1 QUALITY OF REPRODUCTIVE & CHILD HEALTH CARE IN INDIA: ASSESSING THE STATUS - Part-I By PRASANTA KUMAR SAHA CStat (UK), Fellow of the Royal Statistical Society, UK. Chartered Statistician, UK. PRASANTA

2 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION THE CONCEPT OF QUALITY IN CARE OF ANY KIND OF SERVICES OR QUALITY OF GOODS FOR HUMAN CONSUMPTION IS THE PRINCIPAL COMPONENT OF THE CONCEPT OF QUALITY OF LIFE.

3 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION-Contd. CONCEPT OF QUALITY OF LIFE IN A DEVELOPING SOCIETY IS A SUPER- PRECIOUS CONCEPT EVEN TODAY IN A DEVELOPING SOCIETY LIKE INDIA AFTER ITS INDEPENDENCE ABOUT SIX DECADES AGO.

4 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION-Contd. BEING IN THE SACKLES OF FOREIGN RULES FOR HUNDREDS OF YEARS, ABJECT POVERTY, SEVERE ILLITERACY AND LACK OF THE BASIC NEEDS ARE THE CAUSES FOR SUCH A PERCEPTION.

5 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION-Contd. THE CONCEPT OF QUALITY OF CARE IN THE FIELD OF PRIMARY HEALTH SERVICES IS, THEREFORE, YET TO GET ITS IMPORTANCE EVEN NOW. THE GOVERNMENT IS THE PRINCIPAL PROVIDER OF PRIMARY HEALTH CARE IN INDIA.

6 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION-Contd. TO MEET THE COLLOSSAL NEEDS OF THE LARGE POPULATION FOR THE BASIC PRIMARY HEALTH CARE IS AN UPHEAVAL TASK. A LARGE CHUNK OF RURAL POPULATION ARE YET TO GET THE REQUIRED BASIC PRIMARY HEALTH CARE.

7 Quality of Reproductive & Child Health Care in India: Assessing the Status INTRODUCTION-Contd. AS MENTIONED IN OTHER LECTURES, IN RESPECT OF QUALITY OF HEALTH CARE ALSO, THE CONCEPT EMERGED FROM THE RECOMMENDATIONS OF ICPD, CAIRO, THE RELEVANT PTOGRAMME OF ACTIONS [POA] OF ICPD,’94 STATES ‘REPRODUCTIVE HEALTH PROGRAMME MUST MAKE SIGNIFICANT EFFORTS TO IMPROVE QUALITY OF CARE.’

8 Quality of Reproductive & Child Health Care in India: Assessing the Status INITIATIVES : THE LANDMARK OF THE CONCEPT OF QUALITY OF CARE THE GOVT. OF INDIA AT THE CENTER PIONEERED FIRST TIME OFFICIAL RECOGNITION OF THE CONCEPT HISTORIC POLICY REFORM UNDERTAKEN INVOLVEMENT OF STATE GOVERNMENTS

9 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES: PRIOR TO THERE WAS NO POLICY DECISION SPECIFICALLY EMPHASISING THE NEED OF PROVIDING QUALITY SERVICES TO THE CITIZENS PARTICULARLY THE RURAL PEOPLE ACCORDING TO THEIR DEMAND OR FELT- NEED. THE YEAR MAY, THEREFORE, BE TERMED AS THE LANDMARK IN THE HISTORY OF FAMILY WELFARE & RCH SERVICES IN INDIA. RCH PROGRAM WAS ADOPTED IN AS PER RECOMMENDATIONS OF ICPD,’94.

10 Quality of Reproductive & Child Health Care in India: Assessing the Status APPROACH: SERIES OF MEETINGS, CONFERRENCES & SEMINARS HELD CONCURRENCE OF THE COUNCIL OF MINISTERS OF HEALTH & FW TAKEN VISTIS OF CENTRAL TEAM OF EXPERTS OF FW PROGRAM TO STATES WORKSHOPS OF DOCTORS, HEALTH WORKERS ORGANIZED AGE-OLD TARGET BASED SYSTEM FOR FAMILY PLANNING DISPENSED WITH: A PARADIGM SHIFT

11 Quality of Reproductive & Child Health Care in India: Assessing the Status APPROACH- CONTD IT IS BOTH QUALITATIVE & QUANTITATIVE CONCURRENT EVALUATION OF FW PROGRAM UNDERTAKEN IN MAJOR STATES IN IN BASELINE SURVEYS CALLED RAPID HOUSEHOLD SURVEYS CONDUCTED FIRST TIME SURVEY RESULTS MADE AVAILABLE AT DISTRICT LEVELS SURVEY RESULTS COVERED LARGE NO. OF RCH PARAMETERS

12 Quality of Reproductive & Child Health Care in India: Assessing the Status APPROACH-CONTD BOTTOM-UP APPROACH: PLANNING AT GRASS-ROOT LEVEL COMMUNITY PARTICIPATION ASSESSING AVAILABILITY OF FACILITIES IN HEALTH CENTERS REGULAR FIELD EVALUATION MACHINERY

13 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES ON APPROACH: RCH PROGRAM WAS OFFICIALLY INTRODUCED IN A DECISION WAS TAKEN TO UNDERTAKE AN EVALUATION PROGRAM CALLED CONCURRENT EVALUATION IN WHICH WAS AIMED AT REVIEWING THE LATEST STATUS OF FAMILY WELFARE SERVICE IN GENERAL AND PRIMARY HEALTH CARE IN PARTICULAR JUST PRIOR TO INTRODUCTION OF THE NEW PROGRAM CALLED RCH PROGRAM.

14 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES-CONTD: THIS EVALUATION PROGRAM CALLED ‘CONCURRENT EVALUATION’ PROVIDED INFORMATION ON SERVICE VARIABLES AT STATE LEVELS. AT THE SAME TIME THE GOVERNMENT AT THE CENTER AND ALL THE STATE GOVERNMENTS WERE TO INTRODUCE IN AN ABSOLUTELY NEW SYSTEM CALLED DECENTRALIZED PARICIPATORY PLANNING FOR IMPLEMENTING RCH PROGRAM.

15 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES-CONTD: IN FACT THE MOST IMPORTANT FEATURE IN THIS NEW SYSTEM IS THAT AN INNOVATIVE ASSESSMENT PROGARM WAS UNDERTAKEN AS A WORLD BANK PROJECT TO ASSESS (A) THE PERCEPTION OF THE CLIENTS ABOUT RCH SERVICES, (B) TO ASSESS THE QUALITY OF SERVICES THAT THE CLIENTS ARE SUPPOSED TO RECEIVE FROM THE SERVICE DELIVERIES UNDER THE RCH PROGRAM AND (C) TO ASSESS THE AVAILABILITY OF THE SERVICE FACILITIES IN VARIOUS HEALTH CENTERS SIMULTANIOUSLY.

16 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES-CONTD: UNFORTUNATELY SINCE MOST OF THE STATE GOVERNMENTS COULD NOT START IMPLEMENTING RCH PROGRAM EVEN IN THE THIRD YEAR[ ], THE ASSESSMENT PROGRAM UNDERTAKEN THROUGH THE MACHINERY OF A LARGE SCALE OBJECTIVE SAMPLE SURVEYS CALLED ‘RAPID HOUSEHOLD SURVEYS’[RHS] AT DISTRICT LEVEL DID SOMEHOW ‘MISFIRE’ THE ORIGINAL OBJECTIVE OF EVALUATION.

17 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES-CONTD: THE REASON IS, AS MENTIONED ABOVE, RCH PROGRAM STARTED VERY LATE IN MOST OF THE STATES. SO EVEN IN THE THIRD YEAR [ ] OF ITS INCEPTION IN , MAJORITY OF THE RURAL PEOPLE DID NOT RECEIVE THE BENEFITS OF RCH PROGRAM. AS A RESULT THE RAPID HOUSEHOLD SURVEY [RHS] COULD NOT, NATYRALLY, ASSESS, IN THE FIRST PHASE,THE QUALITY OF SERVICES AS ENVISAGED IN RCH PROGRAM.

18 Quality of Reproductive & Child Health Care in India: Assessing the Status CHARACTERISTICS OF THE ASSESSMENT TOOL OF RCH PROGRAM CALLED ‘RAPID HOUSEHOLD SURVEY’ : FIRST TIME IN INDIA SUCH A LARGE SCALE SURVEY: COVERING ABOUT 500 THOUSAND HOUSEHOLDS IN 2 PHASES FIRST TIME SUCH A LARGE SCALE SURVEY IN HEALTH SECTOR FIRST TIME DISTRICT LEVEL SURVEY IN SUCH A LARGE SCALE: MOST IMPORTANT FEATURE IT IS AN OBJECTIVE STATISTICAL SAMPLE SURVEY

19 Quality of Reproductive & Child Health Care in India: Assessing the Status CHARACTERISTICS-CONTD: FIRST TIME SUCH A LARGE SCALE SURVEY WAS CONDUCTED BY PRIVATE SECTOR: SO FAR ALL LARGE SCALE SURVEYS WERE BEING CONDUCTED BY GOVT. AGENCY CALLED NSSO. METHODOLOGIES, QUESTIONNAIRES, TABULATION PLANS, ETC WERE LOOKED INTO BY EXPERT GROUP COMPRISING STATISTICIANS WITH SPEKIALIZATION IN SAMPLING TECHNIQUES, DEMMOGRAPHERS, MEDICAL DOCTORS, WORLD BANK SPECIALISTS, ETC.

20 Quality of Reproductive & Child Health Care in India: Assessing the Status PARAMETRS OR INDICATORS ON RH & CHILD HEALTH COVERED: RHS FURNISHED ESTIMATES ON A VERY LARGE NO. OF PARAMETERS IN RH & CHILD HEALTH. FOR QUALITATIVE ASSESSMENT THE QUESTIONNAIRE WAS STRUCTURED TO COLLECT SPECIFICALLY INFORMATION ON WOMEN HEALTH & CHILD HEALTH FOR THE FIRST TIME. SEPARATE VERY DETAILED QUESTIONNAIRE WAS CANVASSED FOR WOMEN HEALTH IN REPRODUCTIVE AGE GROUP.

21 Quality of Reproductive & Child Health Care in India: Assessing the Status PARAMETERS OR ESSENTIAL INDICATORS [%] ON RCH CARE INCLUDE [ AS IN ]: AGE AT 1 ST COHABITATION BELOW AGE 18 : 59.8 % OF ILLITERATE WOMEN IN REP. AGE GROUP : 56.1 % OF WOMEN ON KNOWLEDGE OF MODERN METHODS OF FP : 57.8 ANC-AT LEAST 3 VISITS : 44.2 DELIVERY AT HEALTH INSTITUTES : 34.0

22 Quality of Reproductive & Child Health Care in India: Assessing the Status PARAMETERS OR ESSENTIAL INDICATORS [%] ON RCH CARE INCLUDE [ AS IN ]-CONTD: SAFE DELIVERY : 40.2 CHILDREN WITH BIRTH WT. BELOW 2500 GM : 16.9 BREAST FEEDING WITHIN 2 HRS. OF CHILDBIRTH : 26.3 FULLY IMMUNIZED CHILDREN : 54.2 WOMEN WHOSE CHILDREN SUFFERED DIARRHOEA : 24.8

23 Quality of Reproductive & Child Health Care in India: Assessing the Status PARAMETERS OR ESSENTIAL INDICATORS [%] ON RCH CARE INCLUDE [ AS IN ] -CONTD: TREATMENT WITH ORS : 11.2 WOMEN WITH PRE-NATAL COMPLICATIONS: 41.3 SYMTOM OF RTI / STI : 29.7 MALES WITH SYMTOM OF RTI /STI : 12.3 AWARNESS OF WOMEN ON HIV / AIDS : 41.9

24 Quality of Reproductive & Child Health Care in India: Assessing the Status PARAMETERS OR ESSENTIAL INDICATORS [%] ON RCH CARE INCLUDE [ AS IN ] -CONTD: AWARNESS OF MALES IN ON HIV / AIDS : 60.3 WOMEN SEEKING TREATMENT ON PRE-NATAL COMPLICATIONS: 46.7 WOMEN SEEKING TREATMENT ON POST-NATAL COMPLICATIONS: 46.6 CLIENTS WITH RTI/STI SOUGHT TREATMENT: MALE : 55.1 FEMALE : 37.6

25 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES : LIMITATIONS OF THE RESULTS ARE THAT STANDARD ERRORS FOR AT LEAST IMPORTANT PARAMETERS HAVE NOT BEEN WORKED OUT. IN FACT THIS IS THE DRAWBACK OF MOST OF THE SAMPLE SURVEYS CONDUCTED BY PRIVATE AGENCIES. THIS IS DUE TO THE FACT THAT NONE OF THOSE AGENCIES EITHER HAVE EVER CONDUCTED ANY STATISTICAL SURVEYS EARLIER OR THEY ARE TRAINED IN SAMPLING TECHNIQUES.

26 Quality of Reproductive & Child Health Care in India: Assessing the Status NOTES : IN INDIA THE INTERNATIONALLY REPUTED ORGANIZATION CALLED NATIONAL SAMPLE SURVEY ORGANIZATION [NSSO] IS THE SPECIALIZAD SAMPLE SURVEY AGENCY IN THE GOVT. OF INDIA WHO ARE CONDUCTING LARGE SCALE SAMPLE SURVEYS IN INDIA SINCE 1950’S. NSSO WAS CREATED BY THE INTERNATIONALLY FAMOUS STATISTICIAN NAMED PROF. PRASANTA CHANDRA MAHALANOBIS WHO HAD ALSO CREATED THE FAMOUS INSTITUTE CALLED INDIAN STATISTICAL INSTITUTE[ISI] AT CALCUTTA, WEST BENGAL.

27 Quality of Reproductive & Child Health Care in India: Assessing the Status IN PART-II OF THIS LECTURE OTHER EVALUATION SYSTEMS WILL BE DISCUSSED. THANKS.