IJCRR - 3(9), September, 2011
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ROLE OF EXISTING BASIC HEALTH UNITS IN FULFILLING THE COMMUNITY HEALTH OBJECTIVES
OF DISTRICT JAIPUR
Author: Sandesh Kumar Sharma, S. S. Chowhan, Kiran Sharma
Abstract:Objective: Importance of Role of Management to improve working of Basic Health Units at gross root level which include Primary Health Care Centres (PHC) and Sub-Centers in deliverance of Quality Health Services through practical measures. Design: A qualitative study Place and Duration: Study was conducted in Jaipur, Rajasthan. Methodology: The Basic Health Units of Jaipur were taken as a model for Study and was carried out in following steps Survey: Physical survey was carried out at PHC and Sub-Centers. ?Interviews: Interviews through personal interaction with all stake holders of basic health units of Jaipur involving health care providers which included Doctors, ANM and Dispensers. Results: As a result of these surveys and interviews it was observed that the Service Providers lacked required degree of training, awareness and commitment. Conclusion: At Jaipur, Health Care Facilities are far from perfection in terms of Quality. The effective and efficient health care system at basic health units is dependent on the introduction of quality management and is considered the essence of its success which is possible through training and creating awareness about its benefits.
Keywords: WHO (World Health Organization), PHC (Primary Health Care Centre), ANMs (Auxilliary Nurse Midwives), LHVs Lady Health Visitors.
Health Care System in Country has been designed on the model of World class Health Care Standards adopted Universally under W H O. India has an extensive public sector service delivery infrastructure based on three tiered healthcare delivery system that is Primary, Secondary and Tertiary. Jaipur district consists of 13 Tehsils spread over vast land, with a population of 4,390,531 approximately. To provide Basic Health Services to the people of rural area of Jaipur, both Government and Private sectors have been striving hard. For this purpose the public sector has 5 primary health care centres and 36 sub-centres (Table 01). The Primary Health Centre (PHC) is looked after by a Medical Officer, Block Extension Educator, one Female Health Assistant, a Dispenser, a driver and laboratory technician. PHC is equipped with necessary facilities to carry out small surgeries (Table 02 and 03). In private sector, NIMS University is the major player to provide Health Care services to the residents of Jaipur. NIMS University has established a Health Care Service Centre in Achrol Jaipur. In Today‘s world, developing countries face serious issues of Equity and fairness in health care delivery management with even a greater need to transform the management systems and practice.2 For this purpose following steps are inevitable. (i) Training: intensive and vide spectrum of training programme in Health Care System to all the stake holders at different tiers need to be started. (ii) Qualification: Job preference for those who attend the programme and qualify for delivery and management. (iii) Benefits: Attractive salary and incentive package for medical staff combined with improved working and living conditions to those fulfilling above two conditions. Other important aspects to look into are Preservice orientation programme and regular in-service training, a supportive monitoring and supervisory mechanism.3 The stress must be on proper training of support staff which includes Auxilliary Nurse Midwives (ANMs) / Lady Health Visitors (LHVs). The Support Worker role is highly effective therefore proper training and adequate supervision is experienced and the support worker is entrusted with a considerable degree of freedom to act.4 Once the trained people come up and perform all the assigned goals, the difference will also be seen in the health statistics and in turn diminish the ever growing pressure of population in the region that has allowed rapid transmission of communicable diseases like malaria, tuberculosis (TB), leprosy, and HIV/AIDS.5 The present trend of Public Private Partnership with proper guidelines can give better results but it has to be without any political interference. Public-private interfacing in the absence of locally established principles, legislative frameworks, policies and operational strategies have been contributing to the adhoc nature of public-private engagement within the country, which has lead to skew powered relationships and lack of clarity in combined models of governance.6 Decentralization without any political influence in Health System may improve the health status. All efforts have to be concerted to support and facilitate the new system, which will mature into Institutionalization of the Health Services at the District Level. Most importantly, it will help in strengthening the Primary Health Care Services catering to the major fraction of the population.7 Assessment of the available resources, their proper allocation and efficient utilization are important considerations for providing efficient health care services. The basic resources for providing health care are:
1. Health Manpower\
2. Money and Material; and
It was observed from the record and during the visit that most of PHCs and Sub-Centers staff were not trained to perform basic function like health promotion, health education for prevention of diseases and offering antenatal, postnatal services, family planning services and immunization. Out of 41 centres 5 are PHC and 36 are SubCenters of Health Department were observed most of them are without basic amenities due to carelessness resulting in faults or damage and needed repair. Record keeping an important component of any organization was also missing. The targeted goals of Health Care for the benefit of people are achievable through trained health care workers. The benefits of health care system depend ultimately on the knowledge, skills and motivation of people responsible for delivering services.9
It was observed that poverty is the root cause of poor health status and thus it is safely assumed that for a low income segment of country, improving health is all that matters.10
A qualitative study was conducted using focus group discussions interviews to understand the quality of health services providers which included health care managers. In all, 48 interviews were conducted from health service providers comprising doctors, nurses, Auxiliary Nurse Mid-Wives (ANMs)/ Lady Health Visitors (LHVs). All participants were recruited based on convenient sampling and their availability for group discussions. The concept of Primary Health Care Centres, basic health units and its management were discussed to understand their perception about the system. Focus group interviews and in-depth discussions during the project visits to Government sector dispenseries and sub centres, it was analyzed thatmost of the health workers felt dissatisfied about the working conditions specially adequacy of man power in terms of strength, training and awareness about the system to take the fruits to the gross root level. They opened that they are forced to handle cases for which they are not trained. We gathered data from the record of different centres and modelled it for qualitative analysis which has produced the following results. Qualitative data analyses produced the following results.
To analyse and assess the working of Towns of Jaipur basic health units, during the period September 2009 till January 2010 total 48 interviews were conducted from health care providers. To maintain the quality service at primary health care, trained personnel is the need of the hour both in terms of professional as well as in managerial capacity, Record keeping is an important component of any organization was also noted lacking. To involve private sector in providing basic health facilities to the community because as this uphill task cannot be overcome by public health sector alone. Total health budget escalated from Rs.4,000 Crores to Rs.21,113.33 Crores ($4.35 billion) with special emphasis on rural healthcare and health for all, The budget allocation for the National Rural Health Mission (NRHM) increased by Rs.2,057 Crores. Government must involve private sector by providing health care infrastructure such as land and / or tax holidays for the construction of much needed health facilities in rural area like Achrol. Staff should be taught to keep a holistic approach, for the reason that persons coming to PHC were not necessarily sick, he / she might have come for any other service offered at PHC. Political influence was described as serous issue on appointment, postings and the people who were absents from their duties. Political influence must be abandoned. Community consultation be made important in primary health care centers. With out any biases sar-panch from community should take notice of the problem of absenteeism and report it to the authorities concerned and ensure action as needed. Government should pay attention to improve facilities in primary health care setting in all B.H.U‘s, PHC‘s, Sub Centers, MCH Centers and dispensaries. Bring significant reduction in infant and maternal mortality through immunization coverage. There should be proper screening of high risk pregnancies during antenatal visits. Proper counselling on the use of any contraceptive. Training course in management and professional subjects for doctors, nursesand paramedical staff for better understand of primary health care is all about. Incentives and job preference to qualified and trained manpower only. Maximize the effectiveness and efficiency of worker by financial incentives. Supportive supervision, performance appraisal, career development and transparent promotion should be prioritized for improving the services and efficiency. By achieving above shall enable the people to take more control over their own health and other factors such as environment, social and personal which effect their health. Drugs alone will not solve the problem of disease, without health education
Study was carried out on the of the residents of Jaipur Rajasthan, one of the largest rural area of the State. We observed high population growth rate coupled with poor health status of the major percentage of the people and thus need extensive health care services, which unfortunately, is not available/accessible at the door steps of the common people of the area. One of the factors leading to the non availability of the health care services is the expensive and lengthy training process of doctors and nurses resulting in acute shortage of health care service providers, especially women.11 The research also showed that there is a need of proper training of employees in public health management to improve the health of the community due to the fact that more than 70% of population of the country lives in the rural area. This rural population of the country has peculiar social and cultural gender related values. Therefore, the Government of India must make the health care system more gender sensitive through appropriate training programs for the service providers along with wide community participation in decision-making processes.12 This study has shown that if we want to improve the health of our nation then we have to improve our basic health units i-e the infra structure, the facilities and most importantly the services. Services can be improved with human resources and that can be done by proper educating doctors, nurses and paramedical staff through educational programs working in primary health care centres. Incentives in terms of salary raise and job benefit must be given to service providers working in remote areas in order to motivate and encourage them to work in competitive and critical environments. In this process, the LHVs (Lady Health Visitors) are the first tiercontact of the health care system. Therefore, they care, teach, and train traditional birth attendants as they (LHVs) have to come across the underprivileged women of the rural area.13 This study also reveals the issue of maternal morbidity and mortality, in the area for the reason that it has less number of female trained staff which includes doctors, nurses and LHVS‘. So the staff should be increased, and the knowledge of the existing female staff should be upgraded. The organization and delivery of health care services in the last decade of the 20th century have been heavily influenced by two themes. First, the proposition delivered from high – volume providers can favourably affect the health status of patients served. The second theme is associated with the growing importance of quality of health care.14 To improve the effectiveness and efficiency of health care system in basic health units it is important to improve the quality of services. One way to achieve this is to have a team approach. This effort should not be one-sided on the part of top management only but also include the people who are working in basic health units (employee) and the community representative (sarpanch). Public private partnership is also important; in this type of partnership Private institution provides human resource for health units and in return government provides land and other incentive like tax relaxation etc. Everyone has to give hundred percent to improve the quality of services and the health of people. The objective of healthcare management is to accomplish the organizational puproses. The healthcare organization‘s purposes are ?to provide the community with the services it needs, at a clinically acceptable level of quality, at a publicly responsive level of amenity, at the possible cost? but doing so is its that simple?15 Largely the study is all about proper Training, Management, improved infra structure and incentives for the employees. With the Involvement of community, public private partnership is required to improve the health of nation. The management issues that need to be addressed on priority in the towns of Jaipur include improved monitoring and supervision, filling of vacant positions and training of staff must be the top priority of government. The health facilities require enhancement in terms of its services delivery system.
This is a small scale model study on the Management, Staff, Community and Public Private Partnership with emphasis on reducing constraints in order to improve the health of people. A health strategy has to be based on a determination of which are the leading health problems in the population, and what are the principal requirements to make the health care delivery system more effective. One major task of improving the health of the population is the development of human resources and educating health service providers. Equipping individuals and health service providers with the necessary knowledge will be a major step towards advancement of the health system. Sufficient number of Health teams and workers at all levels should develop a caring ethos and commit themselves to the improvement of the health status of their communities. Every effort should be made to ensure the improvement in the quality of services at all levels. Emphasis should be placed on reaching the poor, the underserved, the aged, women and children, who are amongst the most vulnerable and incentives must be given to health service providers for motivational purposes.
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