Organizational changes

One of HISP’s objectives is to decentralize the management and the flow of reporting within the primary health care sector (Braa 1997; Braa and Hedberg 2000; Braa et al. 2000). This is in line with the World Health Organization’s guidelines, which encourages decentralization as part of its primary health care strategy to strengthen health management at local level (WHO 1979). Al-though the primary health care structure embedded in India is in its nature built up in a decentralized way, the large gap between the primary health centre and the district headquarter (see figure 5-1 and table 6-2) makes the reporting structure very centralized. The reporting that is done at the primary health cen-tres are done for 8 to 75 thousand people, while for the next step, at the district medical and health officer’s (DM&HO) office in Chittoor they handle regis-trations for 3.75 million people. Hence very little feedback is given from the

district back to the individual primary health centre, except some occasional reprimands for not fulfilling the immunization and sterilization targets.

Between my first and second visit to Kuppam the reporting structure changed to be more decentralised. A new reporting unit between the primary health centre and the district was introduced, thereby lowering the huge gap in popu-lation between these two. The two different structures do not vary much, and I will here only describe the previous and new structure.

State level

Figure 6-2: The new health care reporting structure for Chittoor district The information flow mainly illustrated above can be divided into two main parts. The ‘PHC structure’ is there to support the mother and child health programs and various vertical programs. Below this, the health workers in the sub-centres collect health data on various programs and send it to the primary health centres that aggregate it and send it to the district office who do further aggregation across the different primary health centres and send it to the state.

The APVVP (Andhra Pradesh Vaidya Vidhana Parishat) is a separate structure recently established as part of a World Bank project to strengthen the hospital infrastructure. All district (200+ beds) and area hospitals (100 beds) and

com-munity health centres (30 - 50 beds) come under the purview of the APVVP.

This involves a parallel and independent management and reporting structure flowing from the hospitals to the District Coordinator of Health Services (and not the district medical and health officer as in the first two cases) who in turn send the reports to the Commissioner APVVP (and not the Commissioner for Family Welfare or Director of Health as is the situation in the last two cases respectively).

Table 6-2 illustrates some data on the sizes and administrative leadership of the new and old reporting structure in Chittoor. The new reporting units are divi-sions and sectors. There have been established six sectors in Chittoor: three in Madnapalli division, two in Chittoor division and one in Tirupati division. For the most, the new units exist only on paper. In practice the reports are still sent directly to Chittoor, and thus one cannot say much about the effectiveness of this changeover yet.

Administrative

leader Unit (new) Unit (old) Population CM/Secr. of helath State (Min.

H&FW?)

State (Min.

H&FW?) 75 million

DM&HO 23 Districts 23 Districts 3.75 million

ADM&HO 3 Divisions 1-1.5 million

ADM&HO 6 Sectors 0.5-1 million

MO 84 PHCs 84 PHCs 30 thousand

MPHA Sub centre Sub centre 5 thousand

Table 6-2: Administrative units in Andhra Pradesh and Chittoor

Even though the reporting structure has been reduced from three to two hier-archal levels it still represents a poor referral system. A patient can go to what-ever primary health centre or hospital he or she wants to go to with the same problem. If the patient is displeased with the treatment in one primary health centre, he or she can go to another health centre or the hospital the same day.

Thus the same illness would be registered twice.

HISP tried to push for change in reporting procedures within the district. The idea was to make the reporting unit between the primary health centres and the district work and in turn create a more local reporting structure. The problem is to find a suitable organizational unit that can function for this kind of task without to much extra resources being spent.

One option was to use the mandal offices (revenue offices) to be in charge, but this was turned down because they did not cover enough health centres and because these offices are not directly connected to health (their function is mainly to serve as a local revenue department). Another option was to use the revenue divisions and sub-divisions that each district is divided into. Chittoor has three divisions; Tirupati, Madanapali and Chittoor division, and some of these again are again divided into sub-sections. The divisions do not have any

building or a specific manager within the health hierarchy that can act as a re-porting unit, so this has to be established more or less in an ad-hoc way. For example, to use the case from the pilot project, area hospital in Kuppam could possibly serve as a sub-division reporting unit. It has relatively stable power supply 24 hours day and frequent bus connections.

The overall problem with making these changes has been the problem of con-vincing the decision makers at all levels of the health bureaucracy. Let us begin at the top. The commissioner of family welfare was very reluctant to change any kind of reporting routines in the pilot area. First, this way of reporting is basically more or less how it is done throughout the rural areas in India, so it is hard to just change it. Even though this would only be for a fairly small part of a district, the reporting procedures are interconnected so making changes one place would effect others. I do not think they see the point of setting up a “vir-tual” reporting unit without any real function when the normal reporting pro-cedure had to go on as usual. Second, assigning or reassigning people to the specific posts costs money for the ministry. A third reason for not changing any reporting procedures was given by the commissioner of family welfare herself.

It was not possible for the department to handle three different kind of report-ing systems simultaneously (the CMC-system bereport-ing the second after the exist-ing paper-based). It was probably also a reaction for feelexist-ing left out, as she had suddenly realized that HISP was deeply involved in Chittoor without her knowing about it. Irrespective of reasons, it ended in formal instruction to Chittoor, saying that no reporting procedures were to be changed, and that no support should be given to HISP.

At the middle level, the district medical and health officer’s office in Chittoor, the willingness to make changes was to an extent quite open, especially from the district medical and health officer himself. The only problem was that the district has to conduct itself to the department at state level, and can in theory do nothing without approval from the top. Thus, it was a noticeable setback when instructions of no support came from the department of family welfare.

The district medical and health officer could do nothing more than say “sorry, I can’t help you anymore”, even though, as said; “[he] totally supported HISP”.

At the lowest level, the primary health centres and the sub-centres, some un-willingness to change was put forward. A few health-workers, when explained about the new way of reporting, expressed concern over not reporting directly to the district medical and health officer, which made them feel more impor-tant and their job more meaningful.

District database in Chittoor

To get an overview of the data at all the 84 primary health centres in Chittoor, a DHIS database was put up at the district medical and health officer’s office.

Data was then entered by HISP team members for the months of April through November 2002. This move was done for two reasons.

The first reason was a direct result of a question that was raised during the analysis of the data from the nine primary health centres (this analysis is given in chapter 7). The question was about the equality in the health data reported in DHIS was the same as health data reported through the paper-based system directly to Chittoor. Was the official numbers in Chittoor just as “bad” as what was discovered in the analysis? Having the two sources, one could easily check a primary health centre for a specific month or year to see if the reported figures were the same.

The second reason was more of a strategic one. It started to come apparent that running around the nine primary health centres in Kuppam was not giving enough influence and exhibition of HISP within the primary health sector. Set-ting up a computer and assigning people to the district medical and health offi-cer’s office signalled that something was actually being done and gave HISP closer contact with the decision-makers in the district capitol. It was important to build up a stronghold in the middle of the hierarchy and thus having some sort of control and influence at the top (political influence in Hyderabad) in the middle (close contact with senior health officials in Chittoor) and at the base (support and feedback from the health workers).