Objective="More effective administration and implementation of programmes at sub-district level."
Details for Reform Option "Restructuring of the Health & Family Welfare Department at sub-district level, Rajasthan"
In Rajasthan, the Chief Medical Health Officers (CMHOs) were overburdened with a large workload and huge geographical area making it impossible for them to operate effectively. In addition, the Medical officer in charge of the block (sub-district) Primary Health Centre (PHC) was overburdened with administrative tasks. Therefore, the staff and the Medical Officer (MO) in-charge of block PHC found it difficult to effectively function, i.e., cater to the needs of population and overseeing the administrative tasks. Consequently, changes were introduced in the roles and responsibilities of district level officials for effective implementation of health care programmes.
In order to reduce the workload of CMHO and block PHC, following changes were introduced at district level. In 1999, the districts were notified of the changes with respect of the work distribution of district level officials. The government directed the districts to incorporate following changes within one month.
It was decided that the deputy CMHO (Dy CMHO) should look after all programmes at sub-district level as well as being responsible for administrative issues of the block. The Dy CMHO was previously responsible only for specific programmes such as malaria control, health and family welfare etc at district level.
The deputy CMHO (Family welfare) office was to be relocated at sub-district area and the official was given responsibility for implementation of all family welfare programmes at the district level as well as their area. The drawing and disbursing authority was given to Dy CMHO instead of block PHC. The responsibility included looking after all the programmes, establishment, pension cases, court cases, private institutions, prevention of food adulteration, pre-conception and prenatal diagnostic tests and other administrative responsibilities.
The Dy CMHO was responsible for developing the block action plan and targets for each
Auxiliary Nurse Midwife (ANM) was determined by community need assessment carried out by them.
For performing these duties, the Deputy CMHO was given three to four clerical staff.
The Dy. CMHO was responsible for coordinating with panchayati raj institutions and inter-sectoral coordination at block level.
The reproductive and child health officers (RCHO) at district level who were formerly functioning independently were directed to be working under CMHOs. The staffs of urban malaria scheme are to be shifted to the office of CMHO.
Each Dy CMHO was given responsibility for three to four blocks, depending upon the size of the district. No separate funds are available with Dy. CMHO to meet the mobility and communication requirement for overseeing the health programmes at block level.
In order to tackle the shortage of Dy. CMHOs’ positions, some of the Senior Medical Officers were transferred from districts which were relatively well-staffed to the districts which were most under-staffed. In 2002, the post of Dy CMHO malaria and health was dissolved.
The initiative was put in place in 1999. However it has taken some time for the districts to set-up office, furniture and functioning. Therefore, it is too early to assess the outcome of this administrative restructuring. The Dy CMHO was given more than one block, often two tehsils (sub-district administrative unit) depending upon the size of the district. However, discussion with Dy CMHO revealed that though the concept is good, there are many operational problems. Such as, lack of adequate infrastructure including furniture, office space and adequate personnel; no telephone connections for getting information from the MOs at PHC level (this becomes an acute problem during epidemics when the district administration and state authority require day-to-day reporting) and, no adequate mobility funds were provided.
Since this office was an administrative unit, no donors have been forthcoming to meet infrastructure needs. The reporting mechanisms have also become difficult because they have to report to three-to-four Sub-divisional Magistrates (SDM), one per block. The responsibilities have increased manifold, as they are now responsible to work as food inspector of their sub-division. Also, the Dy CMHO holds a number of meetings for block level functionaries leading to a large amount of his working days being spent on meetings and court cases. Due to shortage of Dy.CMHOs, the existing ones are responsible for more than one sub-division.
Budget needed to set up offices and meet recurring costs is not available. It was mentioned that some of the office furniture was given in kind by local stakeholders. The European Commission through Sector Investment Programme has approved INR 3000 towards installation of telephone connection in the Dy. CMHO offices at Bali, district Pali.
Rajasthan – state wide.
One to two years.
Workload: It reduces the administrative workload of CMHO.
Effective monitoring: Better administration as well as implementation of all national and state level programmes.
Utilisation of services: Sector PHC MO can spend more time on providing preventive and curative services to people.
Nearness to the community: Now it has become easier for the people to approach the health officials.
Administrative: It is necessary to have a Dy CMHO for each block to work with each SDM.
Cost: Creates an additional cost as it is necessary to set up an office for the Dy CMHO.
Workload: Increase in the workload of Dy.CMHO.
Time consuming: Most of the Dy CMHO’s time is spent on attending meetings at block, district and state level at the expense of other programmes.
Infrastructure is required for Dy CMHO to function effectively such as space to hold meetings and a place for other block level administrative staff to sit. This should also include funds for telephone usage.
Personnel required for undertaking administrative, legal and financial matters.
Mobility and communication facilities must be available before posting the deputy CMHO if they are to monitor programmes effectively.
Necessary to fill-up the posts of Dy. CMHO for the efficient management of sub-division.
Who needs to be consulted
Director Public Health.
Yes. The changes have been made within the existing structure and therefore it is sustainable if above pre-requisites are ensured.
Chances of Replication
It can be replicable if recurring costs are put in place for effective functioning including space, telephone and mobility.
The changes in roles and responsibilities of Dy. CMHO will improve the quality of health care services. However, the bottom line is still the requirement for effective monitoring of programmes. Proper understanding of need assessment by field staff will ensure that the targets are met. Accountability is an important issue that needs to be addressed by involving the staff from block to PHC level staff. Additional CMHO is currently responsible for all Family Welfare programmes for the district including Jan Mangal. Therefore, for FW Dy. CMHOs have to report to Add. CMHO.
Dr. Nandini Roy, HS-PROD Research Consultant, IRMS, New Delhi, September 2005.
Last Updated: Prabha Sati, Research Consultant, ECTA, December 2006.