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“(This) time..is very crucial for us as the extension will be decided within a couple of months and we are applying for the same. Citizens Foundation is successfully managing many innovative and integral health care projects in different states of India. We are also planning for working in other states of North East. Therefore, we would appreciate if you can use your management skills to build a platform for us which can help us in Meghalaya in the longer run” Paromita Das, Nodal Officer for Meghalaya, Citizens’ Foundation
Sitting in her office in the sweltering heat of Kolkata, Ms Paromita Das is beset by a number of worries. It has been three years since Citizens’ Foundation has taken over the operation of five health centres in rural Meghalaya from the government. So far, the results have been mixed. While the functioning of these health centres has improved by leaps and bounds compared to the time when the government was running them, a number of concerns remain. Relations with the community in the areas of operation of these health centres are troubled – in one health centre, village representatives have demanded that Citizens’ Foundation hand the facility back to the government, while in another, the community has forced the ouster of a doctor that it was not comfortable with. The Foundation’s service performance, though reasonably good, significantly lags behind some of its peers’ (other NGOs). Staff attrition, inability to hire fresh talent and motivation of health professionals remain major issues. The original Memorandum of Understanding (MoU) with the National Rural Health Mission (NRHM) for running these health centres was for three years, i.e., from 2009 to 2012. It is now due for renewal. The NRHM would examine the NGOs’ performance in terms of service deliveries and extent to which the villages’ health needs are met. Depending on their assessment, they may choose to hand over additional health centres to the NGO, retain the existing number of health centres, reassign health centres between NGOs, reduce the number of health centres under the NGO or not renew the MoU at all. Ms Paromita Das realizes that Citizens’ Foundation must pull up its socks if the contract is to be renewed and a long term relationship established with the NRHM. The Foundation’s motto is ‘Service to Humanity’, and losing one or more health centres would be a major blow to organizational objectives.
About Citizens’ Foundation
Citizens’ Foundation is a non-profit organization that was established in 1997. Its operations are spread over 26 districts in Jharkhand, Meghalaya, Bihar and Uttarakhand. Interventions are made in the areas of health and sanitation, natural resource management, and education and child development. The activities of Citizens’ Foundation fall into the following categories:
1. Health and sanitation This includes operation of Primary Health Centres (PHCs) and Community Health Centres (CHCs), along with the ancillary sub-centres, meant to fulfil the health needs of rural communities in remote and inaccessible areas of Meghalaya. This is done through a Public Private Partnership model, where the operation of the health centres is the taken care of NGOs and the finance and infrastructure are supplied by the government. In addition, Citizens’ Foundation operates Mobile Medical Units (MMUs) to make healthcare available in remote areas of Jharkhand. Other interventions include the VISTAAR training programme for frontline health workers in Jharkhand, and routine immunization programmes. 2. Natural Resource Management and Livelihood promotion This includes the MESO prototype programmes designed to make water harvesting and irrigation techniques available to members of schedules tribes, System of Rice Intensification (SRI) in Jharkhand that increases paddy yield compared to traditional techniques, horticulture development under the National Horticulture Mission Programme, and collective marketing and income generation activities for artisans under the Baba Saheb Ambedkar Hastshipla Vikas Yojna (AHVY). All these activities are carried out in the state of Jharkhand. 3. Education and Child Development Citizens’ Foundation manages the Jharkhand State Bal Bhavan, which aims to foster the scientific spirit and encourage creativity among school students by organizing conferences, seminars and competitions. Additionally, it also manages four schools for child labourers in Bihar under the National Child Labour Programme (NCLP), where children receive financial support apart from education.
Its mission and vision statements are as follows:
Vision statement – Every inhabitant is self-reliant and prosperous through optimum utilization of available resources. Mission statement – To make a difference by developing strategies which are practical, acceptable and sustainable
The organisation structure of Citizens’ Foundation is presented in Exhibit 1. It is headed by a seven member governing body ranging in rank from President to Executive Member. Below the governing body in hierarchy are the Secretary and CEO who head the executive functions. The functional heads and programme managers report to the CEO.
The National Rural Health Mission (NRHM)
The NRHM was launched by the Government of India in 2005 under the Ministry of Health and Family Welfare with the objective of ensuring effective delivery of basic healthcare services. The launch of this mission was prompted by concerns on the state of public health in the country in general, and in the poor and underserved states in particular. For instance, public health spending had dropped from 1.3% of GDP to 0.9% of GDP between 1990 and 1999. Regional imbalances were significant, and delivery of health services was skewed towards the richest part of the population. In order to address these concerns, the plan of action calls for “increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalizing community health centres into functional hospitals meeting Indian Public Health Standards in each Block of the Country.” Under this mission, there is a special emphasis on 18 states that have performed poorly on public health indicators and/or have weak infrastructure. These states are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh. The goal is to “to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children.”
The important components of NRHM’s plan of action are: 1. Accredited Social Health Activists (ASHAs) The ASHA would be a female village member chosen by the panchayat to act as an interface between the village and the public health system at the grassroots level. Her services would be voluntary, but she would receive monetary incentives for achieving different objectives of the health delivery programmes. Her training would be on an ongoing basis and be conducted by the NRHM, funded by the Government of India. 2. Strengthening Primary Health Centres (PHCs) and Sub-Centres PHCs would be improved through regular supply of drugs and equipment, provision of 24*7 operations in at least 50% of the PHCs and observance of standard treatment protocols. Sub centres would be strengthened by releasing untied funds of Rs 10000 per annum. Regular drug supply would be ensured to the sub centres. 3. Strengthening Community Health Centres (CHCs) Under the plan, 3222 existing CHCs having between 30 and 50 beds would be operationalized. Indian Public Health Standards would be outlined that would set minimum norms for infrastructure, staff, management, etc. In addition, the plan envisions adherence
to the Citizens’ Charter by every PHC and CHC, apart from developing standards in hospital care. 4. District Health Plan A District Health Plan would form the core document for implementation of schemes related to water supply, sanitation, hygiene and nutrition. It would be a synthesis of village health plans, state and national plans for health, water supply, sanitation and nutrition. 5. Strengthening Disease Control Programmes The plan envisages integration of national disease control programmes in Malaria, TB, Kala Azar, Filaria, Blindness and Iodine Deficiency into the National Rural Health Mission. Prevention and treatment of these diseases would be done at the CHC/PHC level. Generic drugs to treat these diseases would be provided to the CHCs and PHCs. 6. Public Private Partnership (PPP) for Health Goals The policy document calls for regulation of private health service providers for greater transparency and accountability. It also talks about developing guidelines for public private partnership in the health sector.
Some of the important goals of the mission, as outlined in the Policy Document, are given in Exhibit 2.
PPP Model for Health Service Delivery in Meghalaya
The basic concept of the PPP model is that the operation and management of ‘difficult’ PHCs and CHCs would be turned over to NGOs and private parties. The government would provide funding for salaries and expenses, and would provide the building and its equipment and supplies. The NGO would bring in its staff and expertise to run the health centre, and would be responsible for utilizing the funds provided by the NRHM. The PHCs and CHCs would be run in the same way as government run health facilities, with 24*7 operations. The basic document governing the relationship between the NGO and the government would be the Memorandum of Understanding (MoU) that would have a life span of three years. After three years, it would be due for renewal/reallocation based on the NGO’s performance. The motive for implementation of this programme was the expectation that NGOs, with their professional management setup, would be able to do a better job of health service delivery in remote areas. The government run PHCs and CHCs in these areas did not meet with much success since staff motivation levels were low, absenteeism and turnover were high and outreach programmes were inadequate and failed to have the desired impact.
Since the programme was first implemented in 2009, the functioning of 22 PHCs, CHCs and state dispensaries has been taken over by NGOs, with varying rates of success. A list of all NGOs operating in this sector, along with the PHCs and CHCs under their control, is given in Exhibit 3. (For a map of Meghalaya’s districts and demographic information, please refer Exhibit 4).
Citizens’ Foundation’s in Meghalaya
Citizens’ Foundation has been running 3 PHCs and 2 CHCs for the past three years. While some of these health centres have been quite successful in providing health services and fulfilling objectives of NRHM, others have lagged behind. The NRHM uses five key metrics for assessing a health centre’s performance, which are explained below: 1. Number of OPD cases (OPD) – the number of people availing the Out-Patient Department (OPD) services of the PHC/CHC in a particular year. OPD cases are non-serious ailments for which the patient can receive treatment and return home the same day. 2. Number of IPD cases (IPD) – the number of people admitted to the hospital In-Patient Department (IPD) in a year. IPD cases are more serious and typically involve surgery and/or prolonged care, and for which the patient is in the hospital for more than a day. 3. Number of ANC registrations (ANC) – the number of women registering for and receiving at least one ante-natal check up (ANC) in a PHC/CHC in a year. The NRHM mandates that three ante-natal checkups be performed for every pregnant woman, one for each trimester of pregnancy. However, due to various factors, not all women avail of this service. The ANC figure includes women who have registered for either one or two ante-natal checkups, but not all three. 4. Number of 3 ANC registrations (3 ANC) – this is the number of women registering for and receiving all three ante-natal checkups. This figure is typically smaller than the number of ANC registrations. 5. Number of institutional deliveries (ID) – the number of women opting to deliver babies in a PHC/CHC in a particular year. OPD and IPD cases are chosen as health indicators as they provide the quickest estimate of the effectiveness of a health centre. Maternal healthcare is one of the main focus areas of the NRHM (this is linked to reduction in maternal and infant mortality rate, which are among the most important goals outlined in the policy document), and hence ANC, 3 ANC and the number of institutional deliveries are key metrics. Additionally, ANC and 3 ANC cases are also indicative of the impact of a health centre’s outreach programmes – as these checkups are non-urgent activities, the only way to get pregnant women to the health centres is through better outreach. The performance of each of Citizens’ Foundation’s health centres against the above parameters is shown in Exhibit 5.
The PHCs and CHCs of Citizens’ Foundation follow a ‘typical’ organizational structure as mandated by NRHM. Each health centre has an MBBS doctor and an AYUSH (Ayurveda, Yunani, Siddha and Homoeopathy) doctor, one of whom is the Medical Officer (M.O.) in-charge. They are the designated medical officers responsible for day-to-day functioning of the health centre and administrative tasks. They are authorized to handle IPD cases, deliveries and other surgical procedures. Depending on his level of involvement, the doctor may also participate in outreach programmes and make door to door visits for education and feedback. General nurse-midwives (GNMs) are supposed to assist the doctor in handling IPD/OPD cases, deliveries, etc. and are as such attached to the health centre. Auxiliary nurse-midwives (ANMs) have their primary duties outside the health centre and are supposed to visit village households for education and outreach. Health educators have a similar profile and are expected to coordinate with ANMs for outreach and for organizing events like health melas, Village Health and Nutrition Day (VHND), school health programmes, etc. Additionally, a health centre may also have clerks, accountants, etc. as per requirement.
Nongkhlaw CHC Nongkhlaw CHC is manned by a lone MBBS doctor, Dr. Narendra Singh, who is supported by Dr. Lakshmi Devi, the AYUSH doctor. Staffing is one of the critical issues faced by this CHC. Of the seven doctors who were originally with this facility in 2009, Dr. Singh is the only one remaining. The shortfall is covered by three doctors who visit twice or thrice a week. Even so, Dr. Singh finds it difficult to run in shifts with such a manpower shortage. Even the sub-centre assigned to this CHC is open only once a week and attended to by ANMs because of lack of manpower. Outreach is done by the health educator, Deibor, who visits villagers’ homes daily and educates them about sanitation, family planning, etc. Once or twice a month the doctor himself visits villagers to keep himself informed of their health situation. The doctor enjoys a good rapport with the community since he has been with the facility for three years. Outreach activities such as VHNDs, school health programmes, etc. are conducted 2-3 times a month.
Ichamati CHC The situation is similar at Ichamati CHC, which till recently was run almost single-handedly by Dr. Kamei, the MBBS doctor. The recruitment of two fresh medical graduates has eased the situation somewhat now. Although the CHC has had an AYUSH doctor, Dr. Lipika, for a while now, she has been accused of unprofessional conduct and prolonged unexplained absenteeism. Dr. Kamei has been pulled up by the management in the past for consuming alcohol on duty. Since Dr. Kamei is also relatively new (he has been with the CHC for 8 months), he has not yet been able to build a good rapport with the community – a problem that is further compounded by the fact that he is Manipuri and is unable to communicate in the local language. As a result, outreach is left mainly to the health educator, Romeo.
Kynrud PHC Kynrud PHC suffers from the handicap of not even having a single MBBS doctor. The whole show is run by the AYUSH medical officer, Dr. Manas Kar. In the two years that he has been with the PHC, he has managed to learn the local language and communicates with villagers in it. He also personally visits the villagers’ homes frequently and counsels them on maternal health and family planning issues. However, since there is only one doctor on duty, whenever he has to attend meetings and/or training programmes, there is no one to attend to OPD cases and hence the numbers suffer. Despite his best efforts, the community is not satisfied and wants the PHC to be taken over by the government. They have made representations to this effect to Citizens’ Foundation and the government, and a decision on this is expected soon.
Myriaw PHC While Myriaw PHC has performed reasonably well on health indicators, it has recently run into trouble with the community. The AYUSH doctor, Dr. Mohan, and the ANMs are motivated towards working hard and renewing the contract. However, there have been numerous complaints against the MBBS doctor, Dr. Salauddin Khan, for consuming alcohol on duty and for misbehaviour. As a result of the villagers’ repeated complaints to the District Medical Health Officer (DMHO), Dr. Khan has now been relieved of his post and has been asked to return to his hometown in Manipur. The good work done by Dr. Mohan and his colleagues has come under the shadow of Dr. Khan’s dismissal.
Maweit PHC The fifth PHC at Maweit is the most difficult and inaccessible. It is situated at the end of a 7 hour drive from Shillong through extremely bad roads. As a result, very few visits are made from the head office to this PHC, and the PHC suffers from neglect and lack of oversight. Health indicators for this facility are as such the worst across Citizens’ Foundation. As with other health centres, there is a severe staff shortage as well. The only doctor there, Dr. Alam, resigned recently and the PHC is now manned by the lab technician and the ANMs.
Branch Office – Shillong For administrative tasks and coordination with the Head Office in Ranchi, the branch office in Shillong is the centre point. A project coordinator along with a field officer are posted there permanently, and the nodal officer makes quarterly or yearly visits to ensure the smooth functioning of the office. The outlined tasks here include: Feeding the MIS reports in the computer, and sending the same to Head Office. Ensuring the smooth outflow and inflow of funds from every PHC. Resolving issues with the DMHO (District Medical Health Officer), as and when they surface.
Expediting and monitoring the progress of outreach programmes and any other health interventions run by the PHC at the ground level as part of their monthly plan of action
Head Office - Ranchi Here the nodal officer for Meghalaya and the Functional heads of the foundation are stationed. Once in two months, the financial officer of the foundation travels from Ranchi to Shillong to disburse the salaries. The nodal officer monitors the work of Shillong head office over telephone.
Citizen’s Foundation v/s The Other NGOs
Through various interactions with NRHM personnel, the relative positioning of all the NGOs in the Meghalaya region could be ascertained. Different NGOs were being given varying amount of funding (as illustrated in Exhibit 6). This fund included the amount required for staff salaries, general maintenance of the PHC (health and sanitation, laundry etc) and other administrative expenses. Consequentially, these funds were utilised to serve the needs of varying sizes of populations (as illustrated in Exhibit 7) of villagers, in different geographies. Thus many issues faced by the NGOs are different yet similar in nature. This opens an opportunity to study these issues more in detail, to identify trends across NGOs and suggest implementable solutions.
Organizational Issues at Citizens’ Foundation
The issues faced by The Citizens’ Foundation are manifold – some systemic, some perennial, and some unpredictable. There are, though, a number of problems that are omnipresent in the whole organisation, inherent to the cultural DNA of the organisation. There may be different ways of looking at these, but broadly they can be classified as issues that are internal in nature (inside out) or external in nature (outside in). These are discussed in detail below.
HR issues Of all the functional issues, ranging from operations to finance and everything in between, HR seemed to be the albatross around their neck. So much so that at every level of the organisation structure, there are staffing issues related to hiring, absenteeism, appraisal, training, compensation and retention. The Foundation finds it very difficult to retain medical personnel, who leave the NGO on finding government jobs or higher paying private jobs. Applications for joining Citizens’ Foundation are few and far between, and hence the organization has got itself into a position wherein it has to hire almost anyone who applies. The support staff in a PHC/CHC reports directly to the medical officers in theory. In practice, however, at Citizens’ Foundation, this oversight is poor. Most of the ANMs and health educators work on their own with little reporting to the M.O’s. Part of the reason for this is the chronic shortage of doctors at the Foundation, which leaves them with very little time to oversee the activities of the support staff. Citizens’ Foundation does not advertise for vacant positions, nor does it visit medical college campuses for recruitment. Hiring is primarily word of mouth and relationship based. For instance, a
doctor currently working at the Foundation would recommend it to a friend who would then apply for a job. The organization receives only a few applications, and hence selectivity is low. This is probably because Citizens’ Foundation is relatively lesser known and does not enjoy a big brand name among doctors. Hiring is typically skill and experience based, with relatively low emphasis on cultural and value fit. The Foundation’s salaries are compared with other NGOs’ in Exhibit 8. Even the skill based aspects are severely underplayed, in certain situations. At times, it is just about the availability and the willingness to work. Ability to carry out the job role specifically ignored. This leads to a lot of angst amongst employees who are not able to deliver, not realising that it is due to their incompetency rather than their incapability. There is no system of performance review or appraisal at the end of every year. All employees who have completed a year with the organization are given a blanket pay raise of 10%. Additionally, there are no formalized procedures for training new recruits or for continuing education of existing employees. Training is done on an ad-hoc and informal basis by, say, senior staff to the junior staff. Staff motivation is a critical concern at Citizens’ Foundation. In their interviews with the authors, none of them indicated a higher purpose (such as a desire to serve people, to help improve the health conditions of marginalized villages, etc.) as the driving factor. Most of them joined only because some acquaintance had recommended that they do. Many employees, especially doctors, indicated that they saw this as only a temporary posting and would quit as soon as they got a government job or a job in their home state. The management of Citizens’ Foundation is very handsoff and interferes in the functioning of health centres only when problems crop up. Consequently, it is sometimes criticized by ground-level staff as not being supportive enough. Regarding retention of talent, the entire voluntary healthcare industry suffers due to its very nature. Good doctors would prefer a government job in their current semi urban setting or a private job in an urban environment. The level of commitment towards the cause becomes an overriding factor, where other NGOs such as Bakdil score much higher (owing to their religious allegiance). Thus balancing talent and commitment becomes an issue in such circumstances. Contrary to popular belief, our study concluded that level of commitment must be given priority, as technical competency can be developed externally, yet the alignment towards the cause is more intrinsic and hence more important. This also speaks volumes about the core values of Citizens’ Foundation, that seem to only exist at the top level of the management but not percolating to the bottom of the organisational hierarchy. This leads to higher attrition and conflict between the lower and upper management. The Nodal officer is not able to understand the approach of the field staff, and the field staff in turn feels a sense of disconnect with the Nodal officer and her team. The classic response from either side would be – “I really don’t see where you are coming from”. The lack in HR discipline also leads to poor relationship building and strengthening. Neither does Citizens’ Foundation follow a structured policy of hiring people from the surrounding villages, nor do they do anything outside of their prescribed responsibilities in the charter for the betterment of the villages. This is for two reasons: Firstly the staff requirement for the basic activities is not sufficient, let alone the additional activities they should be taking up. Secondly, even if the people were there they are not motivated enough to build sustaining relationships with the village heads and people. This puts additional pressure on the doctors to personally go out to the village and meet everyone (the children, the workers, the teachers, the opinion leaders, and the heads).
Reporting structure and Communication A major issue is the lack of communication between the field and the head office. PHCs and CHCs of Citizens’ Foundation send monthly MIS reports (detailing number of cases handled in that month, staff positions, inventory positions, etc. in the format specified by NRHM) and attendance records to the head office in Shillong. Apart from this, there are no informal channels of communication. Information is sent to the head office/nodal officer in an ad hoc manner, or only when there are issues. At the Foundation, the management structure consists of a Field Supervisor and an Assistant Project Coordinator at the Shillong office for coordinating between the health centres. The entire project is managed by the Nodal Officer who sits in Kolkata. The location of the nodal officer makes it impossible for her to visit health centres in Meghalaya. Both the employees of the Shillong office make infrequent visits to the field because of their schedules, which leads to a situation in which there is very little oversight of on-ground activities. Communication and coordination between the field and the office is poor, and the management is not apprised of events in the field as and when they happen. To this extent that the leadership (Nodal officer and her team) at Ranchi also seem to have a very “hands-off” approach to issues in Shillong. Their reactive approach is usually triggered when a village sardar directly calls her, complaining about the services of the PHC, and threatening action against them, or when the DMHO calls her and complains about the performance indicators that are dropping in their monthly assessment, and threatens withdrawal of contract in the next cycle. Internal communication at the health centres is weak. Staff meetings are not held regularly at most PHCs/CHCs, but are done on an ad-hoc basis. Meetings with external stakeholders such as ASHAs and community leaders are also infrequent. This is also because of the unclear allocation and enforcement of responsibilities between the internal and external resources. In the PHCs and CHCs of the Foundation, outreach is conducted by the ANMs and the health educators, who go door-to-door and educate people about sanitation, family planning, etc. Outreach programmes include Village Health and Nutrition Day (VHND), held once a month; immunization camps, school health camps, and so on. They typically number 2-3 a month. These programmes are conducted with low-to-medium involvement of the Medical Officer in-charge. For instance, Dr. Singh of Nongkhlaw CHC makes visits to the village about once a month to talk to them about their needs and problems. Dr. Manas Kar of Kynrud PHC visits 2-3 villages a month for outreach. This again points to staffing problems – while the doctors are certainly motivated to connect with the community, but are unable to do so since staff shortages force them to stay back at the health centre to take care of the IPD/OPD cases. This results in duplication and dilution of responsibilities in the PHCs. Also, the outreach may be conducted well even at the PHC level, but its effectiveness is never monitored by the NGO representatives. As a result the outreach loses its objectivity, and becomes an “activity of convenience” for a doctor. Incase there are funds to spare, and lesser load of patients on a particular day; a doctor may allot the responsibility to an ANM to go to a nearby village and conduct a health talk. There are weeks where outreach is not conducted at all. This reduces the recall of the villagers regarding the health services of the PHC, deteriorates the trust the
villagers have on the PHC’s capabilities and also weakens the link between the village community and the PHC and NGO.
Systems and Processes Internal systems are also a big issue with Citizens’ Foundation, which is a corresponding strength for their counterparts Bakdil. These include the documentation systems, the inventory management systems and the patient monitoring systems. The traceability of any communication that is sent and received to and from the PHC is questionable. At the ground level, there is no person identified to look after documentation in specific. Although the systems for contacting and monitoring patients are fairly standardized as per NRHM guidelines, they are not well laid out, designed and deployed at the working level. Ideally whenever a patient comes for treatment, her particulars should be entered into a register kept specifically for this purpose. At the end of the month, these records should be collated into MIS reports. In case of a repeat visit, the patient is supposed to bring in a slip which is matched with her earlier entry in the register to retrieve her history. But of course, this does not happen. Patients, infact, do not even make a comeback because of the distance, time and effort involved in doing so. If the information of the MIS reports was managed and captured “meaningfully” rather than as a “data collection activity”, then these very patients could have been contacted and followed up to cover the last mile. The outreach generated the first footfall at the PHC of the patient, but the MIS systems that were not in place could not followup the patient to engage and ensure the link was maintained. Even the accounting systems are generally weak at Citizens’ Foundation, primarily because there is no provision for an accountant at the health facilities, except at Myriaw PHC. This accountant maintains income and expenditure records, plans RKS funds, and does all the budgeting activities in a systematic manner. But this accountant is now leaving the PHC, as she has been transferred to a government PHC, and the NGO is expected to hire an accountant themselves. As they do not have a prior experience of hiring accountants, they are faced with the additional challenge.
There were a myriad of issues outside of Citizens’ Foundation that were adversely affecting their ability to deliver effective healthcare services to the villages. Coordination with External Stakeholders The ASHA, IEC and RKS networks exist for facilitating the work of the NGO at the PHCs & CHCs. Yet, Citizens’ Foundation was unable to leverage on these resources effectively by not establishing sound processes at the interfaces of these external stakeholders. 1) ASHA Network - The ASHA facilitator is a resource that is provided by the NRHM to the NGOs to help them run the ASHA programme. Yet, this facilitator is most of the times absconding or unaware of the issues prevalent at the ground level. Rather than apprising her of the situation, and delegating the responsibility to her, the Doctors further burden the ANMs and GNMs with her work. This results in duplication and dilution of work. Also, the ASHA’s network and the PHC’s own network are kept insulated from each other. Thus the on
ground activities of the ASHAs are not in sync with those of the PHC. Eg: If the incidence of water borne diseases such as Malaria arises in the nearby villages during rainy season, the ASHAs should be educating the villagers about protecting themselves from mosquito bites by putting mosquito nets and utilising repellent creams, and also staying away from still water bodies during this time as they are the breeding ground for these mosquitoes. Parralely, the ASHAs should inform the same to the PHC so they can hold sessions on Malaria prevention during the VHND and Health Melas, and also stock up extra medicines which would help curing of and prevention of Malaria. This collaborative approach helps in the long term sustainability of the PHC in the village community. 2) IEC Network - IEC is a separate department, under the NRHM, that stands for Information, Education and Communication. The role of the department is to aid or drive effective dissemination of healthcare information into the village community using media. The person responsible for IEC effectiveness at the PHC level is the Health Educator (HE). His/her salary is also incentivised based on no. of village health meetings, counselling sessions, focus group discussions and other workshops conducted. The HE is usually informed about the health state of the village (general diseases prevalent, susceptibility of the community towards an ailment, spread of unhealthy habits of the people (such as alcoholism, smoking etc.) and thus is able to align the content of the media communication with that of the village needs, which is important to build synergy within the system. A conflict would result in interference and confusion amongst villagers. 3) RKS (Rogi Kalyan Samiti) Network - The RKS is a management committee formed at the PHC/CHC and village level to oversee all the basic operations of the PHC/CHC, primarily focussing on the financial transactions. It meets once in a quarter to decide on how to best utilise the funds that are sanctioned by the NRHM under the account of the RKS, and also to correspondingly monitor/audit the spending of the said amount as per the budget decided. To ensure accountability, it consists of members from the local Darbar (Panchayati Raj Institutions), NGO representatives (typically the Medical officer (M.O)), village representatives from educational institutes such as schools and certain government officials. The RKS funds of the PHCs under Citizens’ Foundation were grossly mismanaged. In many cases the funds were underutilised, and hence returned to the NRHM office. Being unaware of the infrastructure related issues troubling the village, the committee would allocate funds based on snippets of information of few areas in focus. And most importantly, there was no long term vision of the committee to save funds for purchases of larger assets that would provide a much needed boost to the health infrastructure of the village. Paltry sums of money would inevitably be spent on procuring extra syringes, medicines and other surgical consumables. 4) VSH&NC (Village Health Sanitation and Nutrition Committee) – The VSH&NC is a cross functional body that looks after assessing the overall health needs of the village. It is a committee that is of the village, by the village and for the village. Since the committee is involved in not only health but sanitation and nutrition as well, it is instrumental in preparing the “Village health plan” on an annual basis, for which it is provided with Rs 10,000 / annum. These plans are then amalgamated to generate the District level health plan. 5) External events and shows – There are a host of other programmes such as the VHND, Health Melas, School health programmes, Village health camps that are organised
throughout the year to increase awareness amongst the villagers towards safe and sound health practices. These are all incorporated under the “outreach strategy” of the PHC. Pictures of these events are given in Exhibit 9.
Best Practices at Other NGOs
Two other NGOs, viz., Bakdil and Karuna Trust, that were studied in the course of the project had vastly different structures, systems and processes. These two NGOs, though very different in approach, gained similar results in terms of societal impact, good health indicators, and sustainable practices. Bakdil – The faith driven approach Bakdil, a Christian missionary run NGO, depends on their faith driven approach to carry forth a flawless healthcare delivery model. This engine of pure commitment to the cause is what makes them the most effective NGO in Meghalaya under the NRHM. They run 5 PHCs in the Garo Hills area. Despite the difficult terrain and inaccessibility of the region, the NGO has been operating in this region in the past 3 years successfully. Given below are some of the best practices followed by Bakdil that can be considered by Citizens’ Foundation for their perusal, and further integration: 1) Sister-in-Charge (SIC) – Bakdil has a unique position in their organisation called the “Sister In Charge”. All the staff of the PHC administratively report to her, and she plays out the role of a de facto head of the entire setup. She not only develops the vision of the PHC, but also helps in ground level execution of some of its most critical processes. She is a source of inspiration for the PHC staff. She ensures regular reporting, frequent meetings and an effective outreach. She almost gets personally involved in every function in the PHC to not only ensure last mile delivery of the task, but also keep the internal and external stakeholders on their toes. The presence of such a highly motivated and dedicated leader ensures effective functioning of the PHC, even with minimal management oversight. 2) Review meetings – Bakdil has a system whereby they not only maintain a calendar of the meetings that they have had / are planning to have, but also maintain all the minutes of the meetings. This ensures accountability, effective followup and a sense of discipline. The meetings are various – with the individual stakeholders, including the ASHAs, the RKS, the internal staff, the head office staff (with the Programme Monitoring officer (PMO) and the overall incharge of the NGO – Father Sunny). The frequency of these visits is pre decided and set to a level which is much higher than the requisite norms of the NRHM and the overall benchmark levels of the industry (in comparisn with the other NGOs). Monthly report meetings happen at Tura, involving all SICs of all the PHCs in that area. During these meetings, each PHC gives a status update through powerpoint presentations. Sufficient management oversight is present when it comes to PHC operations, with Father Sunny and Sister Isabelle making monthly visits to not only maintain a check on the work being carried out, but also recognising the efforts being channelled by the PHC staff towards the cause. 3) Outreach proactiveness – The SIC of the PHC ensures that there is a constant line of communication with the village people that can be used to permanently feed information to
the PHC staff regarding the village health issues, news about any ailing mother and even regarding certain village happenings that may affect the functioning of the PHC in any adverse way. This link between the PHC and village is primarily kept alive by the SIC. Conversely, to expedite information dissemination to the village from the PHC, the SIC ensures a schedule of the ASHAs and the ANMs such that they are able to completely cover each of the 21 villages in one month. The ANMs prepare their daily, weekly and monthly outreach schedules under the able guidance of the SIC. 4) Central HR – All the recruitment, training and appraisal activity is handled by the head office centrally. This helps in standardising performance management processes, preparing training schedules etc. Also, they have set a 3 month probation period for every doctor, nurse or helper they recruit at the PHC. This ensures that the bad apples are automatically removed from the system. Also, unlike Citizens’ Foundation, Bakdil has monthly targets for all categories of staff. This objectivises the efforts of all the staff – right from the head doctor to the chowkidar. At the end of the year, the highest performers are given a cash reward. This entire process is administrated by the Central HR at Tura. Training and Development also happens at the PHC level, with the SIC, owing to her experience, imparting knowledge to the younger staff about a certain relevant topic every week. These series of sessions are known as “Continuing Medical Education”. Even the issue of absenteeism has been dealt with innovatively by carrying out installation of CCTVs at the entrance of the PHC, to not only monitor attendance but also general PHC activity. In some of the other PHCs of Bakdil though, a register has been kept that is maintained 5) Catholic influence – The highest success factor probably for Bakdil is the fact that it is a part of the Church of Tura, and hence has an excellent brand pull in this Christian dominated region. Thus it can draw upon the vast resources and influence of the Catholic Church to fulfil its objectives. Each PHC has an agreement with a Catholic congregation whereby the post of the Sister-in-charge is ‘outsourced’, and the congregation obtains monetary benefit from the arrangement. If nothing else, this translates to an immense motivation on the part of the SIC to devote herself towards the “healing of sick people”.
Karuna Trust – The “pioneers of the PPP model” approach With the 6 PHCs and a State owned dispensary under their control, the Karuna Trust has established itself as a brand to be reckoned with not only in this region but nationally. Karuna Trust was the first amongst NGOs to start working in this area in 1986. They created, refined and established the PPP model as a successful health delivery vehicle in Andhra Pradesh, and then spread it to the rest of India. Thus there are various best practices that Citizens’ Foundation can adapt from them, given the fact that they are not a faith driven culture as observed in the previous case of Bakdil. Many of these are similar in application to Bakdil, and hence those have been marginalised here, to avoid repetition. 1) Inventory management – Karuna Trust has setup an impressive inventory management system wherein stock tallying is done at a daily level, instead of at a monthly level. (refer Exhibit 10) This gives a clear picture to the doctor in charge regarding the inventory levels of key items such as syringes and swabs that need to be always kept in stock. Also, this makes
the safety stock for Karuna Trust leaner and more adjusting towards daily fluctuations. Not only this, the aesthetic style of coding the medicines by colour and arranging them on shelves that are very clean adds a feel good factor to your pharmacist and to his work area. Sharing of best practices – For Karuna Trust, the head office is located at Shillong, which is a formidable distance from the PHC location. Yet, once a quarter, one ANM, one GNM and one Health Educator accompany the doctor in charge to the Head Office for a 3 day health conclave organised by Karuna Trust. This is attended by doctors and staff from each PHC, and the top management from the head office, making it a large gathering. The objective of mobilising such large scale long scale travel from others is to formulate a gathering where “sharing of best practices” alongwith “Competitive benchmarking” can be the main agenda. Outreach frequency and effectiveness – Karuna Trust ranks #1 in terms of the quality of their outreach program. The M.O in charge realises the value of good outreach activation, and hence personally participates in each of the outreach camps. They have almost 7-8 camps a month, the most amongst all NGOs. The planning of these camps is done much in advance, and hence all the stakeholders – the village people, the panchayat and the key opinion leaders – are informed well within time. Most importantly, the quality of the program is kept at the utmost highest level by ensuring mix of education and entertainment, so that the absorption rate of the general public is much higher. So much so, that new formats, that are nowhere followed across Meghalaya, are instituted and religiously followed here at Karuna Trust (such as Baby Shows, wherein women are called to showcase the health of their children to the doctors of the PHC, and the mother of the healthiest baby would win a cash reward. This motivates the mother to turn up for such a show where vaccinations and oral medicine dosages are given out for free.). The innovative nature of these outreach vehicles, has led to them being covered by NRHM newsletters as some of the best practices in the health space of Meghalaya. Motivation to deliver – Karuna Trust, though being an NGO, is completely managed as a professional organisation. The entire staffs, including the doctor, have a variable component of their salary which depends on the extent of achievement of their targets. These targets are set in consultation with the respective superior in the organisation structure, and are mutually agreed upon beforehand. Despite the monetary incentive to deliver, the clear conscience to work with a vision was clearest in case Karuna Trust staff. Infact, most of their staff, was present there just to do something for the people of their community and that money was not very important to them. They even went so far as to compare patients to “customers”, and that serving customers effectively was their one and only duty and responsibility. This completely transforms the culture of the organisation and work environment, making it more congenial to positive change and acceptability. Autonomy – Lastly, Karuna Trust has been known to take decisions regarding critical capital purchases at the very ground level of the PHC. At one of their PHCs, the doctor personally accumulated a portion of the RKS funds over a few years and purchased an entire ambulance for the village! This freedom can majorly be attributed to the decentralised approach of the Head office at Shillong as well. Another similar initiative is a separate room for ASHAs at the PHC that was decided by the doctor in charge, and not the Head Office. The reason given was that “if you require the ASHAs to function, you need to make them feel as if this PHC is like their home. Hence we must have a separate ASHA room in the PHC.”
The Citizens’ Foundation is at the crossroads of its journey towards becoming more than just a social service provider. It wishes to adopt a more community focussed approach, and develop effective systems, processes, checks and balances to ensure that there are no leakages in the system in terms of delivering health care solutions to the people of Meghalaya. But it needs to decide firstly what is wrong with its current way of working, and from where should it start looking at the cracks. It also needs a prioritisation of recommendations, and an action plan to implement them, so that it can embark on a path to effective healthcare delivery.
Exhibit 1: Organizational chart of Citizens’ Foundation
Exhibit 2: Target health indicators for NRHM
Infant Mortality Rate (IMR) Maternal Mortality Rate (MMR) Total Fertility Rate (TFR) Malaria Mortality Reduction Rate Kala Azar Mortality Reduction Rate Dengue Mortality Reduction Rate Leprosy prevalence rate Tuberculosis DOTS services
Pre-NRHM level (2005)
58/1000 live births 301/100000 2.9 1.8/10000 -
Target after NRHM implementation
30/1000 live births 100/100000 2.1 50% by 2010, additional 10% by 2012 100% by 2010 and sustaining elimination until 2012 50% by 2010 and sustaining at that level until 2012 < 1/10000 85% cure rate through entire Mission period
Exhibit 3: List of NGOs operating and PHCs/CHCs controlled by them
Number of PHCs/CHCs/State dispensaries run
List of Health Facilities run
Saipung PHC Umkiang PHC Wageasi PHC Gabil PHC Salmanpara PHC Babadam PHC Siju PHC Ichamati CHC Nongkhlaw CHC Kynrud PHC Myriaw PHC Maweit PHC Barato PHC Sahsniang PHC Umtrai PHC Jirang State Dispensary Warmawsaw PHC Mawlong PHC Mawsahew PHC Aradonga PHC Jatah PHC Dangar PHC
Akhil Bharatiya Kishan Kalyan Samiti (ABKKS) Bakdil
Jaintia Hills Development Society (JHDS) Karuna Trust
Jaintia Hills Jaintia Hills East Garo Hills East Garo Hills West Garo Hills West Garo Hills South Garo Hills East Khasi Hills West Khasi Hills West Khasi Hills West Khasi Hills West Khasi Hills Jaintia Hills Jaintia Hills Ri-Bhoi Ri-Bhoi Ri-Bhoi East Khasi Hills East Khasi Hills West Khasi Hills East Khasi Hills East Khasi Hills
Voluntary Health Association of Meghalaya (VHAM)
Exhibit 4: Demographic information for Meghalaya
Above: Meghalaya’s political map, with its districts and major urban centres, is shown in the figure above1 District-wise population data as per the 2001 census is given in the table below2 District Name East Garo Hills East Khasi Hills Jaintia Hills Ri Bhoi South Garo Hills West Garo Hills West Khasi Hills Total
250,582 660,923 299,108 192,790 100,980 518,390 296,049 2,318,822
Exhibit 5: Service deliveries from 2009-2012 for all of CF’s PHCs/CHCs
Note: Data for 2009-10 is regularized by extrapolating few months’ data to the whole year
OPD IPD ANC 3-ANC ID
Ichamati CHC 2009201010 11 15130 14532 638 870 226 294 226 255 55 56
201112 15217 980 286 149 80
Nongkhlaw CHC 2009201010 11 21396 17233 344 400 174 214 16 57 30 67
201112 22429 366 331 105 66
Myriaw PHC 2009201010 11 9722 14684 8 36 316 261 52 36 0 0
201112 12142 192 375 173 9
Centre for Peace and Development Studies website, http://cdpsindia.org/meghalaya_map.asp, accessed 29 April 2012 2 Census of India website, http://www.censusindia.gov.in/PopulationFinder/Population_Finder.aspx, accessed 29th April 2012
OPD IPD ANC 3-ANC ID
Kynrud PHC 2009201010 11 15123 11648 302 218 72 154 29 48 12 8
201112 12293 324 339 172 48
Maweit PHC 2009201010 11 6047 4681 253 227 241 181 438 20 1 0
201112 4207 472 225 52 3
Citizens’ Foundation - Total 20092010201110 11 12 67418 62778 66288 1545 1751 2334 1029 1104 1556 761 416 651 99 131 206
Exhibit 6: Monthly funds provided under NRHM to PHCs/CHCs under the PPP mode
Akhil Bharatiya Kishan Kalyan Samiti (ABKKS) Bakdil
List of Health Facilities run
Saipung PHC Umkiang PHC Wageasi PHC Gabil PHC Salmanpara PHC Babadam PHC Siju PHC Ichamati CHC Nongkhlaw CHC Kynrud PHC Myriaw PHC Maweit PHC Barato PHC Sahsniang PHC Umtrai PHC Mawlong PHC Mawsahew PHC Jatah PHC Dangar PHC
Jaintia Hills Jaintia Hills East Garo Hills East Garo Hills West Garo Hills West Garo Hills South Garo Hills East Khasi Hills West Khasi Hills West Khasi Hills West Khasi Hills West Khasi Hills Jaintia Hills Jaintia Hills Ri-Bhoi East Khasi Hills East Khasi Hills East Khasi Hills East Khasi Hills
Monthly funding provided (Rs.)
2,40,000 2,25,000 2,52,000 2,34,000 2,47,000 2,34,000 2,36,000 4,00,000 4,18,000 2,38,000 2,18,000 2,18,000 2,22,833 1,89,333 2,01,366 2,00,000 2,28,366 2,05,000 2,05,000
Jaintia Hills Development Society (JHDS) Karuna Trust
Voluntary Health Association of Meghalaya (VHAM)
Exhibit 7: Population Served by PHCs/CHCs of Citizens’ Foundation, Karuna Trust and Bakdil Citizens' Foundation Health centre Population Ichamati 8055 Nongkhlaw 10217 Myriaw 10225 Kynrud 6209 Maweit 6450 CF - Total 41156 Bakdil Health centre Gabil PHC Babadam PHC Salmanpara PHC Siju PHC Wageasi PHC Bakdil - Total Karuna Trust Health centre Mawlong PHC Mawsahew PHC Umtrai PHC
Population 3825 9015 8421 7380 10200 38841
Population 3689 3297 4104
KT - Total
Exhibit 8: Salary data Citizens’ Foundation (Rs) 12000-15000 22000-36000 15000 34000 Karuna Trust (Rs) 18000-20000 30000 20000 30000 Bakdil (Rs) 12000-15000 25000-45000 13500 38000
AYUSH doctor range MBBS doctor range AYUSH doctor median MBBS doctor median
Pictures of External events (Clockwise from top left picture: 1. Crowd present at Health Mela 2. Health Mela poster 3. Baby show being conducted at one of the PHCs.
Exhibit 10: Arrangement of physical inventory at Mawlong PHC, Karuna Trust (tags below each shelf indicate name and expiry date of the medicine)
The cases focuses on key organizational issues that aid or hamper the performance of NGOs in the health service sector in the remote north-eastern corners of India. It can be used as a teaching aid in strategy and/or ADMAP classes. The case is divided into three parts – the first part outlines the dilemma of the protagonist and gives an introduction to the NRHM, the PPP model of health service delivery and the role of NGOs in them. The second part documents the operations of Citizens’ Foundation during the three years that it has been active in Meghalaya. Key performance measures and the performance of the Foundation along those measures have been presented. The third part details the performance of other NGOs working in similar conditions and gives a glimpse of how their operations are managed. The case aims to help students see organizational issues in a holistic manner and evaluate how elements of staffing, structure, strategy, etc. come together to affect performance in an NGO.
The key objectives of the case are as follows: 1. To help understand health and development issues in remote and inaccessible corners of North East India 2. To enable identification of key performance metrics that define organizational effectiveness 3. To help students evaluate performance of an organization in terms of the metrics defined above, and help compare performance across organizations using these metrics 4. To motivate a systematic investigation into the factors affecting difference in performance using strategy frameworks 5. To benchmark best practices across organizations and give recommendations for improving systems in the NGOs, and prioritizing them on the basis of implementability
Questions for discussion
The classroom discussion may proceed along the following lines: 1. What are the strengths and weaknesses of the PPP model for health service delivery in Meghalaya? Do you think it is a sustainable model? 2. What key metrics would you use to evaluate whether an organization has been effective in delivering health services? 3. Do you think Citizens’ Foundation has been successful in its operations in the time that it has been operational in Meghalaya? How would you support your conclusion using the key metrics defined above? 4. Has Citizens’ Foundation been more successful or less successful than Bakdil and Karuna Trust? What metrics would you use to support your conclusion?
5. What are the differences in output between Citizens’ Foundation, Bakdil and Karuna Trust? What are the reasons for these differences? Based on this, what key issues can you identify in Citizens’ Foundation’s operations? 6. If you were to suggest improvements in Citizens’ Foundation’s operations, what recommendations would you make? How would you classify them into short term and long term goals? 7. Suggest a plan of action based on the above recommendations. Which issues would you tackle first?
The case may be discussed in one classroom session of 70 minutes. Students may be asked to read the case beforehand and prepare notes on suggested questions.
The analysis may begin with an assessment of Citizens’ Foundation’s progress in the three years that it has been operational in Meghalaya. For this, the record of service deliveries (along the five parameters mentioned in the report, viz., IPD, OPD, ANC, 3 ANC and ID) may be compared year on year for each PHC/CHC and for the Foundation as a whole. This is shown in Figure 1.
Figure 1: Service deliveries in Citizens’ Foundation’s PHCs/CHCs The trend in service deliveries may be used to analyze whether or not a particular health centre has been successful. Qualitative reasons for a rise or fall in a PHC/CHC’s service deliveries may be obtained from case facts, and may be used to strengthen the conclusion drawn from quantitative data shown in the graphs in Figure 1. The analysis may then proceed to a back to back comparison of service deliveries across different NGOs using the data given in exhibits. It may be useful to compare service deliveries not as an absolute figure, but in terms of per capita population served (which is a measure of effectiveness) and per lakh rupee of funding input given by NRHM (which is a measure of efficient conversion of input to output). This analysis is shown in Figures 2 to 4.
Figure 2: Funding data for three NGOs
Figure 3: Health indicators per 100 population for three NGOs (All OPD figures divided by 100 to bring them on a common scale)
Figure 4: Health indicators per lakh rupee input for three NGOs (All OPD figures divided by 100 to bring them on a common scale) Figure 3 is obtained by dividing OPD, IPD, ANC, 3 ANC, ID and FI numbers by known population figures. All numbers are expressed in per 100 population. Figure 4 shows the output health indicators per lakh rupee funding given to the NGO. These figures are obtained by dividing known health indicators by funding data obtained from Figure 2. All numbers are mentioned on a per lakh rupee basis. Figure 3 indicates that despite having the lowest per capita funding, Bakdil outperforms the other two NGOs by a significant margin in all health indicators except OPD, where the leader is Karuna Trust. Karuna Trust performs better than Citizens’ Foundation in 3 ANC, ID and FI cases, but is still behind Bakdil. Taken at an aggregate level, therefore, these figures indicate that in terms of effectiveness, Bakdil is performing the best, followed by Karuna Trust and Citizens’ Foundation. Figure 4 indicates that Bakdil is the clear leader in all output indicators when measured on a per lakh rupee basis, i.e., it is the most efficient in converting each rupee input into health output. Bakdil is followed by Citizens’ Foundation and then by Karuna Trust on all measures except Institutional Deliveries, where the order is reversed. In full immunization and in OPD, the difference between Karuna Trust and Citizens’ Foundation is only marginal. The next step in the analysis is a systematic study of the drivers of organization performance, i.e., why some NGOs perform better than others despite similar funding levels and similar operating conditions. This analysis may be performed using the McKinsey 7S model, which describes organizational effectiveness in terms of the ‘Hard’ Ss (structure, strategy, systems) and the ‘Soft’ Ss
(staffing, skills, shared values and style). The observations recorded in the case may be classified into each of the 7 Ss to gain a clear understanding of what factors contribute to organizational effectiveness. Finally, areas of improvement for Citizens’ Foundation can be obtained from the benchmark study performed above. These areas can be classified into short term and long term objectives, and recommendations can be given to address them separately. Some suggested recommendations are as follows: 1. 2. 3. 4. 5. 6. 7. Tie-ups with medical colleges for recruitment of doctors Conducting exit interviews with staff who have submitted their resignation Introduction of performance-based pay for all staff (Karuna Trust model) Regular salary payment (monthly) to all non-Grade 4 staff through account deposits Institution of reporting and communication procedures (with minutes) – Bakdil model Separation of administrative and medical functions (Bakdil model) Appointment of an accountant and a clerk-cum-computer operator for every PHC/CHC
The analysis of the NGOs’ operations in Meghalaya will help the student gain a holistic view of organizational performance and help understand how factors such as structure, staffing, systems, etc. contribute to outcomes.
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