establishment of village level health units for sustaining universal health coverage in madhya...
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Establishment of village level health units for sustaining universal health coverage in
Madhya Pradesh, IndiaRakesh Parashar, Aboli Gore, Faiz Ahmed Kidwai
14th World Congress of Public Health, KolkataDr Rakesh ParasharMPTAST - FHI360
Introduction: Gram Arogya Kendra (Village Health Center)
A decentralized service delivery system which caters to the last mile population with basic health services and provides a platform for convergence of health and nutrition services.
Gram Arogya Kendra (GAKs) are established at existing Anganwari Centers
Functional in about 49000 villages in the state.
The health services are delivered by ASHA (Accredited Social health Activist) on regular days and by ANM (Auxiliary nurse and midwife) on the village health and nutrition day (VHND).
Study Objectives
This study tries to inform the health planners and manager about the Gram Arogya Kendra (Village Health Centers) running in Madhya Pradesh as a mechanism for Universal Health Coverage by :
1. Assessment of utility of and acceptance of Gram Arogya Kendras in village residents and health workers
2. Understanding operational challenges in service delivery at GAKs
3. Assessment of functionality of Gram Arogya Kendras
Methodology
• Semi-structured Interviews (Purposive sampling)
50 Village residents from 20 villages20 ASHAs10 ANMs5 Medical Officers
• Status check of functional items on a 57 item checklist
350 GAKs randomly selected from 5 districts
Data collection during April-May 2014 in 5 randomly chosen districts of Madhya Pradesh
Results
Details of information displayed at the GAK
Details of additional information
Availability of medicines & consumables
Instruments/Furniture availability
Infrastructure & Basic amenities
0 10 20 30 40 50 60 70 80 90
60.1
74.9
80.1
75.9
71.3
% Current Status
Status of Gram Arogya Kendra functionality on 57 item checklist
N = 350
47
38
15 Cat A (% of GAKs Scoring 81% & above)
Cat B (% of GAKs Scoring 61% - 80%)
Cat C (% of GAKs Scoring < 60%)
Categories of 350 Gram Arogya Kendra based on the 57 item checklist score
N = 350
Scores on 4 groups of parameters on the 57 item checklist
Names and services provided by ASHA, AWW and Sahayika are
available
List of temporary methods of family planning
Information about married & target couples, pregnant women, Newborns,
under five children, malnourished children, children registered in AWC
available
Birth, Death & Marriage registration details avaialble
0.0 20.0 40.0 60.0 80.0 100.0
76.6
74.3
72.9
89.7
70.6
% Current Status
Infrastructure & Basic Amenities in %
N = 350
Bench
ANC table
Weighing machine for baby
Infantometer for newborn
Weight machine for children
Haemoglobinometer
Stethoscope
Curtains
Functional BP instrument
Hub cutter
Thermometer
Torch
Almirah
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0
64.280.383.7
52.391.4
78.978.9
95.478.0
% Current Status
N = 350
Availability of Instruments and Furniture in %
All vaccines with diluents
ORS
IFA tablets - small & large
Cotrimoxazole tablets
Zinc sulphate dispersible tablets
Paracetamol tablet (500 mg)
Methyl ergomentrine tablets
Albendazole tablets (400 mg)
Dicyclomine tablets (10 mg)
Povidon Iodine onitment
0.0 20.0 40.0 60.0 80.0 100.0
95.4
93.7
79.1
93.7
93.1
81.7
71.4
% Current Status
N = 350
Availability of medicines & consumables in %
Village health register
Death related information
Register for village health committee meetings
Register for other activities being done at the Gram
arogya kendra
Sign board for AWC & GAK
Notice board for displaying information outside the
centre
0.0 20.0 40.0 60.0 80.0 100.0
86.9
79.4
66.6
71.7
% Current Status
N = 350
Details of additional information in %
Results
Key responses from the interviews of health workers and village residents
%(Villagers)How do you think the quality of services currently provided at GAK is – Good/Average/Poor
Percieved changes in role of ASHA: After running GAKs ASHA role is better now.
Is there any change in ASHA's role for the village’s health after GAK is running?
Do you think ASHA is doing correct dispensing of medicines?
Would you like to receive medicines from it in future?
What medicine did you take from GAK? (Fever, Stomach pain - 60%) (Iron -28%)
Have you/ your family member ever taken medicines from GAK?
0 20 40 60 80 100 120
70
68
78
88
96
60
76
24
28
6
Interview of Villagers
Responses from interviews of 50 village residents
Are the services adequate for basic health problems?
What do you think about your role as a health activist, Is it better after GAK is running or it was better earlier?
Are you being comfortably able to manage your duties between sitting at GAK and visiting homes in the village?
Are you confident in correctly dispensing all 16 medicines?
Have your received all 16 medicines required at GAK from ANM?
Have you been oriented for providing services at GAK
0 10 20 30 40 50 60 70 80 90 100
70
60
60
70
75
100
Interview of ASHA
Responses from ASHAs (N=20)
Are the ASHAs in your area dispensing medicines correctly?
Are all 16 provisioned medicines available in your stock for distributing to your GAKs?
Are you satisfied with the services being provided at GAKs?
0 10 20 30 40 50 60 70 80 90
60
60
80
Interview of ANM
Responses from ANMs (N=10)
As per Medical Officer % of Service utilization by villagers - Not started/ Started but little utilization / Started and good
utilization
Service availability at GAK Adequate
Have you conducted any supportive supervision rounds to any GAKs?
Have you met any VHSC members to utilize its funds to procure amenities at GAKs?
Are adequate supplies available in your sector, which can be dispensed at GAKs?
Have you received official instructions and guidelines to establish and run GAKs in your area?
0 20 40 60 80 100 120
4060
80
60
60
100
80
Interview of Medical Officer
(Little Utilization)
(Good Utilization)
Responses from Medical Officers (N=5)
Do you think provision of GAKs shall reduce health related expenditure of villagers?
Do you think GAKs can help in early primary treatment/ early referral at village level?
Do you think the monitoring of medicine distribution from block to PHC and till villages is sound?
Are ANMs visiting for the GAKs for supportive supervision during VHNDs?
Have all ASHAs been oriented about correct dispensing of medicines?
0 20 40 60 80 100 120
80
100
60
60
80
Interview of Medical Officer
Responses from Medical Officers (N=5)
Results Summary: Acceptance
An overall positive attitude and acceptance in village respondents observed, which is backed by good utilization of existing services as well as willingness of utilization in future.
The ASHAs perceive their role better now with a responsibility of providing medication to villagers
The ANMs find their workload to have reduced , however with added responsibility of monitoring ASHAs work
The Sector Medial Officers appreciate the presence of GAKs and find it a good concept to reduce geographical limitation and out of pocket expenditure for basic health problems.
ASHA : • to manage their work• seek more support from ANMs • fixed remuneration for this activity with provision of more dedicated space.
Village residents : • demand for more medicines and for more time spent by ASHA • Medical officer’s visit at least once a month.
ANMs : Rrecord updating by ASHA at GAK remains a problem.
Medical officers find management of supplies and monitoring visits by themselves and ANMs a challenge.
Results Summary: Challenges
Study Limitations
Small Sample with purposive sampling for interviews
Study doesn’t include view point of health planners and managers at higher levels
The functionality assessment is limited to infrastructure, supplies and other input parameters, doesn’t cover service utilization and service quality statistics
The researchers are not exclusive from the implementers of the GAK concept
Discussion and Conclusions
WHO Health System framework- 2007, Six building blocks of health system
Service Delivery - Village level health units, Gram Arogya KendraHealth workforceInformationMedical products, vaccines and technologyFinancingLeadership and Governance
Extended and decentralized service delivery can improve level of health equity and outcomes through improved access and coverage
Improving Access
Reducing out of pocket expenditures
Improved health outcomes
Reduced travelling for minor health issues
Avoiding local private practitioners
Early symptom check
Better early referrals
Elimination of geographical barrier
Universal Health Coverage
Village level health units in Madhya Pradesh, India have shown good acceptance by and large from the beneficiaries and health workers.
Continuity of availability of provisioned medicines and supplies with monitoring and measurement of service delivery, utilization and service quality needs to be continuously improved for effective service delivery at these village level units.
Thank You
Possible research themes in future:
Service delivery – Coverage , Utilization , Quality Outcome measurement Impact on overall village health and functioning of health system Change in social equations-dynamics related to health within the
villages Models of effective monitoring and sustaining supply chains