Abstract
The Government of India has been providing limited maternal and child health services through its Family Welfare programme, but this system is characterised by weaknesses that include inefficient work schedules; non-availability of functioning equipment; poor contraceptive and drug supplies; poor skills and knowledge of health workers; and poor access to services in villages without health centres. For the new Reproductive and Child Health programme to deliver an even wider range of services, the health system will need to be strengthened and the quality of service delivery improved. This paper describes a seven-year operations research project in Parner block, Ahmednagar district, Maharashtra, India, undertaken by the Foundation for Research in Health Systems in partnership with state and district health administrations. It shows the feasibility of establishing a more efficient system, with a minimum of affordable inputs, that increases the use of services by women. Four critical policy changes were implemented: service delivery in each village was changed from household visits to a clinic base, stringent monitoring mechanisms were put in place, in-service training for health workers was instituted and the range of services was gradually increased. This experience is now being applied more widely, with eventual phasing up to full district and state level.
Résumé
Le Gouvernement indien assure des services limités de santé maternelle et infantile avec son programme de protection familiale, mais ce système comporte des lacunes: horaires inadaptés absence d'équipement en bon état; insuffisance de l'approvisionnement en contraceptifs et médicaments; médiocres compétences et connaissances des agents de santé; et manque d'accès aux services dans les villages dépourvus de centre de santé. Pour que le nouveau programme de santé infantile et génésique assure une gamme plus large de services, il faudra renforcer le système de santé et améliorer la qualité des services. L'article décrit un projet de recherche de sept ans à Parner, district d'Ahmednagar, Maharashtra, entrepris par la Fondation de recherche sur les systèmes de santé en partenariat avec les administrations sanitaires de l'Etat et du district. Il montre qu'il est possible d'établir à peu de frais un meilleur système qui accroı̂tra l'utilisation des services par les femmes. Quatre changements essentiels de politique ont été réalisés: dans chaque village, les services sont désormais assurés dans le dispensaire, et non plus à domicile; de stricts mécanismes de suivi ont été créés; les agents de santé suivent une formation en cours d'emploi; les services ont été progressivement diversifiés. Cette expérience est maintenant élargie, et concernera ultérieurement tout le district et l'Etat.
Resumen
El programa de Bienestar Familiar del gobierno de la India provee servicios de salud materno-infantil limitados, pero el sistema está caracterizado por ineficacia en los horarios de trabajo y carencias de equipos, medicamentos y anticonceptivos. A los trabajadores de salud les faltan conocimientos y capacidad técnica, y hay poco acceso a los servicios en las aldeas que no cuentan con un centro de salud. Si el nuevo programa de Salud Reproductiva e Infantil pretende ampliar la gama de servicios, habrá que fortalecer el sistema de salud y mejorar la calidad de los servicios. Este artı́culo describe un proyecto de Investigación Operativa realizado durante siete años en el bloque Parner, distrito de Ahmednagar, Maharashtra, India, por la Fundación para la Investigación en Sistemas de Salud en conjunto con las autoridades de salud estatales y de distrito. Muestra la factibilidad de establecer un sistema más eficiente, con un mı́nimo de insumos de bajo costo, que aumenta el uso de los servicios por las mujeres. Se implementaron cuatro cambios crı́ticos: en cada aldea se reemplazaron visitas a domicilio por la prestación de servicios en la clı́nica, se fijaron mecanismos estrictos de monitoreo, se capacitaron a los trabajadores en el lugar de trabajo, y se amplió gradualmente la gama de servicios. Actualmente se está extendiendo la aplicación de esta experiencia hasta llevarla eventualmente al nivel de distrito y de estado.
The International Conference on Population and Development (ICPD) Programme of Action 1994Citation1 articulated the need to meet the reproductive health requirements of individuals. The Government of India endorsed the Programme of Action and in 1997 envisaged its translation into reality by introducing a Reproductive and Child Health approach into its existing Family Welfare programme. At the programme level, this meant providing a greater range of services: antenatal, delivery and post-partum care; infant/child care; contraceptives; safe abortion; treatment of gynaecological problems, reproductive tract infections (RTIs) and sexually transmitted diseases (STDs); appropriate referral; counselling on human sexuality, gender issues, and responsible parenthoodCitation2.
Realising that this was rather ambitious for its Family Welfare service delivery infrastructure to take on, the Ministry of Health and Family Welfare formulated an essential package of Reproductive and Child Health services. This package was intended to include services for prevention and management of unwanted pregnancy; promotion of safe motherhood and child survival; and prevention and treatment of RTIs and STDs.Citation3 Some of the components in the package were already available through the Family Welfare programme and were delivered through the primary health care system. However, this system had well-known weaknesses, including a lack of resources, poor quality of service delivery and low worker productivity, and needed strengthening.Citation4 Citation5
The health care system in rural India
The health care delivery system in IndiaCitation6 has three main divisions, central, state and local (or peripheral). At the central level, the Ministry of Health and Family Welfare is responsible primarily for policymaking, planning, guiding, assisting, evaluating and coordinating the work of the State health ministries.
The Directorate General of Health Services (DGHS) in the states is the ultimate authority at state level, responsible for all the health services within its jurisdiction. Locally, the district is the principal unit of administration. Each district is further subdivided into different types of administrative areas, called blocks. A block in a district is a unit of rural planning and development. It comprises 100 villages with 80,000–120,000 population. A network of primary health centres (PHC), sub-centres, community health centres and rural hospitals provide primary health care at this peripheral level.
There is one PHC for every 20,000–30,000 rural population. It has one or two medical officers (MO), a pharmacist, a nurse midwife (NM), a male multi-purpose worker (MPW) and a female multi-purpose worker (Auxiliary Nurse Midwife or ANM), two supervisors (male and female, assistants to the Medical Officer of the PHC), a block extension educator, a laboratory technician, a clerk, a driver (subject to availability of a vehicle), and a sweeper or Class IV employee. Its functions are medical care, safe water supply and basic sanitation, prevention and control of locally endemic diseases, collection and reporting of vital statistics, health education, referral services, training of health workers and basic laboratory services. Some PHCs (20% to 60%) in Ahmednagar district also have facilities for selective surgical procedure (vasectomy, female sterilisation, induced abortion and minor surgical procedures).
The sub-centre serves a population of 3,000–5,000. Each sub-centre is manned by a MPW and an ANM. They are mainly involved in providing maternal and child health services, family planning, immunisation and other national programmes (e.g. HIV/AIDS, tuberculosis, leprosy, malaria). However, these programmes have little or no integration at the management level.
Other Government health services include community health centres for a population of 100–200,000, rural hospitals, sub-divisional/ (taluka) hospitals, district hospitals, specialist hospitals and teaching institutions where referrals are made from sub-centres and PHCs. These facilities primarily offer specialist services.
At the time the project began, although the health care system was designed to offer all basic curative, preventive and promotive services, it essentially focused on selective services like family planning and immunisation. Public health expertise and capacity to manage programmes at the PHC and sub-centre level were weak.Citation4 The standard of training for ANMs, MPWs and supervisors was low and their practical skills were almost non-existent.Citation5 Supervisors did not make any efforts to supervise the service delivery process or the quality of work. The PHC staff rarely stayed at their place of posting and were available only for a few hours a day. Equipment and supplies for providing basic services were inadequate and uncertain.Citation7,8
The study
To determine what changes and additional resources would be needed to strengthen the primary health care system so that it could implement the essential Reproductive and Child Health package, the Foundation for Research in Health Systems (FRHS) offered to do a study in Parner block, Ahmednagar district, of Maharashtra state.
In Maharashtra, political commitment combined with administrative efforts have led to the creation of an infrastructure in the health care delivery system in rural areas that is one of the best in the country, almost reaching the norms set under the Minimum Needs Programme. The State has three unique advantages, namely a history of experimentation by the government to find ways to improve the health care system, a number of active NGOs involved in the health sector and a history of NGOs working in cooperation with the government. This had encouraged FRHS to approach the state directorate with a project proposal to study the constraints in the government health care system and how they might be overcome. The incumbent Director of Health Services was a dynamic medical doctor who was interested in the project and aware of FRHS's reputation of working with the government. FRHS, with funding from the Ford Foundation, was already conducting an operations research project to improve PHC services in the area since 1993, when it undertook this study.
Ahmednagar is the second largest district in the state of Maharashtra. It is 120km from Pune, where the State health directorate is situated. There were no externally funded projects in this moderately developed district in 1993. Parner is a predominantly agricultural rural block, with sugar cane plantations and sugar factories. It has 131 villages and a population of 210,000. All the villages have electricity and at least one source of safe drinking water. The literacy rate of 46% is close to the State average and about half the population is below the poverty line.
The existing infrastructure and resources of Parner block were involved in the project implementation. The State government provided major inputs such as the supervision of project activities, contraceptive and other supplies provided in the regular programme, and access to training available in the State. All service delivery activities were undertaken only by district health staff.
The objective was to try out innovative approaches to service delivery using Parner as an experimental block, monitor the process and document the outcome. If these approaches proved successful, the next step was to work out how to scale them up for district- and state-wide implementation, and finally to make recommendations for policy and implementation at national level.
At the outset, a Steering Committee, consisting of two senior officers from the Health Directorate, two from FRHS, and three experts from NGOs in Maharashtra, was appointed for monitoring and guiding project progress. At the district level, to help with the day-to-day functioning of the project, there was an Implementation Committee consisting of the District Health Officer, the Assistant District Health Officer in charge of the project, the project co-ordinator from FRHS and the secretary of the Steering Committee.
FRHS managed the project funds and provided qualified research staff for the project. The project also funded some equipment and travel for research purposes. Any equipment or supplies bought under the aegis of the project were received as “gifts” from FRHS and accounted for as such by the PHCs. FRHS also provided relevant training not provided in the State's training institutes and technical input by making experts available as consultants. FRHS staff at the project headquarters at Ahmednagar consisted of two data entry operators, one office manager, and seven investigators who documented the implementation of the project.
Situation analysis: baseline surveys
A baseline, block-wide study consisting of a household survey and a facility survey had been conducted in 1993 to establish quantitative benchmarks for quality, use of government and private services by women, and the functioning and managerial efficacy of the PHCs and sub-centres.Citation7 Functioning of the private sector was not studied, however.
The household survey covered a sample of married women aged 15–45. Forty villages were selected from the 1991 Census village list with the probability of selection being proportional to population. Of these 40 randomly selected villages, seven were villages containing a PHC headquarters in the block, 17 had sub-centres and the remaining 16 had no government health centres. Just over 25 women per village were selected, 673 from the seven PHC and 17 sub-centre villages and 350 from the 16 villages with no government health centres, using the cluster sampling method.
In the seven PHCs and 17 sub-centres of the selected villages, a facility survey had been carried out to assess the availability of staff, equipment and supplies. All medical officers, supervisors and ANMs from these centres were evaluated to determine the extent of their knowledge and skills as required for their positions.
The surveys highlighted two core issues—sub-optimal utilisation of services by women and deficiencies in service delivery itself. The data analysed in the context of the present study identified specific areas of concern such as the scheduling of Mother and Child Protection clinics, non-availability of services in the villages without government health centres, the inability of women to identify their reproductive health needs and seek care, poor infrastructure of services and shortages of supplies. These concerns were shared with the district and local government health staff of Parner block.
In 1993, the Government health care system in the block consisted of seven primary health centres, 38 sub-centres and one 30-bed rural hospital. The Mother and Child Protection clinics were the most visible face of the government's primary health care system in the district. These clinics were outreach clinics or camps held each month by the sub-centre staff on a specific day in every village (with or without PHC and sub-centre) with a population of 1,000 or more. Villages with a population of less than 1,000 had such a camp or clinic combined with an adjoining village. ANMs were the main service providers at these clinics. Male MPWs assisted ANMs by gathering the children for immunisation and filing records. Female supervisors brought vaccines from the PHC, helped with intrauterine device (IUD) insertions and attended to high-risk pregnant women; male supervisors helped with health education.
The staff, especially the ANMs, acknowledged that there were indeed problems with antenatal service delivery as well as with women's acceptance of services. They felt that a lack of credibility of service providers was the major obstacle in the way of women's acceptance of services, and they put the onus for this squarely on the shoulders of their supervisors and the PHC Medical Officers, from whom they said they received inadequate support. They also described their inability to provide universal and “full” antenatal care (i.e. three antenatal visits, two tetanus toxoid injections, 90 iron tablets, weight and blood pressure measurement and urine test) due to lack of necessary equipment and supplies such as sphygmomanometer, weighing machines and iron and folic acid tablets. They were also not confident in their ability to provide these services because they had not actually practised these skills for years. As a result, most of them provided only immunisation services and the clinics were de facto “immunisation sessions”.
All categories of health staff conceded that the community's perception that private antenatal services were better was valid, and a few ANMs and female supervisors reported that they themselves would prefer private antenatal care.
The district health staff thought that if improvements in quality of care were made in the most frequently used antenatal services, it would certainly pave the way for further modifications in service delivery and increased acceptance and credibility in the community.
The District Health Officer and Assistant District Health Officer suggested that as Mother and Child Protection clinics were their best channels for outreach, innovations in service delivery should be routed through these. However, they cautioned that attempts to enlarge the scope of the clinics to include components of Reproductive and Child Health care other than those currently being offered should be gradual and based on successful improvements in the quality of existing antenatal services.
On the basis of these findings and after discussion, the Implementation Committee planned the project in two phases. The focus of Phase I was the improvement of access to and quality and utilisation of antenatal services. In this phase, the measures taken to address the concerns expressed in the surveys were introduced in two PHC areas first, and after six months extended to two more PHC areas, and a year later to the remaining three PHCs in the block. In the fifth year, they were introduced in three PHC areas outside the block as well. The focus of Phase II over the next three years was on strengthening of post-partum care, and introduction of additional components such as management of RTIs and STDs within the existing system.
This paper describes the implementation of Phase I of the project, including the specific problems identified and the policy and programme measures taken to improve them.
Scheduling of Mother and Child Protection clinics
More than 90% of the villages had at least one Mother and Child Protection (MCP) clinic scheduled in the third week of every month. However, the bus schedule for the clinic sites was not taken into consideration, which meant that the PHC supervisory staff could only be there for 2–3 hours, and this limited the length of time the clinics could be open. While the MCPs were supposed to be attended by a male MPW, an ANM and two supervisors, few male workers came because no specific work was assigned to them. The supervisors and medical officers could also not be of much help as each of them had to visit two or three clinics a day to deliver vaccines. Hence, the ANMs ran most of the clinics singlehandedly.
To ensure that each MCP clinic had the full quota of health staff, the clinics were rescheduled and spread over the entire month in a way that took into account the bus schedule and availability of transport for the workers. This ensured that male MPWs and supervisors could be present to help the ANMs in the clinics, which was critical for a more equitable distribution of the workload. The ANM and female supervisors examined pregnant women, administered immunisations to children and managed women's health problems. Male workers completed registers and cards and provided health education. This work distribution gave the ANMs time to pay more attention to pregnant women and give them services not previously provided, and address the needs of women wanting contraception.
It was then possible to extend the duration of the clinics to five hours each. Medical Officers (MOs) planned their monthly visits to each sub-centre to coincide with the clinic day. At the clinic, the MOs examined the high-risk pregnant women and referred those that were beyond their capacity to manage to the district hospital. The schedule for the MOs' visits was arranged so that they could share the only available vehicle and the supervisors could travel with them to the villages that were distant from the bus route.
Availability of antenatal care
Health services were not readily available in the 16 villages where there were no PHCs or sub-centres, and “full” antenatal care was available only at these centres. ANMs visited women in the villages less frequently than they saw them at the PHCs and sub-centres. In fact, women reported pregnancies only when ANMs visited them at home. More women in villages with a PHC or sub-centre were registered for antenatal services than in those without (85% compared to 69%), more deliveries at home were attended by trained personnel (26% compared to 5%) and more women used contraceptive spacing methods (9% compared to 3%). Child immunisation coverage, on the other hand, was not significantly different (81% compared to 78%) because immunisations were provided through MCP clinics.
All the MCP clinics were held in the morning, a time inconvenient for women with families to take care of. Some MCP clinics were held at schools or temples, and because of this were avoided by some pregnant women.
MCP clinics were supposed to provide the entire range of family welfare services, but because of case overload for the sole ANM providing services, she had not been able to devote any time to pregnant women and restricted her services to dispensing anti-tetanus vaccines and iron tablets only. As a result, at any given MCP clinic, immunisations were provided to about 20–25 children, tetanus toxoid injections to 4–5 pregnant women and contraceptives to perhaps 1–2 women.
Based on these findings, the MCP clinics were made more convenient and efficient. The venues were changed to a fixed, central, acceptable public place which women could visit without hesitation. The help of the village panchayat (council) was sought in finding places where privacy was available for examining pregnant women. The clinic schedule, particularly in the villages without a PHC or sub-centre, was changed to coincide with the weekly market day and bus schedules. A range of clinical services for pregnant women—including physical examination, blood pressure measurement, haemoglobin estimate and urine test—were made available at the clinics, which were held on specific days each month in each village. In the larger villages (over 5,000 population) two clinics were held per month to deal with the caseload and in the smaller villages one per month.
Women's recognition of their reproductive health needs
Among the 80% of women who had registered for antenatal care for their last pregnancy within the previous five years, less than half received “full care”. Initial registration was during a house visit from an ANM, but most of the women did not come for the subsequent number of antenatal visits (minimum three). In the absence of complications, they said they saw no need to obtain care.
About 32% of women had their last delivery within the last five years at home and trained midwives attended fewer than 20% of these. Only 12% of all the women with a delivery in the last five years went for post-partum check-ups. Thus, the importance of antenatal visits, institutional delivery or a trained attendant at delivery and post-partum checkups were either not recognised or not accepted by the women.
Almost half the women surveyed self-reported gynaecological conditions, including menstrual disorders, white discharge, intermittent bleeding, backache, prolapse or the inability to conceive. Less than half of them sought treatment for these conditions, although more than 97% of women interviewed did seek treatment for general illnesses. The majority of the women were unaware that gynaecological conditions could be treated at the PHCs; others were either too ashamed to talk about them or had no one to talk to.
To address these problems, health workers were asked to take every opportunity to talk to women about their need for care, the problems they were experiencing and the services available to them. This was done through health education on reproductive and child health, during the MCP clinics, home visits and other contacts. An effort was made to include all the women who attended the MCP clinics by holding group sessions at the end of the clinic. However, though practical and acceptable, this strategy also had drawbacks. Very active and well-attended clinics meant that health workers could not always devote adequate time to health education. Nor could women who came in early to the camps wait till the end; hence, almost two-thirds of the women attending did not stay for the group session.
Consequently, health workers began to give health education individually while they were providing services, or grouped 2–3 women with similar needs together. These sessions dealt both with the women's immediate needs and the importance of reproductive and child health services, and their availability in the government sector. Women preferred this approach because it saved them time and was directly related to their own health problems. “Safe delivery” was emphasised at these sessions, and Disposable Delivery Kits (DDKs) were given to women in the third trimester.
Male workers and supervisors approached village leaders and panchayat members to tell them about the importance of medical care during pregnancy, delivery and the post-partum period and for other women's health problems. In routine household visits, health workers informed village communities about the MCP clinics and where they were located.
Infrastructure and availability of equipment
The facility survey indicated that more than half the ANMs could not provide all the components of antenatal services because they did not have the necessary equipment, such as blood pressure apparatus, weighing machines or facilities for urine tests.
Furthermore, in the absence of a proper clinic in the village, health workers were inserting IUDs at women's homes. They were not able to examine the women for infections because of insufficient light, but relied on reported symptoms only. Moreover, because ANMs were not knowledgeable about the signs and symptoms of reproductive tract infections and their treatment, the effectiveness of service delivery was affected. Each ANM was therefore provided with a portable equipment kit, weighing around four kilos, that she could carry to her clinic sites. The kit contained blood pressure apparatus, fetoscope, stethoscope, adult and infant weighing machines, DDKs, and a curtain, mat and measuring tape.
Other than the curtain, mat and measuring tape, all the equipment is available to government health staff. To ensure that the ANMs always had equipment in working condition, FRHS workers would carry an extra set of equipment with them whenever they attended an MCP clinic. This way they could replace any faulty equipment, and have it repaired and replaced before the next clinic. Health staff of PHCs and sub-centres had in-service training every six months by the Health & Family Planning Training Centre (HFPTC) and District Training Team (DTT) in use of equipment for antenatal services and to upgrade their skills. In addition, at the monthly meetings of the PHCs, the MOs devoted time to training the workers in the current focus or health programme of the government, such as RTI/STD management. Workers were encouraged to share their field experiences as well. These efforts sensitised workers to women‘s reproductive and child health needs and motivated them to educate themselves so as to educate women.
Contraceptive and drug supplies
ANMs did not recommend birth spacing methods to couples, particularly in the villages without PHCs or sub-centres, because of difficulties in maintaining monthly supplies. In addition, women had difficulty in accessing health centres in the event of complications from oral contraception or IUDs. Hence, ANMs tended to recommend sterilisation, which was carried out at government centres (PHCs & CHCs) with requisite facilities.
One ANM said her team prescribed medicines meant for treating reproductive tract infections for cases of diarrhoea and other bacterial infections, as these were frequent problems, while the proper drugs for treating them were limited. There was also a shortage of Oral Rehydration Solution. Thus, problems with drug supply affected all services.
Although FRHS staff monitoring the MCP clinics reported shortages of medicines and out-of-order equipment to the MOs and district officers, supplies of medicines and iron tablets remained a problem. Once MOs became aware of the shortages, however, they expedited the requisition process from the district stores.
Critical policy changes
The four critical changes which helped to accomplish a more efficient system were:
Service delivery was shifted from a household to a clinic-based approach
In the past, household visits were needed to increase community awareness of services, and this goal had been achieved. Pregnant women had started coming forward for services, and this was a necessary transition. The project showed that MCP clinics were the most viable and affordable way to provide clinical Reproductive and Child Health (RCH) services, provided they were made more efficient and effective. Comprehensive antenatal care and services for RTIs and STDs cannot be provided at household level because there is no privacy or facilities to examine women, discuss their problems and treat them. An efficient village-level clinic managed by capable staff therefore offered the most practical platform for provision of RCH services.
Stringent monitoring mechanisms were put in place
In Parner, FRHS staff monitored the logistic support and training requirements of clinic staff. This facilitated smooth functioning of the clinics. This level of intense monitoring through deployment of special personnel and detailed narrative reports on each session is not possible for the government. Due to pressure of work, the supervisors' reports concentrate more on the actual coverage figures and service delivery. However, the system also includes a supervisory checklist, used by supervisors from PHCs once a month, to assess available supplies and knowledge and skills of health workers. The checklist also gauges the quality of the work of ANMs and male MPWs, and coverage of their services from data collected directly in the community. These checklists were used at the monthly PHC meetings and offered a means of providing feedback to health workers to improve their performance, and to district officers to assess the training needs and supply requirements of workers.
Knowledge and skills of health workers were upgraded through focused training
Training was focused on the issues of current concern, and the use of available equipment and supplies. The training gradually upgraded the knowledge and skills of health workers so that the information was easy for them to internalise. Reorientation training was provided at regular intervals to keep pace with changing programmatic demands such as RTI/STD management. Capacity-building of district-level trainers was also a part of the process of strengthening the system. The involvement of trainers from the government's HFPTC, DTT, ADHO and the PHC Medical Officers throughout the process of assessment of training needs, conceptualisation of sessions and actual conduct of sessions, demonstrated to them that they did not need to add anything extra to their existing curriculum but to highlight certain sessions according to need.
Gradual build-up of clinic-based services
Minimal inputs in the form of working equipment, rational work schedules and support to field level workers for strengthening the antenatal care component of the clinics was the first step that transformed “immunisation sessions” into efficient and effective Mother and Child Protection clinics. Once this was done, interventions aimed at expanding the scope of MCP clinics to include other components of RCH in Phase II were more acceptable to the health staff. Post-partum care and diagnosis and management of gynaecological problems, RTIs and STDs were the next step for the MCP clinics to evolve into Reproductive and Child Health (RCH) clinics. The involvement of men in RCH care was another important transformational step.
Positive effects and limitations of these changes
The most visible achievement of all the measures taken was a 30% increase in attendance of pregnant women, from 4–5 women to 15–20 women per MCP camp during the five-year period. The quality of care also improved, with more than 60% of women attending receiving all the components of antenatal care. Services that hitherto were neglected, such as urine tests and blood pressure measurement were administered to a large majority (89%) of the women attending . Post-partum coverage did not improve, however; ANMs made very few post-partum visits. After these changes were made, ANMs reported:
Table 1. Performance of antenatal services at Mother and Child Protection clinics 1994–2001
While earlier we had to call women to the clinics, now they have started coming on their own. Moreover, they have started enquiring about services for abortion and treatment of gynaecological problems.
Health workers did not complain about the extra work, and not a single clinic had to be cancelled during these five years because of lack of supplies or for any other reason. Rather, workers were happier as availability of supplies and equipment, and the presence of Medical Officers at the clinics, increased their credibility. Moreover, prominently displayed dates and times ensured that clinic schedules were maintained. The revamping and remodelling of clinics was welcomed by the community and supported by other functionaries.
The changes made in the clinic schedules and the work shared by the workers demonstrated to the district officers that the government health system did offer them flexibility in organising service delivery and discharging duties. Also, they showed that it is possible to increase productivity in the existing government system by making rational changes in service delivery without much cost. The kit as well as training together cost only 5–7% of an ANM's annual remuneration.
The accomplishments of Phase I were that it focused on improving service delivery mechanisms. Only a few actions within the control of the district were selected for implementation. When these actions began to have an impact in Parner block, the scope of the intervention was expanded to include other blocks and address additional problems. The step-wise changes in service delivery, implementing them and working for their success was done at the district level with the pro-active involvement of the DHO and ADHO. This could have been its downfall, as a new DHO or ADHO could have discontinued the project and rejected the innovations, especially if there was no state support. Fortunately, the state took a pro-active, interested role as well. The Steering Committee provided policy direction and the Director kept himself informed of the project's progress and showed appreciation for his staff's efforts. This raised the morale of the district staff and motivated them to do better.
All measures taken were based on hard survey data, district data and the health staff's own experience. This gave the staff a sense of ownership. The ideas for strengthening MCP clinics were generated at the brain-storming meeting with all cadres of health staff, and acceptance by them was unanimous. Taking account of details such as bus schedules, equitable distribution of the workload among the health workers and availability of vehicles for distant villages assured the workers that the measures were logical and well-structured, and not an imposition.
There were some limitations to the success in Phase I as well. The ANMs and MOs were advised to inform the ADHO about supply problems directly, but they rarely did so. Communication between health workers, PHC and district officers did not develop to the desired extent. Some ANMs did not take the initiative to report the breakdown of equipment. Their reluctance might have been due to the convenience of not having to carry out certain tasks.
There were still a substantial number of women and children who did not attend the clinics and did not benefit from the measures. Early registration of pregnancies remained below 40%. Even clinic-based services did not prompt pregnant women to come in the early weeks of pregnancy to the MCP clinics. On the other hand, rigorous application of high-risk criteria (including anaemia and short stature) by ANMs resulted in more than a third of pregnant women who did attend being labelled high-risk and referred to MOs . This may have increased the ANMs' credibility but the workload of MOs was also greatly increased. The criteria for referral to the MOs were therefore rationalised to include only those which were harbingers of poor pregnancy outcome for the mother and the child. This reduced the referral rate to 18% by 2001.
Place of delivery was not addressed, other than to give information through health education on the need for “safe delivery”. We worked for safe delivery within the constraints of the government system, to make it more efficient, and also within the constraints of local custom (of home delivery) with a view to improving clinic-based services first.
Notwithstanding these limitations, the experience in Parner block showed that integrating the RCH approach was feasible by changing the manner in which the package of services was devised, delivered and monitored. This could be done without compromising the quality of and access to existing services. Since the success of a reproductive health approach hinges on the extent to which women have access to health services, a programme designed to reach them must pay special attention to reducing the barriers faced by women.Citation9 These steps include making women and their health needs more visible and involving the community in the whole exercise. Our experience in Ahmednagar indicates that the strengthening of existing services with even minimal resources can create a strong foundation that can later be built upon to include the whole range of recommended services.
Acknowledgements
We acknowledge the support and guidance of the late Dr AD Pendse, Assistant Director, Directorate of Health Services of Maharashtra. Special thanks to the District Health Staff of Ahmednagar for their active co-operation, without which implementation of this project would not have been possible. Last but not least, we are grateful to the women of Parner block for their unstinting faith in the project.
References
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