Details for Reform Option "Effective Mini Reproductive and Child Health camps organised by Primary Health Centres, Gujarat"
According to the World Bank, about one-third of the total disease burden in developing country women aged 15 to 44 is linked to reproductive health problems, yet health facilities at the community level in Gujarat were poorly equipped to deal with gynaecological and obstetric morbidities because they did not have the diagnostic facilities, the skills or the drugs to treat them.
What was needed at the PHC level were facilities for routine diagnosis of gynaecological problems, improved obstetric care, sensitive counselling and sound referral services.
The Indian Institute of Management, Ahmedabad, (IIM-A) proposed a camp approach as an intermediate solution till regular services were available at the PHC and sub-centres for the reproductive child health (RCH) programme. It would also give a higher level of services closer to the community on a periodic basis.
Initially, it organised a RCH camp every three months at each PHC level. The dates were fixed in advance and the community was informed about it by the Auxiliary Nurse Midwives (ANMs) and the Anganwadi Workers (AWWs).
The paramedic staff identified women and children requiring this service and facilitated their attendance at the camp. Specialists were arranged from the nearby medical college. PHC ensured adequate privacy and proper sterilisation of equipment needed. Several counters were set up for registration, history taking, laboratory tests, counselling, medicines and health education.
The camp offered services like examination of children by a paediatrician, growth monitoring and immunisation, gynaecological examination of women, lab diagnosis of anaemia, urinary tract infection, pap smear for early detection of cervical cancer, examination of high risk ante-natal cases, referral for further diagnosis and treatment, treatment of all childhood diseases and women’s diseases. On an average, 141 women and 60 children attended each RCH camp.
The camps were then made smaller, but more regular (eg once a month). One gynaecologist attended each camp to ensure a good rapport between the specialist and the PHC staff. Paediatric cases were seen by the PHC’s medical officer (MO) and referred if needed. The PHC staff conducted most of the activities related to the camp. Most of the camps planned (40/ 55) were conducted in one year. On an average 35 women and 25 children attended.
Lastly, the MO in the PHC was given the responsibility of organising a fixed-day RCH clinic at the PHC. The MO was to assure the presence of the specialist and to access additional medicine. A new record proforma was designed which mentioned individual case history, etc.
On an average, 200 cases were attended to in large camps and 63 in mini camps.
Since both the camps had availability of specialist and adequate privacy, RTI problems were detected in about 50% of women complaining about their problems. More than 8% were cases of infertility. The clients were either treated or referred for further investigation and treatment.
A large camp cost INR 60 (€1.07) per client, while a mini camp cost INR 48 (€0.86) per client, when organised externally (ie by IIM-A).
A mini camp organised by a PHC cost INR 19 (€0.34) per client.
The medicine cost approximately INR 9 (€0.16) per client in all the above camps.
It is clear that ‘other costs’ incurred for organising large camps are higher than for mini camps.
Sanand Taluka, Gujarat. May 1996 to January 1999.
Post 1999, continued by the state government. In September 2004, 150 out of 1068 PHCs in Gujarat were carrying out the camps at a rate of two per PHC per month.
Six to eight months.
Manageable: Mini camps are easier to manage by the PHC staff and it increases person-to-person contact between the service providers and the clients.
Strengthens the referral system: Patients now meet the specialists from nearby town or from the Community Health Centre (CHC).
Training: PHC staff got hands-on training from specialists and specialists learnt the realities of PHC and village level care and became more sensitive to rural patients.
Can get marginalised: Mini camps need to be supervised on a regular basis else they run the risk of being sidelined due to several other tasks/ activities of the PHCs.
Continuity: Changes in the PHC staff may affect the effectiveness of the mini camp because the new staff have to be trained once again.
Co-operation of the PHC MO and staff.
Availability of willing specialists to attend the camps.
Cooperation of the district health officer and district Panchayat.
Who needs to be consulted
District Panchayat; district health officer; state government; PHC medical officers; private medical practices who will be offering their services for free.
It is sustainable once the PHC MO is trained to plan and organise mini camps as a routine activity. It can be better implemented if it is conducted under active supervision of an external agency like IIM - A.
Chances of Replication
Good. The state government took over and continued this programme. The National AIDS Control Organisation (NACO) also adopted a similar strategy.
Large numbers of clients attending the services at the camps indicated a large unmet need of the community.
Women prefer female doctors but are prepared to be examined by male gynaecologists if a woman is not available.
Overcrowding of a large camp can affect the quality of the service.
Medicines like vaginal tablets and higher antibiotics are not in the rate contract list at the PHCs and have to be supplied from outside.
Clare Kitchen, Research Consultant, ECTA, New Delhi. September 2004.