Health, and health services in rural Rajasthan

1. Health, and health services in rural Rajasthan

2. Improving Health Status • SevaMandir was keen to find new interventions for its health unit • ..but no idea what the outstanding issues and concerns were • Need to start a descriptive survey • With the view of using survey results plus available knowledge to develop interventions that have a chance to work

3. Udaipur rural health survey • Data collection in rural Udaipur district, Rajasthan • 100 hamlets from 362 villages(poorer than average) • Stratified by distance to road: 50 at least 500 m from a road

4. Survey structure • Four components • 1. Village census • listing, facilities, maps, infrastructure • 2. Facility survey • 143 public facilities • Several hundreds “modern” private facilities • 225 bhopas

5. Survey structure • 3. Weekly facility visits • 49 per facility on average • Are they open? • Who is there? • 4. Household survey • 1,024 households, 5,759 individuals • All members interviewed

6. Household survey • Economic status • Income, consumption, etc. • Education • Work • Happiness and health measures • Depression, symptoms • ADLS & IADLS • Fertility histories • Experience with health care system • Direct measures • Peak flow, weight and height, hemoglobin, blood pressure

7. Poverty • This is a very poor, largely tribal population • More than 40 percent below official PL, cf 13 percent in rural Rajasthan • 46 percent males and 11 percent females are literate • 21 percent households have electricity

8. Health status • 80 percent adult females, 27 percent adult males hemoglobin < 12 gm/dl • Standard cutoffs, men as likely as women to be anemic, older women as anemic as younger women: diet? • BMI 17.8 (men) 18.1 (women), 93% (men) 88% (women) BMI < 21 • Many self-reported symptoms, substantial fraction “serious” • Fever, colds, “body ache,” back ache, chest pains, vision problems, etc. • Personal care ADLS are good • Work functioning often poor: >30% cannot walk 5k, draw water, or work unaided in the fields, 20% difficulty squatting

9. Lots of adaptation • SRHS is OK • 10 rung ladder, 62% rungs 5 to 8 • Only 7% on bottom two rungs • Women consistently poorer health • Happiness is OK • 46% 3 on a 5 point scale • 9% report 1 • Similar to US

10. A perfect Public Health Care system… • India has the model health care system for a large developing country: • An aid post or Subcenter within a few kilometers of each house, serving 3,000 individuals, staffed by one nurse (ANM) provide basic services and referral • PHC and CHC as the second tier, with doctors and specialists • District hospitals as the last tier. • No vacancies in aid post and subcenters

11. … But only on paper • People get most of their health care from the private sector, not the public health care system. • Udaipur health survey: Out of 0.51 visit to a health provider, 0.12 are to a public facility, the rest to private doctors or traditional healers • They end up spending lots of money (7% of their budget in Udaipur survey) to get health care of uncertain quality (36% of main providers have a doctor’s degree and 36% have no college degree of any kind. • Some basic services that the public health care system should deliver are not delivered: In particular full immunization rates were shown to be less than 2.5% at baseline!!

12. What are the problems? • Under-funding and under-equipment. • 20% of the aidposts and one-thirds of the subcenters lack a stethoscope, or a blood pressure instrument, or a thermometer or a weighing scale, • None of the subcenters have a water supply, 7% have a toilet for patients and 8% have electricity • National rural health mission is trying to address that by providing an untied allowance to the subcenter. • Drugs seem to be available. • Lack of demand for those services • Most visits to private facility end with a drip or an injection • Rarer in public facility. • Very high absence rate.

13. Very High Absence Rates • Udaipur Continuous facility survey: facility survey that cover all the subcenters and PHC serving 100 villages, weekly, over a year. • 45% of nurses in subcenters are absent • 36% of medical personel in CHC/PHC is absent • No predictability. • Not isolated problem: Chaudhury et al (2005) show it is the same in India, and over the world. • Negative correlation between usage and absence, so one could hope that reducing absence would increase usage (though causality could go both ways)

14. Private healthcare • Yet households spend 7.3% of budget on healthcare, and only slightly less per visit at public than private facilities • Drugs at public facilities, or doctors • Bhopas important & more so for poorer • More use in villages where public facilities are open less often • Private “doctors” • 41% have no medical degree • 18% have no medical training of any kind • 17% have not graduated from high school

15. Private treatment • Tests performed in only 3% of visits • In 68% of visits patients received an injection • In 12% of visits patients received a drip • In public facilities, these “treatments” are less frequent, tests are not. • Yet, 81% (75%) of visits to a private (public) facility made the patient feel better • SRHS and symptoms are uncorrelated with quality of services • Though lung capacity & BMI worse where facilities are worse

16. What is to be done? • Used these results as a starting point of a discussion of what could be tried: • Key problems: • Health Care: Can the public system be resuscitated • Basic care: If it cannot, can it be replaced to at least provide essential goods such as immunization? • Non health inputs: can diet be improved? Can water supply be improved

17. Three interventions • Need to try three interventions: • Work to Improve attendance by the ANMs in the subcenters. • Focus on immunization: both supply and Demand interventions. • Diet: Decentralized Iron fortification • (we also tried to work on water but had to give up after a while). • All these interventions were implemented in a randomized subset of 135 villages, so that their impact can be rigorously assessed by comparing a treatment and a control group. • They are implemented by staff on the ground, and the monitoring and evaluation is carried out by J-PAL in collaboration with VidhyaBhawan, a local teaching institution.

18. The ANM intervention: A Band-Aid on a corpse • Government appointed extra-nurse in some subcenters (the most remote). • Seva Mandir proposed to monitor the extra nurse • Jan 2006 it was approved, and Seva Mandir was asked to monitor the extra nurse 3 days a week and the regular nurse 1 day a week in the treatment centers which had only one nurse • Punishment for absence ruled by the district administration: for more than 50% absence on monitored days, deduction in proportion of the absence the first month, suspension the second month.

19. S I G N Stamp Sign Stamp Monitoring Technology Date and stime Stamping machine Signing and stamping, 3 times a day Register: secured to the center’s wall, collected once a month, sent to CMHO, who sends to PHC

20. Evaluation Methods • Two ANM: 16 treatment centers, and 12 control centers • One ANM: 33 treatment centers, 39 control centers. • Centers in the study were chosen to serve 135 villages in the Udaipur Health Care Study • Treatment and control center were randomly selected (BEFORE it was decided that there would be two nurses in some centers: no stratification). • “Random checks” (un-announced visit during opening hours on monitored and non-monitored days) one a month (from May 2006)

23. Two ANMs, All Days, Entire period

24. Two ANMs, Monday, Entire period

25. Degradation

26. What happened?? • Were sanctions not applied? • Initially they were applied. Some ANMs were given deduction. In one zone, deductions are more severe than what is imposed by center • ANMs not sensitive to deductions? • Possibly • System perverted from inside

27. Register Records Machine problems Exempted days Absent Half day Present

28. Explanations • Machine problems and exempt days increase at the detriment of presence and absence • Machine problems • When machine malfunctions, ANM must warn Seva Mandir and monitors meets her as soon as possible to exchange it • But as soon as possible depends on her…. • Machines have malfunctioned increasingly often (even new machines) • Some have evidently been misstreated • And finding ANM after machine problems has turned out to be increasingly difficult…

29. Exempt days • Exempt days are reported by the ANM on the register • These are days where she must do some other official duties (meetings, special field work, etc.) • They are not checked by Seva Mandir (which does not have the data) beyond basic credibility (no more than one block meeting per month etc.) • The PHC checks exempt days and implement deductions • Exempt days have increased drastically, especially things like “team work” or “surveys” where it is hard to verify actual presence • Either the ANM invents it or the PHC doctors give it to them. • The CMHO is aware of the increase in exempt days over time, so he must condone the PHC doctors.

30. Conclusion: ANM programs • The program was initially quite effective • In the first 6 months, the rate of presence of monitored nurses (in both types of center, and on all days), increased from 25% in control by 15 percentage point • But it was quickly sabotaged, and has no effect by the end

31. Interventions to improve immunization rates: great success • Improve reliability of supply: • In 60 villages, camps were organized monthly. Main feature is regular schedule. Over 20 months, 67 camps were cancelled, while 1269 were held. • Availability of camps and timing etc. were advertised by Seva Mandir Paraworkers, who also receives an honorarium for each immunization. • Increase parents’ demand: • In 30 of these villages, 1 kg of dal were given for each immunization, and a set of plates for complete immunization

32. Results after one yearImmunization rates • In the intervention hamlets • Comparison Hamlets: • 5.5% full (children 1 to 2) – 44% one shot (children below 2) • Camp Hamlets: • 19% full—69% one shot • Camp + encouragement Hamlets: • 36.5% full—67% one shot • In the neighboring hamlets (within 6 kilometers) • Camp hamlets: • 9.4% full-45% one shot • Camp + encouragement Hamlets: • 27.3% full-53% one shot • Effect of the encouragement goes well beyond the targeted hamlet • In treatment villages, effect of encouragement is to prevent drop out before immunization is complete, not to get the first shot. Average rate of completion of immunization sequence: 60.5% in encouragement camps, 42% in regular camps.

33. Results: Administrative cost per immunization • Main Cost of immunization is salary cost for the GNM (37% of the costs in the encouragement camps and 73% in the other camps)+ cost of travel etc. • So if the GNM can see more children per camps, the cost goes down. • In encouragement camps, GNMs see on average 2.8 times more children than in regular camps • The result is that the cost per shot is smaller in encouragement camps, despite the incentive: Seva Mandir administrative data indicate that the administrative cost per shot is: • Rs 171 per shot in encouragement camps. • Rs 248 per shot in regular camps.

34. Iron Fortification • Anemia is very prevalent. • Anemia is known to: • Cause lack of energy • Be easily preventable with adequate intake of iron • Best solution for regular iron intake is fortification of food but… most of the poor in Udaipur do not buy food that can be fortified

35. Solution: decentralized fortification • Villagers go to the local miller with whole grain (produced and purchase). • A simple machine was designed to mix iron with the flour after milling • Local millers were trained, Seva Mandir provides the iron pre-mix for free and a payment to the miller

36. Results • People take advantage of fortification • Hb levels have improved. • The need to conduct an endline survey to get data on activities, productivity, earnings, etc.

37. Conclusion • Collaboration between NGO and academics allow to design (hopefully) meaningful programs • Evaluation of these programs allow to further understanding of the situation on the ground • Next step, back in the NGO court: what to make of these results.