Primary Health – ICICI Foundation

Situational Analysis of Public Health Research Capacity in India

Research in public health is critical to the development of new vaccines and medicines as well as improved healthcare systems. In 2010, ICICI Child Health initiated a research practice to strengthen public health research in India through a situational analysis to understand the existing capacities, gaps, resources, stakeholders and experiences in this context.

Building Public Health Capacity

To develop institutional and individual public health capacity, IFIG—CCHN supported the setting up of the Public Health Resource Society (PHRS), PHRS worked to empower practitioners at the district and sub-district levels and to build resource groups and active practitioner networks for knowledge and experience sharing, interactive activities, projects and mutual support.

Ranchi Low Birth Weight Project

The “Ranchi Low Birth Weight Project” aimed to understand the combined impact of community health worker and system-strengthening strategies on reducing the proportion of low birth weight. The project introduced the model of Sahiyyas (community health workers) and village health committees, which were scaled up across the state of Jharkhand.

Nutrition Security Innovations Programme

Chhattisgarh Government scales up ICICI Foundation’s Nutrition Security Innovations Programme to 70 blocks across the state

The success of the Foundation’s Nutrition Security Innovations (NSI) programme in 23 blocks of Chhattisgarh has prompted the state to replicate specifics of the programme and other nutrition and communication strategies.

Nutritional status of women and children in Chhattisgarh are particularly poor, with 41 percent women and 48 percent children undernourished. Government services and programmes including the Integrated Child Development Services (ICDS), the Mid-Day Meals Scheme (MDMS) and the Public Distribution System (PDS) are all mandated to have universal coverage in Chhattisgarh. However, the state’s large vulnerable population and issues surrounding coverage and quality of services continue to plague the schemes. The schemes are also affected by factors related to urbanisation and lifestyle changes such as changes in diet and food habits among tribal groups, newer approaches to maternal and child care, and a decrease in the availability of food items high in micronutrients. Additionally, many people are not aware of the various government welfare programmes and schemes. This does not just impact their ability to create effective demand, but also the government’s ability to assess the effectiveness of their programmes in the absence of any community monitoring and accountability. With this in mind, the NSI programme was undertaken in 23 blocks across 11 districts of Chhattisgarh.

In March 2011the Nutrition Security Innovations (NSI) programme concluded in Chhattisgarh. The Government of Chhattisgarh has now taken forward the project in order to implement it across the state, creating vital links within its health delivery system.

The NSI programme was initiated by the foundation within the pre-existing Swasthya Mitanin Programme (community health worker programme) in 2006 in partnership with the State Health Resource Centre (SHRC), Chhattisgarh. The project was aimed at deepening the impact of community health workers (mitanins), and to bring about convergence between health interventions of the Mitanin Programme and the nutritional interventions of the Integrated Child Development Services (ICDS).

Introducing a new cadre

The first phase of the NSI programme rolled out with the introduction of a new cadre of community health workers called Poshan (nutrition) Fellows, whose role is to create awareness about nutrition within their communities. They help to train the mitanins and prashikshaks and provide them with continuous support. One Poshan Fellow is selected for every block, and two coordinators are selected at the regional level to guide and supervise the Poshan Fellows. State-level programme coordinators support the Poshan Fellows and regional coordinators through regular monthly meetings, updates, technical support and systematic problem solving — providing overall guidance to the programme.
SHRC programme staff trained the Poshan Fellows on matters of nutrition, dietary requirements, food security, and other issues relevant to their communities through various workshops. Supported by the Poshan Fellows, the prashikshaks and the mitanins undertook the following specific interventions within the programme:

Chhattisgarh Government scales up ICICI Foundation’s Nutrition Security Innovations Programme to 70 blocks across the state

Nutritional status of women and children in Chhattisgarh are particularly poor, with 41 percent women and 48 percent children undernourished. Government services and programmes including the Integrated Child Development Services (ICDS), the Mid-Day Meals Scheme (MDMS) and the Public Distribution System (PDS) are all mandated to have universal coverage in Chhattisgarh. However, the state’s large vulnerable population and issues surrounding coverage and quality of services continue to plague the schemes. The schemes are also affected by factors related to urbanisation and lifestyle changes such as changes in diet and food habits among tribal groups, newer approaches to maternal and child care, and a decrease in the availability of food items high in micronutrients.
Additionally, many people are not aware of the various government welfare programmes and schemes. This does not just impact their ability to create effective demand, but also the government’s ability to assess the effectiveness of their programmes in the absence of any community monitoring and accountability. With this in mind, the NSI programme was undertaken in 23 blocks across 11 districts of Chhattisgarh.

The first phase of the NSI programme rolled out with the introduction of a new cadre of community health workers called Poshan (nutrition) Fellows, whose role is to create awareness about nutrition within their communities. They help to train the mitanins and prashikshaks and provide them with continuous support. One Poshan Fellow is selected for every block, and two coordinators are selected at the regional level to guide and supervise the Poshan Fellows. State-level programme coordinators support the Poshan Fellows and regional coordinators through regular monthly meetings, updates, technical support and systematic problem solving — providing overall guidance to the programme.
SHRC programme staff trained the Poshan Fellows on matters of nutrition, dietary requirements, food security, and other issues relevant to their communities through various workshops. Supported by the Poshan Fellows, the prashikshaks and the mitanins undertook the following specific interventions within the programme:

Awareness building and behaviour change communication

The most significant role of the mitanin is using behaviour change communication to increase awareness among families on dietary practices and nutritional goals.

While the Mitanin Programme had previously focused on promoting exclusive breastfeeding practices, which contributed significantly to the improvement in child health in the state, this project focuses on other aspects of children’s health, such as appropriate complementary feeding practices and the identification of undernourished children through regular growth monitoring by anganwadi workers.

In an effort to improve maternal health, the Mitanin Programme now focuses on the importance of adequate nutrition for pregnant women and attempts to boost intake of nutritious foods during pregnancy and after delivery.

To involve the community in improving their own nutrition, the Mitanin Programme raises awareness about locally-available nutrition-rich foods, encourages families to develop kitchen gardens, and helps remove superstitions surrounding dietary practices.
Interventions in community monitoring and action – Themitanins, supported by the prashikshaks and the Poshan Fellows, encourage the community to take collective action and monitor the various government-run food schemes. This community mobilisation was facilitated at the hamlet, village and cluster levels.

Locally relevant training modules

One of the innovations of the NSI project was the creation of picture-based training modules that can easily be used by the mitanins for nutrition counselling and mobilisation.

The three modules – Nutrition and Social Security, Child Caring and Feeding Practices, and The Nutrition Book – educate within the context of local cultural practices and are in the Chhattisgarhi language, using local terms for food items. The Nutrition Book identified and presented 173 locally-available foods in Chhattisgarh and listed their nutritional values in terms of vitamins and micronutrients. In addition to detailing the nutritious forest fruits, roots, and leaves that are unique to the state, the book also gives recipes to prepare these foods in order to retain their maximum nutritional value.

Building Public Health Capacity

To develop institutional and individual public health capacity, ICICI Foundation supported the setting up of the Public Health Resource Society (PHRS). PHRS works to empower practitioners at the district and sub-district levels and to build resource groups and active practitioner networks for knowledge and experience sharing, interactive activities, projects and mutual support.

Building institutional and individual capacity in public health at the district and sub-district level is essential for sustainable and continuous improvements in health services and programmes. Trained, motivated, empowered and networked health personnel are required to carry out effective district health planning and other district-level programmes of the National Rural Health Mission.

In 2008-2009, ICICI Foundation supported the setting up of the Public Health Resource Society (PHRS). PHRS functions through network offices known as Public Health Resource Network (PHRN) in the state of Bihar, which has some of the poorest health indicators. This initiative aims to address the critical and growing need to build public health capacity amongst the health functionaries working with the state as well as members of civil society groups. Through a range of training and capacity building initiatives, PHRS seeks to enhance and consolidate resource capacity in these states and to facilitate state and civil society partnership for strengthening the public health system.

PHRS offers the following programmes through its state network offices:

The Distance Learning Programme on Public Health is conducted over an 18-month period, and relies on self-study modules, interactive workshops and mentored field activity. The certificate of level of achievement is provided by PHRN at the end of the course. Indira Gandhi National Open University (IGNOU) has adopted the course structure and modules and offers it as a Post Graduate Diploma Programme in District Health Management.
The Fast Track Capacity Building Programme is designed to improve skills and capacity at the district level in order to facilitate quality district health plans based on situational analyses. The programme began in 2008 and includes three rounds of a six-day long training workshop and operates in Bihar. The programme is a collaborative initiative among state governments, PHRS and the National Health Systems Resource Centre (NHSRC).
The Community Health Fellowship is a two-year full-time programme focused on creating motivated community health professionals with the technical competencies to work with communities, civil society and the government to further the ideals of ‘Health for All’. The fellows are placed in districts and linked to both District Health Societies and local civil society groups in Bihar. The project’s partners are PHRN, SEARCH in Gadchiroli and NHSRC.

Healthy Lokshakti

The three-year programme is being piloted in two tribal blocks of Maharashtra – Trimbak and Peth in Nasik district. It is implemented by Vachan, a non-governmental organisation (NGO), with support from Bhavishya Alliance.

The intervention included

Create and maintain a well-coordinated network linking the communities, grassroots health workers, transport facilities and healthcare institutions in tribal blocks. A health helpline will be set up to receive calls and provide assistance with child and maternal health issues. This will be linked to a transportation system at the block level to ensure that women can travel to access appropriate care during obstetric emergencies.
Setting up a financial at the community level to meet the emergency financial needs of mothers and children.
Provide training for doctors, paramedics and other health personnel including ASHAs (Accredited Social Health Activists) and health workers at the block and district levels.

Project SARAS

The first of the initiatives under technical research in nutrition is the Mumbai Maternal Nutrition Project/ Project SARAS, a research partnership between the Medical Research Council, University of Southampton, UK, SNEHA – India (Society for the Natal Effects of Health in Adults), and the Centre for the Study of Social Change, Mumbai. Based in urban slums in Mumbai, the project is carrying out a randomised controlled trial to test the hypothesis that enhancing the micronutrient quality of women’s diets, from preconception and throughout pregnancy, using locally available foods in the form of a supplement, will improve maternal micronutrient status, increase fetal survival and growth, and reduce low birth weight. Among the innovative features of the study is the emphasis on pre-pregnancy nutritional status and the use of food, rather than pharmaceutical supplements.

Working with Self Help Groups: Kalanjiam Foundation Project

Based on the opportunities presented by women’s self help groups of MFIs, and the positive evidences of working with women’s groups for health and nutrition, this action-research project was centred around federated women’s micro credit self help groups as sites for community intervention in health and nutrition, with a particular focus on concerns of young girls, pregnant women and children.
Located in the rural and tribal contexts of Tamil Nadu and Andhra Pradesh, across 6 districts – Madurai, Ramanathapuram, Dindigul, Theni, Thanjavur, and Adilabad, the project covered ten federations (approximately 200,000 population). Established in 2004, the initiative was structured around the concept of self-health governance which integrated micro-finance and health care by promoting health intermediation with the Self Help Group Federations promoted by the Kalanjiam Foundation, a subsidiary of DHAN Foundation which is a development institution with its base in Madurai, Tamil Nadu.

Mumbai Maternal Nutrition Project

ICICI Foundation supports the Mumbai Maternal Nutrition Project, a randomised controlled trial on maternal and child health. The study tests the impact of enhancing micronutrient quality in women’s diets from before conception to delivery by examining women’s health, foetal growth and their children’s development. In 2010-2011, the project succeeded in achieving its target of enrolling more than 1,000 pregnant women and documenting nearly 700 births.

City Initiative for Newborn Health

The City Initiative for Newborn Health worked to improve the health and survival of mothers and newborns among slum communities in Mumbai. The project strengthened community awareness and action on maternal and newborn health as well as improved the care available at municipal primary health care facilities.

Slum populations in India rank among the poorest, most under-serviced and consequently, most vulnerable groups in terms of health. Available health indicators for the urban poor compare unfavourably with both rural and national averages. In contrast to rural areas, the extremely poor health and nutrition outcomes in urban contexts such as Mumbai persist even with the existence of geographically accessible health infrastructure and services.

An action research study, the City Initiative for Newborn Health (CINH) was initiated aiming at lowering maternal and newborn morbidity and neonatal mortality among underprivileged slum communities in Mumbai. The project covered a population of approximately 400,000 spread over 24 slum clusters across 6 wards of the city. In addition to working with municipal health service providers to improve maternal and neonatal services, the project sought to mobilise the community to improve maternal and neonatal care practices and care seeking. It also worked to strengthen primary care to increase the availability and quality of decentralised antenatal, postnatal, and neonatal services at primary healthcare facilities.

CINH was a collaboration between ICICI Foundation, Society for Nutrition, Education and Health Action (SNEHA), the Municipal Corporation of Greater Mumbai (BMC) and the University College London Centre for International Health and Development.

The Municipal Corporation of Greater Mumbai is supporting these project interventions and strengthening its urban health set up.The project has already been scaled up by Municipal Corporation of Greater Mumbai to cover Mumbai’s western suburbs. Government tertiary care facilities have started backward referrals of patients from hospitals to health posts and maternity homes, which has led to a reduction of overcrowding in tertiary-level government hospitals

District Action Health Plans

Health planning at the district level

Shahkhund Primary Health Centre, a cluster of buildings in the Shahkhund block of Bihar’s Bhagalpur district, provides a strong case for at least two things. First, while Bihar’s rural public health system is not yet functioning optimally, there have been significant improvements in just a few years. And second, District Health Action Plans, an integral part of the decentralised strategy adopted by the National Rural Health Mission, have played a large part in making this happen.
Dr. Jayaprakash Singh, the Medical Officer in Charge (MOIC), has been at Shahkhund since 2001. He has seen the Primary Health Centre (PHC) transform from an under-resourced building with deferred maintenance, limited medications and few patients to a centre that serves the population by delivering babies, giving immunisations, controlling community-level diseases and providing a range of other services.

Dr. Jayaprakash and Mr. Madhukhant, the Block Health Manager of Shahkhund PHC, have been active participants in a series of workshops co-organised by the Public Health Resource Network and the National Health Systems Resource Centre with the support of ICICI Child Health. The workshops provide district-level functionaries with the tools, methods and knowledge required to undertake effective health planning.

District Health Action Planning is one of the primary emphases of India’s National Rural Health Mission (NRHM), the public health programme that aims to improve the quality of rural healthcare in the 18 states with the poorest health outcomes. At its most basic, health planning involves analysing the availability and quality of existing resources along with epidemiological patterns, and then determining what resources are required to improve district-level health outcomes.

Some of the major constraints in preparing these plans have been the lack of capacity at the block and district levels and the unavailability of resources and an institutional framework for comprehensive planning. ICICI Child Health, the Public Health Resource Network (PHRN) and the National Health Systems Resource Centre (NHSRC) devised the workshop series to address these gaps. The workshops taught district and block-level functionaries how to do a situational analysis to assess health needs and accurately estimate what infrastructure, human resources, drugs, supplies and other resources are needed. Just as importantly, the workshops taught the functionaries how to connect these needs to the process for making financial allocations to the district under the National Rural Health Mission. ICICI Child Health’s team also provided direct on-the-job support to the district and block level teams in Bhagalpur to prepare the district plan.

Previously, the preparation of Bihar’s health plans was done at the state level without any consultations in the 38 districts. Based on this health plan, the central government would make resources available to the state healthcare system. But even within a single state, districts may have strikingly varied needs; addressing malaria may be the most pressing need in one, while another may primarily need funds for vaccinating children. Consequently, Bihar’s health plans – as in most other states – had major gaps between what the state estimated was needed by the districts to provide effective healthcare and what the districts actually required. Moreover, there was little flexibility in spending the money, which meant that even if funds were available for certain expenses, they could not be used for other expenditures deemed necessary by districts.

Because of this disconnected planning, Bihar’s utilisation of funds was very low, despite availability of resources. Just two years ago, Bihar spent only 27 percent of the money that was allocated to it under the National Rural Health Mission, returning the rest at the end of the year. Though Bihar’s healthcare system is one of the worst in the country, year after year, money allotted to improve it could not be spent.

For this reason, the National Rural Health Mission zeroed in on including the districts in the planning process. According to the District Health Action Planning process, each district needs to make an assessment of its own resources, priorities and requirements in order to deliver a plan to the state. Based on the districts’ plans, a final state plan is prepared and delivered to the central government.

In addition to the workshops for block and district functionaries, ICICI Child Health facilitated workshops for the Auxiliary Nurse Midwives (ANMs) in Bhagalpur. ANMs play a key role in preparing the plans as they make regular visits to the sub-centres operating at the community level. In Shahkhund and other blocks, the ICICI Child Health-supported workshops taught ANMs how to use a template to assess the requirements of each of the block’s 23 sub-centres. To use the template, ANMs were taught to systematically collect information from the sub-centres on the number of infants in the community, the number of expectant mothers, the number of children from the ages of 1 to 5, and the number of people with various diseases. This information was then consolidated into block level requirements, ultimately working its way into district-level plans.

This has allowed the Primary Health Centres to function much more efficiently, says Dr. Jayaprakash, Shahkhund PHC’s Medical Officer in Charge. As a result of these detailed assessments, the PHC no longer has to wait until community members come to them to know what services they will have to provide. Based on the ANMs’ frequent reporting, the PHC knows already how many vaccines are likely to be required, or how many deliveries might take place, and they are able to estimate the resources they will require to provide this care.

Not only does Shahkhund PHC have a better idea of what resources are likely to be required, the funds for these resources now come automatically to their bank account. This frees them from constantly looking to the district and state for short-term, irregular approvals. Money is released quarterly and as long as 80 percent of the previously released tranche has been spent, the next tranche of funding is released to Shahkhund’s bank account within 24 hours of submitting utilisation certificates. Shahkhund PHC no longer has to depend on the district for funds to buy a water tank or to undertake general facility maintenance; these activities are already planned and budgeted for in the Annual Health Plan. Now instead of focusing on financial backlogs, the PHC can focus on providing healthcare. Similarly, the state government and district administrations do not have to concern themselves with approving ad hoc requests for funds and can focus instead on improving and monitoring programmes.

With new resources have come new patients. Out of the 182,000 people that Shahkhund PHC serves, 68,000 visited the PHC in the 2009-2010 fiscal year. To illustrate what a dramatic change this is, Dr. Jayaprakash observes that the same patient register that did not fill during the entire 2004-2005 fiscal year now fills up within a month.

The fact that the Primary Health Centres have such statistics readily available is itself a testament to the changes brought by the district health action planning process. Through the workshops, district and block managers learned to keep meticulous records and budgets to assist future planning. By building such high levels of capacity at the district level, the process of creating the district health plans has been as fruitful as the plans themselves.

This is particularly important because while state-level bureaucrats may be frequently transferred, the district functionaries are likely to stay in the district. Dr. P. Padmanaban, Advisor to the National Health Systems Resource Centre (NHSRC), has been struck by the high quality of human resources that now exists at the district level in Bihar. District health action planning relies a great deal on the capacity and motivation of individuals working at the block and district levels. And while this may mean that lack of technical knowledge and skills can constrain the planning process, the benefit is that once the capacity has been built at these levels, the process develops a momentum of its own. This, says Dr. Padmanaban, is an important difference between strengthening the capacity of the system and depending on outside agencies for constant support.

As a result of this work, all of Bihar’s 38 districts and 328 of its 534 blocks have prepared Health Action Plans for the coming year. Another achievement is that by March 31, 2010, Bihar’s health expenditure had reached Rs. 6 billion– significant progress for a state that until recently spent only Rs. 3 billion annually.

This year, the National Health Systems Resource Centre drew on the successful methodology and experience of preparing District Health Action Plans in Bihar to work with districts in Uttar Pradesh to prepare 71 district plans for the first time.

Certain gaps in the planning process remain. Communities, for example, have not yet fully participated in the process as mandated by National Rural Health Mission. The process of including community perspectives has begun, however, with the formation of Village Health and Sanitation Committees. These committees have their own bank accounts and access to untied funds that they can use to improve health and sanitation work in the villages. Community-level monitoring is the next step in the plan.

Jharkhand Village Health Committee-Sahiyya Resource Centre

ICICI Foundation has worked in partnership with the Government of Jharkhand to establish the Village Health Committee-Sahiyya Resource Centre to train and support Sahiyyas (community healthcare workers) in all districts in the state. Innovative and contextualised training materials and modules have been developed, so that the training is relevant, comprehensiveand informative. Over 40,964 Sahiyyas have been trained with this new training material.

Developing new products for outpatient healthcare

The Outpatient Healthcare (OP) pilot aimed to lower the out-of-pocket healthcare expenses for India’s rural poor by creating affordable and reliable options for outpatient healthcare. It was launched on the Rashtriya Swasthya Bima Yojana (RSBY) platform to strengthen the delivery of outpatient healthcare at public healthcare facilities and also involve private players to further improve healthcare accessibility for below poverty line (BPL) households in Puri (Odisha) and Mehsana (Gujarat).

ICICI Foundation partnered with Ministry of Labour and Employment (MoLE), the Micro- insurance Innovation Facility of International Labour Organisation (ILO) and ICICI Lombard General Insurance to design and support the delivery of the first outpatient insurance product for India’s poor. It was offered in conjunction with the Government’s RSBY at empanelled government and private outpatient clinics and hospitals. The pilot ended in Mehsana and Puri in May 2014 and September 2014 respectively.

The Outpatient Healthcare pilot has successfully demonstrated how integration of outpatient healthcare with the RSBY platform can improve access to healthcare for BPL households and reduce their out- of-pocket expenses on healthcare. Based on the pilot, the Central government has extended outpatient healthcare in all RSBY empanelled hospitals as a standard product across the nation, potentially benefitting 37 million poor families.

Apna Clinic

Apna Clinic was based on the concept of a wellness clinic that promoted health and general well-being among long-route truckers. It was initiated in 2011 as a pilot project towards increasing the health-seeking behaviour among long-route truckers and improving their knowledge and attitude towards road safety issues.

It provided healthcare services and counselling on issues of health, hygiene and road safety to truckers passing through Transport Nagar at Nigdi in Pune, Maharashtra. It adopted a holistic approach to health, conducted yoga and other wellness activities in addition to providing clinical services. There was a focus on increased stakeholder engagement to induce desired behaviour among truckers. For example, Apna Clinic conducted road safety awareness camps in association with the Regional Transport Office (RTO) and facilitated communication between truckers and RTO officials.