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Quality care at childbirth in the context of Health Sector Reform Program in India: Contributing factors, Challenges and Implementation Lesson

Quality care at childbirth in the context of Health Sector Reform Program in India: Contributing factors, Challenges and Implementation Lesson

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In India during last decade several policies and programmes have tried to accelerate
provision of essential maternity services. National Rural Health Mission (NRHM),
health sector reform program, launched in 2005, primarily aims at health system
strengthening and reducing regional imbalances. Study assesses facilitating factors
and challenges in providing quality delivery care and generates context-specific
implementation lessons in three diverse states in India. Thirty-three in-depth, semistructured
interviews were conducted with policy and program representatives.
The analysis presented is qualitative and descriptive. Analysis shows that NRHM
has infused new life in terms of infrastructure improvements, upgrading lower-level
facilities but challenges remain like inadequate human resources, non-utilization of
allocated funds and poor monitoring. Strategies have been devised to overcome
bottlenecks through task-shifting and quality monitoring. Though the emphasis is
on strengthening the structural aspect of care but to complete the whole quality
of care cycle, equal emphasis is needed on process of care.
In India during last decade several policies and programmes have tried to accelerate
provision of essential maternity services. National Rural Health Mission (NRHM),
health sector reform program, launched in 2005, primarily aims at health system
strengthening and reducing regional imbalances. Study assesses facilitating factors
and challenges in providing quality delivery care and generates context-specific
implementation lessons in three diverse states in India. Thirty-three in-depth, semistructured
interviews were conducted with policy and program representatives.
The analysis presented is qualitative and descriptive. Analysis shows that NRHM
has infused new life in terms of infrastructure improvements, upgrading lower-level
facilities but challenges remain like inadequate human resources, non-utilization of
allocated funds and poor monitoring. Strategies have been devised to overcome
bottlenecks through task-shifting and quality monitoring. Though the emphasis is
on strengthening the structural aspect of care but to complete the whole quality
of care cycle, equal emphasis is needed on process of care.

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© Under License of Creative Commons Attribution 3.0 License
1
HEALTH SYSTEMS AND POLICY RESEARCH2012
Vol.
1
No.
1:2
doi:
10.3823/1101
Quality care atchildbirth in thecontext of HealthSector ReformProgram in India:Contributingfactors,Challenges andImplementationLesson
S. Bhattacharyya
1*
, A. Srivastava
1
, BI. Avan
2
, W J. Graham
3
This article is available from:
www.hsprj.com
Abstract
In India during last decade several policies and programmes have tried to acceler-ate provision of essential maternity services. National Rural Health Mission (NRHM),health sector reform program, launched in 2005, primarily aims at health systemstrengthening and reducing regional imbalances. Study assesses facilitating factorsand challenges in providing quality delivery care and generates context-specicimplementation lessons in three diverse states in India. Thirty-three in-depth, semi-structured interviews were conducted with policy and program representatives.The analysis presented is qualitative and descriptive. Analysis shows that NRHMhas infused new life in terms of infrastructure improvements, upgrading lower-levelfacilities but challenges remain like inadequate human resources, non-utilization ofallocated funds and poor monitoring. Strategies have been devised to overcomebottlenecks through task-shifting and quality monitoring. Though the emphasis ison strengthening the structural aspect of care but to complete the whole qualityof care cycle, equal emphasis is needed on process of care.
Keywords:
Health sector reform, India, Institutional delivery, Polices, Programme,Quality of care
Introduction
Many developing countries since the late 1980s, have initi-ated efforts to improve their health systems through policiesand interventions. The trend toward decentralization of so-cial service delivery and focus on capacity building of healthworkforce and infrastructure development had been initiatedthrough the National Health Policy and Health, Nutrition andPopulation Sector Programme (HNPSP) in Bangladesh, (1)and the Social Action Program in Pakistan (2), Several strate-gies have been tested in the form of introducing user fees,community nancing and decentralization in Sub- SaharanAfrican Countries, (3).As India strives to achieve the fth Millennium DevelopmentGoal (MDG) of reducing the Maternal Mortality Ratio (MMR)from the current level of 254 to 100 by 2015 (4), qualityinstitutional deliveries play a key role in enhancing the sur-vival and well being of both mothers and newborns. The lastdecade (2000-2010) has witnessed signicant expansion inmaternal and child (MCH) programmes across India as wellas formulation of concrete quality assurance strategies. TheNational Rural Health Mission (NRHM) is the agship healthsector reform programme of the Government, launched in2005, with the goal “to improve the availability of and accessto quality health care by people, especially for those resid-ing in rural areas.” The Mission aims at reducing regionalimbalances in health by focusing on ‘high-priority’ states (5).
1.
Public Health Foundation ofIndia, New Delhi, India.
2.
Faculty of Infectious andTropical Disease, LondonSchool of Hygiene andTropical Medicine, U.K.
3.
Immpact, University ofAberdeen, U. K.
Correspondence:
sanghita@ph.org* Public Health Foundation ofIndia. Institute for Studies inIndustrial Development (ISID)Campus, 4, InstitutionalArea, Vasant KunjNew Delhi 110070, India.
 
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HEALTH SYSTEMS AND POLICY RESEARCH
2
© Under License of Creative Commons Attribution 3.0 License
2012
Vol.
1
No.
1:2
doi:
10.3823/1101
Under NRHM, the Indian Public Health Standards (IPHS) havebeen constituted as the basis for ensuring that all levels ofprimary healthcare services across all states adhere to a set ofuniform prescribed norms and standards in terms of physicalinfrastructure, human resources, services provided, treatmentprocedures and behavior with patients (6). Quality has thusbecome explicitly one of the key areas of NRHM, encompass-ing infrastructural norms as well as service guarantees for vul-nerable populations. In terms of long-term vision of NRHM,three key elements of high quality maternal care have beendened as skilled attendance at birth, access to emergencyobstetric and newborn care (EmONC) and efcient referralsystem for timely access to EmOC (7).Progress in the health system in India has not been uniform,and signicant regional imbalance can be observed in healthsystem development across states. The four Southern statesof Kerala, Tamil Nadu, Karnataka and Andhra Pradesh andthe Western states of Maharashtra and Gujarat are amongthe states which have shown consistently better health sectorperformance and health indicators than the less developedstates of Uttar Pradesh, Rajasthan, Bihar, Madhya Pradesh,Orissa, Chhattisgarh and Jharkhand. In maternal health in-dicators, for example, the MMR in Southern states averages149 as compared to 375 in the less developed states (4)The primary aim of the paper is to assess the contributing fac-tors and challenges and to generate context-specic imple-mentation lessons from the perspective of the stakeholdersin three diverse states in India which are at different levels interms of delivery of health services. These issues are in thecontext of the NRHM, one of the major health sector reformprograms in India which aims to provide quality delivery carein maternal health services.
Method
Data
The stakeholders for the study represented respondents atthe central and the state levels, which included planners andprogram managers from the National government as well asthe governments of Orissa, Tamil Nadu and Rajasthan andalso respondents from development, academic and researchinstitutions (
Table 1
). Thirty-three in-depth, semi-structuredinterviews were conducted in the three states between Marchand May 2010. A framework of stakeholders was developedto reect the study setting (context). Interviews were con-ducted according to a common framework and the paper ispart of the broader study to investigate perspectives on cur-rent planning and research agenda for quality of care (QOC)in the eld of maternal, newborn and child health (MNCH).In the interviews, respondents shared their professional andpersonal experiences in the four broad areas related to QOCfor MNCH. These included: a) The current health sector re-form: focus on quality maternal, neonatal and child health;b) Contributing factors; c) Challenges and bottlenecks and d)Implementation lessons.
Analysis
The analysis presented is qualitative and descriptive. Thenarratives have been analyzed using a combined inductive/ deductive approach. In this analysis, data were coded ac-cording to the interview discussion (‘topic’) guide (which alsoserves as the initial analytical framework). Through an itera-tive process of reviewing, and re-reviewing transcripts, data
Table 1.
Stakeholder Framework.
Respondent type/categoryGeographic location (state)Number of respondentsHealth and Family Welfare Department
Government / TAMIL NADUTamil Nadu4Government / RAJASTHANRajasthan5Government / ORISSAOrissa6Government / CENTRALCentral level2
Academic/development sector
Academia / research institutions National2NGOs / National/ StateNational4International NGOs / NationalNational10TOTAL33
 
HEALTH SYSTEMS AND POLICY RESEARCH
© Under License of Creative Commons Attribution 3.0 License
2012
Vol.
1
No.
1:2
doi:
10.3823/1101
3
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were also coded according to emergent themes. A descriptiveanalysis is presented to provide an overview of common is-sues and themes that arose in the discussions.
Selection of Study States
This paper is based on a study that was conducted in Indiaat the national and state levels, which have historically variedlevels of health and development performance. In order tohighlight the context of quality of care in maternal healthpost NRHM, indicator of MMR was taken as criteria to selectthe states, where the states are ranked as excellent, moderateand low performing. But for the present analysis the catego-rization of the states is at two levels, Tamil Nadu the betterperforming state and Orissa and Rajasthan as low performingstates, which are also based on NRHM classication of non-high and high focus states.The three states selected for the study, Tamil Nadu, Rajast-han and Orissa, are at different levels in terms of maternaloutcomes (4). Though in all the states there is visible im-provement over the years, but still in the states of Orissaand Rajasthan MMR is above the national average (
Figure1
). Tamil Nadu is one of the few states in India which hasalready reached the MGD 5.The research was approved by the Institutional Ethics Com-mittee of the institution conducting the study and also writ-ten consent was obtained from the stakeholders.
Figure 1.
Trend in Maternal Mortality Ratio: A comparativescenario among the study states.
Results
This section presents the key ndings from the stakeholderinterviews, relating to the changing quality of care scenariopost-NRHM, and the associated challenges that need to beaddressed by the states. Findings have been arranged in foursub-sections.
The current health sector reform scenario: focuson quality maternal, neonatal and child health
With the advent of NRHM in 2005 a sense of positivity re-garding health policy and programming for MNCH and QOCin India has emerged as a consistent theme across all thestates. NRHM is a departure from historical health planningas it “doesn’t focus on the goals but on inputs, strategies andprogrammes” for the “necessary architectural correction inthe basic health care delivery system”. [7] As a result, whilegood performing states like Tamil Nadu have made appre-ciable advancements, the scale of progress in low performingstates like Orissa and Rajasthan has been truly phenomenalcompared to last few decades.
“...of course in 2000 you didn’t have a National Rural HealthMission…. it was around 2005-06 that the turning point really took place in this country... it’s not just the positiveenvironment but it’s a very fertile environment for maternal health in India, post the launch of NRHM [...] there are policiesand they are backed up by budgets”, 
Senior Ofcial, Ministry of Health Government of IndiaThe impact of NRHM on QoC was corroborated by state anddistrict level planners as well as NGO representatives acrossthe various states, which is reected in terms of increase indelivery at lower end facilities. NRHM, as described by therespondents, seemed to address several key systemic issuessuch as infrastructure, more budgetary allotments, decen-tralisation, and bringing in managers into the health system.
 
The Janani Suraksha Yojana (JSY) a conditional cash transferscheme promoting institutional delivery implemented since2005 have brought into focus the issue the QoC at publichealth facilities . JSY had brought about a ‘pull factor’ thatworked as a catalyst to hasten the pace of health systemsdevelopment and also have highlighted the need of puttingin place the protocols for quality.

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