Enhancing Rural Health Services in Bihar: Achievements and Recommendations

1. The National Rural Health Mission 2nd Common Review Mission Key Observations from Bihar State Visit November 26- December 1, 2008

2. Key achievements: • Sustained improvements in use of public health facilities especially for out patient care and delivery services. • Nearly half of the eligible children are now fully immunized • ASHAs in place and playing active role in community mobilization • Simple but effective daily facility monitoring systems in place to ensure availability of providers, pharmaceuticals and performance • Ancillary services contracted to improve service delivery by public health facilities

3. Key achievements: • All Block PHCs are functioning 24/7 including ambulance services • Enhanced client satisfaction due to better availability of essential drugs, positioning of contractual staff and improvements in local amenities • New cadre rules require mandatory rural work experience and ensure time bound promotions for doctors • Disease control programs are beginning to use data for planning interventions • Successful piloting of Nutrition Rehabilitation Centre

4. Despite these notable achievements by the State during past 3 years, several challenges still remain

5. How to further improve Service Delivery? • Addressing Key infrastructure Gaps • Eliminating Kala Azar and improving coordination between Directorate and State Society for effective delivery of national health programs • Improving and monitoring the quality services that are now increasingly being used • Ensuring sustained supply of drugs and reducing stock-outs • Enhancing access to basic health services through user fee exemptions and making more APHCs functional • Enhancing access to emergency obstetric care at sub-district level • Improving Bio-medical Waste Management

6. How to improve decentralized planning and community processes? • Starting the District Planning Process to respond specific needs of each district • Institutionalizing arrangements for training and supporting ASHA on a sustained basis • Strengthening the community processes such as establishment of Village Health & Sanitation Committees and continued involvement of local bodies in RKS

7. How to further improve Human Resources and Program Management ? • Making nursing and ANMTCs functional and streamlining the admission • Complementing the new cadre rules with well defined posting, transfer and deputation policies and creation of a Public Health cadre • Encouraging multi-tasking of the providers through inservice training: General lab services by TB lab technicians, Skilled birth training to GNMs posted to APHCs, Obstetric and Anesthesia training for medical officers etc. • Institutionalizing structured supervision from state to district and district to block levels as it is happening in immunization

8. Immediate Actions : • Organizing workshops for handholding Block and District level accountants and program managers to ensure submission of all pending SOEs, utilization certificates during next 3 months • Maximizing availability of essential drugs and supplies through contracting an agency to develop and implement Logistic Management Information system for more efficient supply chain management • Creating district RCH technical support teams (one doctor and one nurse midwife) to help improvements in cleanliness, basic infrastructure and quality of care in the labor rooms and maternity wards at Block PHCs and certify facilities reaching basic standards

9. Immediate Actions : • Posting of the doctors trained in Anesthesia and Essential Obstetric Care to appropriate sub-district level facilities where their skills could be used • State Health Society to release and manage funds under disease control programs in consultation with the Directorate of Health Services which will be responsible for planning, implementation and monitoring of these programs. • Completing the selection of Kala Azar Technical Supervisors and state level consultants and ensuring effective IRS in hotspots • Enhancing the range of beneficiaries exempted from user fee. For example, pregnant women, children below 5 years, Kala Azar and Trauma cases

10. Medium Term Actions: • Creating dedicated infrastructure cells at district levels, using type designs for small facilities and engaging consultants for undertaking site surveys and prepare comprehensive facility development plans for hospitals • Enhancing operational skills of program management structures at block and district levels to promptly resolve the implementation bottlenecks such as delayed submission of SOE/UCs, efficient use of untied funds and contract management of out-sourced services • Making additional PHCs functional (Medica/Ayush Doctor/Nurse Practitioner+ minimum no. of nurses) to further improve access to essential health services and reducing load on Block PHCs and District hospitals.

11. Medium Term Actions: • Putting in place institutional arrangements at block, district and state level for sustained training and support for ASHAs • Strengthening community processes such as village health and nutrition days, creation of village health and sanitation committees and continuing enhanced role of PRI representatives in RKS. • Initiating well targeted demand generation activities through ASHAs and ANMs, building on health and nutrition days in partnership with agencies actively engaged in social mobilization • Expanding Nutrition Rehabilitation Centers to other districts

12. Medium Term Actions: • De-linking selection of candidates for ANM and GNM training with appointment and improving infrastructure of training schools on a priority basis to ensure optimal intake of students. • Developing a cadre of supervisors by promoting eligible male and female workers and providing them a bridge course focusing on supportive supervision skills. • Starting a phased approach to improve quality of services beginning with maternal and new born care in District hospitals and Referral Hospitals through skill based in-service training, use of standard operating procedures and facility level QA teams. • Meeting the unmet need for FP services through fixed service days at Block PHCs, promoting spacing methods through training of ANMs and ensuring availability of condoms and IUDs.