Details for Reform Option "Community Based Health Posts in remote areas, Himachal Pradesh"
The hilly terrain of Himachal Pradesh makes it difficult for government health Sub Centres (SC) to reach basic Reproductive and Child Health (RCH) services to villages. According to the norm laid out by the government, an SC is supposed to cover a population of 3000. The 2001 Census reports, statistically, the coverage is good; on an average, as SC covers a population of 2838. In practice, however, it becomes very difficult for an SC to deliver services when it has to cater to more than one panchayat. In remote areas, many SCs have been non-functional for years. People living in these hard-to-reach panchayats are thus deprived of crucial outreach services such as antenatal care and immunisation of children and pregnant women.
With a view to extending basic health services to the segment of the population underserved by the government health system, a Community Based Health Post (CBHP) was set up in October 2004 in five panchayats of Chaupal block, sub tehsil Kupvi, district Shimla. The CBHPs were set up by Social Action for Rural Development of Hilly Areas (SARDHA), a Non-Governmental Organisation (NGO), in collaboration with Panchayati Raj Institutions (PRIs). This initiative was part of Basic Health Project of GTZ, the German development agency.
The 5 panchayats, where the CBHPs were set up, were among the 11 (comprising 45 villages) that had been identified as backward by the Government of Himachal Pradesh. Between the Primary Health Centre (PHC) of the block and the 7 SCs that fell under it there were just one doctor and 4 health workers. As a result, none of them was functioning properly. The nearest First Referral Unit (FRU) was 96 km (5 hours’ drive) away at Rajgarh in district Sirmaur.
Space and essential furniture for the health posts were provided by the panchayat while basic equipment, like a haemoglobin meter, weighing machine, and blood pressure apparatus, were provided by the project. Supplies and consumables that were meant for the non-functioning SCs were redirected to these health posts by the state government. These included Oral Contraceptive Pills (OCP), Iron and Folic Acid (IFA) tablets, condoms, Oral Rehydration Salts (ORS), safe delivery kits, in a list of about 14 routine items.
The CBHP accepts a donation of INR 2 from patients for services rendered. It is a voluntary payment made by patients who wish to.
Community health workers, identified by the panchayat, are trained by the project to provide basic health services like antenatal care, diarrhea management. They also give first aid and treat minor ailments at these health posts. A health worker is paid an honorarium of INR 500, from the money collected from patients. Panchayat health committees and SARDHA monitor and supervise the activities of these CBHPs.
(i) The delivery of preventive and minor curative outreach services have improved in the remote and underserved areas. People now have greater access to health care, including ante-natal services, first aid and treatment of minor ailments. They are also being exposed to Information, Education, Communication (IEC) campaigns. An evaluation is underway to assess the impact of a CBHP on the community.
(ii)About 12% of the population of the five panchayats, that is, 1011 patients, were treated at the health posts in the months of January and February alone.
(iii) People save on opportunity cost involved in travelling and accommodation as some their problems are addressed by the health post.
(iv) The Panchayat Level Health (PLHC) committee was strengthened when it got involved and took ownership of the health posts. The PLHC, on an average, collects INR 800 to INR 1000 per month.
The cost involved in setting up five CBHPs was INR 163,000. Recurring cost of about INR 1000 per month was met by the PLHC through money collected from patients.
Pilot programme launched in five underserved panchayats of sub tehsil Kupvi; block Chaupal, district Shimla in October 2004. The CBHPs began functioning in January 2005.
Orientation, through a series of consulting workshops, of the panchayat representative and the authorities from the Health Department takes around one month.
Strengthening the PLHCs and identification of interested and committed community health workers take about one month.
Initial training of health workers takes about 15 days. The training is conducted by the Block Medical Officer (BMO) and a Medical Officer (MO) of the block.
Setting up and equipping the CBHP take another 15 days.
Access to health: Enables underserved sections of the community to access services not provided by the government health system.
Limited scope: Not all kinds of services can be provided owing to the limited capacity of community health workers.
Local opposition: From unqualified Rural Medical Practitioners (RMPs), who have, over the years, built a good rapport with the community.
Scepticism at higher levels: Initially, from health managers at district and state levels who might have doubts about the functioning and acceptability of the health posts.
Clear identification of the health needs of the community.
Logistical arrangements and funds for procuring equipment, supplies and consumables required to establish the CBHP.
Continuous support and commitment of various stakeholders.
Who needs to be consulted
Opinion leaders from the community and relevant authorities from the Health Department.
Sustainability depends upon the commitment of the community health workers and the rapport they can build by providing quality health services, continuous support of the PRIs and other opinion leaders, availability of supplies and consumables from the Health Department and close monitoring and supervision by the project and the NGO for at least one year.
It also depends on the community accepting the CBHP and having faith in its services.
Chances of Replication
Can be tried out as an option in any remote area where the government has not been able to deliver basic health services at grassroots level.
Considering the fact that the government health delivery system has gaps in infrastructure and human resources, making it difficult to provide services to people in remote areas, one solution is involvement of NGOs in delivering these services.
Dr. Anuradha Davey, Research Consultant, National Institute of Medical Statistics, ICMR. March 2006.