Health, and health services Health, and health services in rural Rajasthanin rural Rajasthan

Improving Health StatusImproving Health Status

Seva Mandir was keen to find new Seva Mandir was keen to find new interventions for its health unitinterventions for its health unit

..but no idea what the outstanding issues ..but no idea what the outstanding issues and concerns wereand concerns were

Need to start a descriptive surveyNeed to start a descriptive survey

With the view of using survey results plus With the view of using survey results plus available knowledge to develop available knowledge to develop interventions that have a chance to workinterventions that have a chance to work

Udaipur rural health surveyUdaipur rural health survey

Data collection in rural Udaipur district, Data collection in rural Udaipur district, RajasthanRajasthan

100 hamlets from 362 villages(poorer than 100 hamlets from 362 villages(poorer than average)average)

Stratified by distance to road: 50 at least Stratified by distance to road: 50 at least 500 m from a road500 m from a road

Survey structureSurvey structure

Four componentsFour components

1. Village census 1. Village census – listing, facilities, maps, infrastructurelisting, facilities, maps, infrastructure

2. Facility survey2. Facility survey– 143 public facilities143 public facilities– Several hundreds “modern” private facilitiesSeveral hundreds “modern” private facilities– 225 bhopas225 bhopas

Survey structureSurvey structure

3. Weekly facility visits3. Weekly facility visits– 49 per facility on average49 per facility on average– Are they open?Are they open?– Who is there?Who is there?

4. Household survey4. Household survey– 1,024 households, 5,759 individuals1,024 households, 5,759 individuals– All members interviewedAll members interviewed

Household surveyHousehold survey

Economic statusEconomic status– Income, consumption, etc.Income, consumption, etc.– EducationEducation– WorkWork

Happiness and health measuresHappiness and health measures– Depression, symptomsDepression, symptoms– ADLS & IADLSADLS & IADLS– Fertility historiesFertility histories

Experience with health care systemExperience with health care systemDirect measuresDirect measures– Peak flow, weight and height, hemoglobin, blood pressurePeak flow, weight and height, hemoglobin, blood pressure

PovertyPoverty

This is a very poor, largely tribal This is a very poor, largely tribal populationpopulation– More than 40 percent below official PL, cf 13 More than 40 percent below official PL, cf 13

percent in rural Rajasthanpercent in rural Rajasthan– 46 percent males and 11 percent females are 46 percent males and 11 percent females are

literateliterate– 21 percent households have electricity21 percent households have electricity

Health statusHealth status

80 percent adult females, 27 percent adult males 80 percent adult females, 27 percent adult males hemoglobin < 12 gm/dlhemoglobin < 12 gm/dlStandard cutoffs, men as likely as women to be anemic, Standard cutoffs, men as likely as women to be anemic, older women as anemic as younger women: diet?older women as anemic as younger women: diet?BMI 17.8 (men) 18.1 (women), 93% (men) 88% (women) BMI 17.8 (men) 18.1 (women), 93% (men) 88% (women) BMI < 21BMI < 21Many self-reported symptoms, substantial fraction Many self-reported symptoms, substantial fraction “serious”“serious”– Fever, colds, “body ache,” back ache, chest pains, vision Fever, colds, “body ache,” back ache, chest pains, vision

problems, etc.problems, etc.– Personal care ADLS are goodPersonal care ADLS are good– Work functioning often poor: >30% cannot walk 5k, draw water, Work functioning often poor: >30% cannot walk 5k, draw water,

or work unaided in the fields, 20% difficulty squattingor work unaided in the fields, 20% difficulty squatting

Lots of adaptationLots of adaptation

SRHS is OKSRHS is OK– 10 rung ladder, 62% rungs 5 to 810 rung ladder, 62% rungs 5 to 8– Only 7% on bottom two rungsOnly 7% on bottom two rungs– Women consistently poorer healthWomen consistently poorer health

Happiness is OKHappiness is OK– 46% 3 on a 5 point scale46% 3 on a 5 point scale– 9% report 19% report 1– Similar to USSimilar to US

A perfect Public Health Care A perfect Public Health Care system…system…

India has the model health care system for India has the model health care system for a large developing country:a large developing country:– An aid post or Subcenter within a few An aid post or Subcenter within a few

kilometers of each house, serving 3,000 kilometers of each house, serving 3,000 individuals, staffed by one nurse (ANM) individuals, staffed by one nurse (ANM) provide basic services and referralprovide basic services and referral

– PHC and CHC as the second tier, with PHC and CHC as the second tier, with doctors and specialistsdoctors and specialists

– District hospitals as the last tier. District hospitals as the last tier.

No vacancies in aid post and subcentersNo vacancies in aid post and subcenters

… … But only on paperBut only on paper

People get most of their health care from the private People get most of their health care from the private sector, not the public health care system.sector, not the public health care system.– Udaipur health survey: Out of 0.51 visit to a health provider, 0.12 Udaipur health survey: Out of 0.51 visit to a health provider, 0.12

are to a public facility, the rest to private doctors or traditional are to a public facility, the rest to private doctors or traditional healershealers

They end up spending lots of money (7% of their budget They end up spending lots of money (7% of their budget in Udaipur survey) to get health care of uncertain quality in Udaipur survey) to get health care of uncertain quality (36% of main providers have a doctor’s degree and 36% (36% of main providers have a doctor’s degree and 36% have no college degree of any kind. have no college degree of any kind. Some basic services that the public health care system Some basic services that the public health care system should deliver are not delivered: In particular full should deliver are not delivered: In particular full immunization rates were shown to be less than 2.5% at immunization rates were shown to be less than 2.5% at baseline!!baseline!!

What are the problems? What are the problems?

Under-funding and under-equipment. Under-funding and under-equipment. – 20% of the aidposts and one-thirds of the subcenters lack a 20% of the aidposts and one-thirds of the subcenters lack a

stethoscope, or a blood pressure instrument, or a thermometer stethoscope, or a blood pressure instrument, or a thermometer or a weighing scale, or a weighing scale,

– None of the subcenters have a water supply, 7% have a toilet for None of the subcenters have a water supply, 7% have a toilet for patients and 8% have electricity patients and 8% have electricity

– National rural health mission is trying to address that by National rural health mission is trying to address that by providing an untied allowance to the subcenter. providing an untied allowance to the subcenter.

– Drugs seem to be available.Drugs seem to be available.

Lack of demand for those servicesLack of demand for those services– Most visits to private facility end with a drip or an injectionMost visits to private facility end with a drip or an injection– Rarer in public facility. Rarer in public facility.

Very high absence rate. Very high absence rate.

Very High Absence RatesVery High Absence Rates

Udaipur Continuous facility survey: facility Udaipur Continuous facility survey: facility survey that cover all the subcenters and PHC survey that cover all the subcenters and PHC serving 100 villages, weekly, over a year. serving 100 villages, weekly, over a year. – 45% of nurses in subcenters are absent45% of nurses in subcenters are absent– 36% of medical personel in CHC/PHC is absent36% of medical personel in CHC/PHC is absent– No predictability. No predictability.

Not isolated problem: Chaudhury et al (2005) Not isolated problem: Chaudhury et al (2005) show it is the same in India, and over the world. show it is the same in India, and over the world. Negative correlation between usage and Negative correlation between usage and absence, so one could hope that reducing absence, so one could hope that reducing absence would increase usage (though causality absence would increase usage (though causality could go both ways)could go both ways)

Private healthcarePrivate healthcare

Yet households spend 7.3% of budget on Yet households spend 7.3% of budget on healthcare, and only slightly less per visit at healthcare, and only slightly less per visit at public than private facilitiespublic than private facilitiesDrugs at public facilities, or doctorsDrugs at public facilities, or doctorsBhopas important & more so for poorerBhopas important & more so for poorer– More use in villages where public facilities are open More use in villages where public facilities are open

less oftenless often

Private “doctors”Private “doctors”– 41% have no medical degree41% have no medical degree– 18% have no medical training of any kind18% have no medical training of any kind– 17% have not graduated from high school17% have not graduated from high school

Private treatmentPrivate treatment

Tests performed in only 3% of visitsTests performed in only 3% of visitsIn 68% of visits patients received an injectionIn 68% of visits patients received an injectionIn 12% of visits patients received a dripIn 12% of visits patients received a dripIn public facilities, these “treatments” are less In public facilities, these “treatments” are less frequent, tests are not. frequent, tests are not. Yet, 81% (75%) of visits to a private (public) Yet, 81% (75%) of visits to a private (public) facility made the patient feel betterfacility made the patient feel betterSRHS and symptoms are uncorrelated with SRHS and symptoms are uncorrelated with quality of servicesquality of servicesThough lung capacity & BMI worse where Though lung capacity & BMI worse where facilities are worsefacilities are worse

What is to be done? What is to be done?

Used these results as a starting point of a Used these results as a starting point of a discussion of what could be tried: discussion of what could be tried: Key problems:Key problems:– Health Care: Can the public system be Health Care: Can the public system be

resuscitatedresuscitated– Basic care: If it cannot, can it be replaced to Basic care: If it cannot, can it be replaced to

at least provide essential goods such as at least provide essential goods such as immunization? immunization?

– Non health inputs: can diet be improved? Can Non health inputs: can diet be improved? Can water supply be improvedwater supply be improved

Three interventionsThree interventions

Need to try three interventions:Need to try three interventions:– Work to Improve attendance by the ANMs in the subcenters.Work to Improve attendance by the ANMs in the subcenters.– Focus on immunization: both supply and Demand interventions. Focus on immunization: both supply and Demand interventions. – Diet: Decentralized Iron fortificationDiet: Decentralized Iron fortification– (we also tried to work on water but had to give up after a while). (we also tried to work on water but had to give up after a while).

All these interventions were implemented in a All these interventions were implemented in a randomized subset of 135 villages, so that their impact randomized subset of 135 villages, so that their impact can be rigorously assessed by comparing a treatment can be rigorously assessed by comparing a treatment and a control group. and a control group. They are implemented by staff on the ground, and the They are implemented by staff on the ground, and the monitoring and evaluation is carried out by J-PAL in monitoring and evaluation is carried out by J-PAL in collaboration with Vidhya Bhawan, a local teaching collaboration with Vidhya Bhawan, a local teaching institution. institution.

The ANM intervention: A Band-Aid The ANM intervention: A Band-Aid on a corpseon a corpse

Government appointed extra-nurse in some subcenters Government appointed extra-nurse in some subcenters (the most remote). (the most remote). Seva Mandir proposed to monitor the extra nurseSeva Mandir proposed to monitor the extra nurseJan 2006 it was approved, and Seva Mandir was asked Jan 2006 it was approved, and Seva Mandir was asked to monitor the extra nurse 3 days a week and the regular to monitor the extra nurse 3 days a week and the regular nurse 1 day a week in the treatment centers which had nurse 1 day a week in the treatment centers which had only one nurseonly one nursePunishment for absence ruled by the district Punishment for absence ruled by the district administration: for more than 50% absence on monitored administration: for more than 50% absence on monitored days, deduction in proportion of the absence the first days, deduction in proportion of the absence the first month, suspension the second month. month, suspension the second month.

Monitoring TechnologyMonitoring Technology

Date and stime Stamping machine

StampSign

SIGN

Stamp

Signing and stamping, 3 times a day

Register: secured to the center’s wall, collected once a month, sent to CMHO, who sends to PHC

Evaluation MethodsEvaluation MethodsTwo ANM: 16 treatment centers, and 12 control Two ANM: 16 treatment centers, and 12 control centerscentersOne ANM: 33 treatment centers, 39 control One ANM: 33 treatment centers, 39 control centers.centers.Centers in the study were chosen to serve 135 Centers in the study were chosen to serve 135 villages in the Udaipur Health Care Studyvillages in the Udaipur Health Care StudyTreatment and control center were randomly Treatment and control center were randomly selected (BEFORE it was decided that there would selected (BEFORE it was decided that there would be two nurses in some centers: no stratification). be two nurses in some centers: no stratification). ““Random checks” (un-announced visit during Random checks” (un-announced visit during opening hours on monitored and non-monitored opening hours on monitored and non-monitored days) one a month (from May 2006)days) one a month (from May 2006)

Two ANMs, All Days, Entire periodTwo ANMs, All Days, Entire period

Treatment Control Difference (1) (2) (3)

A. On all daysCenter open 0.391 0.245 0.091

(0.022) (0.020) (0.051)Monitored ANM present 0.382 0.220 0.104

(0.022) (0.019) (0.049)Number of clients 0.309 0.167 0.081

(0.038) (0.026) (0.062)Number of clients (if center is open) 0.724 0.590 0.077

(0.085) (0.089) (0.186)Number of Visits 496 481 977

Entire period

Two ANMs, Monday, Entire periodTwo ANMs, Monday, Entire period

Treatment Control Difference (1) (2) (3)

B. On MondaysCenter open 0.546 0.408 0.138

(0.036) (0.059) (0.078)Monitored ANM present 0.541 0.394 0.147

(0.036) (0.058) (0.073)Number of clients 0.536 0.203 0.333

(0.076) (0.067) (0.136)Number of clients (if center is open) 0.906 0.464 0.441

(0.124) (0.150) (0.247)Number of Visits 194 71 265

Entire period

DegradationDegradationTreatment Control Difference Treatment Control Difference

(4) (5) (6) (7) (8) (9)

B. On MondaysCenter open 0.594 0.308 0.286 0.443 0.431 0.012

(0.043) (0.133) (0.148) (0.064) (0.066) (0.111)Monitored ANM present 0.586 0.308 0.279 0.443 0.414 0.029

(0.043) (0.133) (0.148) (0.064) (0.065) (0.105)Number of clients 0.586 0.385 0.202 0.426 0.161 0.266

(0.101) (0.180) (0.243) (0.100) (0.071) (0.142)Number of clients (if center is open) 0.911 1.000 -0.089 0.889 0.375 0.514

(0.155) (0.408) (0.431) (0.180) (0.157) (0.279)Number of Visits 133 13 146 61 58 119

May-October November-June

What happened??What happened??

Were sanctions not applied? Were sanctions not applied? – Initially they were applied. Some ANMs were Initially they were applied. Some ANMs were

given deduction. In one zone, deductions are given deduction. In one zone, deductions are more severe than what is imposed by centermore severe than what is imposed by center

ANMs not sensitive to deductions?ANMs not sensitive to deductions?– PossiblyPossibly

System perverted from insideSystem perverted from inside

Register RecordsRegister Records

0%

20%

40%

60%

80%

100%

Feb-06

Mar-06

Apr-06

May-06

Jun-06

Jul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

Jan-07

Feb-07

Mar-07

Apr-07

May-07

Month

Present

Half day

Absent

Exempted days

Machine problems

ExplanationsExplanations

Machine problems and exempt days increase at Machine problems and exempt days increase at the detriment of presence and absencethe detriment of presence and absenceMachine problemsMachine problems– When machine malfunctions, ANM must warn Seva When machine malfunctions, ANM must warn Seva

Mandir and monitors meets her as soon as possible Mandir and monitors meets her as soon as possible to exchange itto exchange it

– But as soon as possible depends on her….But as soon as possible depends on her….– Machines have malfunctioned increasingly often Machines have malfunctioned increasingly often

(even new machines)(even new machines)– Some have evidently been misstreatedSome have evidently been misstreated– And finding ANM after machine problems has turned And finding ANM after machine problems has turned

out to be increasingly difficult…out to be increasingly difficult…

Exempt daysExempt days

Exempt days are reported by the ANM on the registerExempt days are reported by the ANM on the registerThese are days where she must do some other official These are days where she must do some other official duties (meetings, special field work, etc.)duties (meetings, special field work, etc.)They are not checked by Seva Mandir (which does not They are not checked by Seva Mandir (which does not have the data) beyond basic credibility (no more than one have the data) beyond basic credibility (no more than one block meeting per month etc.)block meeting per month etc.)The PHC checks exempt days and implement deductionsThe PHC checks exempt days and implement deductionsExempt days have increased drastically, especially things Exempt days have increased drastically, especially things like “team work” or “surveys” where it is hard to verify like “team work” or “surveys” where it is hard to verify actual presenceactual presenceEither the ANM invents it or the PHC doctors give it to Either the ANM invents it or the PHC doctors give it to them. them. The CMHO is aware of the increase in exempt days over The CMHO is aware of the increase in exempt days over time, so he must condone the PHC doctors. time, so he must condone the PHC doctors.

Conclusion: ANM programsConclusion: ANM programs

The program was initially quite effectiveThe program was initially quite effective– In the first 6 months, the rate of presence of In the first 6 months, the rate of presence of

monitored nurses (in both types of center, and monitored nurses (in both types of center, and on all days), increased from 25% in control by on all days), increased from 25% in control by 15 percentage point15 percentage point

But it was quickly sabotaged, and has no But it was quickly sabotaged, and has no effect by the endeffect by the end

Interventions to improve Interventions to improve immunization rates: great successimmunization rates: great successImprove reliability of supply:Improve reliability of supply:– In 60 villages, camps were organized monthly. Main In 60 villages, camps were organized monthly. Main

feature is regular schedule. Over 20 months, 67 feature is regular schedule. Over 20 months, 67 camps were cancelled, while 1269 were held. camps were cancelled, while 1269 were held.

– Availability of camps and timing etc. were advertised Availability of camps and timing etc. were advertised by Seva Mandir Paraworkers, who also receives an by Seva Mandir Paraworkers, who also receives an honorarium for each immunization. honorarium for each immunization.

Increase parents’ demand: Increase parents’ demand: – In 30 of these villages, 1 kg of dal were given for each In 30 of these villages, 1 kg of dal were given for each

immunization, and a set of plates for complete immunization, and a set of plates for complete immunizationimmunization

Results after one yearResults after one yearImmunization ratesImmunization rates

In the intervention hamletsIn the intervention hamlets– Comparison Hamlets: Comparison Hamlets:

5.5% full (children 1 to 2) – 44% one shot (children below 2)5.5% full (children 1 to 2) – 44% one shot (children below 2)– Camp Hamlets: Camp Hamlets:

19% full—69% one shot19% full—69% one shot– Camp + encouragement Hamlets: Camp + encouragement Hamlets:

36.5% full—67% one shot36.5% full—67% one shot

In the neighboring hamlets (within 6 kilometers)In the neighboring hamlets (within 6 kilometers)– Camp hamlets: Camp hamlets:

9.4% full-45% one shot9.4% full-45% one shot– Camp + encouragement Hamlets: Camp + encouragement Hamlets:

27.3% full-53% one shot27.3% full-53% one shot

Effect of the encouragement goes well beyond the targeted hamletEffect of the encouragement goes well beyond the targeted hamletIn treatment villages, effect of encouragement is to prevent drop out In treatment villages, effect of encouragement is to prevent drop out before immunization is complete, not to get the first shot. Average before immunization is complete, not to get the first shot. Average rate of completion of immunization sequence: 60.5% in rate of completion of immunization sequence: 60.5% in encouragement camps, 42% in regular camps.encouragement camps, 42% in regular camps.

Results: Administrative cost per Results: Administrative cost per immunizationimmunization

Main Cost of immunization is salary cost for the GNM Main Cost of immunization is salary cost for the GNM (37% of the costs in the encouragement camps and 73% (37% of the costs in the encouragement camps and 73% in the other camps)+ cost of travel etc. in the other camps)+ cost of travel etc. So if the GNM can see more children per camps, the So if the GNM can see more children per camps, the cost goes down. cost goes down. In encouragement camps, GNMs see on average 2.8 In encouragement camps, GNMs see on average 2.8 times more children than in regular campstimes more children than in regular campsThe result is that the cost per shot is smaller in The result is that the cost per shot is smaller in encouragement camps, despite the incentive: Seva encouragement camps, despite the incentive: Seva Mandir administrative data indicate that the Mandir administrative data indicate that the administrative cost per shot is: administrative cost per shot is: – Rs 171 per shot in encouragement camps.Rs 171 per shot in encouragement camps.– Rs 248 per shot in regular camps. Rs 248 per shot in regular camps.

Iron FortificationIron Fortification

Anemia is very prevalent. Anemia is very prevalent. Anemia is known to:Anemia is known to:– Cause lack of energyCause lack of energy– Be easily preventable with adequate intake of Be easily preventable with adequate intake of

ironiron

Best solution for regular iron intake is Best solution for regular iron intake is fortification of food but… most of the poor fortification of food but… most of the poor in Udaipur do not buy food that can be in Udaipur do not buy food that can be fortifiedfortified

Solution: decentralized fortificationSolution: decentralized fortification

Villagers go to the local miller with whole Villagers go to the local miller with whole grain (produced and purchase). grain (produced and purchase).

A simple machine was designed to mix A simple machine was designed to mix iron with the flour after millingiron with the flour after milling

Local millers were trained, Seva Mandir Local millers were trained, Seva Mandir provides the iron pre-mix for free and a provides the iron pre-mix for free and a payment to the miller payment to the miller

ResultsResults

People take advantage of fortificationPeople take advantage of fortification

Hb levels have improved. Hb levels have improved.

The need to conduct an endline survey to The need to conduct an endline survey to get data on activities, productivity, get data on activities, productivity, earnings, etc. earnings, etc.

ConclusionConclusion

Collaboration between NGO and Collaboration between NGO and academics allow to design (hopefully) academics allow to design (hopefully) meaningful programsmeaningful programs

Evaluation of these programs allow to Evaluation of these programs allow to further understanding of the situation on further understanding of the situation on the groundthe ground

Next step, back in the NGO court: what to Next step, back in the NGO court: what to make of these results. make of these results.