Details for Reform Option "Using Rural Health Practitioners for social franchising, Bihar, Jharkhand & Madhya Pradesh"
A number of studies have shown that:
(i) The Rural Health Practitioner (RHP) is consulted as the first provider for any health problem that cannot be handled at home i.e. he is preferred to the Primary Health Centre (PHC).
(ii) There are an estimated one million RHPs in India of which 48% have had absolutely no training in medicine.
(iii) His main (in most cases, only) source of medical information is the town chemist, whom he meets three to 4 times a month.
(iv) All serious illnesses and gynaecological problems have to be referred onwards.
Therefore there are two important issues:
(i) the under utilisation of RHPs in that they do not provide any reproductive health or family planning services
(ii) the danger posed by untrained and unqualified persons who are the first level of health personnel to be consulted.
An NGO Janani set up a network of more than 21,000 Titli (butterfly) centres and more than 500 Surya (sun) clinics in the states of Bihar, Jharkhand and Madhya Pradesh.
Surya clinics are referral clinics run by formally qualified, state-registered doctors in the towns.
Titli centres are situated in villages and run by RHPs who have been trained to provide family planning counselling and sell non-clinical contraceptives.
Since RHPs are male, they work with a Woman Health Partner (WHP) who is generally a member of their family (in most cases, wife). RHPs and their female counterparts undertake a two-day training programme on family planning counselling. Female partners help reach out to the village women who are hesitant to approach male health providers on reproductive health matters.
Once trained, detailed protocols along with counselling cards and IEC materials are made available to the RHP trainees and a contract is established with Janani: the franchiser. This contract stipulates that in exchange for benefiting from free training, IEC materials, the promotion of a common logo and for having access to cheap drugs, they are to provide specific reproductive health services of standard quality and at fixed rates.
The network’s name, logo, franchised services and corresponding rates are being widely advertised throughout the three states by the franchiser.
Networked rural providers are met and monitored at regular intervals by the project field teams. Besides replenishing their stocks of contraceptives, which are made available by Janani at subsidised rates, service providers are given a packet of printed IEC material to be used in their centre and catchment area. This kit also includes newsletters and magazines on general health to update them with developments in this field.
Second phase (from mid 2003):
The rural network was expanded to cover every village of Bihar and Jharkhand (targeting about 60,000 Titli centres). Janani took over administration of the Surya clinics through specially-trained administrators so that quality issues (a source of concern in the first phase) can be addressed. Each Surya clinic had to have, besides the administrator, a trained Auxiliary Nurse Midwife (ANM), a counsellor and a lab technician. This expenditure has to be borne by the doctor to remain part of the franchisee network. Thus the number of Surya clinics targeted for this phase was reduced to 360.
Janani monitors the performances of its Titli and Surya Clinics through sales data and regularly conducts market research through reputed organisations.
It claims to account for 5% of the total contraceptive coverage in Bihar and Jharkhand, of which only 10% are clinical services and the rest social marketing.
Cost per couple protected annually by clinical methods like sterilisation: INR 230
Cost per couple protected annually by non-clinical methods like condoms, oral pills, INR 117.
Costs on setting up of Surya clinics, Titli centres and Surya clinic rates are available as Excel sheets from ECTA office.
At present, in three states - Bihar, Jharkhand and Madhya Pradesh. The networking component of the Janani programme (Surya clinics and Titli centres) started on a pilot basis in 1996 and the scaling up happened late 1999. At the latest update (August 2004) 39 Surya clinics and approximately 31,000 Titli centres were functional.
Janani hoped to complete the network of 60,000 Titli centres and 360 Surya clinics within three years (from the beginning of the 2nd phase). The basket of services at the Surya clinics will go beyond family planning to all aspects of reproductive health and even some parts of health care.
Increased access: To family planning services in the rural areas.
Education: RHPs educated on family planning services which they would earlier refer onwards, reducing pressure on PHCs/sub-centres.
Self-sustaining: The clinical services have the potential to become self sustaining. The same networks can address the needs of the poorest if financial mechanisms (like coupons and vouchers) are set up.
Needs government backing: This approach will work even better if government’s enforcement of norms is adequate.
Administration: The programme needs a strong administrative framework and the ability to consistently value add to the networks to make the approach sustainable.
Set-up costs: NGO must have substantial funds to be able to set up the clinics and framework. Then the programme is extremely cost efficient.
Possible opposition: From PHC medical officers and other private sector providers outside the franchise networks who find that the prices they charge come under pressure.
Existence in the state of an NGO comparable to Janani.
Who needs to be consulted
Good because it is based on an existing dominant health care system (of first health care providers).Non-clinical services can be sustained if various services are bundled with the delivery channels.
Clinical services through doctors are fully sustainable.
Chances of Replication
Good where there is an existing network of first health care providers. There may be a need to tailor the providers’ networks differently but it should not pose any major difficulty.
J.P Mishra, Programme Advisor, European Commission Technical Assistance, New Delhi. April 2003.