RURAL HEALTH CARE PROVIDERS – BUILDING CAPACITIES AND BEYOND

Liver foundation , west bengal www.liver-foundation.in

THE RECIPE

1. RELEVANCE AND PHIOLOSOPHY

2. THE PROCESS

3. IS IT USEFUL AND IMPACTING ?

4. ISSUES AHEAD

Private Institutions

Ind

ivid

uals

NGO/Missionaries

INFORMAL RURAL HEALTH

CARE PROVIDERS

Legitimate, Legislated & Regulated Unregulated, Heterogenous behavior & Content

Indian Health Care

OP/IP

Decision Makers

Clinical service:

o Paramedicso Nurses

Public Health Service:

o MPHWo ASHAo Nurses

DOCTORS

Professional bodies Corporate

houses Public sector Hospitals

Formal Sector

Politician

Urban

Urban + Rural

Civil servant

Informal Sector

Rural

o Candle in darknesso Individualistico Non-institutionalisedo Instanceo Social accountability

Urban & Peri-urban

o Institutionalo Modernisedo Non-institutionalised

Informal Rural Health Care Provider

A person engaged in activities & practice in rural health care market and supply goods in professionalized biomedicine guided by supply-demand axis

No TrainingNo Certification

No LegitimacyNo Regulation

Self-employedInformal provider.

Educated unemployed Youths.

Lacks scientific understandingAnd approach.

Empirical “craft” Earning motive.

Good / Bad.

Copy of the existing system.

RHCP

Individual

• Heterogeneous – Formal education - Culture - Quality - Contact

• Craftsmanship – Inflated sense

System

• Intolerance• Lack of focused

measures • Regulation

Enrichment of community understanding Cross-talk and

learning with community

Integrated action within Health System Vehicle for

Multiple Positive Health Action

& MessagesCapacity building of Rural Health Care Providers

[RHCPs]

RHCP orientation

Unregulated

Positive attribute

Negative attribute

Regulated

Net societal benefit

Community participation.

Community competition.

Community vigilance.

Community intervention.

Objectives:

Convert a clan of “Self proclaimed, unqualified doctors” to a clan of enriched health care workers through educational, social and cultural inputs

To Reduce HarmIncrease benefits

INITIATION ENRICHMENT CONSOLI

DATION CONTINUATION

Theory:• Disease oriented

• Adverse effect of drug & Practice

• Legitimacy & Regulation

Theory & Clinical:Life saving care

Public Health Programmes2/3 M

onths : Exam

2/3 Months : Exam

2/3 Months : Exam

RURAL HEALTH CARE PROVIDER [RHCP] Capacity building : CURRICULUM & PLAN

6 -8 hrs / Wk 150 – 200 hrs 75:25

THE WAY WE HAD GONE…SELECTION OF TRAINEES

INITIAL ORIENTATION

STRUCTURED CAPACITY BUILDING EXERCISE

EXAMINATIONS

CONTINUED ORIENTATION AND APPLICATION

MADHYAMIK UPTO H.S. GRADUATION POST GRADUATE HARDCORE0

10

20

30

40

50 42.5

20.37 21.92

1.24

13.86

EDUCATIONAL BACKGROUND

NO

OF

RHCP

12%

25%

24%7%

1%

31%

AGE CLASSIFICATION OF RHCPS (IN YRS)

<3031-4041-5051-60>60NO DATA

CLINIC HOME VISIT CLINIC & HOME VISIT

DID NOT PRACTICE

HARDCORE05

101520253035404550

47.88

19.4422.75

1.76

8.17

NATURE OF PRACTICE N

O O

F RH

CP

0 5 10 15 20 >20 HARDCORE0

5

10

15

20

25

30

2.48

21.51

25.75

14.17

9.62

4.76

20.06

PERCENTAGE (RHCP)/EXPERIENCE (YEARS)

NO

OF

RHCP

ANY TIME TWICE ONCE HARDCORE0

102030405060708090

84.8

6.210.1

8.79

AVAILABILITY OF RHCPs FOR TREATMENT

PRACTICE TIME IN A DAY

NO

OF

RHCP

BIKE OTHER HARDCORE05

101520253035404550

42.3%

49.84%

7.86%

MODE OF TRANSPORTATION OF RHCP

TRANSPORTATION

NO

OF

RHCP

YES NO NO ANSWER0

10

20

30

40

50

60 53.36

0.1

46.53

Was the training was useful? N

O O

F RH

CP

YES NO DID NOT ANSWER0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

Opinion of RHCPs REGARDING NEED FOR CONTINUED TRAINING

Axis Title

NO

OF

RHCP

48%

4%

0%1%

47%

Proposed training schedule

ONCE IN A MONTHONCE IN TWO MONTHONCE IN THREE MONTHTWICE IN A YEARDID NOT ANSWER

1% 2% 8%

41%

48%

Training Module

THEORETICALPRACTICALPRACTICAL>THEORITICALBOTH DID NOT ANSWER

1%

84%

6%9%

incentive FOR training program

EARNKNOWLEDGERESPECTSELF CONFIDENCE

Training & execution: Overall participation

3 months

o Certificationo Integrationo Main stream public health programme

75%

50%

25%

Perc

enta

ge o

f par

ticip

ation 100%

6 months

9months

12 months

2 years

4years

7 years

DOTSCOPD Metabolic

Health

Good practice is retained over time

K

75%

50%

25%

Perc

enta

ge o

f par

ticip

ation

A P

End of Training

Loss of contactKn

owle

dge

Attitu

de

Prac

tice

K A PKn

owle

dge

Attitu

de

Prac

tice

5 years after training

Exposure

IMPACT ASSESSMENT

Case Control design –RANDOMISED Simulated patients and Vignets

2013- 2014 350 RHCPs included

Liver Foundation, West Bengal

Department of Economics, MIT & J PAL

ISERRD , New Delhi

ISSUES :

Are we really achieving ?? - In the ‘MICRO’ levelHealth System Information – Impact for the consumers

Regulation - Accreditation – Certification - Would A Co-operative / Professional society help ?

INTEGRATION & UTILISATION

Replication & Amplification of Capacity Building Projects

Reduce mainstream sensitivity Research :- Academic & Policy

Public Health Programmes - Pilot

RHCP : Peripheral Metabolic Port

50 such

3 X 17 blocks

BP Machine, Glucometer, Anthropometry, Bicycle

Awareness Tool

Exercise Training

Central Port: Confirmation & Validation

Apex Port : Detail Analysis

Attempts at Integration & Focused activities : DOTs Defaulter retrieval

Leprosy Care: Detection & Retrieval

Large scale Metabolic Health Awareness and action project

A PROPOSED INTEGRATIVE MODEL

.

HW ANM AW

TDRHCP SHG

Panchayet

Awareness generation Hepatitis

/metabolic health/

immunization / safe

motherhood

Antenatal checks.

Detection of high risk

pregnancy.

Action - NCD s

Lessons learntIndividual capacity building – Transient vs Persistent Government intervention

Awareness & community action can be fostered

Their social stakes may increase

‘SYSTEM’ is still strategically ambivalent

Mainstream is maintaining an “INFORMED SILENCE”

Rural Health Care Provides

Need• Competence ??• Performance• ↑ Incentives• ↑ Social status

• Regulate• Integrate• Utilize

Lifesaving curative care in “Darkness”Candle of Public Health Messages

Individ

ual System

FUNDING :

Bristol Myers’ Squibb Foundation , USA

National Rural Health Mission , Government of West Bengal