1 Quality of Reproductive & Child Health Care in India: Assessing the Status- Part-II By PrasantaPrasanta Kumar Saha, CStat (UK). Fellow of the Royal Statistical Society, UK. Chartered Statistician, UK.

2 Quality of RCH Care in India: Assessing the Status-Part-II INTRODUCTION In this Part-II of the lecture the system of Evaluation which has been an in-built system in the Family Welfare Program of India for more than two decades will be discussed. It is definitely very interesting to note that in order to check the status of implementation of FW program, policy makers emphasized upon the necessity of evaluation and also monitoring the implementation process long back in the Health sector.

3 Quality of RCH Care in India: Assessing the Status-Part-II INTRODUCTION-Contd This was felt absolutely necessary because of the very basic principle of introducing FW Program in India. The basic principle is the absolutely voluntary approach to the people for accepting population control methods [ currently it is being termed as population stabilization methods]. This approach is to be embraced in a democratic society of India.

4 Quality of RCH Care in India: Assessing the Status-Part-II INTRODUCTION-Contd In order to implement the evaluation and monitoring mechanism in all the States, a ‘Monitoring & Evaluation Division was created about 2 decades back in the Ministry of Health & FW, Govt. of India. The responsibilities of the M&E Division are, quite naturally, very tough. Simultaneously ‘Demographic & Evaluation’ Cell was created in Health Ministry of most of the States.

5 Quality of RCH Care in India: Assessing the Status-Part-II INTRODUCTION-Contd One of the remarkable features of this innovative dimension in the health sector is that the Evaluation machinery in selected regions of the country were created whose principal function is to undertake checking the acceptance of Family Planning Methods by the clients and for checking mainly the immunization program directly in the field through direct contact with the clients in their houses in the rural s well as urban centers.

6 Quality of RCH Care in India: Assessing the Status-Part-II MECHANISM OF EVALUATION SYSTEM: PROCESS EVALUATION IMPACT EVALUATION FIELD EVALUATION AD-HOC EVALUATION

7 Quality of RCH Care in India: Assessing the Status-Part-II NOTE ON EVALUATION MECHANISM: BASIC PRINCIPAL OF AN OBJECTIVE EVALUATION SYSTEM IS TO BUILD UP RELEVANT STATISTICAL, DEMOGRAPHIC AND OTHER INDICATORS WITH REFERENCETO THE SYSTEM. IN RESPECT OF EVALUATION IN THE FIELD OF RCH OR FW PROGRAM, THE VERY IMPORTANT FEATURE IS THAT EVALUATION MACHINERY IS AN IN-BUILT SYSTEM IN THE PROCESS OF POLICY FORMULATION AND POLICY IMPLEMENTATION FOR ABOUT THREE DECADES.

8 Quality of RCH Care in India: Assessing the Status-Part-II NOTE ON EVALUATION MECHANISM: PROCESS EVALUATION: BY PROCESS EVALUATION WE MEAN THAT AT CERTAIN REGULAR INTERVALS OF TIME [ QUARTERLY, SIX MONTHLY OR ANNUALLY] WHEN THE PARTICUALR PROCESS OF FW PROGRAM OR RCH PROGRAM IS CONTINUING, CERTAIN INDICATORS ARE GENERATED. IN RESPECT OF POPULATION STABILIZATION PROGRAM AND FW ACTIVITIES UNDER RCH PROGRAM ARE BEING REGULARLY UNDERTAKEN IN TERMS OF DISTRIBUTION OF MATERIALS AND PROVIDING SERVICES VIZ., INSERTION OF IUD, STERLIZATION OF WOMEN & MEN AND DISTRIBUTION OF ORAL PILLS & CONVENTIONAL CONTRACEPTIVES (CC) [ FOR INSTANCE, CONDOMS].

9 Quality of RCH Care in India: Assessing the Status-Part-II NOTE ON EVALUATION MECHANISM-CONTD: PROCESS EVALUATION-CONTD: COUPLE PROTECTION RATE [CPR]: ON THE BASIS OF THE RELEVANT INFORMATION BEING FURNISHED BY THE HEALTH & FW AUTHORITIES IN THE STATES A VERY IMPORTANT AND UNIQUE STATISTICAL INDICATOR CALLED COUPLE PROTECTION RATE [CPR] IS WORKED OUTANNUALLY. CPR, FOR INSTANCE, CURRENTLY IS ABOUT 50% FOR THE COPUPLE IN THE REPRODUCTIVE AGE GROUP[15-49].

10 Quality of RCH Care in India: Assessing the Status-Part-II NOTE ON EVALUATION MECHANISM: PROCESS EVALUATION-CONTD: CPR: INTERESTING FEATURES OF CPR IN INDIA ARE THAT FOR LAST FEW DECADES CPR INDICATES FEMALE STERILIZATION AS THE HIGHEST COMPONENT WITH MAXIMUM WEIGHTAGE FOLLOWED BY IUD INSERTIONS, OP & CC.

11 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: PROCESS INDICATORS: OTHER IMPORTNATPROCESS INDICATOR: NUMBER OF BIRTHS AVERTED : IT IS CALCULATED FROM THE INFORMATION MATRIX AVAILABLE FOR CPR FOR THE COUPLE IN THE REPRODUCTIVE AGE GROUP.

12 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: IMPACT INDICATORS: THESE ARE MAINLY DEMOGRAPHIC INDICATORS. ONE OF THE MOST IMPORTANT IMPACT INDICATORS OR PARAMETERS IS TFR: TOTAL FERTILITY RATE

13 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: OTHER IMPACT INDICATORS: IMR : INFANT MORTALITY RATE NEO-NATAL MORTALITY RATE MMR: MATERNAL MORTALITY RATIO CBR: CRUDE BIRTH RATE CDR: CRUDE DEATH RATE

14 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: NOTE ON IMPACT INDICATORS: IMR : NO. OF INFANTS DYING UNDER ONE YEAR OF AGE IN A YEAR PER 1000 LIVE BIRTHS. NEO-NATAL MORTALITY RATE : No. of infants dying within the first month of life in a year per 1000 live births.

15 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: NOTE ON IMPACT INDICATORS: IN RESPECT OF POPULATION STABILIZATION PROGRAM THE MOST SIGNIFICANT IMPACT INDICATOR IS TOTAL FERTILITY RATE,THAT IS, TFR. AS PER THE STATISTICAL SCIENCE [ IN WHICH DEMOGRAPHY IS A BRANCH], STATE OF POUPLATION STABILIZATION IN INDIA AT CERTAIN POINT OF TIME WILL BE INDICATED BY TFR MODEL.

16 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: NOTE ON IMPACT INDICATORS-CONTD.: TFR IS DEFINED AS THE AVERAGE NO. OF LIVE BIRTHS AMONG MARRIED WOMEN IN THEIR REPRODUCTIVE PERIOD ASSUMING THAT THEY WILL PASS THROUGH THE SAME LEVEL OF FERTILITY AND MORTALITY CONDITIONS DURING THEIR ENTIRE PERIOD OF REPRODUCTIVE AGE. WHEN TFR= 2.1 WHICH IS BEING CONSISTENT WITH INDIA’S DEVELOPMENTAL ISSUE, IT MAY BE ACCLAIMED THAT POPULATION HAS COME TO THE STAGE OF STABILIZATION.

17 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: NOTE ON IMPACT INDICATORS-CONTD.: THIS MEANS, TEN WOMEN IN REPRODUCTIVE AGE GROUP WILL, ON AN AVERAGE, GIVE BIRTH OF ABOUT 21 CHILDREN [ KEEPING IN VIEW OF THE CURRENT TREND OF SEX RATIO IN INDIA]. HOWEVER, THIS STATE OF TFR =2.1 SHOULD CONTINUE FOR A REASONABLE TIME PERIOD TO EXHIBIT ACTUAL STABILITY OF THE POPULATION. TO SUSTAIN THIS STABILITY CONDITION CONTINUOUS POPULATION CONTROL MEASURES ARE TO BE ADOPTED.

18 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: FIELD EVALUATION: CHARACTERISTICS: A UNIQUE SYSTEM IN FW PROGRAM CONTINUOUS AND CONCURRENT EXPERTFIELD EVALUATION TEAMS DIRECT CONTACT WITH THE ACTUAL CLIENTS MOST OBJECTIVE EVALUATION STUDIES HEALTH CENTERS AND CLIENTS GET SELECTED STATISTICALLY DEMOGRAPHERS & STATE HEALTH PERSONNEL ARE ALSO INVOLVED.

19 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: FIELD EVALUATION: A NUMBER OF WELL DESIGNED FORMATS ARE UTILIZED SEPARATE FORMATS ARE USED FOR QUALITATIVE ASSESSMENT OF PERFARMANCE OF THE HEALTH CENTERS SPECIFIC FORMATS ARE USED FOR ASSESSING THE SKILLS OF HEALTH WORKERS SPECIFIC FORMATS ARE USED FOR ASSESSING COMMUNITY PARTICIPATION IN RCH CARE PHCs ARE SELECTED WITH THE HELP OF PERFORMANCE IN THE CURRENT PERIOD

20 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: FIELD EVALUATION: GENERALLY ONE WELL-PERFORMED AND ONE WITH POOR PERFORMANCE PHCs ARE SELECTED STATISTICALLY WITHIN EACH SELECTED PHC SCs ARE STATISTICALLY SELECTED

21 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: FIELD EVALUATION: WITHIN EACH SELECTED SC, VILLAGES ARE STATISTICALLY SELECTED ABOUT 5000 CLIENTS ARE COVERED IN EVERY ROUND THROUGHOUT THE COUNTRY RELEVANT FORMATS ARE CANVASSED AT THE TIME OF INTERVIEWING EACH CLIENT OR ACCEPTOR OF THE SERVICE. INFORMATION ON PERFORMANCE OF EACH SELECTED PHC AND SC COVERING ALL THE ASPECTS OF SERVICE DELIVERIES, FOR INSTANCE, ON MAINTAININGTHE REGISTERS, WORKING CONDITIONS OF COLD CHAINS, ETC IS CPLLECTED..

22 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: FIELD EVALUATION: SCORING IS WORKED OUT TO EVALUATE PERFORMANCE OF EVALUATION TEAM TO JUDGE THEIR AUTHENTICITY INDICATORS ARE DEVELOPED TO REFLECT BOTH QULATIVELY AND QUANTITATIVELY THE PERFORMANCE OF THE SC AND PHC. FINDINGS ARE SENT TO THE CONCERNED DISTRICT AND STATE AUTHORITY FOR TAKING CORRECTIVE MEASURES FINDINGS ALONG WITH DETAILED REPORT ARE SENT TO THE CENTER THE EVALUATION TEAM DISCUSSES THE FINDINGS WITH CONCERNED STATE AUTHORITY IN THEIR HEAD QUARTER.

23 Quality of RCH Care in India: Assessing the Status-Part-II EVALUATION MECHANISM: AD-HOC EVALUATION : STUDIES ARE UNDERTAKEN BY INSTITUTES LIKE, POPULATION RESEARCH CENTERS WHO ARE REGULARLY ENGAGED IN ASSISSTING RCH PRORAM.

24 Quality of RCH Care in India: Assessing the Status-Part-II CONCLUSION : IN A DEVELOPING SOCIETY EVALUATION MECHANISM DOES NOT TAKE OFF WELL WITH REFERENCE TO THE LOBBY OF HEALTH MANAGEMENT. EVALAUTION MACHINERY FINDS OUT SHORTCOMINGS SYSTEMATICALLY FOR PROCESS CONTROL. IN A DEVELOPING SOCIETY LIKE INDIA THERE ARE ALWAYS CERTAIN INFIRMITIES AND DEFICIENCIES IN HEALTH SERVICES. SINCE THE PRESENT EVALUATION MECHANISM IS CONTINUOUS AND CONCURRENT, ITS FINDINGS ASKING FOR CORRECTIVE MEASURES ARE TREATED AS ROUTINE BY THE SERVICE PROVIDERS THUS GRADUALLY WEAKING THE ENTIRE EVALAUATION MACHINERY.

25 Quality of RCH Care in India: Assessing the Status-Part-II THANKS