Objective="Community management of health services."
Details for Reform Option "Communitisation of Grassroot Health Services, Nagaland"
Nagaland is a hill state in the extreme northeast of India. An important issue identified in ‘Imagine Nagaland’, an innovative programme in which civilians and government servants collaborated to design plans and identify challenges in the state, was the need to revitalise the massive welfare infrastructure and vast network of delivery services set up by the government which had become ineffective and dysfunctional. The community no longer trusted them and was increasingly turning to private institutions for these services. The quest for improvements led to the evolution of a unique communitisation approach. This sought to pool the extensive resources of the government with the potential skills base within the Naga society. The Government of Nagaland enacted the Nagaland Communitisation of Public Institutions and Services Act, 2002, in March 2002 thereby creating the legal and institutional context for the communitisation process to take off.
Communitisation consists of a unique partnership between the government and the community with the aim of improving the delivery of public utility systems. It involves transfer of ownership of public resources and assets, control over service delivery, empowerment, decentralisation, delegation and capacity building. The scheme envisages changed roles and responsibilities on part of both government servants and the community. This focuses on a triple ‘T’ approach:
(i)Trust the user community
(ii)Train them to discharge their newfound responsibilities, and
(iii)Transfer governmental powers and resources in respect of management.
Communitisation of health was built on five initiatives;
(i)Boards or committees with representatives of the user community (village or town ward) were constituted.
(ii)Powers and management functions of government were transferred to the committees or boards, including disbursal of salary to staff running the utilities and also the power to exercise a ’no work, no pay’ principle.
(iii)Assets of the government were transferred to the committee.
(iv)A fund was created, where salaries along with other Government grants and community contributions were credited for running and developing the utilities.
(v)Powers and responsibilities were conferred to these authorities, including critical supervisory and supportive assistance.
In the first phase, all health sub-centres were communitised, which meant that the salary of the staff was to be paid through the Village Health Committee (VHC). Training in two batches, then retraining was provided to the health functionaries and the VHC members. VHC’s were given funds to purchase medicines from any shop they chose on the prescription of the medical officer. Efforts were made to promote indigenous medicine systems and preventive health care.
The impact assessment study of Grassroot Health Services, undertaken by external evaluators in June-July 2004 and supported by UNICEF, was conducted in 50 villages from seven districts, on a purposive sampling basis, ensuring 10% coverage of the programmes.
Efforts by VHCs have created a positive change on health services. A sense of ownership of the health centres is visible amongst both VHC members and beneficiaries. VHCs are effective in galvanising voluntary contributions of material and labour. The following results have been seen:
(i)Attendance of the health functionaries increased to over 90% in all 28 villages studied reaching 100% in 7 of them. Unauthorised absences decreased to between 3 and 5%.
(ii)Improvement in staff visits to sick persons in the village. Noticeable improvements were seen in the attitudes of health centre staff to work and towards patients. This led to improved quality of health care.
(iii)Increased numbers of patients attending health centres, and patients moving from private practitioners and indigenous healers.
(iv)More women and girl children attending health centres. Plus there has been a significant increase of more than 50% in children accessing the health centres across all villages.
(v)At least 83 sub centres, which had no staff earlier, were given one ANM through redeployment.
(vi)Improved availability of medicines in the centres and quality of medicines purchased by the VHCs. Better medicine availability is indicated as having very high impact on health care quality in Mokokchung, Phek and Zunheboto districts.
(vii)Villagers have been provided quarters where none were available.
(viii) Village Development Boards (VDBs) have made financial contributions to repair, refurbish, and extend infrastructure.
No extra cost involved. The allocation under different sectors under the budget head of the government has been transferred to VHCs.
Total estimated cost: Rs. 657,105,000
Reconstruction/ Major repairs of 52 PHC/CHC buildings@ Rs 10,00,000 each : Rs 520,00,000.
Construction of 23 PHC buildings @ Rs 30,00,000 each : Rs 690,00,000
Staff quarters for 108 PHCs/ CHCs @ Rs 30,00,000 each : Rs 3240,00,000
Staff quarters for 394 sub centres @ Rs 3,00,000 each : Rs 1182,00,000
Construction of 144 SC buildings @ Rs 5,00,000 each : Rs 720,00,000
Medicines for 21 CHCs @ Rs 1,50,000 each: Rs 31,50,000
Medicines for 87 CHCs @ Rs 1,25,000 each : Rs 108,75,000
Medicines for 394 SCs @ Rs 20,000 each : Rs 1,88,000
Additional funds were also required for continuing training and capacity building and close supervision and monitoring of the VHCs on regular basis.
350 of the 394 sub-centres, 7 of the 87 Primary Health Centres and one of the 21 Community Health Centres in all the eight districts of the state.
The remaining 144 health centres would be communitised within two to three years.
Approximately three years.
A concept paper on Communitisation was brought out in mid-2001.
Implementation strategies were finalised in late 2001.
An Ordinance was promulgated in January 2002.
The Act was passed in March 2002.
Communitisation of rural health sub centres began in September 2002 and was operational by 2004.
Gender Sensitive: Increasing numbers of women are approaching the health centre in the village itself.
Increased sense of security: Better attendance of health functionaries across all districts and increased patient access.
Health of the children: Children have access to the health centre.
Improved Quality of Medicine: The VHC itself purchases the medicine and availability has improved in communitised centres.
Regular salary: Timely disbursement of staff salaries.
Regular reporting: More regular submission of monthly reports.
Community contribution: This is forthcoming in cash, in kind, through voluntary and free service on fixed days and from private practitioners.
Indigenous system of medicine: This is being promoted in many areas.
Publicising healthcare: Quarterly newsletter by one VHC on health issues has been reported.
Lack of support from officials: The supervisory staff is not willing to surrender their authority to the VHC, resulting in friction.
Hierarchy issues: The dual structure of authority and command creates an anomalous situation for health functionaries who are accountable to their line supervisors and the VHCs.
Dual lines of command: One goes up to the highest echelons of government and the other stops in the village. Transfers of staff desired by the VHCs but decided on by district officials.
Resistance from health functionaries and superiors: At the PHC level, this is a perceived obstacle in many of the districts.
VHC fatigue: VHC members across districts say that the burden of responsibilities consumes their limited time (all work, no pay) and drains their personal resources.
Close collaboration between government officials including the Medical Officer and the VHCs.
Community Participation: The communities are extending widespread public assistance and contributing in both labour and cash.
Who needs to be consulted
Village Health Committee (VHC)
Village Development Boards (VDBs)
Assured according to the VHC, as both the VHC and the government officials want to see it work.
Chances of Replication
Encouraged by the response, the government decided to expand this programme, covering even urban health sub-centres and one Primary Health Centre (PHC) in each district, in the following year.
Based on the experience of the Naga Hospital Authority, other hospitals will be communitised.
Communitisation creates convergence
(i)Between the state’s responsibility to provide health for all and citizen aspirations for a health safety net.
(ii)In effective management of state institutions through people’s institutions grounded in the social capital of the village.
Suggestions from VHCs/ beneficiaries to strengthen communitisation of health services:
(i) More funds to buy emergency drugs, paediatrics drugs and equipment.
(ii) Upgrade, repair, rebuild or refurbish Sub- centre.
(iii) Increase attendance of medical officers at Sub-centre.
(iv) Implement VHC decisions and recommendations.
(v) Mass awareness for enhanced community involvement.
(vi) Training for VHC members and government functionaries.
(vii) Adjustment for VHC members for days of work.
(viii)Guidelines for cooperation with officials.
Dr Arti Bahl, Research Consultant, CBHI,New Delhi