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Health, and health services in rural Rajasthan. Improving Health Status. Seva Mandir 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
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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
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
Survey structure • Four components • 1. Village census • listing, facilities, maps, infrastructure • 2. Facility survey • 143 public facilities • Several hundreds “modern” private facilities • 225 bhopas
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
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
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
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
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
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
… 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!!
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.
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)
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
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
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
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.
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.
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
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)
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
Register Records Machine problems Exempted days Absent Half day Present
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…
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.
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
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
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.
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.
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
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
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.
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.