectorReview of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand

The Power of

Innovations and

Partnership

APRIL 2012This publication was prepared for review by the United States Agency for International Development. It was prepared by Futures Group International.

Sustainability

Scale-up

Equity

AccessGenerating Demand

Quality