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 School of Health System Studies
Tata Institute of Social Sciences

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 TEAM CLAIRVOYANCE 2010

Faculty Coordinator:

Dr. Anil Kumar

Dr. Sandhya Krishnan

Our Student Coordinators:

Dr. Jaya Khushlani

Dr. Juhi Gautam

Dr. Khyati Tiwari

Dr. Mandar Bodas

Dr. Parag Chaudhary

Dr. Priyanka Nagdeo

Dr. Pretty Jetty

The Souvenir committee:

Chief Editor: Dr. Mathew George

Team:

Dr. Deepthi Alle

Dr. Niharika Tiwari

Dr. Sujay Bhishnu

Mr Lal Mangaih Hauzel

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Director’s Message

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Clairvoyance Coordinator’s Message

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Dean’s Message

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 Table of Contents

Sr. Page
Title
No. No.

1) From Editor’s Desk 11

2) The Thin Line Between Advocacy and Research 13

3) Quality Management In Hospitals: Accreditation and Beyond 15

4) Quality In Hospital: Administrator’s Challenge 18

5) Measuring Quality- Accreditation and Beyond 24

6) Training And Development: A Key to Quality Often Missed 28

7) Patient Centric Corporatization: Making The Twain Met 33

8) MDG’S In Bihar: Examining Strategies, Exploring Possibilities 38

A Critical Review On Functioning Of Asha With Special Reference to

9) 44
Orissa

10) The Black Window 51

11) The Valley of Flowers 53

12) The Concept of Stand and Work: A Serious Health Threat 55

13) Need of the Aged 57

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 From Editor’s Desk

School of health systems studies proudly presents its annual event clairvoyance 2010, a
mega event and a platform for the Health care industry, alumni and the distinguished
scholars in the field of public health to come together and have academic deliberations on
the health care scenario of the country. Every year the issues addressed by the event are
appreciated for its contextual relevance and the productive discussions and learning it
generates. This year also the focus of the event is “Healthcare in South Asia: Revisiting the
last decade, foretelling the next”. The transcending of the topic of clairvoyance from
national to that of a global region is itself an indication of the growth of the School and its
impact on the policy makers and health professionals at an international level. At this
juncture, the school announces the initiation of its MPH with specialization in Health
policy, economics and finance. This is the latest addition to the ongoing School’s venture
that started with positioning its expertise in the field of hospital and health services
administration by grooming MHA professionals and more recently by extending its
expertise into the field of Public Heath with special focus on social epidemiology.
Adhwan, the souvenir is a token of appreciation for the participants and a platform where
the Faculty, Alumni and the Students of the School of Health Systems Studies document
their experiences and insights on the variegated realm of the health sector. We are fortunate
to have the opening session by Prof Susan Rifkin on the close link between advocacy and
research. Subsequently the souvenir brings to you the diverse orientations about quality
ranging from the challenges in translating guidelines into action and raising some pertinent
questions on the discourse of quality. The second session traces the diverse experiences of
health services system especially in the context of NRHM and the kind of inequities
prevalent. Final session is about health problems of the vulnerable, viz. the elderly, the
working population and the women.
We, the editorial group are extremely grateful for the contributors for their manuscripts
within a short notice and our sincere thanks to all those who have helped us make this
venture possible. Special thanks to the sponsors who have supported through their
sponsorship.

With Warm Regards,

Editor’s Desk

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 THE THIN LINE BETWEEN ADVOCACY AND RESEARCH

Professor Susan B. Rifkin

TISS Professor
Clairvoyance 2010

Recently a Phd student of mine presented the topic of his thesis. He asked the question:
how can delivery of services for children and families affected by HIV/AIDS be
improved in a decentralized health system? The question assumes that
decentralization of health services is effective and research is going to tell us how it can
improve services. Such an assumption is questioned by the increasing evidence that
decentralization of services has had numerous problems related to costs, human
resource capacities and administrative infrastructures. It can be argued the research
question is tends more toward advocacy for decentralisation than research into its
effectiveness.

The advantage of working with a research student is that such a pitfall can be pointed
out. In this case, the student changed to undertake to an investigation of the potentials
and limitations of a decentralized health service in providing care for HIV/AIDS
families.

However, the initial formulation is indicative of a trend within the sphere of health
policy that has a much more public face. At the Global Forum for Health Research in
Mumbai India in September 2005, some research papers presented findings that were
based on advocacy. An example was a study of gender and ARV (anti retrovirals) in an
African country. Instead of asking the question of whether gender played a role in the
acceptance and use of ARVs among poor populations, the study looked for evidence that
supported their premise that gender and equity did play a role in access. (Bongololo, G.
2005) This alarming trend appears to be the result of availability of funding that is
based more on belief than a rigourous research examination.

The recent report by the Center for Global Development calling for impact evaluation
reflects the concern in this trend of donors, policy makers and intended beneficiaries of
social service programmes. The authors argue that lacking systematic collection and
analysis of information little is learned about social interventions. As a result, countless
funds are spent on repeating mistakes at the loss of time, experiences and in the worst
cases, of lives. They argue that what is needed is impact evaluation which collects and
analyses evidence within an agreed standard to enable people to learn lessons from
past mistakes. “Impact evaluation asks about the difference between what happened
with the program and what would have happened without it.” ( Center for Global
Development, 2006 p.12)
The argument can also be applied to research in the area of health policy and by
extension programmes that emerge from these policies. Research needs first to ask
what is the evidence that a policy works then ask how it can be improved. Should the
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research investigate an intervention for improving the policy, a framework that leaves
room for evidence that the policy is not working needs to be the research basis.

Good research always allows for the negative hypothesis to be proven. By allowing
advocacy to become the center of investigation critics can easily say the findings are
ideologically biased or lack necessary scientific rigour. Replacing research with
advocacy investigations runs the same risk as forging scientific data. The results are
wish lists of the investigators and are not a contribution to our knowledge about the
universe. In addition, in the present environment, they increasingly contribute to the
loss of resources that need desperately to be used to save lives and improve decimating
poverty.

References:
Bongololo, Grace, Using research to promote gender and equity in the provision of anti-
retroviral therapy in Malawi WHO, Global Forum on Health Research ,2005

Center for Global Development. When will we ever learn? Improving lives through
impact evaluation. Washington, D.C.: Center for Global Development, May, 2006.

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 QUALITY MANAGEMENT IN HOSPITALS:
ACCREDITATION AND BEYOND

Dr. M. Mariappan
Asst. Professor TISS

Introduction:
Quality is defined in various contexts by different authors. One of the definitions on
quality is the totality of features and characteristics of a product or service that bear on
its ability to satisfy stated or implied needs. But the simple definition for quality is
defect free. The delivery of care should be defect free so that the patient gets
appropriate care. It is to be noted that the concept of superior or inferior quality does
not exist in health care delivery. In other words there is no possibility in grading the
quality whether it is higher or lower. Further, it is a matter of perception and therefore
subjective in nature. Since healthcare is associated with several processes, it is a matter
of making services without any defect. It means that the various processes of delivery of
care are designed and executed as per the desired specification. Further there is scope
for standardizing these processes. This we call it as accreditation.

Process-driven approach:
As per the accreditation criteria the various services of the hospital is translated into
process-driven approach. However there are issues in defining the process. Further
updating the healthcare providers’ knowledge and skills in executing such process is
not an easy task because of cultural and behavioral aspects. In industry if the whole
production process is well defined and the same is strictly followed the outcome is
perfect, it means no defect and the product passes through the quality check. In this
case if there is certain failure whether defining process or implementation of the
process there would be some defect or waste that could cost money but there is no loss
of human life. Assume that the same thing happens in healthcare delivery there is a
possibility of human loss and loss of reputation for the hospital. So accreditation is a
careful activity which requires consistent effort and hard work. The paper brings out
certain arguments which need to be addressed pre and post accreditation.

What healthcare quality demands?

The quality of care demands many fundamental supports. As administrators we always
think about how the quality can be achieved? What would be the benefit achieved by
ensuring the quality of services? But in real sense we must look at the other side like
achieving the quality of services we need to offer something such as time, effort, cost
and other obligations. We need to define the path of the healthcare delivery model. Here
the issue is clear alignment with clinical process and non-clinical process. It means the
ability of the healthcare providers to make sure that there is a strong and clear
coordination and cooperation between these groups. Further it is necessary to ensure
that the health care providers’ understanding about the quality and its importance. Also
make sure that the healthcare provider’s intentions on providing care or following the
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process does not change under any circumstances. It means the consistency in
following the guidelines without any compromise in a transparent manner. The ability
of the organisation is to meet the minimum requirement of healthcare providers
physical and socio psychological conditions at the work place. Many developed
countries have ensured that the work environment and quality of work is right to the
employees. The healthcare administrators have to address these issues.

What are the real benefits achieved by accomplishing healthcare quality? How do
we measure such benefits?
Most of us think that by adopting the clear process and providing careful attention on
the work process shall lead to achieve the quality. But the issue is whether such quality
is primarily helping the patients or the organization. The most challenging question is
how quality can be made beneficial to both hospital and the patients mutually. One can
argue that when we provide right care the patient is free from diseases. Nobody can
assure that the successful delivery of care endorses life long term benefit to patients as
the patients are always prone to get affected by another illness. Hence the basic
definition of health care quality should be treated separately. Health care quality is
determined by various factors which include human, technical, technological, social,
cultural and other factors. So it is not so easy to make sure that desired level of care
achieved in a specified time.

Quality Indicators:
Certain parameters are used to measure Quality and are called quality indicators.
According to NABH and JCI more than 100 indicators are used to measure the quality
and most of them are in practical use. A hospital undertakes the exercise of
accreditation by mapping the process and ensures that the suggested quality indicators
are achieved. The primary outcome of the indicators will be known by monitoring the
quality process. But actual outcome of quality should be based on the value patients’
attribute to the ‘quality’ services they get. Also it is the responsibility of the hospital to
make sure that the patients are prepared to accept those values and see how they are
really abiding to it. At the same time the healthcare organisation would have achieved
cost reduction through quality measures.

Measuring Quality Costs:

There are three important areas of cost to be found, measured and improved. They are
cost of conformance, cost of non-conformance and cost of lost opportunities. The cost of
conformance has two aspects one is cost of prevention and cost of appraisal. The
prevention cost associated with prevention of failure such as design quality
improvements, employee quality training design, quality engineering etc. The appraisal
cost includes quality check of materials purchase, confiming the work process, quality
audit, working with quality standards, inspection of tools and techniques, employee’s
training, maintaining quality records, patient relations etc. The cost of non-
conformance consists of three major areas. 1. Cost of internal failure such as waiting
time, delay in attending patients, errors at various level, wastage of materials including
medicines, consumables, radiological raw materials, etc. Further the cost of internal
failure includes rectifying certain mistakes while carrying out services or after the
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completion of care. 2. Cost of external failure is associated with the rejection of patients
on the particular services, doctors or hospital which arises due to poor service delivery
or the result of patient dissatisfaction. This can be against medical advice, transfer
patients with their request etc. Also any amount claimed by patients due to medical
negligence 3. Cost of exceeding the requirement such costs are associated with poor
information delivery, providing redundant copies of document, reports which are read,
or some no important information shared to the patients when they need. Finally the
cost of lost opportunities includes loss of existing customer or potential customer. It
may be difficult to measure the loss potential patients. However few indicators like
cancelling the appointment, shifting to other hospitals, wrong services offering to the
patients, non-availability of certain important services can give some indication about
the amount of lost. The cost of quality is the sum of lost of conformance, lost of non-
conformance and cost of lost opportunity. It can be estimated any institution may be
incurred the quality cost which ranging from 5 to 25 percent.
Conclusion:
Health care quality seems to be more subjective and measuring such quality is optional.
The process of delivery of care is to be confirmed and directed towards aiming at
reducing the cost, providing safety to the patients as well satisfying their needs. It is
important to understand doing things right as well doing right things which makes lot
of difference in healthcare. Healthcare administrators should prepare themselves to
accept the process of quality standards as well be able to know the mutual benefits
achieved from quality programmes. Beyond accreditation the quality management must
ensure that there is a positive exchange of values between the healthcare providers and
patient community which in turn create trust on healthcare delivery.

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 QUALITY IN HOSPITALS:
ADMINISTRATOR’S CHALLENGE

Neeraj Lal,
Vice President-Quality,
Shalby Hospitals, Ahmedabad,

‘Quality’ is a word that we use every day; what exactly does it mean in a Hospital?
All of us want goods and services to be of a ‘good quality’ or ‘high quality’ if possible. All
of us know that to get anything of a ‘high’ quality, more effort needs to be put in and the
cost may be a little higher, yet we justify the higher efforts and cost with phrases like
‘No Compromise’ etc. In hospitals ‘Quality’ is a separate department. The present article
is based on the insights I had while Implementing Quality in Shalby Hospitals.

What is Quality?
There are numerous ways of looking at Quality. Apart from being ‘Best’, Quality may
also be thought of as ‘Value for Money’. This means that we get goods or services of a
fairly good quality yet the cost is not very high.
Naturally this idea of quality is popular with the consumer, but the supplier will have to
bear higher costs to maintain quality and yet offer Quality Services at a lower cost to be
considered ‘Value for Money’. The supplier will benefit by creating value for his
business and getting the loyalty of customers.
At the basic level, getting ‘Quality’ means getting exactly what is promised or offered or
named. For example when we buy a shirt, Quality means a garment of fabric which will
last over at least a hundred washes, will not tear or fade, the fit and the stitching will be
perfect, the buttons will last till the life of the shirt and it will offer protection from heat
and cold to the wearer. Do the shirts that we buy offer all the listed items? Does the
fabric fade? Does it tear easily? Do the buttons fall off? Is the shirt material too thin and
transparent? Answers to such and hundreds of similar questions decide quality.

Cultural Background
The concept of Quality may differ from person to person and culture to culture. The
need for Quality will also differ for different goods and services. People may accept poor
quality in disposable items because ultimately they are to be thrown off. Yet the same
people might insist on eating the most expensive type of wheat or rice because they are
concerned about their food.
Some people will accept a cheaper television with fewer features because they cannot
afford a costlier piece with the latest hi-fi features. This is not a compromise on quality
but a compromise due to necessity. But the same people may spend more when it is a
question of medical treatment for a member of the family.

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Quality in Healthcare
What about Quality when it is a question of healthcare? Can we honestly say that a little
compromise here and there will not affect the outcome of medical treatment given to a
patient?
The answer is a big NO. Any compromise in the healthcare service industry may lead to
nasty outcomes.
A very unfortunate and sad example is the recent outbreak of hepatitis in Gujarat due to
reuse of syringes. It is a standard protocol to discard and destroy disposable needles
and syringes. It was not done, the syringes were reused. Syringes used on infected
patients were also used on other patients without sterilization. The result was that the
other patients, innocent people, were infected with hepatitis and died. They should
never have been infected with hepatitis except for the fatal reuse of syringes which
should have been destroyed and burnt after first use.
In healthcare Quality has to be taken care of in infrastructure, equipment and services.
The actual quality of healthcare no longer depends on how well qualified a doctor is but
how adequate his team is and how well equipped his hospital is.
Can the doctors and the paramedical staff work as a team to face emergency situations?
Does the hospital have life saving equipment in working condition? An answer of YES to
all these questions enables ‘QUALITY’ in a hospital.

Equipment
The better the quality of equipment, the better would be the outcome. This is so
obvious, but here there is a clash between profit and commitment. The philosophy of
the top management of a hospital will decide what equipment the hospital will buy.
There are business pressures like competition, business cycles, newer technologies
which dictate what equipment is taken. If a hospital’s equipment is the best in the world
it is of course ideal. But if cost constraints do not allow the best, the equipment should
at the least be functional. It must satisfy the needs of the patients.

Infrastructure
Then comes the infrastructure. Is it ideally designed? Do the patients have the least
difficulty in reaching the hospital? Once inside the hospital is the structure safe and
solid to hold the number of people that may be expected to come? Are the electrical
systems safe? Are there adequate lifts and are they reliable? Has the relevant inspector
checked the lifts for safety? Are the lifts certified?
How is the building protected against fire? Are there enough fire extinguishers? Is the
fire fighting system checked and certified by the relevant departments? Is a mock fire
drill done from time to time to train the staff about how to react in case of a fire?
Is the building dust free and air conditioned? A centrally air conditioned building
becomes important in infection control. Pathogenic bacteria cannot flourish in cooler
temperatures and hence severely burnt patients who are prone to infections are kept in
chilled rooms. Also, a centrally air conditioned building will be relatively dust free and
hence infection free because the minute dust particles may harbor disease producing
(pathogenic) bacteria.

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There are hundreds of such questions which need to be addressed correctly before the
adjective ‘Quality’ can be applied to a hospital. All the above do not constitute luxury.
Most of the above items are necessary basics in a multi specialty hospital.

Service
Perhaps the quality of service is the most crucial component of Quality in a hospital.
Service includes not only the medical and surgical services, but also each and every
service that a patient or his/her relative might need during hospital stay.
In the times of nursing pioneers like Florence Nightingale, the concept of quality did not
exist because equipment was rudimentary, infrastructure was never custom made for a
hospital, any building was converted into a hospital as and when the need arose. But
what made Florence Nightingale a saint amongst nurses was that she dedicated herself
to serve patients. Today she is a cult figure for nurses. Nurses dedicated to nursing
think of her as a Godlike figure and follow her precepts.
What is ‘Quality’ in nursing care? A smile as soon as he or she enters a patient’s room (it
must be remembered that a nurse means both a male or a lady nurse) Talking to
patients, encouraging them to face their troubles bravely, using light humour to make
patients smile, touching them gently, washing and cleaning them with empathy and
most important of all, enjoying the work and thinking about nursing work as service to
society and God.
There are other routine procedural things like being available 24x7, informing patients
before any procedure, explaining patients about a procedure if it involves pain or
discomfort for the patient and so on.

Training
Better Quality in nursing care is achieved through both motivation and training.
Training has to be continuous. As new staff is appointed, they need to be trained to
maintain the hospital standards. Older staff needs to be updated about newer medical
methods and techniques. All staff needs to be reminded about smiling at patients again
and again as nursing is a tough profession.
What is true for nursing is also true for all other ancillary services in a hospital. Apart
from nursing, a hospital has attendants who help patients in personal matters, catering
staff who serve food, Patient Relationship Officers who are an interface between the
patient and his/her needs, Medical Officers who monitor the patients and so on. If a
hospital gives the best service to a patient, and during the discharge process if a billing
person behaves rudely, the whole treatment experience may be marred. If the
ambulance driver who drops the patient home or at the airport demands a tip, again
that will reflect very badly on the hospital.
Accreditation
Ultimately what are the rewards of Quality? Does investing more money in building an
ideal hospital and buying state of the art equipment and gathering the best of staff to
run the hospital ensure that the best patients will come to that hospital?
Answer may be yes, provided patients come to know about the hospital. How will
people know how good a hospital is? Is there any benchmark which shows how good
the hospital is? Of course there is. Just as good quality food items have the ‘AGMARK’,
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well maintained hospitals who follow all the good practice procedures and protocols
can also apply for and get accreditation from the Quality Council of India through
National Accreditation Board for Hospitals and Healthcare Providers (NABH).
International bodies like Joint Committee International (JCI) also give accreditation and
certification.

Corporate Tie Ups

Such certification makes the hospital known as a good institution. This makes it easier
for corporate decision makers whether to sign a contract with a hospital for the
treatment of their employees. Thus an accredited hospital has a much higher chance of
being empanelled by companies which offer free or subsidized medical treatment to
their employees.
There are a few more areas and departments which must be mentioned in an article on
Quality in the Healthcare Service Industry.

Medical Waste Management

Hospital waste is special because it is a potential source of spreading infection. Hence
first and foremost all hospital waste must be separated in four types of containers
which are color coded blue, yellow, black and red. Sharp objects like needles go in one
container, soiled cotton wool and gauze in another, food waste has a separate container
and so has paper waste.
The approximate amount of waste that may be generated by each hospital is estimated
by standard of reckoning. If a hospital generates less waste, the authorities of that
hospital may be questioned as to whether they are throwing waste into garbage dumps.

Operation Theatres
Also called OTs, these are the most critical rooms in any hospital. After every surgery of
a wounded patient the OT will be cleaned and fumigated to prevent transmission of
infection from one patient to the other. All OTs will undergo deep cleaning and
fumigation once a week. All the instruments used in each and every operation must be
first washed and then sterilized as per predefined protocols before the next operation.
All the clothes that the surgeons and anesthetists wear during operations must be
similarly washed and then sterilized.

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Infection Control
This is perhaps the most important section of any hospital. The aim is to prevent
transmission of infection from one patient to the other. It is best done by preventing
any accumulation of dirt anywhere. The toilets, the floors, each room and each bed for
that matter are kept hyper clean.

Medical Insurance
In today’s times most of the times the payments for medical treatment is done through
Medical Insurance. If a patient has a Medical Insurance he/she needs to claim the cost of
the treatment from the insurance company. A good hospital will have a separate cell
that helps patients get approval and payment for treatment from their insurance
companies. This eases the burden on the patient. The quality of food served to patients
in a hospital needs to be constantly monitored. For environmental conservation, non
renewable natural resources like water need to be harvested from rain. All possible
measures must be taken to avoid the waste of both electricity and water. Thus Quality
in the Healthcare Service Industry is not a onetime investment. It is a person
independent continuous ongoing process.

Why Quality?
It is but natural to ask what is the necessity of ‘Quality’ in hospitals. The question will be
answered by the eye opening data found in the USA based ‘Institute of Medicine’ (IOM)
website (http://www.iom.edu/) on the following link:
http://www.iom.edu/CMS/8089/14980.aspx

The IOM is an organization of the Us Federal Government.

Healthcare: Shortcoming in Quality (USA)
 Between 44,000-98,000 Americans die from medical errors annually.
 Only 55% of patients in a recent random sample of adults received
recommended care, with little difference found between care recommended for
prevention, to address acute episodes or to treat chronic conditions
 Medication-related errors for hospitalized patients cost roughly $2 billion
annually.
 41 million uninsured Americans exhibit consistently worse clinical outcomes
than the insured, and are at increased risk for dying prematurely.
 The lag between the discovery of more effective forms of treatment and their
incorporation into routine patient care averages 17 years.
 18,000 Americans die each year from heart attacks because they did not receive
preventive medications, although they were eligible for them.
 Medical errors kill more people per year than breast cancer, AIDS, or motor
vehicle accidents.
 More than 50% of patients with diabetes, hypertension, tobacco addiction,
hyperlipidemia, congestive heart failure, asthma, depression and chronic atrial
fibrillation are currently managed inadequately

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Quality in India
It may be noted that most of the above situations can be cured by implementing Quality
in US Healthcare. If the condition of US Healthcare is so shabby, it may be assumed that
Indian healthcare may not be much better. Except for a few centers in Indian metros,
‘Quality’ is sadly missing from the Indian Healthcare Scenario.

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 MEASURING QUALITY:
ACCREDITATION AND BEYOND

Suvankar Mridha,
Assistant Manager – Quality,
Aware Global Hospitals, Hyderabad

Role of Accreditation bodies, revolution and driving factors & challenges:

Healthcare Quality is a new term introduced in the field of healthcare service delivery
and with the introduction of Accreditation systems like JCI, NABH etc. , the ways of
defining healthcare quality has changed a lot. In the late 40s when the International
Organization of Standardization constituted Quality Systems came into existence
nobody believed in the parameters of healthcare quality. Well, the concept of ISO and
various Quality Management Systems Protocols had been contributing in the field of
Quality.
Various ISO principles have contributed in this regard and intention of improving the
levels of Quality in the products has introduced a culture of Globalization.

After the efforts of ISO 9001 series quality management systems and other various
accreditation systems like ISO 14000, ISO 18000 contributed a lot in various field. As
the healthcare needs are increasing and introduction of consumer protection Act 1986
came into existence the need of customer satisfaction and customer focus has got a
prime preference and it is now becoming a trend of enhancing the quality levels in the
healthcare services. Accreditation systems are one of the means of maintaining a
culture of healthcare quality services. In India, the concepts of domestic accreditation
systems like NABH that is National Accreditation Board for Hospital and Healthcare
Providers is now going to acquire a major and giant shape. More than 366 hospitals
have applied in the NABH accredititation but only 58 hospitals including big corporate
healthcare giants and govt. hospitals got the accreditation. Some Indian hospitals are
concentrating on achieving international accreditations like JCAHO.

Hospital Accreditation – The Present Scenario

Joint Commission International’s standards and qualifications are derived from an
international consensus of achievable expectations for structures, outcomes, and
processes for medical facilities. The standards are designed to accommodate cultural,
religious, and legal factors within specific countries and regions. JCAHO’s Joint
Commission International (JCI) was founded in the late 1990s to survey hospitals
outside of the United States. JCI, which is also not-for-profit, currently accredits
facilities in Asia, Europe, the Middle East, and South America. A January 2008 press
release says that since 1999, JCI has accredited more than 140 hospitals in 27 countries.
In India, hospitals that are focusing on international marketing and medical tourism are
keen to get JCI accreditation which will enable them to get overseas patients who are

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interested in coming to India to get treatment in cost effective way without
compromising the quality & outcome of the treatment.

Quality Council of India has formed a separate and exclusive domestic accreditation
system like NABH, NABL etc keeping the economics and various other dimensions of
Indian healthcare market. The aim of this accreditation is to reach to every level of
healthcare system irrespective of public or private investments thus disregarding the
concept of cost as a major hindrance factor. NABH’s accreditation focuses on learning,
self development, improved performance and reducing risk. Its assessment relies on
establishing technically competent healthcare organization in terms of accreditation
standards and in delivering quality services with respect to its scope. It goes beyond
compliance and calls for excellence on continued basis. It is this feature, which makes it
market driven involving all stakeholders; be it consumers, empanelling agencies,
regulators and other third parties.

NABH accreditation is based on optimum standards, professional accountability and

encourages healthcare organizations to pursue continual excellence. Cardinal principles
of accreditation evaluation are as follows:
 Hospital operations are based on sound principles of system-based organization,
which are transparent and objective in nature.
 Accreditation standards are implemented and institutionalized into hospital
functioning.
 Patient safety and quality of care, as core values are established and owned by
management and staff in all functions and at all levels.
 There is a structured quality improvement programme based on continuous
monitoring including feedback on patient care services.

The evaluation process incorporates interview with patients, residents and staff. It calls
for on-site visit to patient care areas and to departments addressing issues related to
physical assessment of infrastructure, medical equipment, security, infection control,
etc. as required by the accreditation standards. It involves a comprehensive review of
not only facility but also of clinical competence and operational excellence of hospital to
deliver services within its scope.

Measuring Quality – Essence of Accreditations

Accreditation systems are based on documentations, trainings and implementation of
standards. These days, documentation can be made with the help of various resources
available in the internet and training can also be organized but when it comes to
implementation of standards the real challenge comes to existence.

Implementation of Practices for Measuring Quality is a key area which has its own
importance and glamour. Measuring the performance like Turn around Time of any
process, delay time frame, working on reengineering of the process, Implementation of
customer feedback mechanism etc. These indicators are quantitative easurement of any
quality trait. It doesn’t describes anything but it gives us a “value” which gives a results
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“positive” or “negative” like “Compliance” or “Non-Compliance” to the mentioned
standard.

Key Performance Indicators:

Key Performance Indicator (KPI) is commonly used by an organization to evaluate its
success or the success of a particular operational activity in which it is engaged.
Sometimes success is defined in terms of making progress toward strategic goals, but
often, success is simply the repeated achievement of some level of operational goal
(zero defects, 10/10 customer satisfaction etc.).

Key Performance Indicators define a set of values used as a basic measure to be pitted
against the achieved quantitative level. These raw sets of values, which are fed to
systems in charge of summarizing the information, are called indicators. Indicators
identifiable as possible candidates for KPIs can be summarized into the following sub-
categories:

Operational Indicators:
These indicators focus on enhancing the operational excellence and upgrading the
efficiency of a protocol. It includes measuring Turn around Time of LAB reports, TAT of
discharge process, Time Motion Study of OPD patients, Number of Lab Errors, Billing
Errors,

Human Resources Indicators:

Employee Satisfaction Rate, Attrition Rates, Absenteeism rate etc.

Patient Safety Indicators:

Number of Medication Errors, Number of Adverse Drug Reactions, Number of Adverse
Anaesthesia Reaction/Events, Number of Needle Stick Injuries, Number of Security
related incidents (like theft), Percentage of adherence to lab safety compliance.
Compliance Score of legal status like periodic renewal of licenses e.g. PNDT, Biomedical
Waste Handling rules 1998.

Financial indicators used in performance measurement and when looking at

an operating index includes the variation percentage of expenses on electricity,
purchase of capex and operational items etc.

KPI-Formulation & Implementation Strategies

Implementation of KPI can be done with respect to individual departments also with
various guidelines based on accreditations. If we are talking about departments then
Human Resource Cell should monitor the Employee Satisfaction rate, Attrition Rate, No.
of employee coming late etc. If we want to look at hospital infection control protocols
with respect to accreditation then Infection Control Indicators; Surgical Site Infection
Rate, Respiratory Tract Infection Rate, Urinary Tract Infection Rate etc. are helpful to
arrive at a definite understanding of the same. Calculation of these rates can be done
with the help of CDC guidelines, Agency for Healthcare Research and Quality. With
23
implementation of patient satisfaction questionnaire or employee satisfaction
questionnaire we can monitor the satisfaction matrix of the external and internal
customers respectively. As far as Implementation is concerned, all these indicators can
be implemented online or can be drafted in the form of MIS report (if it is departmental
indicators). If it’s a subjective indicator then it can be done through questionnaire or by
Occurrence Reporting Form.

Monitoring and Experience change

Monitoring is an important aspect for all these performance indicators because these
monitoring keeps them alive and kicking. Quality is a continuous process and it should
go on otherwise the efforts injected in achieving an accreditation goes vain. A
designated Quality professional with his team and various committees including few
top management representatives can monitor and present the data along with report
mentioning about the proposed action and recommendation to be taken for turning
around each nonconformity.

This process should be continuous and mixed with various quality improvement
projects like FOCUS PDCA, Six Sigma Implementation Projects, and BPR projects etc.
Prolonged monitoring of these data with a defined frequency will give trend patterns.
For e.g. If we collectively analyze quarterly data of Hospital infection control rates in the
hospital then we can arrive at a specific pattern which will help to change or set our
protocols.

Change will be compelled to be introduced because these indicators give us an idea

where we should improve and how we should proceed. With the help of domain expert
and committees and implementation of required initiatives and measure all can be
minimized.

24
 TRAINING AND DEVELOPMENT:
A KEY TO QUALITY WHICH IS OFTEN MISSED

Dr. Sandeep Moolchandani

sandeep.moolchandani @tiss.edu

Training and development in today’s business landscape is not just another regular
organizational requirement but a critical factor which separates high performance
organizations from those in their downward journey.

The knowledge intensive nature of the health services mandates an ongoing

comprehensive training and development programme in a hospital which covers all the
training requirements at institutional, departmental and individual levels. Apart from
utilitarian perspective, employees must receive training in particular areas and be able
to demonstrate their knowledge so that the hospital can receive certain types of
accreditations and can be compliant with the industry standards.

Employees are considered to be most important asset to the organizations. The value of
an employee as an asset increases manifold, especially in a hospital setup where the
employees are directly involved in delivery of products and services. The
empowerment of the employees in hospital can serve as a major factor for achieving
long term competitive advantage.

In its 2006 State of the Industry Report, the American Society for Training &
Development (ASTD) finds that leading organizations increased learning investments in
two key areas: annual expenditure per employee and learning hours". ASTD reports:
"Employee learning and development is taking center stage as business leaders
increasingly understand that a highly skilled, knowledgeable workforce is critical to
achieving growth and success.

How Training and Development Works Wonders for Organizations?

Training And Development is a subsystem of an organization. It ensures that
randomness is reduced and learning or behavioral change takes place in structured
format. Properly trained and highly skilled human resource is perceived as the greatest
asset of an organization. Skilled personnel contribute to efficiency growth, increased
productivity and market reputation of an organization. This has been realized by
industrial, commercial, research establishments and even governments. Invariably,
after realizing the importance of Training and Development many companies started
emerging with a separate department focusing mainly on training for its employees.

25
Training and Development Outcomes

A sufficient investment into training and development translates not only into meeting
regulatory requirements and getting/renewing accreditations but also into tangible
return on investment in terms of improved outcomes and increased revenues.

Even more than monetary outcomes it has been shown that perceived access to
training, social support for training, motivation to learn, and perceived benefits of
training are positively related to commitment of the employees to the organization.
Thus right employee training, development and education, at the right time, in right
amount; has a potential to provide big payoffs in terms of increased productivity,
knowledge, loyalty, and contribution.

Training Requirements by some accrediting agencies

Often the organizations become clueless when the question to objectively define the
training and development requirements arises. Here it is lot more easy to start with
training requirements defined by various accreditation standards and agencies like
NABH, JCAHO, OSHA, AABB, CLIA etc. Some of the common areas where attention is
warranted by these are as follows:
 The staff shall be well acquainted to the policies and procedures of the
institution and of the respective departments.
 Inductive and ongoing training programmes in critical areas such as infection
control, disaster management, drug safety, patient safety, employee/patients
rights and responsibilities
 Ongoing programme for professional training and development of the staff.
 Maintenance of training and development records in the employee portfolio,
 Assessment of staff development needs on hospital wide, departmental and
individual levels.
 Monitoring and evaluation of the training programme including objective
evaluation of the training outcomes and performance.

Table I in the appendix lists some of the important areas that should be a part of a good
training and development programme in a hospital.

Categories of training and development needs

The training and development requirements of the hospital staff can be divided into
following three tiers:

 Tier I: Critical Areas

 Tier II: Soft Skills

 Tier III: Functional/Technical Skills

26
Tier I: Critical Areas
This competency development area includes all those skill sets and required knowledge
which is directly associated with quality of healthcare delivery. Many accreditation
standards recognize these skills and mandate the existence of training and development
programmes to impart them and document the delivery.

Tier II: Soft Skills

In this era of patient centric healthcare services, it is prudent to develop positive
behavioural skills in our employees. In addition to service delivery, good soft skills are
also important for success of the organization as a whole. Organizations across the
globe have realised that professionals with just technical skills only partly complement
the essentials of being a ‘complete professional’.

Tier III: Functional/Technical Skills

These skills form the core of the services provided by healthcare service providers. A
major chunk of these skills are imparted as functional/ technical education before the
employee joins the organization. But the organizations have the responsibility to tweak
these skills to their needs and ensure that acceptable acumen is maintained by the
provision of continued education and on the job training.

Methodologies of Training
It is a common practice to heavily rely on a 30 odd pages manual outlining the safety
procedures and other standards of conduct to orient the employees. With the self-
learning process involved with the hard copy manual, the expected compliance rates
are quite low.

It is always advisable to supplement with cognitive methods like lectures,

demonstrations & discussions; and behavioral training methods like case studies,
games & role plays.

Interactive modes which include computer based training are gaining wide popularity
and acceptability in the industry. These methods have been shown to be cost effective
and scalable while producing better results when compared to conventional means.

Training Hours
There is no prescribed number of training hours, the amount of training depends upon
the needs of the organization, the modes of training being used, the performance
lacunae it wants to address, various local and national regulations to be met; and so on.
It is advisable to come up with an individualized training and development plan which
is best suited for the organizations’ needs.

Conclusion

27
Training and development is one of the crucial areas which can help the organizations
to cope up with high paced changes happening in the external environmental. But sadly
it is also one of the areas which is often missed or not given due importance in
managing the change process in the organizations.

“Lessons from the other industries” is the buzz phrase we often hear. It will be apt to
conclude with the same phrase and a hope that these lessons are internalized by the
healthcare industry.

Appendix
Table I: Some of the important areas that should be a part of a good training and
development programme in a hospital.

Training Areas stressed upon by both NABH Training areas stressed upon
Other Standards
and JCAHO by JCAHO only

Disaster Prevention and Management

Managing violence and Hospital Emergency Codes
 Fire training aggression
 Hospital Disaster Management
 Medical Gas Safety and Handling

Rights and Responsibilities

 Vision/Mission
 Policy & Procedures
 Staff Rights and Responsibilities
 Patient and family rights and
responsibilities
Infection Control and Biomedical Waste
Management

 Infection Control
 Hand Hygiene
 Biomedical Waste management
Cardiopulmonary Resuscitation and First
Aid

 First aid training Paediatric basic life support

 Adult basic life support for patient
handlers
 Advanced Cardiac Life Support
 Paediatric Care Basics

28
General Safety
Vulnerable adults
 Slips, trips and falls
Investigation of incidents,
 Manual handling (Control and Child protection
complaints and claims (NHS
Restraint) and Transfer of patients
Hospitals)
 Essential food hygiene for Food Sentinel Event
handlers
 Blood glucose monitoring for patient Error Reporting
handlers
 Quality Improvement Programme

Medication Management

 Drug administration for patient

handlers
 Sedation and Pain Relief Guidelines
 Look-Alike Sound-Alike Medications
 Prescription of Medications
 Dispensing and Administration of
Medication
 Adverse Drug Events
Employee Safety

 Basic Health & Safety Awareness (Staff

Oriented)
 Blood handling and Blood Borne
Pathogens for Healthcare workers
 Inoculation incidents
 Disciplinary and Grievance handling
procedure (General Orientation)
Laboratory

 Laboratory Continual Education

Programme
 Laboratory Investigations Process
Flow
 Laboratory Safety Programme
 Lab Quality Management Orientation
Radiology

 Radiology Continual Education

Programme
 Radiology Investigation Process Flow
 Radiation Safety
 Radiology Quality Management
Orientation
Training in Hospital
HMIS Management Information
System

29
 PATIENT-CENTRIC CORPORATIZATION:
MAKING THE TWAIN MEET

Dr. Anuja Joshi

The last decade has been a revolutionary journey for healthcare in the Indian
subcontinent, as it finally begins to take centre stage after prolonged subordination and
anticipation. The excitement is palpable amongst healthcare providers, the government
and other stakeholders alike, as Indian hospitals rise to stand up shoulder to shoulder
with world class healthcare providers. Driving this revolution is a wave of business
restructuring - we know as Corporatization.

Some say that this is just a part of the metamorphosis most sectors undergo in a fast
developing economy like India. On a more critical note however, there may be more to
it than meets the eye. The transformation seems well beyond apparent swanky
infrastructures and medical technology. The very perception of patients, doctors &
hospitals is changing at a pace that is startling most of those involved and affected by
the same. There is a paradigm shift occurring in the way healthcare will be delivered in
the times to come. But again, should this be a matter of concern or even thoughtful
discussion?
It should indeed, because healthcare is no ordinary sector. It is the unlikely business of
saving lives.

Where do we start?
We could start with understanding the evolution of Corporatization in healthcare.
Necessity was the most primary driver considering healthcare is an essential service in
society. Given the enormity and the diversity of the population of a country like India,
this ‘necessity’ probably was soon a challenge for any government to manage. As a
result, what should ideally have been a social security measure provided by the State,
was opened to other organizations to provide as a service at a cost. It was at this
juncture that healthcare was transformed into a ‘sector’ subject to the formidable forces
of the ‘market’.
Healthcare is probably the most input-intensive and outcome-sensitive industry. The
new players, who started singly or in small groups, were struggling at both ends- first,
to arrange for inputs whether in terms of capital or professionals and next to ensure
favorable outcomes in terms of affordable and effective treatment. Rising expectations
and paying capacities of a burgeoning middle class, started creating a demand that
called for organizations, much larger and more organized than islands of private
providers. Going back to the essential nature of healthcare services, the scope for
business per se is both tremendous and relatively immune to typical market
fluctuations. This was a huge business opportunity in waiting. Thus was the advent of a

30
new breed of players in the form of ‘corporations’ who promised a restructuring of the
healthcare industry to world class standards.
Some of the other major influences were lessons from the west, especially the health
systems of the United States of America. State of the art hospitals, high paying jobs for
healthcare professionals and the best medical technology in the world were attractive
ideals to aspire for.
Accreditation was another inspiration from the west. Simply put, it was aimed to
building and ideally running hospitals at a benchmarked uniform international
standard. Getting accreditation automatically offers the credibility of maintaining
international standards for either the department or the hospital as a whole.

Impact of corporatization
Initially, corporatization translated into well planned investments; quality
infrastructure and creating a ‘brand’ image for the hospital. One of the first and key
steps to sustain such a venture was finding a pool of multiple investors for the capital
and ensuring returns on this investment, through pricing. Having had some success
with this, the next step was scaling up in terms of volumes, to generate generous
margins and cut running costs. What started with large single hospitals was now
developing into a chain of corporate hospitals spread over major cities in the country.
These new hospitals also embraced quality infrastructure effectively. Infact, the
interiors of most newly built hospitals could give some of the best hotels a run for their
money! Specially formulated healing environments for inpatient departments, a flurry
of well trained attendants and great food were just some of the creature comforts for
those who could afford them.
Setting standard operating protocols was the other cornerstone of corporatization.
Meant to streamline the working of the organization as per evidence based standards,
they also assist newer professionals to learn the right way to do things rather than rely
on trial and error.
Ownership in the meantime shifted to the hands of a separate board of management
who were not necessarily doctors but trained in hospital management or business
administration. Everyone else became an employee, including all medical professionals
who would be bound by the policy guidelines of the hospital. The hospital was now
bigger than any of its employees.

The other side of the story

At the receiving end of this transition, were patients with mixed reactions to the
situation. Many of those who could easily afford it initially patronized these hospitals
for the promised quality on offer. The market however, did not remain monopolistic for
long, and competition was quick to set in. This competition unlike in other sectors
however, did not lead to fall in prices. Not very adept at dealing with competition,
hospitals resorted to adhoc marketing and newer service attractions, without analyzing
their potentials leading to a paradoxical increase in prices for the end users. Very soon,
the cost of corporate healthcare spiraled out of reach for the middle class. .
The relative subordination of doctors in these hospitals, led to two groups: clinical and
administration, both striving to ensure their importance and decision making
31
capacities. One of the probable options sought was defensive medicine, at the cost of the
patient who had little choice but to agree. Fewer patients meant tighter competition
and malpractices began to creep in the system. The hospital/patient-doctor bond
translated into a legal customer-provider contract with patients dragging the once
demigod doctors to courts!

In the backdrop of the situation so far, it seems apparent that the gap between
healthcare providers and patients is widening at an alarming rate, and needs to be
bridged before the damage is irreversible.
The point to note here, is that corporatization like globalization, is an evolutionary
phenomenon that is bound to have favorable and unfavorable repercussions. The catch
lies in maximizing the favorable outcomes and dealing with the unfavorable ones to
minimize damage.

Hence, the need for making the twain meet, the only way being a patient-centric
approach to corporatization.

Patient-centric: Ethical, Intelligent and Affordable

corporatization in that order

Ethical
The raison d’etre for healthcare is the patient and at stake is the patient’s life. There
cannot be any hospital that could justify malpractices of any magnitude under the
pretext of rising costs, evidence based medicine or just blatant commercialism. Unless
the hospital commits to ethical practices irrespective of the challenges involved, there is
no way it can even attempt to regain the patient’s trust, leave apart loyalty.
It is also important to remember that affordability is not a trade off for ethics. The
human life cannot be equated with the pay potential of the patient, and acts of both
omission and commission count for unethical practices.

Intelligent
The first important aspect of intelligent planning is comprehending ‘quality’. As
discussed before, quality is often relative, and customizing quality to the user is the key.
There are certainly places where quality may be absolute like in case of infection
control, but interiors can certainly be experimented with. Sky lit domes, well
maintained internal gardens/ potted plants and children’s paintings can be brilliant
alternatives to typical expensive interior options. The focus must remain on
cutting/minimizing all avoidable input costs without compromising on the outcomes.
The second important aspect is a SWOT analysis of India as a market. We are a nation of
volumes and variations. Any hospital model must aim to reduce costs through large
volumes. These numbers may however not be easy to achieve in urban areas, simply
because they are already saturated and land is dear. The idea then is to use the
variation. The tier 3 and 4 cities are growing faster than we can comprehend back home
32
in our cities. Instead of fighting over a contracting size of the pie in these urban areas, it
makes absolute sense to reach out to the growing demands in the semi-urban and rural
areas. It is also preferable to train local residents to work for these hospitals rather than
haggle with reluctant urban staff.

Affordable
The cost of quality healthcare is a rather interesting debate. That is because neither
inputs nor outputs can be compromised with. Given the fact that investors would
obviously be looking for returns, it is worthwhile making them understand why it takes
time to make money in healthcare. Returns are slow, but usually certain, unless
expectations are unrealistic.
An option here would be staggering and sharing input costs over time. This can be
feasible in volume based models in semi-urban and rural setups. Diagnostic facilities,
support services could be shared or efficiently outsourced in the local areas at very
affordable rates. Other overheads like administrative costs, electricity and staffing could
be kept at minimum possible with effective technology like HMIS, telemedicine and
green hospital infrastructures.

Public private partnerships

Considering the major players in the health market are private/corporate and public
companies, the most logical concept is the emerging trend for public-private
partnerships, PPP in India. PPP, as Kent Buse and Gill Walt explain is a collaborative
relationship which transcends national borders to involve at least 3 players, out of
which one is a corporation (or industry) and the other, an inter-government
organization to achieve a shared health-creating goal on the basis of mutually agreed
division of labor.
PPPs could be of various types, either owned by public sector involving private players
like in GAVI, SIGN or RBM programs, or have NGOs involve corporate participation like
World heart federation. The local governments may choose to tie up with key private
providers like Government of Chhattisgarh with Apollo and Escorts hospitals for the
“Bal Hridaya suraksha yojana” for pediatric cardiac ailments or the Government of
Gujarat, with IIM-A, FOGSI, Sewa and private practicing gynecologists for the
“Chiranjeevi yojana” to ensure safe deliveries.
Keeping in mind the promises PPPs offer to make, a word of caution may nonetheless
be exercised. The concept is still emerging, and there isn’t yet substantial evidence to
prove its capability in mass application, so a gradual, and well calculated approach
would be pertinent atleast initially. A formidable, responsible and transparent
governance to protect from exploitation, forging of figures, and to ensure that public
interest is preserved throughout as the target of all activities.

At a closing note, the relevance of the patient-centric approach deserves a reiteration.

All of the options discussed above, are expansions of this very basic ideology. Whatever
happens in healthcare must protect and benefit the patient before anyone else, because
he is the most vulnerable of all stakeholders involved. The most reliable question for
any decision-making in healthcare is whether it benefits the patient. If it does not
33
benefit the patient, don’t do it because it won’t benefit anyone else in the long run
either!

34
 MDG`S IN BIHAR:
EXAMINING STRATEGIES, EXPLORING POSSIBILITIES
Dr. Sujay Bishnu
bishnusujay@gmail.com

Introduction:
Bihar is one of the poor states when it comes to the health system of the state and so is
true for the health status. NRHM has included this state in their high focus state and is
categorised under “BIMARU” way back in 2005. After the whole new paradigm of MDG
it is prudent to judge the state Government’s actions under the lens of MDG.
The State Health Society, Government of Bihar (SHSB) is committed towards promoting
the right of every woman, man and child to enjoy a life of health and equal opportunity.
SHSB under the aegis of Department of health has taken steps to bring about outcomes
as envisioned in Millennium Development goals, RCH II, NRHM programme and Vision
2010 Bihar. In general, it aims at minimizing intra-regional variations in the areas of
Reproductive and Child Health including population stabilization through an integrated,
focused and participatory programme.

The Goal:
The goal to be achieved by 2010 under the above mentioned programmes is to improve
quality of life of the people by:
 Reducing Maternal Mortality Ratio (MMR) from 371 to 100 per 1, 00,000 live
births,
 Reducing Infant Mortality Rate (IMR) from 61 to 30 per 1000 live births,
 Reducing Total Fertility Rate (TFR) from 4.3 to 2.1 for population stabilization
with enhanced satisfaction of clients with medical services.
 The Health Department of Bihar is making all out efforts to reduce the IMR and
has initiated an innovative program.

Status and Situation

In the state important RCH indicators such as MMR, IMR and TFR are showing declining
trends whereas institutional delivery, complete ANC and contraceptive use are
increasing steadily. The state has identified poorly performing districts and is now
focusing on them for further improvement. The status of important RCH indicators in
the state shows the current situation.

35
Indicators that have reduced
 MMR has declined from 389 (1998) to 371 (SRS 2003-05)
 IMR has declined from 63 (Census 2001) to 61 per 1000 live births (SRS 2006-
07)
 Total Fertility Rate (TFR) has decreased from 4.3 to 4.0 (NFHS-III 2005-06) to
3.9 (SRS 8)
 Percentage of children under age 3 who are underweight has marginally
declined from 48 % to 47 % (GOB 2009-10)

Indicators that have Increased

 Institutional deliveries have increased from 12.1 (NFHS-I 1992-93) % to 22 %
(NFHS-III 2005-06) to 27.7 % (DLHS-III 2007-08)
 Antenatal Care has increased from 15.9 % (NFHS-II 1998-99) to 16.9 % (NFHS-
III) to 45% (DLHS-III 2007-08)
 Full Immunization coverage has increased from 10.7 (NFHS-I 1992-93) % to
41.4 % (DLHS-III 2007-08)
 Contraceptive use has increased from 23.1 % (NFHS-I 1992-93) to 34.1 %
(NFHS-III).
 Sex ratio from 825 to 871 (CRS 2006-07).

Strategic Direction
An examination of the various programmes in the state will help us understand the
strategies of the state of Bihar in achieving the above set targets/ goals. The Health
Department of Bihar has set some strategic direction that encompasses year wise
objectives, technical strategies; interventions include program and services for
improving maternal health, child health, family planning, adolescents' health etc. On
close analysis it can be seen that the complete programme is bifurcated into common
programme strategies as well as specific core program strategies for taking effective
actions.
These common strategies in turn have impact on all the components of RCH viz.
maternal health, child health, family planning, adolescent health etc whereas specific
core programme strategies have wider impact on the specific programme component. It
has been envisaged that all these strategies should converge and go hand-in-hand to
achieve the outcome. To accomplish these strategies the state considers that
strengthening institutional mechanisms, infrastructural development, ensuring
adequately trained human resources etc. are fundamental requirements for getting
better programme outcomes. Convergence of strategies and progress is as described
below:

i) Core Strategies:
As mentioned earlier some of the core themes that directly address the MMR, TFR
include special schemes such as MUSKAN, that focus on complete Routine
Immunization and MAMTA addressing child health, incentives to health staff along with
several others.
36
 ii) Common Programmatic Strategies:
In addition to the above common programmatic strategies directed at capacity building,
quality assurance, gender mainstreaming, community participation, serving vulnerable
community through mobile units etc.
iii) Strengthening Institutional Framework :
Complementary to the above initiatives are mechanisms for strengthening the existing
institutional framework like Recruitment and placement of qualified human resource,
formation of a functional, accountable State/District Health Mission and an Integrated
Organizational Structure for the Department of Health;

Brief discussions on few of their initiatives are attempted below:-

1. Free referral support for pregnant women

Description- According to the MAPEDIR Purulia study; if we see where do the women
die? We will see that about 25% could not reach health facility. This is true for whole of
India. In case of Bihar the scenario is much worse, given the fact that the Maternal
Mortality Rate is very high in this state. Here comes the role of strengthening referral
system.
Objectives-
 To increase institutional delivery in the state by provision of free referral
transport.
 Improve the utilization of referral transport services (Dial 102) by pregnant
women for delivery services.
 To ensure safe delivery by cutting down on the second delay i.e. delay in
transportation.
 Reduction in Maternal Mortality
 Assuring 24/48 hours stay at the institution

2. Chiranjeevi Yojana in Bihar

Description- The Chiranjeevi Yojana is an exemplary scheme in the area of Public
Health which has contributed significantly in improving the access to Institutional
deliveries for marginalized section of the society by reducing the maternal deaths.
The scheme will use a voucher type of system or BPL cards to target the BPL or families.
The scheme would cover the service charges for normal and complicated deliveries and
direct and indirect out-of-pocket costs such as travel and cost of accompanying person
on cashless basis. With the BPL cards, the families can visit any of the empanelled
private nursing home or private hospital for maternity services (normal or caesarean)
and are not required to pay any fee.

Discussion- This initiative can do wonders for a poor state like Bihar. It has been
thoroughly researched and understood that the fear and inability to incur expenditures
related to delivery has been one of the major impediments for institutional delivery and
impacted upon the overall impoverishment.

37
On the other side of the coin this can be bane for the public health delivery system.
When Government’s strategy is pumping more blood into the system in terms of Human
resource and infrastructure, then this kind of voucher based financing would take the
beneficiaries towards private health care delivery system more frequently.
Subsequently the poor people might end up spending more out of pocket in terms of
paying for bribes or other hidden costs.

3. Beti Bachao Abhiyaan

Description- As female foeticide is a concern both in rural and urban areas, this year,
Beti Bachao Abhiyaan will be launched to sensitize people against this heinous practice.
Massive awareness drive with the support of College students, women’s organizations
and other voluntary associations is planned this year. Human Chain, rallies, seminars,
workshops and press conferences will be organized for the same.

Discussion- The state has certainly improved their sex ratio over last decade. But still it
is very much skewed against women.(elaborate this point how?) This initiative can
impinge on the stake holders to take an active part to improve the sex ratio even further
and thereby improving the basic requirement of MDG.

4. Family friendly certification of the Hospitals

Description- A Family friendly Hospital is a health care facility where the practitioners
who provide care for women and babies adopt quality practices that aim to protect,
promote and support activities conducive for the health of mother and baby viz;
antenatal care, safe delivery, exclusive breastfeeding of neonate, and postnatal care in
an enabling environment. The mother and child friendly hospital initiative primarily
focused to improve the quality of maternal and newborn care in the health facilities.
The certification systems proposed will help the facilities to achieve some quality
standards which will enable them to reach the ISO certification at a later date.

5. Institution Based Maternal and Infant Death Review (MIDR)

Description- A Consultant Maternal and Child Health will be the nodal officer for MIDR.
The Nodal officer will identify and notify names of institutions which will take up
MIDRs. In the first phase, this exercise will be limited to 10 District Hospitals only.

Discussion- This is in line with NRHM directives. It has direct implication on MDG 4
and 5. Further they need to expand the process to the periphery for a better community
level understanding and further decision making.

6. Nutritional Rehabilitation Centre (NRC)

Description- Initial discussions with UNICEF on establishment of NRCs in the 2007
flood affected districts resulted in the dea of NRC for the first time in Bihar. It was
thought worthwhile to pilot NRCs for treatment of children suffering from severe forms
of malnutrition in two flood affected districts with support from UNICEF for supervision
and monitoring of activities, especially in the initial period of management of NRCs.
38
Thus the NRCs were established in the districts of Muzaffarpur and East Champaran
during August-September 2007. The results have been very encouraging with 1444
SAM children benefitting till date, of which around 98% belonged to the socially
excluded class. Based on these impressive results from the two piloted NRCs in the
management of child malnutrition, it has been decided to scale these units in a phased
wise manner. A total of eight NRCs have been established in Phase-1 in districts of
Muzaffarpur, East Champaran, Samastipur, Darbhanga, Madhubani, Khagaria, Sitamarhi
and Sheohar.

Discussion- Tried and tested concept in Africa and in various part of the country, now
the project sees first day-light in Bihar. The people living in the basin of river Koshi
suffers from problems like malnutrition and Poverty, which are directly causing
increased IMR. The NRCs will have direct and indirect impact on MDG 1, 4, 5 and 7.

7. MAMTA concept
Description- Objective was to reduce the MMR and IMR. This category (which
category? Explain mamta) of staffs will work in the institutions only. They are the
trained dais of the villages. The selection criteria is
 Age between 25-45 years

 From Chamar/Ravidas caste

 Education upto class 8

 Residence within 3 km of PHCs

 Having not more than 2 children

 Not pregnant at time of selection

The responsibilities include observation of the mothers and the newborns at the
hospitals up-to 48 hrs after the delivery. They will be given Rs 100 for each case. They
were given 1 day training for this.

Discussion- There were an in-built construct of resistance in the efforts of promotion

of institutional delivery. Government wants the ASHAs to bring the pregnant women to
have their delivery conducted at the public health care delivery systems.
Simultaneously the Dais are also supposed to conduct safe delivery. At the community
level, this created a conflict of interest between the ASHAs and the Dais. The recruits of
MAMTAs are nothing but the Dais coming from the same community. In Bihar they are
given a separate role to play which is essentially in line with the broad objective of the
health system and the conflict of interest has also been avoided.

8. Dulara se Muskan
This is an initiative whereby a household survey via community active volunteers who
will be given some small honorarium to ensure community participation will be
conducted and the surveyed mother and children will be marked as DULARA. The
39
objective is to track all newborn child and pregnant women, strengthening of ANC and
ensuring prevention of dropout of immunization-strengthening of RI (MUSKAN
initiative).

Discussion- By doing this the state Government and UNICEF wants to ensure
community participation. In every form of RI strengthening initiative, there is always
existence of one big hurdle, which is community participation. When MDG goal 8 calls
for global partnership, this is prudent to have community partnership as a mean to
reach that.

Conclusion- The purpose of the above article has been to examine briefly the strategies
of the public health services of the state of Bihar towards achieving MDGs. It is obvious
that there are core strategies, common programmatic strategies and complementing to
the above two are the initiatives to strengthen the institutional framework. Here the
strategy need to be appreciated for its concerted effort towards a common goal but the
real challenge is to ensure coordination between the various strategies and how to
ensure strengthening of the existing health services system in the overall process.

References:

 State Health Society; Government of Bihar; 2009-10; State PIP 09-10

 www.mohfw.nic.in/NRHM/.../Bihar_NPCC_08_09_First_Draft.pps

 Aradhana Johri; MOHFW, GOI; 2009; GIM_2009_Routine

Immunization_Bihar_India_PPT.

40
 A CRITICAL REVIEW ON THE FUNCTIONING OF ASHA UNDER NRHM:
WITH SPECIAL REFERENCE TO ORISSA

Antaryami Dash
dashantaryami@gmail.com

The key element in NRHM is introduction of a trained female Accredited Social Health
Activist (ASHA) in every village selected by the Panchayat to create awareness, mobilize
public participation, promoting institutional deliveries, mobilize full immunization and
prepare village health plan, etc. etc. This has been one of the most important initiatives
of the mission.
When we discuss about ASHA, concepts like Mitanin program of Chhattisgarh (May
2002) and Bare-foot doctors of China automatically come to our mind. Though the
program was initiated as an independent initiative with many features different from
the Mitanin program, as the program expands more and more, changes make it very
similar to the Mitanin program. ASHA, as a community health worker, was thought from
many dimensions. One of them is after the deplorable withdrawal of 1978 community
health worker (CHW) programme. The programme (a male and female community
health worker in each village) was hacked to death by uncaring bureaucrats and the
apathetic Congress regime in the mid- 1980s.1
Then the NRHM came as a compulsion to show the pro-poor face of the new
government in 2005.

The ASHA under NRHM is primarily a woman resident of the village – married/
widowed/ divorced, preferably in the age group of 25 to 45 years. She should be a
literate woman with formal education up to class eight. ASHAs are chosen through a
rigorous process of selection involving various community groups, self-help groups,
Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the village Health
Committee and the Gram Sabha. ASHA undergoes series of training episodes to acquire
the necessary knowledge, skills and confidence for performing her spelled out roles.
This training includes 23 days of induction training spread over a period of 12 months.
It has been recommended that the first round of training may be 7 days, to be followed
by another 4 rounds, each lasting 4 days to complete induction training. This includes
both thematic and modular training for ASHAs. There is periodic retraining for at least
12 days a year. 2 days once every alternative month.

She gets compensation for loss of livelihood on days when she has to work full time-
like attending training and meeting. She also gets incentives linked to National
programs. Very recently a budgetary provision of Rs. 7,000 to Rs. 10,000 per ASHA per
year would be made till the year 2012. (*Expected)

41
The issue of honorarium and its relationship to motivation:
One of the most important issues of the ASHA, in comparison to Mitanins in
Chhattisgarh, is honorarium. Mitanins, at its onset, were never paid any honorarium.

The reasons for demanding that the ASHA should be paid are:
Need to compensate for loss of livelihood.

 One cannot secure participation of women without monetary compensation.

 Even if we secure participation initially it will be unable to sustain in the long
run without the motivation afforded by monetary incentives.
 When everyone else in the health system is paid it would be unfair and
discriminatory not to pay these women, who are poorest in the network of
workers for public health.
 The reasons behind Mitanin program for not paying any honorarium are:
 The amounts considered for payment are too meager to compensate a livelihood.
 The introduction of a small payment would make the entire burden of work
solely her task and the community would not participate to the extent it has
been envisaged.
 Not paying her safeguards the selection process from pressures that would
otherwise be inevitable and most damaging.
 Here, the Mitanin (Community Health Volunteer) should not have to face any
loss of livelihood on account of her participation. Only that much of work is given
which can be done without loss of livelihood. Her workload is estimated at about
8-10 hours weekly or about 2-3 hours per day for 3-4 days per week. However,
any other work that involves livelihood loss - like attending the immunization
session or escorting a pregnant mother to the hospital must also be
compensated. It is envisaged this will come to about two days a month.

Discussion:
What, if it is not money, motivates the ASHA to undertake this task?

 Some of the ASHAs have young children and they see the opportunity for
enhancing their own knowledge. Some educated women seek an opportunity for
using their skills and the social recognition that comes with it.
 In the village (especially in tribal area), the sense of community is strong and can
act as a motivating factor. In such communities, social recognition and one’s own
desire to serve the community can be a powerful motivating factor.
 This is not to say that these ASHAs would not welcome a monetary incentive, but
they understand the compulsions of the program. What they seek is
1. Support in the form of continued training and visits.
2. Regular refill of their drug kits and
3. Prompt and courteous care for the people they refer to the PHC/CHC.

42
Monetary incentive would only be a fourth priority but the system finds it difficult to
deliver even these three basic requirements. Delivering these three basic supports that
ASHA demands, requires a substantial monetary and effort investment- a point too
often forgotten by the Govt. In its absence even monetary compensation is never
adequate.

The ASHA program is not a cheap low cost alternative to ANMs. Ideally we expect the
cost of drugs at about Rs.10, 000 per ASHA per year, i.e. an outlay of Rs.600 crores
annually for the 6 lakhs ASHAs of the high focused states as a whole. If on the other
hand we pay those ASHAs (say Rs.1000 per month= Rs. 12,000 per year) in addition to
other social mobilization activities the sum required would be another Rs. 720 crores.
That is a total of Rs. 1320 crores and the probability that we would get the desired
outcomes is by no means certain.

ASHA remuneration through NRHM:

(* Incentive break up for Orissa. All states do not have all the components of NRHM. So
it may vary across states)

 For promoting institutional delivery under JSY= Rs 600 per institutional delivery

 (Rs 50 per Antenatal check up x 3 = Rs 150

 Rs 200 for the service provided,

 Rs 250 for the mobility support)

 To help in the immunization session Rs 150 per session = Rs 150 per month

 As a drug provider for 6 months in DOTS is Rs 250 per cured patient = Rs 42 per
month per case

 As motivation for female sterilization = Rs 150 per case

 As motivation for male sterilization = Rs 250 per case

 Rs 100 for one training session = Rs 100 per month

 To attend monthly sector meeting = RS 100 per month

 To attend GKS meeting = Rs 50 per month

 To attend Mamta Divas (VHND) = Rs 50 per month

 For Pulse Polio Rs 75 per day x 3 days = Rs 225 in year = Rs 19 per month

 For promoting cataract surgery Rs 175 (75 per case + 100 for mobility) = Rs 175
per month (if distributed evenly)

43
  For blood slide collection in F.T.D Rs 20 per slide = Rs 200 per month average

The calculation shows that an ASHA can get at least Rs. 2526 per month if the area is
having a birth rate of 24 and it has seasonal variation. If number of delivery will
increase, the final earnings will increase substantially. If number of T.B patients, fever
cases, cataract cases is more, then definitely one can earn Rs. 4,000. Even if she earn Rs.
1000 per month, that is enough even for a man in rural area where in the name of
NREGA they hardly get 10 days of work in a month. This has improved many ASHA’s
socio-economic condition. Each one has got a bicycle in Orissa and soon they will be
given a mobile phone. For some of the poorest it was a dream come true.
It will be self explanatory if we will look at the recruitment of ASHA that has happened
in two different phases. In the first phase, we hardly found any 8th class passed women.
Majority of them do not fit to the guideline of required age, education etc. Initially there
were fewer acceptances in the community for a job like ASHA. But recently in 2009 we
had another phase of selection, where out of 15 ASHAs selected in my block (where I
was working), we got one B.Sc (Hons), two B.A, four +2, five 10th passed and the rest are
8th passed. There are examples of political intervention, bribe to the Medical Officer, and
local violence to select one particular candidate, etc. are seen for this round of selection
of ASHAs. This indicates that this has become an acceptable employment at least for the
rural community.
If we will see the drug list we will find that she has to dispense certain drugs that range
from ORS packets to Chloroquine and Artesunate. We realize that an ASHA must have
that much of knowledge to read the thermometer, diagnose a case of Malaria through
blood test, diagnose pregnancy though urine test and give the exact dose of
Chloroquine, Artesunate, Paracetamol, etc. in divided dose with proper advise. In their
training module, subjects from Malaria, T.B, and Leprosy to AIDS, Snake/Dog bite are
there. This has really become a challenging task for them. And the interesting part is
that they now love this task and want to be recognized as a savior of mankind.
The entire ASHA program is now running through incentives. There is no fixed salary
for them so far. But if we will look at the issues seriously there are certain anomalies.
They are as follows:

1. ASHA gets Rs 600 for promoting one institutional delivery but she gets Rs. 150
for promoting female sterilization, which is less beneficial for her. In the same
line, the mother also gets Rs. 1400 for institutional delivery while she gets only
Rs. 500 for adopting sterilization, which is less beneficial for her.

2. I have seen ASHA who prefers to bring and motivates only pregnant mothers for
delivery. Similarly, there are very poor families who want a child every year just
to get Rs. 1400 and they do not care if the child dies next day. They will again try
for next 1400 rupees, next year. And this goes on until the mother dies.
3. The focus on population stabilization is neglected by ASHAs in NRHM.

44
4. The Government once again ignored the hazard of incentive based population
control scheme warned by M.S Swaminathan.2 From R.C.H- I, R.C.H-II to NRHM,
everything are now incentive based.

5. If a pregnant mother goes to another village or city for her delivery during the
early 3rd trimester of her pregnancy (This usually happens in our society. The
mother goes back to her home and the first child born in its maternal
grandfather’s house), then the ASHA does not cooperate the lady in giving her
Janani Surakshya Yojona card before delivery and is very reluctant in providing
proper post-natal care to the mother and child after delivery. This happens, as
the ASHA knows she is not going to get any incentives in this CASE.

6. In the second and third phase of ASHA selection, many educated ASHA came in.
Education is now required since the ASHAs are directed to give medication for
Malaria, Diarrhoea, T.B, Leprosy, etc. It is now required for them to read and
comprehend those five training modules. However, so far, it has not been
observed that the educated, upper class ASHA works better than those literally
illiterate ones.

7. Anytime Government is unable to provide adequate amount of medicines in the

ASHA’s drug kit in accordance with the need of the community.

8. There is some kind of conflict between ASHA and A.W.W, Multi Purpose Health
Worker (M/F) in the community as ASHA now takes some of the works that was
originally done by A.W.W and M.P.H.W.

9. While the strategy of deploying ASHAs was reasonable, but it had not been
anticipated that the inability of the existing departmental structures to
implement such a large scale mobilization, the absence of support structures and
the piece rate system of payment may jeopardize the entire program. The
implementation of the ASHA initiative is poor according to Jan Swasthya
Abhiyan. The NRHM was a compulsion to show the pro-poor face of the new
government. It has been found during a study conducted by Jan Swasthya
Abhiyan that most of the ASHAs had yet to start work; the Anganwadi worker or
the Auxiliary Nurse Midwife allocated them work.
10. Under NRHM, the ASHA was required to be accountable to the community and
not subservient to the ANM or AWW. But it is found that they are subservient to
ANM and AWW.
11. In a recent study done by Ravindra H. Dholakia et all., from IIM, Ahmedabad, it is
found that the presence of ASHA in the high focused state has so far not made

45
 any material difference to the health indicators.3 The study has targeted five
health indicators, such as Institutional Delivery, IMR, Immunization Rate, Ante-
natal Care Rate, Unmet Needs in both High Focus and Non High Focus states with
and without NRHM in the year 2007-08. In all five indicators the test was
statistically insignificant; leading to the conclusion that giving special attention
to HFS for reducing regional disparity has not achieved any results so far. This
study reveals that none of the correlations for HFS and only 3 out of 10
correlations for all states are statistically significant at 5% level. Introduction of
ASHA is significantly but negatively related with the health indicators like
change in unmet need, level of percentage of immunized children and level of
institutional delivery rate.

Conclusion:
We face three main problems.4 For some diseases, we have no tools or only imperfect
ones. In other cases, we have excellent tools, but high cost puts them beyond the reach
of the poor who need them most. Thirdly, we often have powerful interventions that
are cheap or even free, but fail because we lack the systems and personnel for their
delivery.
These are life - and -death failure and we find them unacceptable. Though the policy
frame work of NRHM is made by taking into account many global primary health care
and community health model and approach, yet due to the lack of this trained
professionals we face many problems.
There has been a mixed experience of this functioning of ASHA under NRHM. For many
of the rural villages they are doing something sensible. But they are not the substitute of
M.P.H.W, ANM and AWW. One thing for sure, there has never been such a flow of money
to public health in India as happened under NRHM.
If we can monitor their functioning well, then majority of the issues like primary health
care, surveillance, screening of common avoidable diseases can be tackled. Through
them we got a huge health work force for rural India. Optimizing their activities is
necessary.

References:
1) Shyam Ashtekar . 2008. The National Rural Health Mission: A Stocktaking.
Economic & Political Weekly, September 13, p 23-26
2) Ashish Bose. 2000. National Population Policy, 2000: Swaminathan to
Shanmugham. EPW, Vol. 35, No. 13 (March. 25-31, 2000), pp. 1058-1059.

3) Ravindra H. Dholakia et all. 2009. NRHM: Sprint, Marathon or Stroll? YOJANA,

October, p 36-39

4) Margaret Chan. 2008.Primary Health Care; Now more than ever. WHO, Geneva.

46
5) Green A and Bennett S. 2007. Sound Choices: Enhancing capacity for evidence
informed health policy. Geneva: World Health Organization.

6) Shukla A. 2005. National Health Rural Mission: Hope or Disappointment? Indian

Journal of Public Health, 49 (3): 127-32.

7) Rajalakshmi T.K. 2007. The second national health assembly in Bhopal, Criticizes
the NRHM and the government health care priorities. Frontline, Vol. 24, Issue 7

8) Report on Second National People’s Health Assembly (2007). Available at

http://www.whoindia.org/LinkFiles/HSD_Resources_Second_National_Peoples_
Health_Assembly. [pdf] Downloaded on 18th January 2010.

9) GOI. 2005. Accredited Social Health Activist Guidelines, Ministry of Health and
Family Welfare, Government of India, April 2005.

47
 THE BLACK WINDOW

Dr. Niharika Tiwari

drniharikatiwari@gmail.com

The human spirit never fails to amaze me. I wonder how the disadvantaged groups go
on with their lives, leaving the unfulfilled promises, the hopes and the disappointments
behind them. I see through my black window, the contrasting view of high rise buildings
and aspirations, and the shanties and the shattered dreams in a single frame. I should
have become used to this by now. After all, I have lived in Mumbai for the whole of my
life. Somehow, I never got used to it.

The government seems to have woken up to the health needs of the disadvantaged. The
government and the policy makers are of the view that if monetary barriers to seeking
healthcare are taken care of, they may be able to provide healthcare to all the people-
young or old, rich or poor. But is it real? Can it be done?

I believe that these inequities and barriers are not just because of money. They are also
in the minds of the service providers and also the disadvantaged. I wonder a lot of
times; would I be happy of my achievements if all others achieved them too? Would I
have the same attitude to winning if I knew that no one would lose? It is the competitive
spirit of the Homo sapiens that made them the most “intelligent” species. Can we really
forgo it to reduce the inequities that exist?

It has been documented that the practitioners, inadvertently, suggest Total knee
replacement (TKR) as a therapy for moderate to severe osteoarthritis to more men than
women with similar presentations. Is this gender inequity? Or is it just that the doctors
are sub-consciously more aware of female roles in the community and home that makes
them hold back from suggesting therapy?

Whenever I walk through the Bandra Skywalk (It is an amazing piece of work!) I
wonder how such a structure would help the people with loco-motor disabilities. It
would just act as a barrier to their right to freedom. Are the people designing these
structures not sensitized to the needs of the population? Or is it that they just close
their minds to them so that their progress is not hampered?

Take maternal health for example. We, in the provider’s shoes, tend to keep the
“educated” and the “rich” patients more informed about their illnesses than the
“uneducated” and the “poor”, where we only seem to provide them with medications
and explain them the dose. We may say that the educated are in a more receptive state
with regards to the information. Do we ever stop to wonder, Is this the only reason why
the information inequity exists between the groups?

Inequities of gender, class and religion are as much a part of our life now as were a few
decades ago. When I join people or groups who try to lobby for demands of the
48
disadvantaged groups, I wonder whether I see myself at a better position than the
population sub-consciously. Is that why I feel for the disadvantaged? Is it that
consciousness that drives me to work for them?

If we look around us, we will find that in a way, we have made inequities a part and
parcel of our lives, and in a way, we revel in them. If only the policy-makers could find a
way to address our ideologies, I believe that battle against Inequity will be easily won.

49
 THE VALLEY OF FLOWERS

Dr. Khyati Tiwari

khyati16@gmail.com

The lush green surroundings and the flowing rivers had a positivity embossed in them
which motivated me to put in the best efforts for internship. The backup gyan remained
in the back of the mind which made space for the new learnings, this time I was open
for all the opportunities and challenges coming my way; keeping in mind only one
mantra, “Act as if what you do makes a difference. It does”. The work assigned to me
required documentation for the process of health advocacy on the effective or not so
effective implementation of Janani Suraksha Yojna in the tribal district of Barwani
which lies in the southern part of Madhya Pradesh. Almost 67% of the population
residing in the valley belongs to Bhil and Bhilala tribes.

Janani Suraksha Yojna, under the broader umbrella of National Rural Health Mission
was implemented all over India in 2005. This was considered to be an effective way of
modifying the existing National Maternity Benefit Scheme. The main objective of JSY
was to reduce the Maternal Mortality Rate, Infant Mortality Rate and increase the count
of institutional deliveries and thus the concept of Village Health Worker was
operationalized keeping in view the financial constraints a BPL family faces, the
construct of incentivization was introduced for the beneficiary as well as the facilitator.

All what it started with was a clearly demarcated definition of Maternal Health and the
responsibilities and Duties of the government based health services and what it should
comprise of, but the field visits and the various perceptions about the expression made
it more amorphous, more lacking boundaries and overlapping with different
dissimilitude. The repetitive problems which caught my attention were related to
inaccessibility to the various programmes and services in place which were either
considered normal or never caught attention were something very gross leading to a
major gap in the working of the whole system. This was one of the most intriguing facts
about the tribes and the problems they are made to suffer from, the worst part being
reasons for this at most places is not known.

Among the known existing inadequacies, dwelt the other set of nonfigurative societal
norms which made maternal care inaccessible to a poor, tribal female. Inadequate
infrastructure; buildings in dilapidated state; age old equipments which have not being
repaired or replaced; unavailable laboratory facilities at the primary and secondary
health centers; uninstructed referral units; non-existent conveyance facilities; etc are
being talked about in almost every single evaluation report; what is actually missed out
and side lined are the non-conceivable circumstances which make these facilities more
farfetched for the actual donees.

The absolute unavailability of resources along with the circumstances created make the
government programme launched a failure in terms of numbers. Due to lack of
50
awareness about any of the schemes and programmes, females in this belt are not able
to claim their rights to safe motherhood. The total absence of civil amenities like roads
and conveyance facilities, overshadow the available knowledge; the unfriendly
behaviour of the medical and non medical staff makes it an alien environment for the
people; the illegal sum of money charged for the poor quality services, makes the
incentives non appealing for the tribal people.

About 91% of the total population in Barwani is dependent on agriculture which is not
taken to be a full time occupation by most owing to the unfavorable climatic conditions;
clearly states a situation where the general per capita income of the rural population is
less then Rs 300. Individual endowment, by a woman in the family is less than 30% of
the household income. The low literacy rate especially for the females (ranges from 0%
to 36%) degrades the possibility providing women an institutional basis for drawing on
social capital.

Gender gap comes in the frame in terms of health of the female who holds a liability to
society to heighten the labour force and also bears the responsibility of motherhood
and channeling the values down the family hierarchy; thus is fixed in the reproduction-
production nexus. At the same time the un- evaluated household work which is
considered to be ‘women’s job’ makes inequality persistent in all roles of life. Ironically
the roles played by a wife, mother and sister are hardly ever acknowledged in terms of
health and healthy living in this society; neither is this realized by the state and nor in
the policies hence framed for the benefit of the womanhood.

These preconditions hence claim for quality research and considerate humane touch in
designing of policy which not only meets the superficial, practical needs but also should
recognize the deep seated, strategic needs. The policies which assert on improving the
indicators should go beyond to the level of empowering the females to make decisions
for self good, allowing them to hold discretion for good and bad and above all
recognizing themselves as equals in society with the same rights and responsibilities.

Where one half of the population is un-empowered, distressed, disabled and

dissatisfied; the other half can never progress. So, let’s commit ourselves to empower
each and every one of ‘us’ and then life will not be a contest where every day starts
with the race to earn the day’s living and ends with the darkness of weariness; but a
splendid journey through a valley of flowers…

51
 The Concept of Stand and Work:
A Serious Health threat

Dr. Lord Wasim Reza

lwreza@gmail.com

Post liberalization and economic boom comes up with huge opportunity and
employment in the service industry for all social classes. Additionally, in this era
shopping malls, fast food chain etc has grown to an extent that we can find it at every
corner. This corporate culture has brought serious health risk and calls for certain kind
of ‘discipline’ in the employee’s life. One such ‘discipline’ is to ‘stand and deliver’. In
United Kingdom it has been estimated that almost 11 million workers deliver on their
feet during their work hours. Due to it every year over 2 million sick days are lost due to
lower limb ailment with about 200000 people report lower limb ailment (Trade Union
congress, UK). Prolonged standing implies work in standing position for 8 hour with a
break of 30 minutes for lunch. In cities like Delhi or Mumbai, an employee stands for
almost 12 hour including 2-3 hours of travelling and 8 hours of work. The current pace
of urbanization and modernization raises the above chances of standing posture
(forceful) while working and is expected to increase in south Asia. This problem gets
aggravated by poor transport system and infrastructure of cities on south Asia.

The practice of long standing is visible among the educated man and women as well as
among those working in hotels and hospitality industry, shopping malls, retails shop
floor, even in hospitals. Hospitals are called as gods place and doctor is treated as
second form of God. These practices are carried out in these holy places. Majority of
these places do not require standing. Workers of lower status jobs are more likely to
stand as compared to higher stature job with less access to sitting arrangement while
working.

Prolonged standing at workplace should be discouraged on the ground of health

hazards. The commonly associated risk is stress, fatigue and discomfort, swelling of
legs. Pain in shins, knees, thighs, hips, and lower back. 8 hours of standing leads to
hypotension in initials days and hypertension in later stage of life. It also causes
worsening of existing coronary heart disease. Increased risk of preterm birth, birth
defect and spontaneous abortion is also reported. Varicose vein and Achilles tendonitis
is most common disease found in prolonged standee (Tüchsen F, Krause N and others
Standing at work and varicose veins, Scandinavian Journal of Work, Environment and
Health, vol.2 no.5, pages 414-20, 2000).

Universal declaration of human rights in article 23 says, “Everyone has the right to
work, to free choice of employment, to just and favourable condition of work and
protection against unemployment” (UNHR Declaration 1948). In article 7B of
international covenant on economic, social and cultural rights 1976 advocates about
safe and healthy working condition. As per the covenant “Safety is a fundamental right

52
and it is essential for the attainment of health peace, justice and well being” (Montreal
Declaration 2002, Article 1). The Indian factory act 1948 also advocate for the health,
safety and welfare of all worker. India being signatory to the above international
regulation and parliament having its indigenous law in the form of Indian factory act –
1948 provides the mandate for the government to act.

The concept behind standing has rarely to do with the etiquette and politeness. . This is
obvious from the belief that says “Receiving the customer in standing posture shows
courtesy and conveys the message of availability and sitting in presence of customer
reflect rudeness” (Professor Karen Messing, University of Quebec, Montreal). On the
contrary, doctors and lawyers who are having higher social stature receive their
customer in sitting posture. In this case our society do not notice rudeness and turn
blind eye. The job is same with different standard. This contradiction is a reflection of
the concept of hierarchy prevalent in work settings and it may be classified as one form
of slavery. I may call this neo-slavery.

These are the workers who are always at non negotiable position with greater risk of
losing job. Therefore they never raised their voices and in corporate setting they also do
not have union who can bargain on their behalf. In India Standing is never treated as an
occupational hazard. The standing posture will not be followed for more than 30% of
total working day. If standing is required then there should be concept of rotation on
regular interval should be there. Sitting position should be preferred and adjustable
chairs to be given to the employee. The choice of standing or sitting should be given to
worker and should not be enforced in the name of culture. A study is required to assess
the social factors and behaviour of workers in prolonged standing. Right based
approach along with strict regulation can be promoted to curb this inhuman trend in
south Asia.

The standing (forceful) is associated with the slavery and social hierarchy. Standing for
respect is expected from the people of lower of social stature or those works on socially
inferior stature job like reception, security guard etc. This is also associated with
corporate work culture hierarchy. The cultural legitimacy and work culture hierarchy
should be denied to preserve the health of people who are forced to deliver on feet. This
will save the health of people on one hand and increase the productivity. On other hand
in decreased morbidity will contribute the in the productivity of nation.

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 NEED OF THE AGED

Dr. Ranjit Kumar Mandal

tissranjit@gmail.com

The world’s population is ageing and many countries have acquired the label of an
“Ageing Nations” where the median age of the population is raising with time. Asia
and Europe are the two regions where a significant number of countries will face severe
population ageing in the near future.

Asia is estimated to be home to approximately 414 million senior citizens, more than
half of the world's elderly population. There are currently 167 million Chinese citizens
over the age of 60, accounting for over 12 percent of the population and India is also in
the label of ageing population with about 8.4 % of the population above 60 years. The
reason of this demographic transition is due to increase in the longevity and decrease in
the fertility rate.

In Japan, one of the fastest ageing countries in the world, in 1950 there were 9.3 people
under 20 for every person over 60. By 2025 this ratio is forecast to be 0.59 people
under 20 for every person older than 60. The median age of population of the world as
a whole are 23.9 in 1950, 26.8 in 2000, and will be 37.8 in 2050. United nation has
forecasted that India will surpass China with its growing population before 2045. By
2025 it has been estimated that there will be 5 elderly people out of 8 people in both
the country (china and India).

In India, approximately 90 percent of senior citizens lack any kind of healthcare or

social security and 66 percent can't afford two meals a day (Times of India Report). To
combat this trend, The Maintenance and Welfare of Parents and Senior Citizens bill was
drafted in 2007, making it a legal obligation for children to take care of elderly family
members. The government is providing incentives for children to take care for their
parents. Indian State governments have also taken steps to ensure financial security,
healthcare, shelter welfare and other needs of older persons. Even Businesses are
strategically planned for aging baby boomers and seniors.

Technological advancements meant to help seniors have also been emphasized by

India's Department of Science and Technology in an initiative called The Technology
Interventions for Elderly (TIE). The program encourages Indian students to think about
the issues that the elderly population faces and develop creative solutions that could be
implemented by the government.

Similarly China is attempting to plan for its elderly citizens as well. China has included
blueprints for a senior healthcare system in its Five-Year Plan, because there is
currently little being done to prepare the country for the demands of the older
population.

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But do the elderly need what the government is planning to provide them? Their felt
need is different than the perceived need of the government for them. They feel that
free health treatment, free food, free medicines, and clothes should be provided to
them. Family members and others should obey them. They seek family support and
proper food and medicine on time. To meet some unexpected expenditure, there must
be some cash in their hand. So any kind of pension allowance will be beneficial to them.
Children should take care for their parents. Son & daughter-in-law should respect their
in-laws. Many elderly also thinks that sons are useless and they should have daughter
only. Free vehicles should be provided to them for assessing the health care services.
Separate clinics should be open for them. Healthcare facilities is lacking in rural areas.
Public Curative services should be made available to them at least up to the primary
health center level. There should some authority to listen to their problems and
understand the problems.

It seems that seniors are not getting what they deserve and needed. They deserve due
respect and their felt need should be met if government will be able to implement the
concept of horizontal equity in its policy.

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 THANK YOU FOR YOUR PARTICIPATION

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9930640275

Dr. Parag Chaudhary

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www.tiss-clairvoyance.com

email: clairvoyance10@tiss.edu | clairvoyance10@gmail.com

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