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HEALTH SYSTEMS AND POLICY RESEARCH
2012
Vol. 1 No. 1:2
doi: 10.3823/1101
Quality care at
childbirth in the
context of Health
Sector Reform
Program in India:
Contributing
factors,
Challenges and
Implementation
Lesson
S. Bhattacharyya1*, A. Srivastava1, BI. Avan2, W J. Graham3
This article is available from:
www.hsprj.com
Abstract
In India during last decade several policies and programmes have tried to acceler-
ate provision of essential maternity services. National Rural Health Mission (NRHM),
health sector reform program, launched in 2005, primarily aims at health system
strengthening and reducing regional imbalances. Study assesses facilitating factors
and challenges in providing quality delivery care and generates context-specific
implementation lessons in three diverse states in India. Thirty-three in-depth, semi-
structured interviews were conducted with policy and program representatives.
The analysis presented is qualitative and descriptive. Analysis shows that NRHM
has infused new life in terms of infrastructure improvements, upgrading lower-level
facilities but challenges remain like inadequate human resources, non-utilization of
allocated funds and poor monitoring. Strategies have been devised to overcome
bottlenecks through task-shifting and quality monitoring. Though the emphasis is
on strengthening the structural aspect of care but to complete the whole quality
of care cycle, equal emphasis is needed on process of care.
Keywords: Health sector reform, India, Institutional delivery, Polices, Programme,
Quality of care
Introduction
Many developing countries since the late 1980s, have initi-
ated efforts to improve their health systems through policies
and interventions. The trend toward decentralization of so-
cial service delivery and focus on capacity building of health
workforce and infrastructure development had been initiated
through the National Health Policy and Health, Nutrition and
Population Sector Programme (HNPSP) in Bangladesh, (1)
and the Social Action Program in Pakistan (2), Several strate-
gies have been tested in the form of introducing user fees,
community financing and decentralization in Sub- Saharan
African Countries, (3).
As India strives to achieve the fifth Millennium Development
Goal (MDG) of reducing the Maternal Mortality Ratio (MMR)
from the current level of 254 to 100 by 2015 (4), quality
institutional deliveries play a key role in enhancing the sur-
vival and well being of both mothers and newborns. The last
decade (2000-2010) has witnessed significant expansion in
maternal and child (MCH) programmes across India as well
as formulation of concrete quality assurance strategies. The
National Rural Health Mission (NRHM) is the flagship health
sector reform programme of the Government, launched in
2005, with the goal “to improve the availability of and access
to quality health care by people, especially for those resid-
ing in rural areas.” The Mission aims at reducing regional
imbalances in health by focusing on ‘high-priority’ states (5).
1. Public Health Foundation of
India, New Delhi, India.
2. Faculty of Infectious and
Tropical Disease, London
School of Hygiene and
Tropical Medicine, U.K.
3. Immpact, University of
Aberdeen, U. K.
Correspondence:
sanghita@phfi.org
* Public Health Foundation of
India. Institute for Studies in
Industrial Development (ISID)
Campus, 4, Institutional
Area, Vasant Kunj
New Delhi 110070, India.
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Under NRHM, the Indian Public Health Standards (IPHS) have
been constituted as the basis for ensuring that all levels of
primary healthcare services across all states adhere to a set of
uniform prescribed norms and standards in terms of physical
infrastructure, human resources, services provided, treatment
procedures and behavior with patients (6). Quality has thus
become explicitly one of the key areas of NRHM, encompass-
ing infrastructural norms as well as service guarantees for vul-
nerable populations. In terms of long-term vision of NRHM,
three key elements of high quality maternal care have been
defined as skilled attendance at birth, access to emergency
obstetric and newborn care (EmONC) and efficient referral
system for timely access to EmOC (7).
Progress in the health system in India has not been uniform,
and significant regional imbalance can be observed in health
system development across states. The four Southern states
of Kerala, Tamil Nadu, Karnataka and Andhra Pradesh and
the Western states of Maharashtra and Gujarat are among
the states which have shown consistently better health sector
performance and health indicators than the less developed
states of Uttar Pradesh, Rajasthan, Bihar, Madhya Pradesh,
Orissa, Chhattisgarh and Jharkhand. In maternal health in-
dicators, for example, the MMR in Southern states averages
149 as compared to 375 in the less developed states (4)
The primary aim of the paper is to assess the contributing fac-
tors and challenges and to generate context-specific imple-
mentation lessons from the perspective of the stakeholders
in three diverse states in India which are at different levels in
terms of delivery of health services. These issues are in the
context of the NRHM, one of the major health sector reform
programs in India which aims to provide quality delivery care
in maternal health services.
Method
Data
The stakeholders for the study represented respondents at
the central and the state levels, which included planners and
program managers from the National government as well as
the governments of Orissa, Tamil Nadu and Rajasthan and
also respondents from development, academic and research
institutions (Table 1). Thirty-three in-depth, semi-structured
interviews were conducted in the three states between March
and May 2010. A framework of stakeholders was developed
to reflect the study setting (context). Interviews were con-
ducted according to a common framework and the paper is
part of the broader study to investigate perspectives on cur-
rent planning and research agenda for quality of care (QOC)
in the field of maternal, newborn and child health (MNCH).
In the interviews, respondents shared their professional and
personal experiences in the four broad areas related to QOC
for MNCH. These included: a) The current health sector re-
form: focus on quality maternal, neonatal and child health;
b) Contributing factors; c) Challenges and bottlenecks and d)
Implementation lessons.
Analysis
The analysis presented is qualitative and descriptive. The
narratives have been analyzed using a combined inductive/
deductive approach. In this analysis, data were coded ac-
cording to the interview discussion (‘topic’) guide (which also
serves as the initial analytical framework). Through an itera-
tive process of reviewing, and re-reviewing transcripts, data
Table 1. Stakeholder Framework.
Respondent type/category Geographic location (state) Number of respondents
Health and Family Welfare Department
Government / TAMIL NADU Tamil Nadu 4
Government / RAJASTHAN Rajasthan 5
Government / ORISSA Orissa 6
Government / CENTRAL Central level 2
Academic/development sector
Academia / research institutions National 2
NGOs / National/ State National 4
International NGOs / National National 10
TOTAL 33
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were also coded according to emergent themes. A descriptive
analysis is presented to provide an overview of common is-
sues and themes that arose in the discussions.
Selection of Study States
This paper is based on a study that was conducted in India
at the national and state levels, which have historically varied
levels of health and development performance. In order to
highlight the context of quality of care in maternal health
post NRHM, indicator of MMR was taken as criteria to select
the states, where the states are ranked as excellent, moderate
and low performing. But for the present analysis the catego-
rization of the states is at two levels, Tamil Nadu the better
performing state and Orissa and Rajasthan as low performing
states, which are also based on NRHM classification of non-
high and high focus states.
The three states selected for the study, Tamil Nadu, Rajast-
han and Orissa, are at different levels in terms of maternal
outcomes (4). Though in all the states there is visible im-
provement over the years, but still in the states of Orissa
and Rajasthan MMR is above the national average (Figure
1). Tamil Nadu is one of the few states in India which has
already reached the MGD 5.
The research was approved by the Institutional Ethics Com-
mittee of the institution conducting the study and also writ-
ten consent was obtained from the stakeholders.
Figure 1. Trend in Maternal Mortality Ratio: A comparative
scenario among the study states.
Results
This section presents the key findings from the stakeholder
interviews, relating to the changing quality of care scenario
post-NRHM, and the associated challenges that need to be
addressed by the states. Findings have been arranged in four
sub-sections.
The current health sector reform scenario: focus
on quality maternal, neonatal and child health
With the advent of NRHM in 2005 a sense of positivity re-
garding health policy and programming for MNCH and QOC
in India has emerged as a consistent theme across all the
states. NRHM is a departure from historical health planning
as it “doesn’t focus on the goals but on inputs, strategies and
programmes” for the “necessary architectural correction in
the basic health care delivery system”. [7] As a result, while
good performing states like Tamil Nadu have made appre-
ciable advancements, the scale of progress in low performing
states like Orissa and Rajasthan has been truly phenomenal
compared to last few decades.
“...of course in 2000 you didn’t have a National Rural Health
Mission…. it was around 2005-06 that the turning point
really took place in this country... it’s not just the positive
environment but it’s a very fertile environment for maternal
health in India, post the launch of NRHM [...] there are policies
and they are backed up by budgets”,
Senior Official, Ministry of Health Government of India
The impact of NRHM on QoC was corroborated by state and
district level planners as well as NGO representatives across
the various states, which is reflected in terms of increase in
delivery at lower end facilities. NRHM, as described by the
respondents, seemed to address several key systemic issues
such as infrastructure, more budgetary allotments, decen-
tralisation, and bringing in managers into the health system.
The Janani Suraksha Yojana (JSY) a conditional cash transfer
scheme promoting institutional delivery implemented since
2005 have brought into focus the issue the QoC at public
health facilities . JSY had brought about a ‘pull factor’ that
worked as a catalyst to hasten the pace of health systems
development and also have highlighted the need of putting
in place the protocols for quality.
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“An institution that has been conducting 4 deliveries a month
has now around 40 deliveries to conduct. This would mean
additional seating arrangements, toilet coops, drinking water
facility, many more beds, labour rooms tables are needed.
This pull factor has substantially contributed for accelerat-
ing the system, but now the focus needs to be providing
good care”. Senior Official, Ministry of Health, Government
of India.
All respondents were unanimous in their appreciation of the
JSY scheme in terms of the demand generated, however the
unintended effects of JSY especially in making quality take a
backseat at the facility level were also pointed out.
“More deliveries are happening and I am sure it will have im-
pacts on maternal mortality with time…but it is like attracting
people by giving money …it’s a short cut to quality, in some
places quality may be deteriorating …there are evidence of
over congestion, deliveries are happening on the floor, cor-
ridor etc…because there is not adequate capacity …so there
may be a counter intuitive, negative impact in some places.”
Senior Academic
Contributing factors
Decentralization is the key contributing factor for giving
States the onus for developing their health systems. In this
respect, the state of Tamil Nadu is widely regarded as a suc-
cess story in public health programming, having the advan-
tage of an early start. Since 80’s, Tamil Nadu has adopted
a “more coherent, state-owned, state-driven approach” to
health policy and planning, prioritising social development
and structural reform. Through a dedicated Public Health Act
(and associated public health cadre), the state has focused on
solutions for human resources (HR) through the empower-
ment of frontline Village Health Nurses (VHNs), the strategic
upgrading of infrastructure and facilities, and the strengthen-
ing of the health management information system (HMIS),
which includes measures for the routine monitoring of QOC.
“Maternal and child health cannot be seen in isolation; for
example, Tamil Nadu Medical Service Corporation is not for
maternal and child health…it’s for the entire health system.
Overall system strengthening is needed to have a good de-
livery of maternal and child health services.”
Former Director of Public Health, Tamil Nadu
In terms of human resource engagement, capacity expan-
sion, infrastructure improvements and supplies of essential
equipment, NRHM infused a new life into the starved health
sector. The improvement is also visible in the states of Orissa
and Rajasthan which have hitherto been performing poorly
in terms of infrastructure, human resources and accessibility.
“we have recruited more people in the last 5 years than in
the last five 5 year plans. One could actually calculate and say
that over a lakh and a half service providers were recruited.
This sort of drive in HR was not there for many years”.
Senior Official, Ministry of Health Government of India
Flexible funding under NRHM is the other key aspect and the
states have taken the lead in initiatives to strengthen service
delivery like operationalising the First Referral Units (FRUs)
and Comprehensive Emergency Obstetric and Newborn Care
(CEmONC) centres.
Janani Suraksha Yojana (JSY) a conditional cash transfer
scheme for institutional deliveries under NRHM has lead to
upgrading of lower-level facilities like the Primary Health Cen-
ters (PHC). In Tamil Nadu, institutional delivery along with
CEmONC facility is now available at the PHC level also.
“Earlier 80% institutional deliveries were in District hospitals;
now the figure has declined to 26%. Decentralization of in-
stitutional deliveries has taken place with functionalization
of PHCs”
State Programme Manager, Tamil Nadu
Referral in Tamil Nadu has been further strengthened not
only through emergency transportation, but also by providing
mobile phones to different health cadres and displaying their
numbers at the entrance to the PHC.
Challenges and bottlenecks
Progress has not been uniform across all states, as is evident
through the contrast between Tamil Nadu and the two states
of Orissa and Rajasthan, which are still grappling with inad-
equate human resources, infrastructure and supplies, non-
utilisation of allocated funds and poor monitoring of health
systems.
Human resource shortage has become all the more pertinent
in the wake of increasing institutional deliveries under JSY,
and is one of the key obstacles in delivering quality care.
Health workers, particularly doctors, are reportedly difficult
to recruit for rural postings; their retention is another major
issue. Inadequate numbers of staff with poor clarity over roles
and responsibilities seem to be imposed on systems that give
rise to poor motivation, low morale, and lack of recognition
of effort and achievement.
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‘We are dealing with inadequate human resources and with
the dilapidated buildings, women are lying on the floor and
they are getting discharged as soon as they can”. District
Programme Manager, Orissa.
With regard to infrastructure, both maintaining buildings
and equipments to provide healthcare was a dominant and
persistent theme in both Orissa and Rajasthan. Despite the
flexibility and availability of funds under NRHM, planners are
not able to configure infrastructure according to local needs.
Under- utilization of allocated funds is evident in both Orissa
and Rajasthan, while Tamil Nadu could readily absorb and
spend allocated funds and further strengthen its service de-
livery.
“I notice most of the states around are not spending …it
just means that their health system has suffered from quite
a long tenure of underinvestment …and that is why they are
not absorbing all the money “
Health Expert, Bilateral Agency
Monitoring and evaluation (M&E) procedures were also fre-
quently described as problematic as data is not maintained
properly and often considered a burden, more bureaucratic
than beneficial to programme implementers across the states.
“If you go to any district, no one will be able to tell you that
this is the IMR or MMR rate because the reporting is not
proper. If you don’t have the exact reporting about maternal
deaths or infant deaths have taken place, then how can one
say that we are moving in positive or the negative direction”.
District Programme Manager, Rajasthan
Patient’s experience is one of the key criteria for QOC, a
challenge that was reported even in Tamil Nadu. Insensitive
provider behavior at secondary and tertiary level facilities was
cited as one of the main reasons why community women
preferred to deliver at PHCs.
“We have developed the primary health care system but the
main lacunae is in the secondary and tertiary system, so in
order to make women comfortable we have introduced the
birth companion system”
State Programme Manager, Tamil Nadu
Implementation solutions and lessons
In spite of the many challenges, an overall sense of positivity
can be seen both in Orissa and Rajasthan in terms of delivery
of quality health services. The states have devised state-specific
policies to address the issue of human resources. They are also
experimenting with task-shifting, which includes the training
of Ayush (homeopathic) doctors in skilled birth attendance,
besides increasing the seats in medical colleges, and increasing
remuneration and retirement age of health personnel.
“there are 600 contractual doctors who have been recruited;
200 posts of specialists (gynecologists/anesthetists/pediatri-
cians) were advertised recently - remuneration was increased
from Rs. 40,000 to 60,000 and age bar was relaxed to 60
years to encourage retired persons to apply.”
District Programme Manager, Rajasthan
With respect to monitoring, in recent years maternal death
audits have been piloted in some districts of Orissa and Ra-
jasthan, based on the experience of Tamil Nadu.
NRHM, as described by the respondents, seemed to ad-
dress several systemic issues such as infrastructure, lack of
funds, promote decentralisation, bringing in managers into
the health system etc. and these cumulatively had a salutary
effect on MNCH outcomes across the country. However, in
a country as vast and varied as India it takes time for the
effects of the reforms agenda of NRHM to percolate down
to the peripheral levels. This is especially the case in areas
where health systems have been neglected for several de-
cades. Many respondents, while acknowledging the reform
agenda of NRHM and its impact also pointed out that it
was a work in progress and the pace of reforms needed
to be sustained if long term changes were needed particu-
larly in effecting quality of care for maternal health service
(Figure 2). This was captured succinctly in the words of an
expert, who said:
“This is a situation where the house is not fully in order before
the guests have been invited.”
Maternal Health Expert , Government of India
“Since introduction of this NRHM, things have improved…
before that there was paucity of funds, manpower, infra-
structure, apparatus and equipments, trainings etc., but a lot
of things still need to improve.”
District Medical Officer, Rajasthan
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Discussion
Developing countries like India have tested with similar reform
program, which has resulted in success, like in Malaysia with
the Maternal and Child health strategic plan (2006-2010)
where quality forms the core, has resulted in a high rate
of institutional delivery touching almost 98% (9). Similarly
in Bangladesh and Nepal by upgrading and betterment of
the facilities and training of the service providers in those
facilities have resulted in improvement in maternal health
outcome (10, 11), as in Bangladesh MMR has declined from
514 in 1986-90 to 400 in 2003, that is 22 percent in the 11
intervening years of Health, Nutrition and Population Sector
Program (12).
In India the present study findings reveal an overall positive
influence of NRHM in addressing health system challenges in
India, which has been noted by other studies as well. A study
in Rajasthan, for example, notes that renovation of physical
infrastructure under NRHM has led to improved staff morale
and increased patient inflow (13).Despite the positive impacts
of NRHM, serious implementation issues exist. These may, at
least in part, stem from health systems and health infrastruc-
ture that suffers from chronic and long term under-invest-
ment (14). Findings highlight that while NRHM is effectively
tackling these bottlenecks, many challenges persist. Human
resource is one such challenge, other challenges being gaps
in infrastructure and supplies, and lack of supervisory and
managerial efficiency. Similar challenges have been reported
in other developing country settings as well. One of the big-
gest maternal health challenges lies in the availability, reten-
tion and training of skilled birth attendants (15). The skewed
ratio often leads to overburdening of providers with clinical
as well as administrative workload, thus compromising quality
of care (16). Similarly on the supply side inadequate equip-
ments, drugs, supplies like blood to the EmOC facilities and
supervision remains a gap in most of the countries where
MMR is still high (17,18).
Figure 2. The stakeholder’s Perspective: Effect of NRHM on Quality care at Child Birth.
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Similar issues have been reported in a multi-state study in In-
dia, which reports delays in recruitment, insufficient training
of community health workers, staff absenteeism and apathy
of doctors posted in rural areas as key health system chal-
lenges (19). In India there is still a preference for private facili-
ties mainly on account of good staff behavior and availability
at all times, and good physical infrastructure (20). Higher level
of patient dissatisfaction was also associated with staff ab-
senteeism, lack of medicines and long waiting time (21).
Regional imbalances, however, are still persistent and NRHM
has not succeeded in removing the imbalance in health in-
frastructure at least at the sub-centre and PHC levels, with
high-focus states lagging behind in implementation as com-
pared to more developed ones. This is a critical stakeholder
observation which is corroborated by other studies as well.
Patients utilizing PHC & OPD services are considerably higher
in non high-focus states. A large proportion of health centres
in high-focus states has not been able to spend untied funds
for infrastructure up-gradation in spite of glaring shortages/
structural problems (22).
It can be reasonably concluded that the current policy and
programming environment is characterized by positivity with
the advent of NRHM. Not only is there increased funding,
but also a tangible ‘vibrancy’ in the health system. This is
reflected in innovations like the ASHAs, JSY and many other
small-scale initiatives (23). Infrastructure, human resources,
supplies and equipment are avenues for holistic health sys-
tem policy and programming to achieve QoC for MNCH (24).
The success of such efforts would, however, vary in different
regional contexts. Experiences from well performing states
like Tamil Nadu, which has explicitly focused on health sys-
tem reform, demonstrate that in settings where public health
systems have been given priority, policies and programmes
can be coherently, easily and effectively implemented (25).
This is also a way forward for the path to be taken by other
states in their efforts towards quality MNCH.
Conclusion
In the initial phase of health system reform program in In-
dia the emphasis is on strengthening the structural aspect
of care that is physical infrastructure, human resource, sup-
plies. But the process of care which includes safety, timeli-
ness, responsiveness and patient-centered care like respect,
dignity, emotional support is crucial to get positive outcome
in terms of decline in morbidity and mortality of mothers
and newborns (26, 27, 28). To complete the whole quality of
care cycle, equal emphasis is needed on process of care also.
Current public health QOC norms in India incorporate clinical
effectiveness and management, but are less clear on relatively
intangible aspects like responsive and patient centred care.
The focus is undoubtedly on structural elements, given the
gross structural deficiencies that plague India’s health system.
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