Objective="Scope and quality of primary health centre services."
Details for Reform Option "Providing 24–hour delivery services in Primary Health Centres, Tamil Nadu"
In Tamil Nadu, many Primary Health Centre (PHC) buildings were being under utilised due to a lack of skilled personnel to conduct deliveries round-the-clock and, as in many other parts of India, the number of deliveries conducted in PHCs was very low. The clientele generally went to secondary and tertiary hospitals, the private sector or delivered at home.
It was therefore decided to provide round-the-clock services at PHCs. This was implemented in two phases.
In the first instance, under the Reproductive and Child Health (RCH) Project, a model involving a high degree of medical involvement was envisaged and staffing levels of medical officers were duly increased.
However, an examination of PHC performance revealed that these additional inputs in staff had not resulted in anywhere near a commensurate increase in output, in terms of either the number of deliveries or the number of outpatients treated. This was because it was difficult to ensure constant availability of a doctor, even when posted, since they generally live in the towns, not at the PHCs, and the proposed incentive of INR 200 per delivery conducted between 8 pm and 7 am was an insufficient incentive for them to travel back to work during these hours.
On the basis of these results, it was decided to implement a modified version of the scheme. Since it is not possible to conduct Caesarean cases in a PHC without a gynaecologist and an anaesthetist, it was clear that the presence of qualified paramedical personnel to conduct normal deliveries was the most important requirement for improving PHC performance.
In terms of medical presence, analysis of PHC attendances indicated that the critical hours were between 8 a.m. and 5 p.m. with paramedical staff available thereafter to conduct minor ailment clinics. It was therefore decided to employ three additional staff nurses, two sanitary workers (cleaners) and one driver, all on a contractual basis, to provide 24-hour services.
Staff nurses are preferred for this purpose as they are better skilled in conducting deliveries, treatment of minor ailments, provision of obstetric first aid and in early identification of complications and may not require additional training. (Staff nurses undergo 3 1/2 years training with exclusive training in midwifery for 6 months)
After implementation, these PHCs showed a “vast improvement” in the Maternal and Child Health (MCH) services as shown by the increase in the number of deliveries, including those carried out at night. The number of minor ailments treated outside the outpatient hours in the PHCs have also gone up due to availability of nurses round the clock.
Evaluations indicated that the increase in medical staff had little impact on the number of deliveries being carried out. The critical factor was 24-hour availability of skilled female paramedical staff. In the PHCs which instituted this regime, there was a large increase in the number of deliveries being carried out including during the night.
The monthly employment costs per PHC of three staff nurses, one sanitary worker and one driver are INR 13,500 per month .
Madurai, Theni, Dharmpuri, Krishnagiri, Thanjavur, Thiruvarur and Nagapattinam districts of Tamil Nadu, since the financial year 1999 – 2000.
Approval of the activity by the funding agency: three months.
Preparation proposal to state government, getting orders and budget allocation by state government: three months.
Recruitment of staff nurses: 6 months.
Despatch of orders and joining of staff nurses: one month.
Facilitates: Makes better use of existing PHC facilities.
Encourages: Institutional delivery by providing an accessible local service.
Reduces hospital burden: Relieves secondary and tertiary hospitals dealing with normal deliveries.
Possible opposition: From ANMs who may oppose the entry of staff nurses, fearing they will lose the informal payment they get from delivered mothers and fearing a threat to their existence.
Nurses may also object to having to work in rural settings and in PHCs rather than hospitals.
Availability of trained staff nurses.
Who needs to be consulted
Programme officers. District officers. Director of Medical and Rural Health services to ascertain the availability of staff nurses.
This programme was sustained using the RCH State Implementation Plan funds.
Chances of Replication
Good. Tamil Nadu has already up-scaled from 90 PHCs to 180 PHCs using the balance fund available under the integrated financial envelope of the national component of the RCH Project.
Under the second phase of the RCH Project, the 24-hour delivery care activity plans to be extended to 700 PHCs in the state in two phases.
The staff nurses who will be posted in these PHCs will also be empowered with skills to provide obstetric first aid e.g. post partum haemorrhage, premature labour, sick newborn etc.
Sara Joseph, Researcher, ECTA, New Delhi. September 2004.