MEETING THE PRIMARY HEALTH CARE NEEDS OF

RURAL ASSAM THROUGH INTRODUCTION OF MID

LEVEL HEALTH CARE WORKERS- LESSONS FROM INDIA’S

EXPERIENCE WITH RURAL HEALTH PRACTITIONERS

DR. SUCHITRA LISAM, MBBS , MPH, PDCE

INTERNATIONAL CONFERENCE ON GLOBAL PUBLIC HEALTH 2014; 3th-4th

JULY, 2014, NEGOMBO, SRILANKA

BACKGROUND

• Lack of health workers is one of the main constraints in achieving population health goals in many countries including India

• India has 1 skilled service providers (doctors, nurses and midwives) per 1,000 population as against the international norm of 2.3 per 1,000 population to achieve 80 percent coverage of the population with skilled attendants at birth

• Majorities (70%) of health workers employed in private sector and 60% of these health workers reside in urban areas which skews the distribution of health workers

• Density of allopathic physicians in urban and rural areas was 11.3 and 1.9 respectively, reflecting the higher proportion of physicians reporting insufficient qualifications in rural areas.

INTERVENTIONS FOR ATTRACTION AND RETENTION OF HEALTH

WORKERS IN REMOTE & RURAL AREAS

Ref: WHO Global Policy Recommendations, 2010

A. Education

A1 Students from rural backgrounds

A2 Health professional schools outside of major cities

A3 Clinical rotations in rural areas during studies

A4 Curricula that reflect rural health issues

A5 Continuous professional development for rural health workers

B. Regulatory

B1 Enhanced scope of practice

B2 Different types of health workers

B3 Compulsory service

B4 Subsidized education for return of service

C. Financial incentives C1 Appropriate financial incentives

D. Professional and personal support

D1 Better living conditions

D2 Safe and supportive working environment

D3 Outreach support

D4 Career development programmes

D5 Professional networks

BACKGROUND- ASSAM STATE (STUDY SITE)

PHC: 938

Districts: 27

Total SCs: 4604

INDICATORS INDIA ASSAM

Total population(Census 2011) crore

121.01 3.12

Sex ratioCensus 2011)

940 958

TFR(NFHS-III)

2.6 2.4

CBR(SRS 2013)

21.6 22.8

IMR(SRS 2012)

42 55

MMR(SRS 2009)

212 347

Doctor

population ratio

1:1800 1:1722

Percent of fully

immunized (12-23

months) children (DLHS-III)

53.5 50.7

Rural population:

26,807,034

BACKGROUND

Assam passed the “Assam Rural Health Regulatory Act in

Sep’2004 for creation of mid-level health professionals to serve

the rural population

Vide the Act, Assam Rural Health Regulatory Authority was

formed to regulate and develop the 3 yrs curriculum of Diploma

in Medicine and Rural Health Care (DMRHC) course

Under the Act, Jorhat Rural Medical Institute was established

for starting the DMRHC course in Sep’2005

Act defined the diploma holders in DMRHC as “Rural Health

Practitioners” who are eligible to practice medicine /rural

health carein rural areas, perform notified procedures, treat

notified common ailments/ diseases, use common notified drugs

and are not permitted to use “Doctor” or “Dr” before and after

his name

STUDY OBJECTIVES

To examine the trend in ranges , types and uptake of health care

services before and after deployment of RHPs at SCs

To assess & compare performance of SCs with RHPs to those SCs

without RHPs in studied districts

To understand the perspectives of beneficiaries, community, officials

and ANMs about the ranges, types and quality of health care services

provided before and after deployment of RHPs

To understand the perspective of RHPs about DMRHC, their

role, work experiences, challenges faced etc

To provide suggestions for improvement of RHP model

STUDY DESIGN

Mixed Research method – primarily qualitative complemented by

quantitative technique

Triangulation method for consolidation/validation of data

obtained from varied sources-

o Review of secondary data on RCH indicators for SCs/districts;

o Review of government documents

o In-depth interviews /FGDs using semi-structured questionnaire

Purposive random sampling method used for selection of 8 high

focus districts (HFDs) out of 14 HFDs on the basis of criteria like:

o Average performing district (RCH indicators)

o Availability of RHPs in SCs in district in 1 year prior to study

o Feasibility to conduct field visits (study period: Apri-Sep’13)

CRITERIA FOR AVERAGE PERFORMING

DISTRICT

key RCH performance indicator Range of percentage

% of pregnant women with 3 ANC check

up against estimated pregnancies

≥80% ≥60%-<80% <60%

Point Given 3 2 1

% of immunized children less than 1

yr against estimated live births

≥80% ≥60%-

<80%

<60%

Point Given 3 2 1

% of institutional deliveries against

estimated deliveries

≥60% ≥40%-

<60%

<40%

Point Given 3 2 1

SAMPLE SIZE DISTRIBUTION

Districts SCs visited RHPs ANMs/

MPWs

Beneficiaries GD held Officials

Nagaon 8 8 12 26 3 3

Jorhat 9 9 13 11 3 3

Hailakandi 10 10 9 15 4 2

Golapara 17 17 23 41 4 2

Nalbari 10 10 15 23 2 5

Cachar 11 11 8 16 0 2

Darrang 8 8 13 15 2 3

Karimganj 18 18 15 19 3 3

Total SCs=91 RHPs=91 ANM=108 Beneficiaries=

166

GDs=21 Officials

=23

STUDY FINDINGS- Curriculum

Three Years Curriculum (class room, laboratory and clinical

rounds/postings) + 6 months of compulsory internship

First Year Anatomy, Physiology , Biochemistry, Community Medicine – Part. I

Second Year Pathology , Microbiology, Pharmacology, Community Medicine- Part

II

Third Year Medicine and Pediatrics, Surgery and Orthopedics

Basics of Eye & ENT, Dentistry, Obstetrics and Gynecology

6 months pre-

registration

internship at

civil

hospitals/PHC/

CHC

Ante Natal Care, conduct of Normal Deliveries, New Born Care,

Post Natal Care, Preliminary emergency medical Care, First

Aid Management, Minor Surgeries

STUDY FINDINGS- SELECTION /POSTING OF

RHP

Eligibility qualification is 10+2 (Science

subjects) having 50% pass mark for (G) &

40% for reserved category (all having rural

background )

Since the first batch passed out in

Sep’2008; state has recruited 92 RHPs

under NHM (completed course), deployed

at SCs in HFDs

No. of RHPs increased from 92 to 370 in

2012-13

No. of SCs remains static at 4604 from

2009 to 2012 ( RHPs are deployed in 4-5%

of SCs)

Year Total

RHP

Total

SCs

2009-

10

92 4604

2010-

11

181 4604

2011-

12

260 4604

2012-

13

370 5135

COMPARISON OF SCs PERFORMANCE Name of

District

Mothers who had 3 ANC visits during last

pregnancy (%)

Before RHP

deployment

After deployment of RHP

2008-09 2010-11 2011-12 2012-13

Nagoan 46.5 61 72 70

Jorhat 54.6 78 71 79

Hailakandi 52.3 70 72 81

Golapara 33.3 68 67 76

Nalbari 49.0 68 74 76

Cachar 51.1 53 64 58

Darrang 39.6 67 65 68

Karimganj 42.8 58 59 100

SUB-CENTERS PERFORMANCE

247

4478

11563

20372786

856

2284

7264

12419No of Deliveries conducted in RHP posted SC

No of Deliveries conducted in SC without RHP

Total Delivery Conducted in the SC

2010-11 2011-12 2012-13

SUB-CENTERS PERFORMANCE

314638

663116

819415

135255 175588

1218352

449893

838704

2037767

Total OPD cases treated at RHP posted SC

Total OPD in SC without RHP

Total OPD cases treated at SCs

2010-11 2011-12 2012-13

STUDY FINDINGS – RHP PROFILE

Gender ,N=91 No. Percent

Male 68 76.9%

Female 23 23.1%

Age , N=91

22-24 26 29.6%

25-27 44 48.3%

>27 21 21.8%

Source of Information, N=91

Print media 79 86.8%

Friends/relatives 10 11.0%

TV 2 2.2%

Reasons for pursing course, N=90

Serve rural community 60 67%

Good job opportunity 20 23%

Improved social status 10 10.2%

RHP’S PERSPECTIVE

Print media was the major source of information about the course.

Interest for serving community and good job perspectives remained the main reason for pursing the course among RHPs.

DMRHC was similar to MBBS course in terms of subjects and contents taught; notable differences was the lack of Forensic Medicine, Major Surgery, Dermatology & Psychiatry and relatively shorter duration of course. Few wanted extension of course duration and internship period.

Majority of respondents considered that course was suitable for serving in rural health settings and felt that internship program was very helpful in delivering their routine duties.

Current posting was located outside their home-district and State Government has not provided any residential facility/quarter.

Main treatment provided was symptomatic management of minor ailments (common cold, fever, diarrhea etc.), NCD (diabetes, hypertension etc.),communicable diseases, initiation of deliveries

Challenges faced by RHPs were location of SC, lack of accommodation and referral transport facilities

ANM PERSPECTIVES

Changes in service delivery (load) after joining of RHPs, N=108

Increase uptake Decrease uptake Remained same

OPD 104 (96.3%) 0 4 (3.7%)

ANC 104 (96.3%) 0 4 (3.7%)

Institutional delivery 96 (88.9%) 5 (4.6%) 3 (2.8%)

Home deliveries 3 (2.8%) 83 (76.9%) 17 (15.7%)

PNC 96 (88.9%) 2 (1.9%) 6 (5.6%)

Immunization 81 (75%) 2 (1.9% 19 (17.6%)

Family Planning 55 (50.9%) 6 (5.6%) 42 (38.9%)

Laboratory services 52 (48.1%) 11 (10.2%) 40 (37%)

Community processes including VHND, N=103

68 (63%) 1 (0.9%) 34 (31.5%)

BENEFICIARIES’S PERSPECTIVE

18.7

1.2

1

16.311.4

29.5

48.2

3.6

30.7

33.734.3

57.2

24.1

29.5

36

36.7

29.5

9.61.2

54.8

26

9

16.9

1.26.6

2.4

0

20

40

60

80

100

120

IEC Lab service Medicines overall satisfaction with services

Time spent on counselling, check

up

Behavior and attitude of staffs

Very Poor

Poor

Average

Good

Very good

COMMUNITY’S PERSPECTIVE

Provision of ANC/PNC services have become more

systematic and available daily

SCs have started conducting institutional

deliveries, manage common ailments, manage accidental

& emergency cases like burns etc

Availability of medicines has improved

Decreased case of Infant and Maternal related illnesses

and deaths due to timely referral

People are increasingly availing Family Planning and

Immunization services.

Effective screening of patients before making referrals

STAKEHOLDERS’ PERSPECTIVE

• Perspectives of Faculties/Students:

Faculty & students commented that current Diploma course should be upgraded to a Bachelor degree course

Lack of adequate faculty, especially the senior teacher

positions, has hampered the teaching program

Internship period be increased from 6 months to 12 months

Faculty development programme to be developed

• Perspectives of Government officials:

Good model as people’s perceptions towards service delivery in SCs has changed dramatically.

Many officials felt RHP model could be scaled up provided they receive adequate trainings and are well equipped to deliver quality health care services.

DISCUSSION

Deficiencies in DMRHC

Improve Access & service utilization

Infrastructure gaps/ other support system

Potential for scaling up of RHPs

Weak capacity building /support

system

CONCLUSIONS

Education

• Up-gradation of DMRHC to Bachelor course

• Review of internship period

• Preferential selection of candidates from minority/difficult areas

HR Managerial

• Revision of current Roles/Responsibilities of RHPs

• Creation of career pathways

Training & Supervision

• Development of Integrated Training program

• Establishment of a support supervisory system

Enabling work environment

Provision of residential quarter & rental arrangement

Regular supply of water & electricity , infrastructure up-gradation

The importance of recruiting and admitting future physicians who have grown up in rural and remote settings now seems clearly established... However... only a fraction of what could be done in this area is currently being done.

By Barer Stoddart, 1999