IMPLEMENTATION OF
HEALTH CARE
PROGRAMMES
B.V.L.NARAYANA
RAILWAY STAFF COLLEGE
STRUCTURE OF
PRESENTATION
•
•
•
•
•
•
•
DEFINITIONS
KEY MESSAGES
ROLE OF PROGRAMME CHARACTERISTICS
RESOURCE GENERATION
RESOURCE MOBILISATION
RESOURCE UTILISATION
MONITORING, EVALUATION, COURSE
CORRECTION
• MODEL
• CONCLUSION
Health indices comparison
Indicator name
Av. Value
for
India
Lowest in any
state
Highest in any state
Infant mortality rate
58
13( Manipur )
76 ( Madhya Pradesh)
Maternal mortality ratio
301
110 ( Kerala )
517( Uttar Pradesh)
Institutional deliveries ( %)
40.7
12.2 (Nagaland)
99.5( Kerala)
Full ANC check up ( %)
50.7
16.5 ( Bihar)
96.5 ( Tamil Nadu)
Children fully immunized
43.5%
80.8 % (TN)
20.1( Nagaland)
Children breastfed at birth
23.4 %
7.2% (UP)
65.4(Mizoram)
Children underweight ( < 3)
45.9%
22.6 (Sikkim)
60.4 (Madhya Pradesh)
Utilization of government
facilities by poorest
37.9%
19.4% ( Bihar)
55 % ( Karnataka)
Source: Health profile of India 2006
Motivation
Developed
countries
INDICATORS
Developing
countries
India
( average)
India
(highest)
India
(lowest)
9
100
58
76
13
13
114
95
130
19
3
41
46
60.4
22.6
40
630
301
517
110
5
40
27
NA
NA
31
164
6.8
NA
NA
Full ANC %
97
65
50.7
96.5
16.7
Safe deliveries %
98
45
40.2
99.7
12.2
Children fully immunized %
90
60
43.5
80.8
20.1
NA
32
23.4
60.4
7.2
IMR(/ 1000 live births)
<5 MR(/ 1000 live births)
UNDERWEIGHT %
MMR ( / Lakhs births)
Deaths due to TB( / Lakhs population)
Deaths due to AIDS(/ Lakhs population)
INTERVENTIONS
Children breast fed %
Source : National health profile 2006, based on NFHS 3(2005-06)
Comparison of health indices
state
<5 MR
Malnutrition
MMR
Andhra Pradesh
88
37
195
4.6
Kerala
19
26
110
4.3
Karnataka
77
44
228
5.7
Tamil nadu
69
36
134
2.2
Punjab
67
29
158
4
Gujarat
84
44
180
3.8
Haryana
91
33
162
3.6
Maharashtra
65
51
149
4.3
West Bengal
69
47
194
3.9
Madhya Pradesh
116
57
379
3.7
Bihar
84
55
371
2.7
Uttar Pradesh
112
53
517
2.7
Rajasthan
107
52
445
3
Orissa
130
55
358
4.5
India
95
46
301
%TB deaths
3.8
Motivation
• Disparity in distribution of mortality and
morbidity
– Between developed and developing countries
– Between states in India
• Conditions preventable
• Proven cost effective interventions available
• Common health care programmes
• Why the disparity in India
Motivation
• India and other developing
countries
• Investments and funding (Bajpai, Dholakia
and Sachs 2006; CMH 2001)
•Mediated through good governance
(Wagstaff and Claeson 2004 )
–Institutional factors
(NCMH 2005; Wagstaff and Claeson
2004)
Implementation
is
one
of
the
key
issues
–Service delivery mechanisms (Bajpai and
Goyal 2001; Mavalankar 1999; Seshadri rao 2001; Wagstaff and Claeson
2004)
INDIA THE CONTEXT
• Contributes to 20% of worlds mortality and
morbidity
• High variation in mortality and morbidity
• Last 60 years
– Gap between intention and reality
– Unfocussed infrastructural development
– Lack of a good referral system
– emphasis on centrally driven and
controlled vertical disease specific programs
• Communicable diseases contribute 50% of
burden (NCMH 2005)
INDIA THE CONTEXT
• National health policy(2002) ; By 2010
the goals stated to be achieved are ( sujata
rao 2004):
• increase public investment from 0.95 of GDP to 23% of GDP
• increase utilization of primary care facilities from
19% to 75%
• reduce MMR(maternal mortality ratio) by 75%(
from 540 to 135)
• reduce IMR( infant mortality rate from 62/1000 to
<30/1000
• eradicate polo, eliminate leprosy
• reduce deaths due to TB and malaria by 50%
Concepts
• Implementation of strategy
(Wheelen and Hunger
2001).
– “the process by which strategies and policies are
put into action through the development of
programs, budgets and procedures”
• Policy Implementation
– actions by people that are directed at achievement
of objectives set forth in the policy decision
(Van
meter and Van Horne 1974).
Characteristics ( Hrebiniak and Joyce 2001)
– Is a dynamic, non linear process
– Multiple variables interacting, reciprocal causality(
Fajourn 2000)
– Takes time
(Miller 1997)
–
for effect, for study
Literature review Health
care
• Millions saved (what works group, CGDEV 2006)
–
–
–
–
Study of 20 successful program implementations
Identified policy level factors
Program characteristics influence implementation
No pattern of association of success in
implementation with socio-economic contexts
– Even in weak policy environments effective
implementation is possible
• Secondary analysis shows role of
community involvement
DEFINITIONS
• Implementation is defined
– as the process of allocation of tasks
– and resources and
– creation of administrative mechanisms to monitor
and integrate actions required to
– achieve the objectives of program/strategy,
including those which cross organizational
boundaries.
• Is a process– Sequence of events, actions and activities
unfolding over time in a context ( Pettigrew
1997)
Scope of
research
Inputs
Process
Action
planning
Output
Corporate
strategy
Business
strategy
Policy
Program
Influencing
Process
factors
characteristics
Health
Policy
Health care
Program
Influencing
Process
factors
characteristics
Budgeting
Action
Outcomes
Process
outcome
Program
outcome
Process
outcome
OPERATIONAL FRAME WORK
Program
outcome
Task organization
• Programme characteristics
– Type of goods/services planned
– Organization of service delivery
• Inter-linkages among components
• Key steps in process
– Technology used for service delivery
– Implementation organization
High
Requirement of intensity of resource
Low
High
Intra organisation coordination
Low
health
AIDS
Condom use
AIDS
fertility
Mental
health
RCH
Vector
control
ORS
CANCER
Iodine
Vitamin
deficiency A deficiency
measles
NLEP
II
TB
Blindness
control
ICDS
IDSP
Small
pox
Low
Intensity of interactions
Low
Intersectoral coordination
High
High
Task organization
• Based on the degree of intangibility, a service
good can be classified as:
– search goods where the customer can test it or get
information about it before deciding to buy e.g. : a
test drive of a car
– experience goods where the customer has to
experience the service before you can make an
opinion about it e.g. a meal in a restaurant
– Credence goods where even after purchase you are
not sure of the quality of the service—e.g. health
care service.
• relationship between the service provider and
the customer becomes important and need to
be incorporated in service delivery strategy
(Susan Segal horn 2001).
Task organization
• How will service delivery be done
• What activities are components of it
• Who will do these activities and whose
control are they under
• What technology will be used to do it
• Interrelationships among activities
–
–
–
–
Determines
Determines
Determines
Determines
criticality
dependencies
coordination costs
nature of governance mechanisms
• Identifies the implementation organization
Comparison of programmes
Characteristic
NBCP
RNTCP
NVBDCP
RCH
Number of
components
Two
One
Two
Four
Technology used
Mediating
Long linked
Intensive
Long linked + intensive
Dependencies
within
group
Pooled
Sequential
Sequential
Reciprocal
Dependencies
across
group
None
None
Reciprocal
Reciprocal
Components
under direct
control
All
All
One
Varying levels
Control
mechanisms
Financial
incentives
Cooperation,
material
incentives-skills
Cooperation
Cooperation, financial
incentives in some cases
Key resources
Surgeons
LT,MO
MO,LT
MO, FHW, specialists
Mechanisms to
get alternate
resources
Pooling,
contracting
Community
provision,
contracting
Community provision,
Pooling, community provision,
contracting
Comparison of programmes
Characteristic
NBCP
RNTCP
NVBDCP
RCH
Lead/lag of
impact of
interventions
None
Moderate, 6-9 months
Moderate for vector
control measures
Long lag
Requirement of
skill levels
High at tertiary or
secondary level
Medium at PHC level
Low
Low to very high
Degree of
standardizati
on of
treatment
Very high
High
High
Low to very high
Task grouping
At highest level
At programme unit level
At field unit level
At field unit level
Scope for resource
transfer
Very high
Restricted
Minimal
Minimal
Evaluation and
control
At highest aggregate
level
At unit level
At lowest level
At lowest level
Coordination
costs
Low
Medium
Very high
Very high
Facilitation by
Planning, incentives,
innovation in
technology
Planning, standard
guidelines, training,
cooperation
Planning, continuous
feed back,
cooperation,
coordination
Planning, continuous
feed back,
cooperation,
coordination
Implementation organisation-NBCP
Training of
suregons
JD headqua
rters
DH, GH,
MCs,CHC
OPD
PHC
equipment
community
surgery
NGO
Incentives
NGO s and
PP
cataract
patients
screening
camps
opthalmic
assistants
Implementation organisation NVBDCP
monitoring
and feed
back
PPs and
CHCs
PHCs--MO
,LT,MHS
district
DMO
JD-NVBDCP
state
SC--MMP
W,FHW
blood smear
collection
positive
cases
spraying
teams
focal
spraying
villages-MLV,GA
M,AWW
fever
surveillance, BS
treatment
community
IRS schedule
vector teams
vector
density
studies
anti -larval
measures
anti vector
measures
hatchery
and seeding
teams
biological
control
ITM nets
community
nets
IMN usage
and
distribution
Implementation organisation RNTCP
STO-state
headquarters
DTO
contractual
LTs
MO-TC
monitoring
and feedback
PHI/MO
for categoris
ation
training
treatment
STLS--Micro
scopy quality
DMC/ LTS
OPD
screening
DOTS
worker
private
DMCs
sputum
examination
referral from
community
AWW.GAM.
MLV.MMP
W,FHW
PPS,
STS--treatm
ent follow up
treatment as
DOTS
worker
Implementation organisation RCH
house to house
survey--CNAA
activity plan
district plan
feed back
state headquarters-Addl director FW
targets
District head
quarters--CDHO
, RCHO
primary health
centre-MO,LT,
FHS
sub centre
MMPW FHW
identification
of high risk
cases
village
--AWW
community
immunisation
initiatives
referrals to
PHC
capital
projects
services at
PHC level,
lab tests
facilities, equi
pment,staffing
FRUs
FP
motivation
health
education
management of
complications
referrals to
FRU
services at
SC level
MCH
services
management of
high risk cases
special
clinics
specialist
services
institutional
services
Differences in service delivery
Resource generation
• Role of top management crucial--Attention
– Consists of polity, administrative head,
technical head/heads
– Suggests possible resource generation
mechanisms
– Drives all processes by identification of key
resources
– Focuses on implementation
– Determine the cognitive architecture of the
system—determines problem and opportunity
identification and utilization
– Identifies new initiatives and incorporates
Resource distribution
• Key role of middle management-directioning
– Make available key resources at point of use
– Focus on distribution mechanisms-translate
processes into activities
• Motivates field staff to produce
– Analyze and identify future requirements—
existing and new resources
– Ensure focus of staff, discipline
Resource utilization
• Role of unit heads--governance
• Use of resources to deliver service
• Require supervision and discipline
– To maintain alignment with desired
output
– Improves with participation in planning
– Is a function of work load facilitation
• Micro planning, management of extra work
load, scarcities, technical help, skill
development
Resource utilization
• Use of governance mechanisms to
–
–
–
–
Control output
Discipline staff
Facilitate performance evaluation
Generate feed back
• From staff
• From consumers
– Validity and reliability of data
• to be used in planning
• Identify new initiatives
• Governance mechanisms—
– Direct control
– Cooperative mechanisms
Monitoring, evaluation,
course correction
• Starts at the field level
• Have process monitoring
– Identify outcomes at every step of process to
monitor
– Record, analyze –identify reasons for deviation
– Incorporate corrections into process
• Skill development
• Technology introduction
• Discipline staff
• Ensure focus of staff, unit heads,
programme heads
Mega frame- mapping of factors
Key factor
Service delivery
UNIT
 Final services
DISTRICT
 Resource delivery
STATE
 Idea delivery
Motivation to
produce
Work load
management
 Interest of staff


 Adequacy of
facilities and
equipment
 MO interest


 Supervision
Adequacy of
resources
 Adequacy of field  Adequacy of key staff
staff
Alternate resources  Availability of
alternate resources
Training and

learning
Initiatives and
management skills
 MO interest and
Supervision
Process monitoring 
Resource
generation

 Policy directives
 Utilization of adaptation
 Policy directives
mechanisms
 Emphasis on skill development  Incorporation of
initiatives
 Learning from past experiences
 CDHO focus and initiatives
 Top management
focus
 Emphasis on monitoring

 Focus on
implementation
 Identification of
key resources
Consistent allocation
Take away messages
• Understanding of characteristics of
service delivery—important
– Determines key resources
– Directs logic for governance
mechanisms
• Positioning of responsibility and
attention –should be appropriate
– Ability to solve problems, take
opportunities—idea, power, execution,
Take away messages
• Resource allocation
– Ensure consistent allocation
• Ability to generate
• Efficiency of utilization
• Management of scarcity
• Resource distribution
– Ensure availability at point of use
consistently
Take away messages
• Resource utilization
– Ensure ability to use resources appropriately
• Alignment with purpose-service to be delivered
– Ensure continuous adaptation to
• Changes being done in services
• Feed back systems
– Listen to consumers
– Listen to field staff
– Ensure validity and reliability of field or
primary data
– Monitor and correct processes
Take away messages
• Maintain slack of key resources
– Helps manage scarcities
– Facilitates introduction of new services
• Position mechanisms to generate key
resources at short notice
– Alternate resources generation
– Emergency mechanisms
• Look for problems, new services demand
and plausible applications as solutions
THANK YOU –
ANY
QUESTIONS
Resource allocation-NBCP
RESOURCE GENERATION AND DISTRIBUTION
GOI
resource
provision
INCENTIVES
-- monetary---capital
Medical
colleges
STATE
PROGRAMME
HEAD FOCUS
RESOURCE UTILISATION
NGOS and
PPS in
DISTRICT
SKILL
LEVELS
TRAINING,
INFRASTRUCTURE,
CONSUMABLES
SUPERVISION
GOVERNMENT
DISTRICT
SURGEONS
SURGEONS
CATARACT
SURGERY
OUTCOME
Resource allocation--RNTCP
RESOURCE UTILISATION
RESOURCE GENERATION and DISTRIBUTION
SERVICE DELIVERY
COMPONENTS
SERVICE
PROVIDERS
FHW/MHW
STATE HEALTH
SYSTEM
Provision of
field workers
Provision of
community
workers
DISTRICT
PROGRAMME
HEAD FOCUS
Community
worker
DOTS
MO
OUTCOME
Categorisation
Provision of
MOs
NGOS/PPS
Enrollment of
NGOS/PPs
Pvt DMCs and
Contractual
LTS
Management of
DMCs and
LTs
DMCS and
LTS
Diagnosis
EQA/IQA
PHI
monitoring
SUPERVISION
Supervisor
monitoring
Resource allocation--NVBDCP
RESOURCE GENERATION
RESOURCE UTILISATION
RESOURCE DISTRIBUTION
INITIATIVES
SUPERVISION
Community
aspirations and
feed back
DISTRICT
HEAD
FOCUS and
work
facilitation
Provision of
field workers
Fever
surveillance
Field
workers
Provision of
staff
Provision of
community
workers
Community
workers
Consumables
HEADQUARTERS
Spraying
contracts
MO S
Supervision
and work
facilitation
Training and
skill
development
PROGRAMME
STRATEGIC
CONTEXT
IMN
Vector
density
Spraying
Supervisors
Contract
labor
Fish
hatcheries
Number of
cases
LTS
IMN
impregnation
GOI
CONSUMABLES
Detection
and
diagnosis
Vector
controlbiological
Vector
density
studies
Entomologist
Seeding
contracts
Entomologists
RESOURCE
PROVISION
MECHANIS
MS
UNIT
HEAD
SERVICE
DELIVERE
RS
SERVICE
DELIVERY
COMPONE
NTS
OUTCOMES
Resource allocation -RCH
SITES OF SERVICE DELIVERY
COMMUNITY
---Aspirations and feedback
CNAA
POLITICAL
SYSTEM
TOP MANAGEMENT
FOCUS
STRATEGY AND
INITIATIVES
LINKAGES WITH-medical colleges;
international agencies
SERVICE PROVIDERS
MOOTIVATION -- field
staff, MO, speciaslists
RESOURCE PROVISION
MECHANISMS-provision
of staff, provision of MOs
and specialists, provision of
equipment, provision of
infrastructure, provision of
consumables,
DISTRICT HEAD
FOCUS
MONITORING and
EVALUATION
SUPERVISION AND
MONITORING
DATA COLLECTION
and RECORDING
TRAINING and SKILL
DEVELOPMENT
OUT REACH
REGULAR SERVICES
MO S --INITIATIVES-supervision, work
facilitation, community
participation,
microplanning, on job
training and knowledge
enhancement,
SEVICE
DELIVERY
COMPONENTS
-Maternal health,
child health,
RTI/STI. Health and
nutrition eductaion;
FP services;
EMERGENCY SERVICES
VITAL EVENTS
SURVEY
RESOURCE DISTRIBUTION
SPECIALIST CLINICS
TRANSPORT
FRU s
STATE HEALTH
SYSTEM
RESOURCE GENERATION
SC/PHC
RESOURCE UTILISATION
OUTCOMES-BR,IMR,CPR
,TFR,MMR